Measure Dx: Implementing pathways to discover and learn from diagnostic errors.

Despite the high frequency of diagnostic errors, multiple barriers, including measurement, make it difficult learn from these events. This article discusses Measure Dx, a new resource from the Agency for Healthcare Research and Quality that translates knowledge from diagnostic safety measurement research into actionable recommendations. Measure Dx guides healthcare organizations to detect, analyze, and learn from diagnostic safety events as part of a continuous learning and feedback cycle.

Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment.

Objectives: Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer.

Methods: Collectively known as patient safety learning laboratories, grantee teams engage in phase-based activities that parallel a systems engineering process-problem analysis, design, development, implementation, and evaluation-to gain an in-depth understanding of related patient safety problems, generate fresh ideas and rapid prototypes, develop the prototypes, ensure that developed components are implemented as an integrated working system, and evaluate the system in a simulated or clinical setting.

Struggling to invent high-reliability organizations in health care settings: Insights from the field.

The Mission of the Agency for Healthcare Research and Quality (AHRQ) has been to support and conduct health services research and to disseminate those research findings. Recently the Agency has changed its mission to: "Improving the quality, safety, efficiency and effectiveness of health care for all Americans." For agency personnel working with the topic of patient safety, that change has created a need to develop greater awareness of the current patient safety initiatives underway at leading health care systems in order to determine where AHRQ might best play a role in helping these systems more rapidly adopt new practices to improve patient safety.