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41. Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-substitution-errors
    January 01, 2023 - received both drugs in a LASA pair within a 6-month period, representing a potential LASA substitution error … For 34 percent of the pairs, no patient received a substitution error. … , the cumulative total of subjects who received both drugs amounted to less than one potential LASA error … This project advanced LASA error prevention in pediatric care by developing a prioritized list of LASA

42. Errors in Paramedic Endotracheal Intubation (pdf file)
    digital.ahrq.gov/sites/default/files/docs/page/2006Wang_051611comp.pdf
    January 01, 2006 - Form University of Pittsburgh School of Medicine - Department of Emergency Medicine Overall ETI Error … 5% 10% 15% 20% 25% 30% 35% Tube Misplacement or Dislodgement ≥4 Attempts ETI Failure Any ETI Error … Pe rc en ta ge o f T ot al E TI 1 in 4.5 Exposed to an ETI Error University of Pittsburgh … School of Medicine - Department of Emergency Medicine Per-Service ETI Error Rates 0% 10% 20% 30% … a (very) complex and difficult skill.  Not proven to have clinical benefit.  Prone to significant error

43. A Three-pronged Approach to Monitoring the Effect of an EMR Implementation on Medication-related Events in a Pediatric Hospital (pdf file)
    digital.ahrq.gov/sites/default/files/docs/page/2006Dye_051111comp.pdf
    June 05, 2006 -  Trigger-based chart reviews • Trigger tool developed based on IHI methodology 7 Medication Error … Do not readily self-advocate and ask questions 10 Self Report System - Results 11 Medication Error … to administer oral meds  Many forms/doses/quantities  Adding doses to food/feeds 13 Medication Error … Assessment Plan Medication Error Assessment Plan (cont'd.) … Observation Medication Error Assessment Plan Trigger Tool Chart Reviews Medication Error Assessment

44. Human Factors Considerations in the Design and Implementation of Telemedicine Integrated Ambulance-Based Environments for Stroke Care - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r03hs026809-madathil-final-report-2022.pdf
    January 01, 2022 - The consequences and probability of making an error along with the criticality of the error were identified … The items from the SHERPA technique (error type, error mode, consequence, recovery, probability, criticality … messages or a lack of specificity in the error messages. … Error messages. … of the error and suggestions for how to fix it.

45. AHRQ's Guide to Evaluating Health Information Exchange Projects - Appendix D (pdf file)
    digital.ahrq.gov/sites/default/files/docs/page/guide-to-evaluating-hie-projects-appendix-d.pdf
    June 16, 2021 - observe the following: Before After Number of Errors in 100 Sampled Prescriptions 27 3 Observed Error … observe the following data… Before After Number of Errors in 100 Sampled Prescriptions 5 3 Observed Error … might observe: Before After Number of Errors in 100,000 Sampled Prescriptions 4,932 2,592 Observed Error … Even if, by chance, the observed data are a few errors off from the “true” error rate, the overall rate … would still not change in a significant way, and you still would conclude that the prescribing error

46. NLP to Improve Accuracy and Quality of Dictated Medical Documents | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/nlp-improve-accuracy-and-quality-dictated-medical-documents
    January 01, 2023 - Conduct error analysis to estimate the prevalence and severity of SR errors.  … An annotation schema was developed that included 12 general error types such as insertion or deletion … In evaluating SR notes, an error rate of 7.4 percent was observed in pre-edited notes; this dropped to … Errors noted under the schema found that deletions were the most prevalent general error type, English … Several error-detection models were developed utilizing NLP and tested for accuracy using F1 scores.

47. Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2011 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2011
    January 01, 2011 - The error rates of these 200 medication pairs will then be estimated by reviewing patient medication … After estimation of the error rate, the positive predictive value will be identified for the screening … To measure the error rates of the final list of medication pairs, the research team will review patient … intended drug (e.g. amiodarone and amantadine), high risk of harm for receiving the second drug in error

48. Health IT Hazard Manager Beta-Test Appendix D: Relational Analysis Results (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/AppendixD_HIT_Hazard_Manager_Beta_Test.pdf
    June 16, 2021 - Feedback to the User (28) Incorrect Patient Information (20) For those Hazards caused by “User Error … ”, what causes, in addition to “User Error”, were selected? … Unforced User Error was selected in 16% (n=79) of all hazards. … For 55 hazards with Unforced User Error, at least one other causation category was also selected: … Factors Unforced User Error 4.4% (n=22) 1.8% (n=9) 2.4% (n=12) 1.8% (n=9) 1% (n=5)

49. Preventing Wrong-Drug and Wrong-Patient Errors with Indication Alerts in CPOE Systems – Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r01hs024945-lambert-final-report-2022.pdf
    January 01, 2022 - wrong-patient computerized provider order entry (CPOE) errors and (b) on the rate of each type of error … Intercepted Wrong-patient (WP) Error Rate. … For a WP-RAR event to be confirmed as an error, the following criteria must be met: 1. … Intercepted Wrong-Drug (WD) Error Rate. … Furthermore, the error may have affected the validity of some of our statistical assumptions.

