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digital.ahrq.gov/health-care-theme/human-factors
January 01, 2023 - broad range of errors that may occur in practice that may be missed by using traditional retrospective error
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digital.ahrq.gov/sites/default/files/docs/activity/evaluating_the_impact_of_2009_update_2.pdf
January 01, 2009 - Medication Errors
Results of the medication error
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/effect
January 01, 2023 - Project Name
Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care
January 01, 2023 - This significant source of error can cause injury and fatality, and occurs in all health care settings
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use/annual-summary/2012
January 01, 2012 - Project 5 : This project found no difference in prescription error rates 3 months after implementation … Relatively low error rates were found, both during implementation and during sustained use among practices
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digital.ahrq.gov/sites/default/files/docs/publication/p20hs015325-hartzema-final-report-2005.pdf
January 01, 2005 - type is rare in CAH and multiple use of opioids may in many instances correctly flag a medication
error … ;
administration; education; monitoring; and use."1
National Coordinating Council for Medication Error … Also, frequency for each error
type will vary. … Each of these steps introduces possibility of error due to illegibility and delays the time a first dose … This indicator could further
be broken down into the type of error.
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digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/medication-errors-prospective
October 05, 2005 - Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit
Authors: Shulman, R., Singer, M., Goldstone, J., Bellingan, G. Journal: Crit Care Publication Date: 2005 Oct 5 Volume: 9 Issue: 5 Pages: R516-21 HIT Description: computerize…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/Post-UsabilityEvaluationQuestionnaire.pdf
November 08, 2010 - Error messages Unhelpful 0 1 2 3 4 5 6 7 8 9 Helpful
11. … Exploring new features by trial and Difficult 0 1 2 3 4 5 6 7 8 9 Easy
error
12.
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_5_ADE_and_Near_Miss_Incident_Classification_Form.pdf
September 30, 2009 - Medication Error
4. Exclusion
5. Confidence regarding above judgement? ____ 1. … Error intercepted
(choose only one) 2. Definitely preventable
3.
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digital.ahrq.gov/ahrq-funded-projects/finding-safer-way-novel-interaction-design-approaches-health-it-safety
January 01, 2023 - These factors combine to increase the likelihood of clinician error, which in turn can harm patients. … Health Record/Electronic Medical Record Population: Nurse , Physician
Towards a usability and error … Towards a usability and error "Safety net": A multi-phased multi-method approach to ensuring system usability … These combined factors increase the likelihood of clinician error, which in turn can harm patients.
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digital.ahrq.gov/medical-condition/stroke
January 01, 2023 - Telemedicine-Integrated Ambulance-Based Environments for Stroke Care
Task, usability, and error … McElligott (2021) Task, usability, and error analyses of ambulance-based telemedicine for stroke care
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixE_HIT_Hazard_Manager_Beta_Test.pdf
May 23, 2013 - (1)
• Faulty vendor implementation/configuration (2)
• Faulty design (7)
2
• Unforced user error … • Faulty reference information (4)
• Miscalculation of a result (3)
• Data Quality Other: keying error … , Miscalculation due to human error in setup of
calculation
• Faulty recommendation (2)
• CDS Other … erroneous, faulty logic
• Faulty design (1)
• Software Design Other entries: client configuration error … (1)
• Implementation Other entries: Lack of adequate usability testing (1)
5
• Unforced user error
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digital.ahrq.gov/ahrq-funded-projects/virtual-continuity-and-its-impact-complex-hospitalized-patients-care
January 01, 2023 - Virtual Continuity and its Impact on Complex Hospitalized Patients' Care
Project Final Report ( PDF , 159.53 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent…
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digital.ahrq.gov/sites/default/files/docs/SocioTechnical_Resources.pdf
March 28, 2007 - A review of medical error reporting system design
considerations and a proposed cross-level system research … Toward and
theoretical approach to medical error reporting system research and design. … Multiple user considerations
and their implications in medical error reporting system design.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023793-gold-final-report-2021.pdf
January 01, 2021 - Finally we determined whether the source of the
error was in the creation of the tool itself (for example … from the presentation were not
documented or incorrectly represented on the tool), or whether the error
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancer/citation/diagnostic-errors
January 01, 2023 - Diagnostic errors: moving beyond 'no respect' and getting ready for prime time.
Citation
Singh H. Diagnostic errors: moving beyond 'no respect' and getting ready for prime time. BMJ Qual Saf 2013 Oct;22(10):789-92.
Link
http://www.ncbi.nlm.nih.gov/pubmed/24048615
Principal Investigator
…
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digital.ahrq.gov/ahrq-funded-projects/parentlink-better-and-safer-emergency-care-children/citation/impact-patient-0
January 01, 2023 - Impact of a patient-centered technology on medication errors during pediatric emergency care.
Citation
Porter SC, Kaushal R, Forbes PW, et al. Impact of a patient-centered technology on medication errors during pediatric emergency care. Ambul Pediatr 2008 Sep-Oct;8(5):329-35.
Link
http://www.n…
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digital.ahrq.gov/ahrq-funded-projects/nlp-improve-accuracy-and-quality-dictated-medical-documents/citation/incidence
January 01, 2023 - Incidence of speech recognition errors in the emergency department.
Citation
Goss FR, Zhou L, Weiner SG. Incidence of speech recognition errors in the emergency department. Int J Med Inform 2016 Sep;93:70-3. PMID: 27435949.
Link
https://www.ncbi.nlm.nih.gov/pubmed/27435949
Principal Inv…
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digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/citation/automated-detection-look
January 01, 2023 - Automated detection of look-alike/sound-alike medication errors.
Citation
Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication errors. Am J Health Syst Pharm 2017 Apr 1;74(7):521-527. PMID: 28336762.
Link
https://www.ncbi.nlm.nih.gov/pubmed/2833…
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digital.ahrq.gov/ahrq-funded-projects/improving-guideline-development-and-implementation/citation/dropping-baton
January 01, 2023 - Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.
Citation
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors. Jt Comm J Qual Patient Saf. 2009 Sep…