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21. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - Extensions (NCEs) Contracts Grantee Profile Preventing Medication Errors … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Medication errors that occur outside the hospital can be lethal for children with chronic conditions, … Children with cancer are at particularly high risk for errors due to weight-based dosing calculations … With a continued focus on reducing medication errors in children with chronic conditions, Dr.

22. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Patient Safety Terminology Medical errors*: Medical errors happen when something that was … Most errors result from problems created by today's complex health care system, but errors also happen … If anything, errors related to LEP are bundled as being caused by "communication errors," which does … We identified three common causes of errors (or potential errors) for LEP and culturally diverse patients … Medical Errors Patient is Ethiopian speaking.

23. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
    June 01, 2020 - resulting in substantial preventable morbidity and mortality and excess healthcare costs. 1 Diagnostic errors … organizations (HCOs) to “monitor the diagnostic process and identify, learn from, and reduce diagnostic errors … endorses hundreds of measures), 4,5 none is being used routinely to assess and address diagnostic errors … detect patient safety concerns cannot always specifically detect diagnostic error, and even when these errors … provide knowledge and recommendations to encourage HCOs to begin to identify and learn from diagnostic errors

24. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
    March 31, 2008 - levels of harm: (1) prescription drug errors, (2) coordination of care errors (specifically errors … Prescribing errors. … Clinical activity errors included mistimed procedures, examination errors, diagnostic errors, and delays … errors. … errors.

25. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
    January 01, 2024 - errors of severity category B (p < 0.0001). … that reported 8,087 medication errors and 143 NFCHs that reported 159,519 errors. … Harmful errors (categories E through I) accounted for approximately 2% of reported errors from the … Taxonomy of medication errors. … Medication errors observed in 36 health care facilities.

26. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
    July 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Types and origins of diagnostic errors in primary care settings. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

27. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
    January 01, 2024 - Scope Earlier research suggests that medication errors, excluding wrong-time errors, average 10% or … , including wrong-time errors. … Although the ICC was lower when considering medication errors without wrong-time medication errors ( … between the rate of interruptions and medication errors when wrong-time medication errors were included … when considering the variable that only included medication errors excluding wrong-time errors (p=

28. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1.html
    July 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors

29. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2.html
    July 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors

30. Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/crane-report.pdf
    January 01, 2024 - Reducing medical errors 3. Promoting evidence-based care 4. … : both active errors and latent errors • Safety targets: medication prescribing, patient identification … PAs also agreed that making errors in medicine is inevitable. … share information about errors and their causes. … PAs make errors.

31. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - Training Resources AHRQ Papers on Diagnostic Safety Topics Diagnostic errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Improving Education—A Key to Better Diagnostic Outcomes ( PDF , 2 MB) The Contribution of Diagnostic Errors … Journal Articles The PRIDx framework to engage payers in reducing diagnostic errors in health care  

32. Using Home Visits to Understand Medication Errors in Children (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
    May 28, 2008 - Errors in Children Kathleen E. … , administration errors). … systematically interviewed parents about medical errors, and none addressed errors in ambulatory care … Medication filling and refilling errors. 2. Medication administration errors. 3. … , and administration errors.

33. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
    November 29, 2004 - , including both errors of omission and errors of commission. … For some types of errors, such as drug-related errors, denominators that included only those patients … Of those with errors, 1,796 had one error, 1,570 had 2 errors, 191 had 3 errors, and 14 had 4 errors … to glucose and lipid errors. … Overall, patients with glucose errors are significantly more likely to have analogous lipid errors.

34. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
    January 01, 2024 - The most common types of errors were inappropriate abbreviations, followed by dosing errors. … The most frequent cause of errors was illegibility. … of 6.3 serious medication errors per 1000 patient-days. … a high rate of nursing transcription errors (20%). … Overall, we found a total of 219 IV medication errors.

35. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/grants-2019.html
    March 01, 2024 - year 2019 for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors … In 2019, AHRQ awarded the four grants below that will more precisely define the scope of diagnostic errors … University of California, San Francisco Project Aims: To determine the incidence of diagnostic errors … , and to use risk estimates to calculate incidence and impact of factors contributing to those errors … To explore machine learning techniques that yield robust, accurate models to predict diagnostic errors

36. Advances in Patient Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/advances/index.html
    July 01, 2022 - Moores Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (   PDF , … Turley Ambulatory and Rural Learning from Errors in Ambulatory Pediatrics (   PDF , 186 KB) Julie … Wasserman, Lynne Uhring Identification, Classification, and Frequency of Medical Errors in Outpatient … Allan Klock, Richard Cook Clinical Inertia and Outpatient Medical Errors (   PDF , 333 KB) Patrick J … Kleinpeter Simulation The Use of Surgical Simulators to Reduce Errors (   PDF , 824 KB) Marvin P

37. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality.html
    September 01, 2021 - Related to Diagnostic Safety and Quality Issue Briefs The Contribution of Diagnostic Errors … Improving Diagnostic Safety and Quality in Healthcare The Contribution of Diagnostic Errors … : State of the Science Next Page Table of Contents The Contribution of Diagnostic Errors … The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Page originally created September 2021 Internet Citation: The Contribution of Diagnostic Errors

38. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
    January 01, 2004 - Background Errors of medication use are among the most common types of medical errors and include … errors. … Over half of these errors were dosing or frequency errors, and the physician ordering the medication … committed the majority of these errors. … errors may be undercounted.

39. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
    June 01, 2020 - rich detail that, at least in some cases, may offer insight into ways to prevent or mitigate future errors … However, no standardized mechanisms exist to report diagnostic errors. … Despite widespread efforts to enable providers to report errors, 17 , 52 clinicians find reporting tools … onerous and are often unaware of errors they make. 53 It has also become clear that a local champion … objects during procedures), administrative data are not sufficiently sensitive to detect diagnostic errors

40. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - Introduction The Risk from Medication Errors Medication errors are the most common source of risk … The index has a reported kappa value of κ = 0.62.19 Category B errors are actual errors that were intercepted … CAHs that reported 8,087 medication errors and 143 NFCHs that reported 159,519 errors (Table 2). … Harmful errors (Categories E - I) accounted for approximately 2 percent of reported errors from the … Reporting of Errors by Pharmacy Personnel Of the 156,089 actual errors reported (Categories B - I)