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Topics
- Adverse Drug Events (ADE) (4)
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- Care Coordination (1)
- Children/Adolescents (2)
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- Diagnostic Safety and Quality (6)
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- (-) Medical Errors (29)
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- Medication: Safety (2)
- Newborns/Infants (1)
- Opioids (1)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 29 Research Studies DisplayedAuerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Newman-Toker DE, Nassery N, Schaffer AC
Burden of serious harms from diagnostic error in the USA.
Americans who experience serious harm from misdiagnosis annually. Serious harm is defined as permanent morbidity or morality. This cross-sectional analysis used nationally representative observational data. The authors estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). US-based cancer registries were used to find annual new cancers. They derived diagnostic errors and serious harms by multiplying by literature-based rates for disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories). Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), they estimated total serious harms annually in the USA to be 795,000 (plausible range 598,000-1,023,000). Using more conservative assumptions they estimated 549,000 serious harms. These results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. Fifteen dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.
AHRQ-funded; HS027614; HS029350.
Citation: Newman-Toker DE, Nassery N, Schaffer AC .
Burden of serious harms from diagnostic error in the USA.
BMJ Qual Saf 2024 Jan 19; 33(2):109-20. doi: 10.1136/bmjqs-2021-014130..
Keywords: Healthcare Cost and Utilization Project (HCUP), Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality of Care, Adverse Events
Carroll AR, Johnson JA, Stassun JC
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
This study’s objective was to test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was conducted from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Observed dosing errors were the main outcome measured, and secondary outcomes included caregiver-reported medication knowledge. Among 198 randomized caregivers (mean age 31.4 years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 percentage points). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group. The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%], and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]).
AHRQ-funded; HS026122.
Citation: Carroll AR, Johnson JA, Stassun JC .
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
JAMA Netw Open 2024 Jan 2; 7(1):e2350969. doi: 10.1001/jamanetworkopen.2023.50969..
Keywords: Children/Adolescents, Health Literacy, Communication, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinician-Patient Communication, Hospital Discharge, Medication: Safety
Cohen TN, Berdahl CT, Coleman BL
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
This study’s objective was to understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. The authors randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. Results showed that among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Seven of these events were linked to COVID-19.
AHRQ-funded; HS027455.
Citation: Cohen TN, Berdahl CT, Coleman BL .
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
J Nurs Care Qual 2024 Jan-Mar; 39(1):51-57. doi: 10.1097/ncq.0000000000000720..
Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors
Liang C, Gong Y
Enhancing patient safety event reporting by K-nearest neighbor classifier.
The debate on structured or unstructured data entry reveals not only a trade-off problem among data accuracy, completeness, and timeliness, but also a technical gap on text mining. The reesarchers suggested a text classification method for predicting subject categories. Their results demonstrated the feasibility of their system and indicated the advantage of such an application to raise data quality and clinical decision support in reporting patient safety events.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
Enhancing patient safety event reporting by K-nearest neighbor classifier.
Stud Health Technol Inform 2015;218:40603.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Public Reporting, Clinical Decision Support (CDS), Health Information Technology (HIT), Data
Parker SH
Human factors science: Brief history and applications to healthcare.
This section will define the science of human factors, its origins, its impact on safety in other domains, and its impact and potential for impact on patient safety.
Patient Safety, Medical Errors, Health Care Quality
Citation: Parker SH .
Human factors science: Brief history and applications to healthcare.
Curr Probl Pediatr Adolesc Health Care 2015 Dec;45(12):390-4. doi: 10.1016/j.cppeds.2015.10.002.
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Keywords: Patient Safety, Medical Errors, Quality of Care
Fernandez R, Grand JA
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
This article highlights guiding team science principles from the organizational psychology literature that can be applied to the study of teams in healthcare. The authors' goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
AHRQ-funded; HS020295; HS022458.
Citation: Fernandez R, Grand JA .
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
Curr Probl Pediatr Adolesc Health Care 2015 Dec;45(12):370-7. doi: 10.1016/j.cppeds.2015.10.005.
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Keywords: Patient Safety, Teams, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Liang C, Gong Y
On building an ontological knowledge base for managing patient safety events.
The authors developed a semantic web ontology based on the WHO International Classification for Patient Safety (ICPS) and AHRQ Common Formats for patient safety event reporting. The ontology holds potential in enhancing knowledge management and information retrieval, as well as providing flexible data entry and case analysis. They detailed their efforts in data acquisition, transformation, implementation and initial evaluation of the ontology.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
On building an ontological knowledge base for managing patient safety events.
Stud Health Technol Inform 2015;216:202-6.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Okafor NG, Doshi PB, Miller SK
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The researchers found that the utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012.
AHRQ-funded; HS017586.
Citation: Okafor NG, Doshi PB, Miller SK .
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
West J Emerg Med 2015 Dec;16(7):1073-8. doi: 10.5811/westjem.2015.8.27390.
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Keywords: Emergency Department, Adverse Events, Medical Errors, Patient Safety, Public Reporting, Quality of Care
Yamada NK, Yaeger KA, Halamek LP
Analysis and classification of errors made by teams during neonatal resuscitation.
