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161. Delphi Method | Digital Healthcare Research
     digital.ahrq.gov/research-method/delphi-method
     January 01, 2023 - Delphi Method Preventing Perioperative Medication Errors and Adverse … Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision … Project Name Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of … communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors … communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors

162. Risk Assessment | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
     January 01, 2023 - all possible failures that can occur within a system and then determines what the effects of those errors … Description The process decision program chart (PDPC) provides a systematic means of finding errors … They are similar to other analysis methods such as fault trees as they analyze errors based on the … potential causes of those errors.

163. Medication Management: A Closed Computerized Loop | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/medication-management-closed-computerized-loop
     January 01, 2023 - Population Rural Populations Health Care Theme Adverse Events Medication Errors … reduction in the number of reported unexpected adverse drug reactions and a 10 percent decrease in errors … Observations of medication administration yielded a 45 percent reduction in observed medication errors … project resulted in heightened awareness of patient safety and a loss of complacency about the sources of errors

164. Role of IT in Improving Patient Safety (pdf file)
     digital.ahrq.gov/sites/default/files/docs/page/2006StromPepper_051211comp.pdf
     May 23, 2011 - Review of IT Structures of PennMedicine CCEB Improving Patient Safety by Reducing Medication Errors … psychometric personality inventory CCEB Project 4 Outcomes • The “near misses” for medication errors … CCEB Project Four Qualitative Summary Outcomes • An emerging theme focused on the errors created … by technological solutions designed to reduce errors • Several examples illustrate the unintended … :�Overall Organization Project 4: Medication Errors�Related to Workplace Stressors�(Ross Koppel, PhD

165. Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/medication-error-reporting-and
     March 01, 2007 - Purpose of Study:  To compare the number and type of medication errors reported before and after the … Intervention:  Implementation of CPOE Evaluation Method:  The type, number, and severity of medication errors … before and after CPOE implementation were compared, as well as the type of personnel reporting the errors … Quality of Care and Patient Safety Outcome:  During the month of implementation, the number of ordering errors … on service and an online medication error reporting system likely caused the increase in documented errors

166. Section 10 - References | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/ahrq-funded-projects/current-health-it-priorities/clinical-decision-support-cds/chapter-1-approaching-clinical-decision/section-10-references
     December 12, 2008 - About Medication Errors ; accessed 9/30/2008. … About Medication Errors.  … USP-ISMP Medication Errors Reporting Program ; accessed 12/12/2008. … Preventing Medication Errors: Quality Chasm Series . … Relationship between medication errors and adverse drug events.

167. Chart Review | Digital Healthcare Research
     digital.ahrq.gov/research-method/chart-review
     January 01, 2023 - Decisionmaking & Problem Solving in Acute Care An Etiology for Medication Ordering Errors … An Etiology for Medication Ordering Errors in Computerized Provider Order Entry Systems - Final Report … Principal Investigator Abraham, Joanna Project Name An Etiology for Medication Ordering Errors … About Epilepsy Surgery Patients Automated detection of wrong-drug prescribing errors … Automated detection of wrong-drug prescribing errors.

168. Statewide Implementation of Electronic Health Records | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/statewide-implementation-electronic-health-records
     January 01, 2023 - Type of Care Primary Care Specialty Care Health Care Theme Medication Errors … 2) To what extent will adoption of EHRs reduce medication errors and improve the quality of ambulatory … Understanding the nature of medication errors in an ICU with a computerized physician order entry system … Ambulatory prescribing errors among community-based providers in two states. … Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated

169. Medication Reconciliation to Improve Quality of Transitional Care - 2011 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2011
     January 01, 2011 - Period September 2009 - September 2012 AHRQ Funding Amount $1,181,628 Summary: Medication errors … account for approximately 20 percent of all medical errors in the United States each year. … facilitation of inpatient MR improves completion of MR and decreases the incidence of drug-related medical errors … Determine whether electronic facilitation alters medical reconciliation and the incidence of medication errors

170. Evaluating the Impact of an ACPOE/CDS System on Outcomes (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015319-sullivan-final-report-2007.pdf
     January 01, 2007 - We posited that few errors would result in ADEs. … ; that is, whether errors caused harm. … The majority of errors were potential errors only (25.1% pre- and 6.9% post-implementation: Level A, … or potential errors; however 92% (25.1% / 27.4%) of these errors were not actual errors, but potential … Surprisingly, errors involving Beers ). 6.9% of the errors reached the patient.

