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digital.ahrq.gov/ahrq-funded-projects/systems-engineering-approach-improving-medication-safety-clinician-use-health
January 01, 2023 - Medication Safety with Clinician Use of Health IT Document Type: Logging Tool
Primary Care Visual Error … Reporting Tool Description:
The Primary Care Visual Medication Error Reporting Tool is a tool … Link:
Primary Care Visual Error Reporting Tool
Project Name: A Systems Engineering Approach:
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digital.ahrq.gov/principal-investigator/chalil-madathil-kapil
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/publication/uc1hs015284-reiling-final-report-2008.pdf
January 01, 2008 - As a result, this study will focus on these types of error. … Wrong time accounted for 58% of the errors (6%
error rate) pre and 63% (5.4% error rate) post. … Wrong techniques accounted for
36.6% of the errors (23% error rate) pre and 81.8% (8.3% error rate) … Wrong time errors accounted for 81% (9.2% error rate) pre
and 54% (2.7% error rate) post. … James Reason, Human Error (New York: Cambridge
University Press, 1990).
2.
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digital.ahrq.gov/health-care-theme/medication-safety
January 01, 2023 - broad range of errors that may occur in practice that may be missed by using traditional retrospective error … epidemiology of order errors and to test the effectiveness of proposed system improvements on order error
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digital.ahrq.gov/organization/northwestern-university
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).
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
January 01, 2023 - multiple patient records open at the same time improves provider efficiency but may increase this risk of 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
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digital.ahrq.gov/goal/knowledge-creation
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).
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digital.ahrq.gov/2018-year-review/research-spotlights/leveraging-health-it-test-solutions-are-replicable-scalable-and
January 01, 2018 - 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
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digital.ahrq.gov/funding-mechanism/transforming-healthcare-quality-through-information-technology-thqit-planning
January 01, 2023 - Healthcare Quality Through Information Technology (THQIT) - Planning Grants
Error … Error analysis leading technology development. TIES 2006;7(6):525-49.
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixE_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - (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/sites/default/files/docs/July%20Teleconference%20Transcript.pdf
June 16, 2021 - Well one thing we’ve looked at is
explicit voluntary error reporting. … some way to verify that that’s a reasonable error rate. … New error types that we hadn’t
thought of. … Dispensing 14%, the transcription 11% and administration error is 26%. … The most common error in kids is what’s called a 10-
fold error, where decimal points may be misplaced
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digital.ahrq.gov/track-5-achieving-and-sustaining-improvements
January 01, 2023 - 30pm Renaissance Ballroom West A
Track 5-IV Handoffs in Healthcare
Minimizing opportunity for error … consist of an overview of the knowledge base of EHR safety, a study of perceived workforce stress and error
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digital.ahrq.gov/ahrq-funded-projects/supporting-continuity-care-poisonings-electronic-information-exchange/annual-summary/2010
January 01, 2010 - verbal communication increases the potential for data loss, delayed time to treatment, and medical error … The following thematic elements were identified: workflow integration, communication, medical error, … outcomes including effects on communication, information availability for decisionmaking, and medical error
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digital.ahrq.gov/ahrq-funded-projects/promoting-patient-safety-web-based-patient-profiles
January 01, 2023 - Method: Case Study , Qualitative Technology: Health Information Exchange Population: Elderly
Error … Error analysis leading technology development. TIES 2006;7(6):525-49.
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digital.ahrq.gov/track-9-emerging-approaches-drive-change-healthcare
January 01, 2023 - These scenarios show examples of what can happen when IT solutions designed to reduce error can actually … become the cause of error.
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_5_ADE_and_Near_Miss_Incident_Classification_Form.pdf
June 16, 2021 - 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/sites/default/files/docs/workflowtoolkit/Post-UsabilityEvaluationQuestionnaire.pdf
December 18, 2021 - 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/organization/tufts-medical-center
January 01, 2023 - Tufts Medical Center
EMS Based TIPI-IS Cardiac Care QI-Error Reduction
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digital.ahrq.gov/sites/default/files/docs/reducing-provider-burden-slides-012518.pdf
January 25, 2018 - Built-in redundancy/error recovery
6. Structure-rounds-shift change
7. Organizational culture
8. … Built-in redundancy/error recovery
6. Structure-rounds-shift change
7. Organizational culture
8. … Built-in redundancy/error r covery
6. Structure-rounds-shift change
7. Organizational culture
8. … Built-in redundancy/error r ecovery
6. Structure-rounds-shift change
7. … Built-in redundancy/error r ecovery
6. Structure-rounds-shift change
7.
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digital.ahrq.gov/document-type/book-publication
January 01, 2023 - Interaction Design Approaches to Health IT Safety
Towards a usability and error … Towards a usability and error "Safety net": A multi-phased multi-method approach to ensuring system usability