50. Tools for Optimizing Medication Safety (TOP-MEDS) - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/u19hs021093-lambert-final-report-2017.pdf
    January 01, 2017 - Results Laboratory test error rates (and other metrics) significantly predicted real-world error rates … The results indicated that error rates on the tasks were positively correlated with real-world error … error rates (adjusted R2 = .12 and R2 = .18). … With the error rate (the complement of the error rate will be called as the accuracy rate) of a new … Pseudo-code for error detection algorithm.

51. Detecting Med (Medication) Errors in Rural Hospitals Using Technology | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/detecting-med-medication-errors-rural-hospitals-using-technology
    January 01, 2023 - The goals of the program were to: (1) introduce voluntary, anonymous, electronic medical error and ADE … Vulnerable Population The impact of a Web-based reporting system on the collection of medication error … The impact of a Web-based reporting system on the collection of medication error occurrence data.

52. Laird, Rosemary | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/laird-rosemary
    January 01, 2023 - Laird, Rosemary Error analysis leading technology development. … Error analysis leading technology development. TIES 2006;7(6):525-49.

53. Logging Tool | Digital Healthcare Research
    digital.ahrq.gov/document-type/logging-tool
    January 01, 2023 - Medication Management for Low Literate Elderly Patients Primary Care Visual Error … Reporting Tool Description The Primary Care Visual Medication Error Reporting Tool is

54. Development and evaluation of patient-reported outcome score visualization to improve their utilization (PROVIZ) - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r21hs027228-gold-final-report-2021.pdf
    January 01, 2021 - The new visualization resulted in longer response times or higher error rates when participants were … y-axis directions corresponding to semantic language resulted in quicker response times and lower error … We collected the response times and error rates of the 3 charts with the highest performance from our … Thus, our overall hypothesis was that smiley-timelines would result in the lowest error rate and the … We analyzed both the response time and error rate of each of the 5 graphs by plotting the difference

55. Human Factors Considerations in the Design and Implementation of Telemedicine-Integrated Ambulance-Based Environments for Stroke Care | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/human-factors-considerations-design-and-implementation-telemedicine-integrated
    January 01, 2023 - A qualitative analysis determined the sources of disruption and a systematic human error reduction and … prediction approach (SHERPA) to determine the possibility of human error while providing care using … The evaluation identified issues with the systems design regarding the information architecture, error … Technology: Telehealth/Telemedicine Population: Nurse , Paramedic , Physician Task, usability, and error … McElligott (2021) Task, usability, and error analyses of ambulance-based telemedicine for stroke care

56. Paramedic | Digital Healthcare Research
    digital.ahrq.gov/population/paramedic
    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 … Investigator(s) Chalil Madathil, Kapil EMS Based TIPI-IS Cardiac Care QI-Error

57. USA, IL, Evanston | Digital Healthcare Research
    digital.ahrq.gov/location/usa-il-evanston
    January 01, 2023 - significant increase in problem placement rates, a modest increase in order abandonment (when a wrong patient error … was detected), and a slight increase in order retractions (when a wrong drug error was detected).

58. Health IT Hazard Manager Beta-Test Appendix B: Revised Hazard Manager Ontology (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/AppendixB_HIT_Hazard_Manager_Beta_Test.pdf
    June 16, 2021 - hardware location, lighting, engineering) • Inadequately secured data • Hardware Failure • Use error … Security, virus or other malware • Incompatibility between devices • Equipment/Device function ○ Error … in charting, communication or display ○ Loss of clinical data ○ Medication error—software related

59. Supporting Continuity of Care for Poisonings with Electronic Information Exchange - 2011 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/supporting-continuity-care-poisonings-electronic-information-exchange/annual-summary/2011
    January 01, 2011 - verbal communication increases the potential for data loss, delayed time to treatment, and medical error … outcomes including effects on communication, information availability for decisionmaking, and medical error

60. ParentLink: Better and Safer Emergency Care for Children (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r01hs014947-porter-final-report-2007.pdf
    January 01, 2007 - Outcome: Medication Error The primary outcome was the number of medication errors per 100 patients … Definitions of Error. … Consistent with Institute of Medicine definitions, a medication error was defined as an error in drug … by error type. … the initiation of an incorrect action (error of commission).