171. AHRQ National Web Conference Q&A - Assessing Safety Risks Associated with EHRs (pdf file)
     digital.ahrq.gov/sites/default/files/docs/safety-risks-ehr-qa-082916.pdf
     August 29, 2016 - our systems safe and resilient to wrong-patient errors. … For instance, a surveillance system could continually look for order-retract errors. … from identity theft of EHR, which can result in wrong-medication errors? … QUESTION: You mentioned errors related to time spent addressing a pop-up. … What kinds of errors have you seen, and is there a threshold delay when those errors start happening

172. Electronic Prescribing and Electronic Transmission of Discharge Medication Lists (pdf file)
     digital.ahrq.gov/sites/default/files/docs/activity/electronic_prescribing_and_electronic_transmission_of_discharge_medication_lists_2010_pdf__2.pdf
     January 01, 2010 - The first is a multi-center before-and-after study measuring the impact on medication errors of switching … If rates of errors vary greatly between commercial systems there are potential policy implications for … All medication errors will be reviewed by two experienced physicians who will use this tool to rate … the severity of the medication errors and ADEs. … Improvements were primarily attributed to reducing inappropriate abbreviation errors.

173. Human Factors | Digital Healthcare Research
     digital.ahrq.gov/health-care-theme/human-factors
     January 01, 2023 - Investigator(s) Hettinger, Aaron Zachary An Etiology for Medication Ordering Errors … Order Entry Systems Description This research assessed the etiology of medication ordering errors … , finding that errors stemmed from multi-level risk factors and showing the utility of a void alert tool … to prospectively capture the broad range of errors that may occur in practice that may be missed by

174. EHR Solutions for Accurate Reporting of Data on Interprofessional ICU Rounds - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs023793-gold-final-report-2021.pdf
     January 01, 2021 - , and the role the EHR and clinical users play in the genesis of these errors. … These extra elements of verbal communication can actually further compound errors. … Indeed, cognitive errors and errors in medical decision making are believed to be the largest class … of medical errors for non-procedural areas. … This implying less frequently ordered labs were more likely to experience reporting errors.

175. Improving Patient Safety/Quality with Health Information Technology Implementation | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/improving-patient-safetyquality-health-information-technology-implementation
     January 01, 2023 - Type of Care Acute Care Health Care Theme Adverse Events Medication Errors … Further, we designed around precarious events, specifically medication errors, by identifying the prevalence … of medication errors, near misses and preventable adverse drug events in our current manual patient … around patient safety and supported by a centralized IT system that will help the hospital prevent errors … These included: operative and post-operative complications and infections, medication errors, patient

176. Medication Reconciliation to Improve Quality of Transitional Care - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2012
     January 01, 2012 - Period September 2009 – July 2013 AHRQ Funding Amount $1,181,628 Summary: Medication errors … account for approximately 20 percent of all medical errors in the United States each year. … facilitation of inpatient MR improves completion of MR and decreases the incidence of drug-related medical errors … Determine whether electronic facilitation alters medication reconciliation and the incidence of medication errors

177. Evaluating the Impact of an ACPOE/CDS System on Outcomes (pdf file)
     digital.ahrq.gov/sites/default/files/docs/activity/evaluating_the_impact_of_2009_update_2.pdf
     January 01, 2009 - Use Summary: Computerized provider order entry (CPOE) has emerged as a viable option for reducing errors … It also evaluated the impact of the system on medication errors and downstream preventable adverse drug … Results of the medication error and ADE study revealed that the frequency of errors declined from … , perhaps due to few errors in this category. … Characterization of prescribing errors in an internal medicine clinic.

178. Cost-of-Poor-Quality Analysis | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/cost-of-poor-quality-analysis
     January 01, 2023 - If there appears to be a minimal number of steps with red circles, attempt to determine what errors can … occur, how to determine when errors have occurred, and what is in place in the process to control these … errors.

179. Pitts, Samantha | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/pitts-samantha
     July 24, 2024 - Patient Safety Event Date July 24, 2024 - 2:30pm - July 24, 2024 - 4:00pm Medication errors … Preventable medication errors cost the nation more than $21 billion annually across all care settings … research developed strategies to optimize CancelRx implementation and measured its impact on dispensing errors

180. July Teleconference Transcript (pdf file)
     digital.ahrq.gov/sites/default/files/docs/July%20Teleconference%20Transcript.pdf
     April 25, 2013 - We can also learn about errors that are standard reported errors that reported to Government agencies … Errors can occur at any of these levels. … ordering errors. … and the errors with potential for harm. … in transcription errors.