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181. Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error, Improve Outcomes, and Reduce Misuse, Overuse, and Underuse of Outpatient Primary Care - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs025374-weiner-final-report-2022.pdf
     January 01, 2022 - are medical errors caused by inattention to patient context. … Preventing contextual errors: Given that contextual errors are frequent, harmful and costly, preventing … Contextual Errors in Medical Decision Making: Overlooked and Understudied. … Listening for what matters : avoiding contextual errors in health care. … Contextual Errors in Medical Decision Making: Overlooked and Understudied.

182. Improving EHR Design Increases Patient Safety—Especially for Children | Digital Healthcare Research
     digital.ahrq.gov/2018-year-review/research-spotlights/improving-ehr-design-increases-patient-safety-especially-children
     January 01, 2018 - research team identified pervasive problems with EHR systems that regularly lead to patient safety errors … lower body weight and less developed immune systems make children less able to tolerate even small errors … “Poor interface design and poor technology implementations can lead to errors that may result in patient … Improving EHR design and usability will reduce errors that can lead to patient harm. … functionality of CDS and other EHR functionality can help increase the safety of EHR systems, which will reduce errors

183. Centers for Education and Research on Therapeutics (CERTs) (U19) | Digital Healthcare Research
     digital.ahrq.gov/funding-mechanism/centers-education-and-research-therapeutics-certs-u19
     January 01, 2023 - Research on Therapeutics Automated detection of look-alike/sound-alike medication errors … Automated detection of look-alike/sound-alike medication errors. … Project Name Tools for Optimizing Medication Safety (TOP-MEDS) Learning from errors … Learning from errors: analysis of medication order voiding in CPOE systems.

184. Enhancing Medication CPOE Safety and Quality by Indications-Based Prescribing | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing
     January 01, 2023 - notation of a medication’s purpose-–into the prescribing process has the potential to prevent medication errors … Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. … Mistakes made by patients and providers can lead to medication errors. … Including medical indications in the prescribing process can reduce medication errors. … Specifying the indication during the prescribing process can help avoid medication errors; however, the

185. Comprehensive Information Technology (IT) Solution for Quality and Patient Safety - 2009 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety/annual-summary/2009
     January 01, 2009 - would bring greater magnitude of benefits in pediatrics than in adult medicine to prevent potential errors … Specific Aims Improve pediatric patient safety by reducing medication errors. ( Achieved ) Improve … During August 2005, smart pump technology for syringes was implemented to prevent medication errors at … the bedside by catching any miskeys and/or pump programming errors. … Overall error rates, including low-severity errors, dropped to almost zero by late 2007.

186. Murphy Diagram | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
     January 01, 2023 - They are similar to other analysis methods such as fault trees as they analyze errors based on the … potential causes of those errors.

187. Computerized Provider Order Entry | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/key-topics/computerized-provider-order-entry
     January 01, 2007 - treatment-related information as well as tools aimed at improving patient care and reducing medical errors … ICUs Medication errors: a prospective cohort study of hand-written and computerized physician order … for Continuous Medication Infusions in a Pediatric ICU A comparison of medication administrations errors … Only one study showed a significant reduction of the number of medication errors. … science, sociology, and cognitive science), they interpret the nature of these errors.

188. Health Information Technology and Improving Medication Use - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use/annual-summary/2012
     January 01, 2012 - 2007, recognizing that health information technology (IT) has great potential to reduce medication errors … (Achieved) Evaluate errors arising from implementation of electronic prescribing. … Recommendations for minimizing e-prescribing errors and their unintended consequences were developed. … , indicating that most errors are amenable to modification of systems. … Although primary care providers are in the best position to identify and correct errors, the results

189. Advancing Health Information Exchange During Inter-Hospital Transfer to Improve Patient Outcomes | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/advancing-health-information-exchange-hie-during-inter-hospital-transfer-iht
     January 01, 2024 - This gap in information can lead to patient harm, such as therapeutic errors and delays in care, and … Evaluate the impact of this intervention on clinician-reported medical errors, medical errors attributable … Researchers will evaluate the impact of this intervention on patient safety outcomes, including medical errors … While critical to meeting the needs of patients, inter-hospital transfers can result in errors that reduce … An evaluation of the platform will examine its impact on patient safety outcomes, such as medical errors

190. Electronic Prescribing and Electronic Transmission of Discharge Medication Lists | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/electronic-prescribing-and-electronic-transmission-discharge-medication-lists
     January 01, 2023 - Management Protected Health Information Data Sharing In the ambulatory setting, medication errors … Evidence indicates that health information technology (IT) decreases medication errors in the inpatient … The first was a multi-site, pre-post study measuring the effects of health IT on medication errors when … The specific aims of the study were to: Measure the effects on medication errors of transitioning … Finally, the cohort controlled study did not find a reduction in the incidence of medication errors.

