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digital.ahrq.gov/sites/default/files/docs/improving-hit-safety-qa-020717.pdf
February 07, 2017 - opinion, how soon will patients have access to their progress notes for informed choice
making and error … QUESTION:
How can we avoid proliferating multi-varied error checking, as we have many EHRs?
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015002-ferris-final-report-2008.pdf
January 01, 2008 - In 1987, Folli et al. studied two academic pediatric hospitals demonstrating a
medication error rate … Kaushal’s ongoing pediatric medication error study to perform
a controlled trial that determined the … Medication
error prevention by clinical pharmacists in two
children's hospitals. Pediatrics.
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digital.ahrq.gov/sites/default/files/docs/page/08-0085_bcma.pdf
August 01, 2008 - If these challenges are not addressed, new
opportunities for error in the medication administration process
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kuperman-gj-et-al-2003
January 01, 2003 - Although CPOE has the potential to reduce many sources of error, organizations must take care as CPOE
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/lobach-df-et-al-1997
January 01, 1997 - Lobach DF et al. 1997 "Computerized decision support based on a clinical practice guideline improves compliance with care standards."
Reference
Lobach DF, Hammond WE. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med 1997;102(1):89-9…
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digital.ahrq.gov/sites/default/files/docs/page/health-information-technology-evaluation-toolkit-2009-update.pdf
January 01, 2009 - Compare error rates
pre- and post-
implementation with
chi-squared test: graph
error rate. … Compare
error rates
pre- and post-
implementatio
n (assumed to
be zero) with
chi-squared
test. … T-test comparing means
of the time-motion data
before and after
Graph error rates. … Compare error rates pre-
implementation and post-
implementation with chi-
squared test. … Rate 5% 3%
Would you feel confident concluding that the error rate actually fell?
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digital.ahrq.gov/2018-year-review/research-spotlights
January 01, 2018 - Research Spotlights
AHRQ Health IT Safety Investigators are Using Health IT to Make a Real Difference in Improving Patient Safety
Research on Health IT Safety Special Emphasis Notice ( NOT-HS-16-009 ):
AHRQ continues to fund research on safe health IT practices related to the design,…
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digital.ahrq.gov/ahrq-funded-projects/safety-through-enhanced-e-prescribing-tools-stepstools-developing-web-services
January 01, 2023 - a series of pediatric prescribing use-cases, site visits to pilot users, and an examination of the error
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2010
January 01, 2010 - This significant source of error can cause injury or even fatalities and can occur in all types of health
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs024750-sherwin-final-report-2019.pdf
January 01, 2019 - Errors
were codified based on likely source:
Coding error – ICD codes not consistent with charted … As in previous phases, error checking was performed to identify route causes. … We considered manually
adjusting the temperature threshold in response to the error review but elected … This error, prior to correction, was accounting for 32%
of all false positives. … Once the specific error was discovered, the programmers were able to determine the issue
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs022087-singh-final-report-2018.pdf
January 01, 2018 - We expanded a previously developed EHR-related error taxonomy to
categorize types of EHR-related safety … The
most common error was “EHR technology working incorrectly” (41.6%), followed by issues with
the … Analysis of diagnostic error in
paid malpractice claims with substandard care in a large healthcare … Diagnostic Error in
Medicine: Analysis of 583 Physician-Reported Errors.
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digital.ahrq.gov/ahrq-funded-projects/decision-making-and-clinical-work-test-result-followup-health-information
January 01, 2023 - Clinical Staff/Clinician
Payment innovations to improve diagnostic accuracy and reduce diagnostic error … Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
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digital.ahrq.gov/program-overview/research-stories/improving-safety-postoperative-handoff-communication-telemedicine
January 01, 2023 - Improving Safety in Postoperative Handoff Communication with Telemedicine and Machine Learning
Theme:
Optimizing Care Delivery for Clinicians
Subtheme:
Using Digital Healthcare Tools to Improve Patient Safety
Implementing a postoperative handoff intervention augmented with telemedicine an…
-
digital.ahrq.gov/sites/default/files/docs/page/08-0093_cpoe.pdf
August 01, 2008 - Layout 1
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov Health IT
AHRQ's Health IT Portfolio. AHRQ’s health information technology (health IT) initiative is
part of the Nation’s strategy to put information technology to work in health care. By developing
secure and privat…
-
digital.ahrq.gov/health-information-exchange-1
January 01, 2023 - Health Information Exchange
1. State Medicaid Director Letter: Health Information Exchange-Electronic Health Record (EHR) Incentive Programs ( PDF , 221 KB)
Author(s): Center for Medicaid, CHIP and Survey & Certification, Center for Medicare & Medicaid Services Source: US Department of…
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021472-cummins-final-report-2019.pdf
January 01, 2019 - Health information exchange
supported collaboration could reduce error, improve decision-making, and … Verbal information exchange between PCCs and EDs can lead to miscommunication, data loss, and error. … This approach leaves ample opportunity for miscommunication, inadequate communication,
and error. … These circumstances complicate workflow and create additional opportunities for
error.(10)
4 … Context
Health information exchange supported collaboration could reduce error
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digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-slides-081811.pdf
August 18, 2011 - , life-threatening
& serious events
Preventable
61%
Of less serious events
Preventable
34%
Error … Preventable vs Non-Preventable
Adverse Drug Events by Severity
Preventability of Adverse Drug Events
Error
-
digital.ahrq.gov/ahrq-funded-projects/tulare-district-hospital-rural-health-electronic-medical-record-consortium/annual-summary/2008
January 01, 2008 - Successfully deploy a fully integrated EMR system using proven health IT practices to reduce medical error
-
digital.ahrq.gov/2020-year-review/research-summary/designing-intelligent-systems-support-cognitive-work-clinical
January 01, 2020 - $2,491,816
Emergency departments are complex environments with a high potential for error
-
digital.ahrq.gov/ahrq-funded-projects/decreasing-ades-montana-frontier-critical-access-hospitals-through-hit
January 01, 2023 - Decreasing ADEs in Montana Frontier Critical Access Hospitals through HIT
Project Description
Project Details -
Completed
Grant Number
P20 HS014995
Funding Mechanism(s)
Transforming Healthcare Quality Through Information Technology (THQ…