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21. EMS Based TIPI-IS Cardiac Care QI-Error Reduction System | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/ems-based-tipi-cardiac-care-qi-error-reduction-system
    January 01, 2023 - EMS Based TIPI-IS Cardiac Care QI-Error Reduction System Project Final Report ( PDF … developed, implemented, and measured the impact of an emergency cardiac care quality improvement (QI) and error … The impact of a prehospital/hospital quality improvement and error reduction system was demonstrated … EMS Based TIPI-IS Cardiac Care QI/Error Reduction System - Final Report. … Principal Investigator: Selker, Harry Project Name: EMS Based TIPI-IS Cardiac Care QI-Error Reduction

22. Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
    January 01, 2019 - This methodology included data driven error pattern detection, point of error video capture and retrieval … Cases were assigned as an unlikely error, a possible error, and a highly likely error. … A generous cut-off is four hours, if > four hours, it is an unlikely error Point of Error 1. … Interruption Error? … DATA DRIVEN ERROR PATTERN DETECTION 2. POINT OF ERROR VIDEO CAPTURE AND RETRIEVAL 3.

23. Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve Outcomes in Ambulatory Care | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual
    January 01, 2023 - Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve … the dosage of a patient’s medication to manage deterioration of a chronic condition is a contextual error … Saul Project Name: Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … Saul Project Name: Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve

24. Using Aviation Technology to Prevent Healthcare Errors: The Health IT Black Box | Digital Healthcare Research
    digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
    January 01, 2019 - Similar to the airline industry’s use of a “black box” that captures actions leading up to a near miss or error … of a sudden they're in what we call automaticity mode, they're going to be more likely to make that error … Seeing the EHR through the eyes of the clinician, at the exact moment that an error occurs, is a powerful … The value of this tool is amplified when the same error is demonstrated across institutions, providers … EHRs have frequently been identified as sources of error and frustration.

25. Develop and Validate Health IT Safety Measures To Capture Violations of the Five Rights of Medication Safety | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/develop-and-validate-health-it-safety-measures-capture-violations-five-rights
    January 01, 2023 - clinicians realize they have ordered the wrong dose or frequency for a drug, are caught before the error … the epidemiology of order errors and to test the effectiveness of proposed EHR improvements on order error … mistakes does not correct or prevent errors, it provides the facility with information to discover error … Yet, human error is very common in the healthcare environment. … The research team will conduct a randomized controlled trial of wrong-patient error rates between systems

26. Murphy Diagram | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
    January 01, 2023 - DEFINE ERROR EVENTS. Begin by defining the first error as clearly as possible. 4. … CLASSIFY ERROR ACTIVITY INTO DECISIONMAKING CATEGORY. … DETERMINE ERROR CONSEQUENCE AND CAUSES. … of the error are. 6. … Advantages Allows multiple potential causes for an error to be identified.

27. An Etiology for Medication Ordering Errors in CPOE Systems - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r21hs025443-abraham-final-report-2020.pdf
    January 01, 2020 - Additionally, clinicians can also report on the type of medication ordering error (including duplicate … to the errors, and error- mitigation strategies to prevent the ordering error under inquiry. … , (b) identify the true type of ordering error (referred to as “chart review-based” type of ordering … error); (c) verify whether the clinician-CPOE-selected or clinician-reported type of ordering error … ordering error had an impact on patient safety.

28. Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error, Improve Outcomes, and Reduce Misuse, Overuse, and Underuse of Outpatient Primary Care - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r01hs025374-weiner-final-report-2022.pdf
    January 01, 2022 - Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error, Improve Outcomes … Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … In other words, about 14% (0.41 x 35%) of overall care was derailed by a contextual error. … In designing the innovation, we asked “how might CDS be deployed to reduced contextual error?” … Contextual Error. In: Kattan M, ed.

29. Detecting Med Errors in Rural Hospitals Using Technology - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015400-brown-final-report-2008.pdf
    January 01, 2008 - From this date forward, we began collecting medication error reports from all eight rural hospitals. … At this time, we began collecting medication error reports from all eight rural hospitals. … A total of 805 error reports were made during this time period. … Count of where in process the reported medication error occurred Figure 2b. … C ount o f st aff who d is covered the rep orted medication error Figure 9a.

30. AmbulDATAFORM 4 ADE Incident Identification Formatory Pedi Med Study (pdf file)
    digital.ahrq.gov/sites/default/files/docs/resource/Dataform_4_ADE_Incident_Identification_Form.pdf
    June 16, 2021 - Dose error If yes: ____ 2.01 Overdose ____ 2.02 Underdose ____ 2.03 Dose omitted (from order … Refill Error ____ 16. Failure to recognize drug-drug interaction ____ 17. … Any work resulting from Medication Error? ____ 1. … At what level did this error occur? ____ 1. … Was the error intercepted?