191. Virtual Continuity and its Impact on Complex Hospitalized Patients’ Care - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/virtual-continuity-and-its-impact-complex-hospitalized-patients-care/annual-summary/2012
     January 01, 2012 - by the PCP in the care of hospitalized patients should decrease medication, diagnostic, and followup errors … A pre-post study compared the frequency of discharge medication errors before and after initiation of … Differences in medication errors remained statistically significant on multivariable analysis adjusting … No significant differences were seen between groups in clinically important medication errors or in 30 … Clinically significant medication errors were rare and not significantly different between groups.

192. HIT for Medication Safety in Critical Access Hospitals - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/p20hs015325-hartzema-final-report-2005.pdf
     January 01, 2005 - Sources of Medication Errors § Prescribing Errors § Transcribing Errors § Dispensing Errors § … Administration errors II. … Medication Errors and HIT § Prescribing Errors: Pharmacy Management System § with Clinical Decision … For example, it can be argued that medication administration errors such as IV administration errors … Many of these errors go unreported.

193. Decreasing ADEs in Montana Frontier Critical Access Hospitals through HIT | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/decreasing-ades-montana-frontier-critical-access-hospitals-through-hit
     January 01, 2023 - Type of Care Acute Care Health Care Theme Adverse Events Medication Errors … appears to have improved the overall reporting of prescription, transcription, and dispensing process errors

194. Health Information Technology and Improving Medication Use - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/u18hs016970-bates-final-report-2012.pdf
     January 01, 2012 - Medication Errors and Adverse Drug Events Medical errors and problems in patient safety are as common … errors per script. … to describe these errors. … For example, the proportion of omitted duration errors ranged from 7.7% to 63.2%, omitted dose errors … Scope Background/context: Medication errors are defined as errors in drug ordering, transcribing,

195. Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs024713-adelman-final-report-2023.pdf
     January 01, 2023 - Keywords: computerized provider order entry, patient photo, wrong-patient errors. 2. … Wrong-Patient Retract-and-Reorder Measure for identifying wrong-patient errors. … Other types of unmeasured wrong-patient errors may have been prevented by the intervention. … Does computerized provider order entry reduce prescribing errors for hospital inpatients? … Role of computerized physician order entry systems in facilitating medication errors.

196. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review | 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/effects-computerized-physician
     June 23, 2003 - of study:  Not Available Study Design:  Systematic review Outcomes:  Adverse drug events, medication errors … controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (ed, mediation errors … isolated CDSSs, 3 demonstrated statistically significant improvement in antibiotic associated medication errors … or adverse drug events and 1 an improvement in theophylline-associated medication errors.

197. Medication Safety in Primary Care Practice - Translating Research into Practice | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/medication-safety-primary-care-practice-translating-research-practice
     January 01, 2023 - Care Theme Medication Safety Quality Improvement Quality Measurement Medication errors … morbidity; therefore, work is needed to specify relevant measures and conduct interventions to reduce these errors … medication refill protocols, and using performance reports to identify patients with potential prescribing errors … System , Electronic Health Record/Electronic Medical Record Medication prescribing and monitoring errors … Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research

198. Supporting Health Systems in Advancing Care Delivery | Digital Healthcare Research
     digital.ahrq.gov/program-overview/research-stories/supporting-health-systems-advancing-care-delivery
     January 01, 2023 - Displaying Patient Photos in Medical Records Reduces Errors, Improves Patient Safety Patient photos … displayed in the electronic health record significantly reduce wrong-patient order errors and improve … Retract-and-Reorder Measures to Improve Medication Safety New measures to identify near-miss medication errors

199. Health Information Technology and Improving Medication Use | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use
     January 01, 2023 - Evaluate errors arising from implementation of electronic prescribing. … They noted an average of 1.03 errors per prescription, of which 35 percent were classified as ADEs. … systems are associated with unique patterns of errors. … Low rates of errors were noted during implementation and after sustained use. … Errors associated with outpatient computerized prescribing systems.

200. 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 - errors, 35% action errors, 10% retrieval errors, 6% selection errors and 0% checking errors. … Most errors were found to occur at medium probability, and overall, most errors were considered of medium … probability errors were considered low criticality. … This works well to mediate errors and address heuristic violations. … Telemedicine consultations and medication errors in rural emergency departments.