This study was performed to determine and characterize common deviations from The Neonatal Resuscitation Program (NRP) algorithm during neonatal resuscitation. It concluded that errors of commission, especially when performing advanced life support interventions such as positive pressure ventilation, intubation, and chest compressions, are common during neonatal resuscitation and are sources of potential harm.
AHRQ-funded; HS012022.
Citation: Yamada NK, Yaeger KA, Halamek LP .
Analysis and classification of errors made by teams during neonatal resuscitation.
Resuscitation 2015 Nov;96:109-13. doi: 10.1016/j.resuscitation.2015.07.048.
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Keywords: Medical Errors, Newborns/Infants, Newborns/Infants, Guidelines
Stevens AD, Hernandez C, Jones S
Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.
The study’s goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared to conventional medication administration, in simulated prehospital pediatric resuscitation scenarios. It found that the novel syringes decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.
AHRQ-funded; HS017526.
Citation: Stevens AD, Hernandez C, Jones S .
Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.
Resuscitation 2015 Nov;96:85-91. doi: 10.1016/j.resuscitation.2015.07.035..
Keywords: Medication, Emergency Medical Services (EMS), Children/Adolescents, Medical Errors, Comparative Effectiveness
Thompson DA, Marsteller JA, Pronovost PJ
Locating errors through networked surveillance: A multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.
The objectives of the study were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement. It identified 6 top priority hazard themes: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment.
AHRQ-funded; HS013904.
Citation: Thompson DA, Marsteller JA, Pronovost PJ .
Locating errors through networked surveillance: A multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.
J Patient Saf 2015 Sep;11(3):143-51. doi: 10.1097/pts.0000000000000059..
Keywords: Patient Safety, Medical Errors, Adverse Events, Surgery, Cardiovascular Conditions, Prevention
Senathirajah Y
Safer design - composable EHRs and mechanisms for safety.
In this paper, the author discussed how the different drag/drop interaction paradigm has implications for health IT safety via several mechanisms. These mechanisms included display fragmentation and the need to changeably prioritize information elements, interruptions, fit to tasks and contexts, and rapid changeability allowing low-cost readjustments when lack of fit is found.
AHRQ-funded; HS023708.
Citation: Senathirajah Y .
Safer design - composable EHRs and mechanisms for safety.
Stud Health Technol Inform 2015;218:40602.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Primary Care: Models of Care, Patient Safety
Rosenbluth G, Bale JF, Starmer AJ
Variation in printed handoff documents: results and recommendations from a multicenter needs assessment.
The objective of this study was to determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. It identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17 percent) were uniformly present in all sites’ handoff documents.
AHRQ-funded; HS019456.
Citation: Rosenbluth G, Bale JF, Starmer AJ .
Variation in printed handoff documents: results and recommendations from a multicenter needs assessment.
J Hosp Med 2015 Aug;10(8):517-24. doi: 10.1002/jhm.2380..
Keywords: Patient Safety, Medical Errors, Communication, Comparative Effectiveness, Care Coordination
Crane S, Sloane PD, Elder N
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
This study assessed the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. It found that all 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 quality improvement projects based on the reports.
AHRQ-funded; HS019558.
Citation: Crane S, Sloane PD, Elder N .
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
J Am Board Fam Med 2015 Jul-Aug;28(4):452-60. doi: 10.3122/jabfm.2015.04.140050..
Keywords: Adverse Events, Medical Errors, Patient Safety, Primary Care, Public Reporting, Quality Improvement, Quality of Care
Sage WM, Jablonski JS, Thomas EJ
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
The researchers sought to determine the frequency of nondisclosure agreements in medical malpractice settlements and the extent to which the restrictions in these agreements seem incompatible with good patient care. They found that an academic health system with a declared commitment to patient safety and transparency used nondisclosure clauses in most malpractice settlement agreements but with little standardization or consistency.
AHRQ-funded; HS019561.
Citation: Sage WM, Jablonski JS, Thomas EJ .
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
JAMA Intern Med 2015 Jul;175(7):1130-5. doi: 10.1001/jamainternmed.2015.1035..
Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety
Manojlovich M, Adler-Milstein J, Harrod M
The effect of health information technology on health care provider communication: a mixed-method protocol.
The purpose of this study is to describe, in detail, how health information and communication technologies facilitate or hinder communication between nurses and physicians. It seeks to (1) identify the range of health information and communication technologies used in a national sample of medical-surgical acute care units, and (2) describe communication practices and work relationships that may be influenced by health information and communication technologies in these same settings.
AHRQ-funded; HS022305.
Citation: Manojlovich M, Adler-Milstein J, Harrod M .
The effect of health information technology on health care provider communication: a mixed-method protocol.
JMIR Res Protoc 2015 Jun 11;4(2):e72. doi: 10.2196/resprot.4463..
Keywords: Adverse Events, Communication, Health Information Technology (HIT), Patient Safety, Medical Errors
Nuckols TK, Smith-Spangler C, Morton SC
The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis.