31. Weiner, Saul | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/weiner-saul
    January 01, 2023 - Project Name Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve … Project Name Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error … Project Name Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error

32. Context is Critical: Understanding When and Why Electronic Health Record-Related Safety Hazards Happen | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/context-critical-understanding-when-and-why-electronic-health-record-related
    January 01, 2023 - Analyze the context of the error through video review and systematically categorize the observed errors … Five error types were explored: wrong-route errors, wrong-weight errors, wrong-sided errors, free-text … EHRs have frequently been identified as sources of error and frustration. … Blackbox: A Multidisciplinary Team-Based Framework for HIT Error Pattern Detection - Final Report. … EHRs have frequently been identified as sources of error and frustration.

33. Selker, Harry | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/selker-harry
    January 01, 2023 - Principal Investigator Selker, Harry Project Name EMS Based TIPI-IS Cardiac Care QI-Error … Reduction System EMS Based TIPI-IS Cardiac Care QI/Error Reduction System - … EMS Based TIPI-IS Cardiac Care QI/Error Reduction System - Final Report. … Principal Investigator Selker, Harry Project Name EMS Based TIPI-IS Cardiac Care QI-Error … Reduction System EMS Based TIPI-IS Cardiac Care QI-Error Reduction System

34. NLP to Improve Accuracy and Quality of Dictated Medical Documents - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024264-zhou-final-report-2019.pdf
    January 01, 2019 - We determined the error rate (i.e., the number of errors per 100 words), the median error rate with … , error types, and the observed prevalence of errors compared to participants’ perceptions about error … error analysis. … error. … contain an error.

35. Using Electronic Records to Detect and Learn from Ambulatory Diagnostic Errors (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r18hs017244-thomas-final-report-2010.pdf
    January 01, 2010 - Prevalence of diagnostic error was estimated to be 2.8%. … error to be 2.8% of primary care records in our study population. … Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. … Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493- 1499. 28. … Minimizing Diagnostic Error: The Importance of Follow-up and Feedback.

36. Detecting Med (Medication) Errors in Rural Hospitals Using Technology - 2008 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/detecting-med-medication-errors-rural-hospitals-using-technology/annual-summary/2008
    January 01, 2008 - University of Mississippi Medical Center was awarded this grant to set up a rural hospital medication error … year 1, an analysis focusing on technology capacity, physical space, personnel, and current medical error … CME) credits focusing on the importance of reporting medication errors and use of a Web-based medical error … Specific Aims Introduce voluntary, anonymous, electronic medical error and adverse drug event (ADE … Initially, the Internet was planned to be the sole means through which the medication error reporting

37. Develop and Validate Health IT Safety Measures to Capture Violations of the 5 Rights of Medication Safety – Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024538-adelman-final-report-2022.pdf
    January 01, 2022 - The element changed between the two orders indicates the type of error. … We found substantial variation based on error type. … Who Caught the Error? … The PPV for detecting each type of order error reached the target of >75%. … What is a medication error? October 10, 2022. 31. Grober ED, Bohnen JM. Defining medical error.

38. A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation - Slides (pdf file)
    digital.ahrq.gov/sites/default/files/docs/improving-hit-safety-slides-020717.pdf
    February 07, 2017 - • 76% of radiologists believed error rate by report < 10% Author Doc Type Sample Size Error Rate … ► Confusion sets ► Error frequencies ► Error patterns • Develop automated methods to detect … General Error Types. . Figure Semantic Error Types. . 55 Preliminary Results Results. . … Overall Error Rates and General Types. . Error Rates across ..All Note Types and Stages. . … Error Examples. . Discussion: Productivity and .Quality. Discussion: Error Checking.

39. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r03hs018841-basco-final-report-2013.pdf
    January 01, 2013 - For 34% of the LASA pairs, no patient received a substitution error. … The first error is that the patient does not receive the intended drug, and the second error is that … They were asked to assume only a one-month error, meaning that the substitution error would not recur … Round 3 therefore contained 608 potential LASA error pairs. … of the maximum possible error frequency.

40. Track 6: Using Reporting Systems for Safety and Quality Improvement | Digital Healthcare Research
    digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
    January 01, 2023 - Improving the Accuracy and Utility of Reporting Systems This session will describe efforts to optimize error … Track Changes Over Time This session focuses on the use of reporting systems to identify and monitor error … Applications of Reporting Systems This session will highlight novel approaches to the implementation of error … that connects information in the pre-hospital setting with ED and hospital information, the Medical Error … Prevention and Reporting System (MEPARS), and an innovative error reporting and review process for nurses