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digital.ahrq.gov/ahrq-funded-projects/electronic-records-improve-care-children/citation/dropping-baton-during-handoff
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;…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs022911-chaudhry-final-report-2017.pdf
January 01, 2017 - -10-
1.2 Error analysis
We performed a detailed analysis of the errors we encountered … Error Analysis and Categorization
Error type Specific Error No. of
errors
Ability to
address … With incremental development and error resolution we achieved 100%
accuracy. … Validation of the CDSS in the clinical setting
1.2 Error analysis
Table 3. … Error Analysis and Categorization
2.
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018151-smith-final-report-2013.pdf
January 01, 2013 - Key Words: medical error; hospitalization; medication reconciliation
The authors of this report … <0.001
None 1,836 (53) 1,650 (58)
Medically indicated variance 1,009 (29) 814 (29)
Medication error … 645 (18) 359 (13)
Clinically important medication error 9 (1.4) 11 (3.1) 0.10
30-day Follow-up … Interestingly, our clinically important medication error rates were much lower than typically
reported … Low and unchanged medication error rates suggest that patient outcomes would be no
different with or
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digital.ahrq.gov/sites/default/files/docs/activity/r18hs018151-smith-annual-summary-2012.pdf
January 01, 2012 - information
transfer processes, this stratification of care can lead to information loss and medical error
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digital.ahrq.gov/2018-year-review/research-spotlights/improving-ehr-design-increases-patient-safety-especially-children
January 01, 2018 - Improving EHR Design Increases Patient Safety—Especially for Children
Poor EHR design can harm patients.
Dr. Raj Ratwani and his research team identified pervasive problems with EHR systems that regularly lead to patient safety errors and other issues, regardless of vendor. “If we don’t focus on EHR technolog…
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digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing
January 01, 2023 - The team hypothesized that the new system would significantly improve ordering speed, error rate, and
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digital.ahrq.gov/program-overview/impact-stories/supporting-clinicians
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
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digital.ahrq.gov/ahrq-funded-projects/improving-patient-safety-and-clinician-cognitive-support-through-emar-redesign
April 30, 2024 - , Physician
A text mining approach to categorize patient safety event reports by medication error … A text mining approach to categorize patient safety event reports by medication error type.
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digital.ahrq.gov/sites/default/files/docs/implementation/Bellamy.ppt
April 01, 2005 - Feedback and Communication About Error
1. … Nonpunitive Response to Error
R1. Staff feel like their mistakes are held
against them. … improvement
Teamwork Within Hospital Units
Communication Openness
Feedback and Communication
About Error … Nonpunitive Response To Error
Staffing
Hospital Management Support for
Patient Safety
Teamwork Across
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience-research/steele-aw-et
January 01, 2023 - Steele AW et al. 2005 "The effect of automated alerts on provider ordering behavior in an outpatient setting."
Reference
Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med 2005;2(9):864-870.
[Link]
Abstract
"B…
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digital.ahrq.gov/sites/default/files/docs/activity/health_information_technology_and_improving_medication_use_2010pdf_2.pdf
August 01, 2011 - Project 3: Preliminary results have characterized the types of errors, error rates across different e-prescribing … systems, differences in errors between systems, and range in error rates in areas such as inappropriate
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digital.ahrq.gov/ahrq-funded-projects/medication-management-closed-computerized-loop
January 01, 2023 - Medication Management: A Closed Computerized Loop
Project Description
Other Resources
Project Details -
Completed
Grant Number
UC1 HS015231
Funding Mechanism(s)
Transforming Healthcare Quality Through Information Technology (THQIT…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/lesselroth-bj-felder-rs
January 01, 2023 - medications and most providers believed that associated activities were
unpredictable, redundant, and error-prone
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digital.ahrq.gov/ahrq-funded-projects/statewide-implementation-electronic-health-records
January 01, 2023 - the effectiveness of EHR implementation strategies, correlates of EHR adoption, impact on medication error … Statewide Implementation of Electronic Health Records Document Type: Data Collection Form
Medication Error … Link:
Medication Error and Near Miss Classification Form
Project Name: Statewide Implementation
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use
January 01, 2023 - safety threats early after transitioning to a new e-Prescribing system, and leads to sustained low error … Record , Electronic Prescribing , Health Information Exchange , Voice Recognition
Medical error … Medical error: a 60-year-old man with delayed care for a renal mass.
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digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/will-electronic-order-entry
April 01, 2002 - averted
75%
reduction
6613
33,064
Net
savings, $
0.3
hr/error
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digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/effect-bar-code-technology
January 01, 2005 - Effect of bar-code technology on the incidence of medication dispensing errors and potential adverse drug events in a hospital pharmacy
Authors: Poon, E. G., Cina, J. L., Churchill, W. W., Mitton, P., McCrea, M. L., Featherstone, E., Keohane, C. A., Rothschild, J. M., Bates, D. W., Gandhi, T. K. Journal: AM…
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digital.ahrq.gov/sites/default/files/docs/activity/2011_016970_bates_pdf_3.pdf
January 01, 2011 - 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/citation/r01hs024713-adelman-final-report-2023.pdf
January 01, 2023 - Since all patients are at risk for an order error, all patients for whom at least 1 order was placed … the
order session, rather than each order, represents an independent opportunity for a wrong-patient error … For all analyses, the effect was estimated
using odds ratio (OR), standard error (SE), and Wald test … The impact of
computerized physician order entry on medication error prevention.
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digital.ahrq.gov/sites/default/files/docs/publication/Parisetal_HFES2008.pdf
January 01, 2008 - research
team reviewed all medication safety events to adjudicate the
occurrence of a medication error … Pharmacist clarification of
an ordering error and pharmacist consults on the dose to be
administered