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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.
-
digital.ahrq.gov/sites/default/files/docs/publication/r18hs017037-ornstein-final-report-2010.pdf
January 01, 2010 - Scope: Medication errors in primary care practice cause morbidity but work is needed to specify
relevant … measures and conduct interventions designed to reduce these errors. … Scope
Medication errors in primary care practice are an important cause of morbidity but the extent … of these errors is largely unknown and effective interventions for reducing these errors need to be … model improved practice performance on several categories of preventable prescribing and
monitoring errors
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digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge/annual-summary/2012
January 01, 2012 - $577,880
Summary: Hospital patients discharged with pending test results are at risk for medical errors … These errors may arise from poor methods of managing test results and poor communication with followup
-
digital.ahrq.gov/2020-year-review/research-summary/improving-delivery-health-services-health-systems-level
January 01, 2020 - While errors may happen at all stages of the medication process, different tools have been developed … Digital healthcare tools can reduce medication dosing errors and preventable adverse events such as drug-drug … hospital inpatient computerized provider order entry (CPOE) system, to identify medication ordering errors … The research team found that all reported ordering errors were due to a combination of associated risk
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digital.ahrq.gov/sites/default/files/docs/page/johnson-success-story.pdf
August 29, 2013 - Medication Prescribing
Made Simpler and Safer
Children are particularly vulnerable to medication
errors … Medication errors
pose a greater threat to children than to adults for a
number of reasons. … In an effort to reduce outpatient pediatric medication
errors and to save time calculating doses, Dr … Electronic Prescribing (PedSTEP)
project, which looked at the impact of e-prescribing
on medication errors
-
digital.ahrq.gov/ahrq-funded-projects/past-initiatives/transforming-healthcare-quality-through-health-it/taconic-health-information
March 31, 2008 - electronic data exchange, and does it actually improve the quality of health care and reduce medical errors … "We will look carefully at medical errors, adverse drug events, quality issues, and cost in all three … practitioners who can't do this on their own, to improve the quality of health care, and to reduce medical errors
-
digital.ahrq.gov/principal-investigator/vandenberg-ann-e
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
-
digital.ahrq.gov/ahrq-funded-projects/improving-healthcare-quality-information-technology
January 01, 2023 - Care
Acute Care
Ambulatory Care
Health Care Theme
Adverse Events
Medication Errors … Health Care (SVHC) and five private physician practices serving a rural area wanted to reduce medical errors … goals were: 1)demonstrate an increased culture of safety that encourages and supports the reporting of errors
-
digital.ahrq.gov/organization/columbia-university
January 01, 2023 - Principal Investigator(s)
Schnall, Rebecca
Assess Risk of Wrong-Patient Errors … were limited to having one patient record open at a time versus up to four and found no difference in errors
-
digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/diagnostic-omission-errors-acute
January 01, 2006 - Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making
-
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
-
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
-
digital.ahrq.gov/sites/default/files/docs/activity/improving_pediatric_safety_and_quality_with_hit_2009_update_2.pdf
January 01, 2009 - The project then measured outcomes—including dosing errors, guideline adherence, and
quality of documentation—related … designed to assess effects of an EHR with weight-
based dosing decision support on rates of dosing errors … The reduction in dosing errors was partially offset by errors resulting
from improper use of the CDS
-
digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge/annual-summary/2011
January 01, 2011 - $577,880
Summary: Hospital patients discharged with pending test results are at risk for medical errors … These errors may arise from poor methods of managing test results and poor communication with followup
-
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
-
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
-
digital.ahrq.gov/ahrq-funded-projects/taconic-health-information-network-and-community-thinc
January 01, 2023 - Type of Care
Primary Care
Health Care Theme
Interoperability
Medication Errors … electronic data exchange, and does it actually improve the quality of health care and reduce medical errors … "We will look carefully at medical errors, adverse drug events, quality issues, and cost in all three … practitioners who can't do this on their own, to improve the quality of health care, and to reduce medical errors
-
digital.ahrq.gov/sites/default/files/docs/eRx_MMA_Pilot_Slides_A%20(3).pdf
April 01, 2008 - Woolley
Value & Benefits- Pharmacies
� Better prescription information that will reduce medication
errors … Value & Benefits- Payers/PBMs
� Enhanced patient safety and reduced costs related to
medication errors … National
Council Quality Assurance)
� Over 7,000 deaths each year due to manual-process
prescribing errors … pharmacy and ask to speak to a
pharmacist
The Cognitive Psychology of Missed Diagnoses
� Context errors … � Availability errors: The physician chooses the most
likely diagnosis over conditions that are more
-
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.
-
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