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digital.ahrq.gov/ahrq-funded-projects/preventing-perioperative-medication-errors-and-adverse-drug-events-through-use/citation/usability
January 01, 2023 - Project Name
Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs017020-singh-final-report-2010.pdf
January 01, 2010 - Primary outcome was adverse drug events (ADE’s) in older adults,
ascertained using a trigger tool chart … Key Words: Medication safety, adverse drug events, primary care, older adults, team resource
management … events. … Incidence
and preventability of adverse drug events among older
persons in the ambulatory setting. … Experience with a trigger tool for identifying adverse
drug events among older adults in ambulatory
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017258-gardner-final-report-2010.pdf
January 01, 2010 - We assessed the patients for
adverse events during home visits at baseline and 1, 2, and 3 months. … Existing clinical strategies for
monitoring potential drug adverse events rely on frequent psychiatric … Plans for Future Analyses
In future analyses, we will compare chart-documented adverse events against … adverse events
as determined by an examiner blind to the patient’s randomization. … We predict higher agreement
between chart-documented adverse events and examiner-determined adverse
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digital.ahrq.gov/ahrq-funded-projects/preventing-perioperative-medication-errors-and-adverse-drug-events-through-use/citation/development
January 01, 2023 - Project Name
Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of
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digital.ahrq.gov/location/usa-ms-jackson
January 01, 2023 - Description
Implemented and evaluated a voluntary system for reporting medical errors and adverse … drug events in eight small rural hospitals; identified barriers to technology, described the epidemiology
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use
January 01, 2023 - Events
Medication Errors
Medication Reconciliation
Medication Safety
The Centers … medication events, using clinical-decision support (CDS), evaluating new processes for medication reconciliation … The team evaluated the accuracy of adverse drug events (ADE) determination in the ambulatory setting. … drug events involving multiple drugs using publicly available clinical decision support tools. … Preventability of adverse drug events involving multiple drugs using publicly available clinical decision
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/zheng-k-et-al-2009
January 01, 2009 - Design: A homegrown EHR was adapted to allow real-time capture of comprehensive UI interaction events … These events, constituting time-stamped event sequences, were used to replay how the EHR was used in … In either case, quality of care may be undermined and patients may be exposed to a higher risk of adverse … events."
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digital.ahrq.gov/ahrq-funded-projects/improving-pediatric-safety-and-quality-healthcare-information-technology
January 01, 2023 - controlled trials and taking advantage of a set of natural experiments, the applicant assessed changes in adverse … drug events and patient reports of care experience associated with the implementation of a CDSS in a … Specific aims included assessment of: 1) the influence of weight based dosing on pediatric adverse drug … events; 2) the influence of a test result tracking system on appropriate follow-up of ordered tests;
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use/annual-summary/2011
January 01, 2011 - These cross-disciplinary cores currently support projects on soliciting information from patients on adverse … medication events, using clinical decision support (CDS), evaluating new processes for medication reconciliation … telephony to ask outpatients identified from electronic health record (EHR) data if they are experiencing adverse … The team reviewed a large dataset of adverse drug events involving multiple drugs in community hospitals … to build on previous research and develop recommendations to prevent adverse drug events.
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digital.ahrq.gov/ahrq-funded-projects/closing-feedback-loop-improve-diagnostic-quality/annual-summary/2010
January 01, 2010 - includes proactive followup of patients’ response to treatment (including medication adherence and adverse … events) and feedback to health care providers. ( Achieved )
Assess the impact of automating the followup … Impact will be measured in terms of: 1) diagnostic quality; 2) prevention of adverse events; 3) patient
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digital.ahrq.gov/ahrq-funded-projects/scaling-and-spreading-electronic-capture-patient-reported-outcomes-leveraging
January 01, 2024 - Current measures of surgical quality emphasize processes, adverse events, and resource use, which are … a clinical registry that collects patient characteristics, perioperative details, and postoperative adverse … events occurring within 30 days for quality improvement purposes.
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digital.ahrq.gov/sites/default/files/docs/page/2006Levett_051711comp.pdf
June 16, 2021 - Metrics
Reduction in patient complications and readmissions
related to bleeding, thromboembolic events … , and
adverse drug events
Risk profile of patients developing complications
Reduction in deaths … DRG, Physician, Diagnosis,
Procedure, Trending
– Including ICD-9 codes used in risk assessment: Adverse … Clinical risk assessment tool: This tool will characterize and
profile patients at risk for adverse
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digital.ahrq.gov/events/national-web-conference-utilizing-health-it-improve-medication-management-care-elderly
January 01, 2023 - Gurwitz and Field who will summarize their research on the incidence and causes of adverse drug events
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digital.ahrq.gov/health-care-theme/medication-errors
January 01, 2023 - Intelligence-Based Health Information Technology Tools to Optimize Critical Care Pharmacist Resources Through Adverse … prediction tools integrated into visualization dashboards to guide critical care pharmacists in preventing adverse … drug events.
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digital.ahrq.gov/principal-investigator/reiling-john
January 01, 2023 - system community-wide; identified the prevalence of medication errors, near misses, and preventable adverse … drug events; assessed costs and customer satisfaction both before and after implementation.
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017037-ornstein-final-report-2010.pdf
January 01, 2010 - drug events. … drug events (ADE)s. … drug events. … Monitoring/Preventing Potential Adverse Drug Events
• Annual serum creatinine monitoring for ACE-inhibitor … Drug Events
*
*
*
9
practice site visits for QI planning and network meetings for best
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digital.ahrq.gov/ahrq-funded-projects/electronic-communications-across-provider-settings
January 01, 2023 - Acute Care
Ambulatory Care
Behavioral Health
Home Health Care
Health Care Theme
Adverse … Events
Medication Management
Medication Reconciliation
The Electronic Communications
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs015274-carayon-final-report-2009.pdf
January 01, 2009 - We examined whether the prevalence, type or seriousness of medication
errors and adverse drug events … Data on medication errors and adverse drug events (ADEs) were
collected in the Adult and Cardiac ICUs … However, the number of adverse drug events per patient-day significantly increased in
both units. … Ongoing
analysis of those medication errors and adverse drug events and their patient-related harm … Systems
analysis of adverse drug events.
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digital.ahrq.gov/health-care-theme/medication-management
January 01, 2023 - Intelligence-Based Health Information Technology Tools to Optimize Critical Care Pharmacist Resources Through Adverse … prediction tools integrated into visualization dashboards to guide critical care pharmacists in preventing adverse … drug events.
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digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
January 01, 2005 - Design Recommendations,
con’t
• Active Failures
– Operative/Post-Op Complications/Infections
– Events … to Medication Errors
– Deaths of Patients in Restraints
– Inpatient Suicides
– Transfusion Related Events … Shared Values and Beliefs about Safety within the
Organization
• Always Anticipating Precarious Events … •ICU: 43 – 84 dBA
•ER:
–Range: 52 – 96
–Ambulance door
alarm: 76 dBA
Design around
precarious events … :
Adverse drug
events
•Retrospective
chart review using
the *IHI trigger
tool
*Institute for Healthcare