The primary objective of this systematic review and meta-analysis study was to quantitatively assess the effectiveness of computerized provider order entry (CPOE) at reducing preventable adverse drug events (pADE). It found that CPOE is associated with cutting in half the number of pADEs. Medication errors were also about half as common with CPOE.
AHRQ-funded; HS017954
Citation: Nuckols TK, Smith-Spangler C, Morton SC .
The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis.
Syst Rev. 2014 Jun 4;3:56. doi: 10.1186/2046-4053-3-56..
Keywords: Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Patient Safety
Murray DJ, Freeman BD, Boulet JR
Decision making in trauma settings: simulation to improve diagnostic skills.
The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries. The results of this preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach.
AHRQ-funded; HS018734; HS022265.
Citation: Murray DJ, Freeman BD, Boulet JR .
Decision making in trauma settings: simulation to improve diagnostic skills.
Simul Healthc 2015 Jun;10(3):139-45. doi: 10.1097/sih.0000000000000073..
Keywords: Shared Decision Making, Diagnostic Safety and Quality, Critical Care, Patient Safety, Medical Errors
Reiter-Palmon R, Kennel V, Allen JA
Naturalistic decision making in after-action review meetings: the implementation of and learning from post-fall huddles.
In this study, the authors added to our understanding of Naturalistic Decision Making (NDM) in healthcare and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. They found that the use of self-guided post-fall huddles increased over the time of the project, the types of errors identified as contributing to the patient fall changed, and the proportion of falls with less adverse effects increased during the project time period. They concluded that , over time, self-guided AARs can be useful for some aspects of learning from errors.
AHRQ-funded; HS021429.
Citation: Reiter-Palmon R, Kennel V, Allen JA .
Naturalistic decision making in after-action review meetings: the implementation of and learning from post-fall huddles.
J Occup Organ Psychol 2015 Jun;88(2):322-40. doi: 10.1111/joop.12084.
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Keywords: Adverse Events, Falls, Shared Decision Making, Medical Errors, Patient Safety
Gallagher TH, Mazor KM
Taking complaints seriously: using the patient safety lens.
This editorial defined a patient safety lens that favors learning over protection. It listed five critical components of the patient safety lens and concluded that the first and most important step entails expanding our perspective beyond the technical execution of care to encompass and appreciate patients’ reports of their care experiences.
AHRQ-funded; HS022757.
Citation: Gallagher TH, Mazor KM .
Taking complaints seriously: using the patient safety lens.
BMJ Qual Saf 2015 Jun;24(6):352-5. doi: 10.1136/bmjqs-2015-004337.
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Keywords: Healthcare Delivery, Medical Errors, Patient Safety, Patient Experience, Clinician-Patient Communication
Singh H, Allen JI
Patient safety counterpoint: systems approaches and multidisciplinary strategies at the centerpiece of error prevention.
The understanding and awareness of patient safety issues has led to many calls for systems improvement, transparency, and accountability for more than a decade. The authors encourage all of those interested in this topic to critically examine the recent literature in relevant topics related to patient safety, systems thinking, and preventable delays in cancer diagnosis from across the globe.
AHRQ-funded; HS022087.
Citation: Singh H, Allen JI .
Patient safety counterpoint: systems approaches and multidisciplinary strategies at the centerpiece of error prevention.
Clin Gastroenterol Hepatol 2015 May;13(5):824-6. doi: 10.1016/j.cgh.2015.01.005..
Keywords: Patient Safety, Medical Errors, Cancer
Singh H, Sittig DF
Setting the record straight on measuring diagnostic errors. Reply to: 'Bad assumptions on primary care diagnostic errors' by Dr Richard Young.
This letter responds to a letter by Dr. Richard Young who criticizes Singh’s article on measuring diagnostic error. Singh defends his systems-based approach to advancing the science of measuring diagnostic error and acknowledges some of the uncertainties and evolution in the diagnostic process that Dr. Young writes about.
AHRQ-funded; HS022087
Citation: Singh H, Sittig DF .
Setting the record straight on measuring diagnostic errors. Reply to: 'Bad assumptions on primary care diagnostic errors' by Dr Richard Young.
BMJ Qual Saf. 2015 May;24(5):345-8. doi: 10.1136/bmjqs-2015-004140..
Keywords: Diagnostic Safety and Quality, Medical Errors, Patient Safety, Primary Care, Quality Measures
Singh H, Sittig DF
Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.
The authors developed a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). They described how their framework serves as a conceptual foundation for system-wide safety measurement, monitoring, and improvement of diagnostic error. They posited that the Safer Dx framework can be used by a variety of stakeholders including researchers, clinicians, health care organizations, and policymakers, to stimulate both retrospective and more proactive measurement of diagnostic errors.
AHRQ-funded; HS022087.
Citation: Singh H, Sittig DF .
Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.
BMJ Qual Saf 2015 Feb;24(2):103-10. doi: 10.1136/bmjqs-2014-003675.
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Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Medical Errors, Patient Safety, Quality Measures