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digital.ahrq.gov/ahrq-funded-projects/medication-monitoring-vulnerable-populations-information-technology-mmiti/annual-summary/2010
January 01, 2010 - , Heart Disease, Lung Disease
Summary: The Institute of Medicine report, Preventing Medication Errors … , offered some of the first broad insights into the risk of medication errors in ambulatory settings … Quality lapses and errors related to medications are some of the most prevalent risks across all care … settings, and morbidity due to these errors is costly.
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digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge
January 01, 2023 - Safety
Many patients discharged from a hospital with pending test results experience medical errors … These errors occur because pending tests are often not communicated to the followup provider, and systems … hospital discharge generally felt that the delivery of the results improved quality of care, decreased errors
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digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-slides-081811.pdf
August 18, 2011 - • Communication errors between health care
providers are common in the care of older
patients. … • High INR was due to multiple errors.
• Patient was denied an important and
beneficial therapy. … Adverse Drug Events
injury resulting from a medical intervention related
to a drug
Medication
Errors … (errors vs ADEs)
Adverse Drug Events among Older
Adults in the Ambulatory Setting
Gurwitz, J. … Occurred
0 20 40 60 80 100
Patient Errors
Monitoring
Prescribing
Percent of total Preventable ADEs
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digital.ahrq.gov/2019-year-review/research-summary/supporting-clinicians-improve-decision-making-and-patients-care
January 01, 2019 - explored the adaptation of a “black box,” the flight data recorder used to analyze and prevent aviation errors … captures mouse movements and keystrokes by EHR end users so they can be used for root cause analysis of errors … found that the health IT black box methodology can identify and facilitate the review of EHR-based errors
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digital.ahrq.gov/ahrq-funded-projects/decision-making-and-clinical-work-test-result-followup-health-information
January 01, 2023 - Medical Record Population: Physician
Learning from patients' experiences related to diagnostic errors … Learning from patients' experiences related to diagnostic errors is essential for progress in patient … Record Population: Administrator , Clinical Staff/Clinician , IT Staff
Finding diagnostic errors … Finding diagnostic errors in children admitted to the PICU. … Entry System Population: C-Suite Officer
Helping health care organizations to define diagnostic errors
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2010
January 01, 2010 - December 2010
Target Population: Adults, Safety Net
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
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digital.ahrq.gov/ahrq-funded-projects/improving-outpatient-medication-lists-using-temporal-reasoning-and-clinical
January 01, 2023 - patient’s electronic health record (EHR) is critical to prevent medication prescribing and administration errors … subsequently used by clinicians at the point of care, thereby reducing prescription and administrative errors … In addition, such a system could be used to detect potential medication errors.
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digital.ahrq.gov/funding-mechanism/department-health-and-human-services-program-support-center-psc
January 01, 2023 - Human Services Program Support Center (PSC)
Reduction in medication errors … Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems
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digital.ahrq.gov/2020-year-review/research-dissemination/ahrq-funded-researchers-disseminate-findings-high-impact-journals
January 01, 2020 - the following:
Displaying Patient Photos in Electronic Health Records Reduces Hospital Order Errors … to the banner of EHRs enhanced patient identification and significantly reduced wrong-patient order errors
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digital.ahrq.gov/location/usa-md-rockville
January 01, 2023 - While health information technology (IT) systems are expected to significantly reduce medication errors … , studies have found that issues with usability and information design can actually facilitate errors
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digital.ahrq.gov/ahrq-funded-projects/artificial-intelligence-and-human-factors-healthcare-quality-safety
September 30, 2024 - into artificial intelligence (AI) implementation and usage, this research has the potential to reduce errors … on understanding how people interact with systems and technology to improve performance and reduce errors
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015038-friedman-final-report-2007.pdf
January 01, 2007 - in
prescribing by physicians resulting in drug-drug interactions) and delivery (errors by pharmacists … In practice, errors in the use of these medications have been difficult to either preventxiv or verify … Equally important in the avoidance of preventable medication errors following transplantation is the … Errors identified
are individually addressed with a combination of focused education and corrective … An additional one third (6/16) of errors involved patient compliance or drug
availability.
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digital.ahrq.gov/ahrq-funded-projects/tulare-district-hospital-rural-health-electronic-medical-record-consortium/annual-summary/2008
January 01, 2008 - Quantitative data and methods were used to understand the impact of the IT system on medication errors … clinic physicians the opportunity to use computerized provider order entry (CPOE) to reduce medication errors … near-simultaneous firing of the Chief Nursing Officer, may have temporarily led to more patient care errors … The EMR project did not demonstrably reduce medical errors or improve hospital finances, but it has received
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/event-tree-analysis
January 01, 2023 - To examine the potential for errors within a system. … This first task list should describe the normal performance of the scenario, free from any errors.
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digital.ahrq.gov/ahrq-funded-projects/electronic-medication-management
January 01, 2023 - Type of Care
Acute Care
Primary Care
Health Care Theme
Medication Errors … When patients transfer to new health care settings, there is an increased risk of medication errors … To decrease such errors, policymakers such as the Joint Commission have focused on improving the quality
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022894-pratt-final-report-2020.pdf
January 01, 2020 - Scope: Medical errors cause significant mortality and morbidity each year. … adult hospital—to help us understand patients’ needs and support ideas for preventing
medical errors … Scope
Medical errors … received national attention for many years, including efforts to encourage patients to
speak up about errors … , less work has actively involved patients in preventing, detecting,
and recovering from these errors
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digital.ahrq.gov/sites/default/files/docs/page/2006Gurwitz_051711comp.pdf
January 01, 2005 - Adverse Drug Events
Medication
Errors
ADEs
Preventable
Introduction
Adverse drug events (ADEs … among nursing home residents,
and preventable adverse drug events are
most commonly associated with errors … clinical information
into the clinical decision support system
• Setting the bar too high: ADEs vs errors
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/task-analysis
January 01, 2023 - hierarchical task analysis (HTA), looking for information such as displays and controls used, possible errors … decomposes it to describe the task's features, such as devices and interface components used, duration, errors
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digital.ahrq.gov/health-care-theme/quality-measurement
January 01, 2023 - Medication Safety
Description
This research showed that automated measurement of electronic order errors … can be readily integrated into electronic health records to study the epidemiology of order errors and
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digital.ahrq.gov/type-care/internal-medicine
January 01, 2023 - Using Electronic Records to Detect and Learn from Ambulatory Diagnostic Errors
Description … record-based trigger methods can enable more meaningful measurement and surveillance of diagnostic errors