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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
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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/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/health-it-tools-and-resources/health-it-costs-and-benefits-database/comparison-voice-automated
June 01, 2003 - Total number of errors made by computer was 16.7 times the total number of errors made by human transcribers
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digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/physician-characteristics
July 01, 2006 - potential drug-allergy and drug-drug interactions Facilitators: Belief that CPOE may lead to fewer errors … of the CPOE system were more likely to believe that CPOE led to fewer medication and non-medication errors
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digital.ahrq.gov/sites/default/files/docs/activity/tulare_district_hospital_rural_health_electronic_medical_record_2009_update_2.pdf
January 01, 2009 - 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
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digital.ahrq.gov/sites/default/files/docs/activity/medication_reconciliation_to_improve_quality_of_transitional_care_2010_pdf__2.pdf
January 01, 2010 - Summary Status as of: 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/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/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/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/sites/default/files/docs/implementation/U%20of%20MN%209-17-05.ppt
November 24, 2003 - Flights - 1 in 8,000,000 flights
Background - IOM Report
cont’d
Death in Hospitals from Medical Errors … , con’t
Active Failures
Operative/Post-Op Complications/Infections
Events Relating to Medication Errors
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-records-detect-and-learn-ambulatory-diagnostic-errors/citati-0
January 01, 2023 - Eric
Project Name
Using Electronic Records to Detect and Learn from Ambulatory Diagnostic Errors
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digital.ahrq.gov/ahrq-funded-projects/using-electronic-records-detect-and-learn-ambulatory-diagnostic-errors/citati-1
January 01, 2023 - Eric
Project Name
Using Electronic Records to Detect and Learn from Ambulatory Diagnostic Errors
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digital.ahrq.gov/ahrq-funded-projects/current-health-it-priorities/clinical-decision-support-cds/chapter-1-approaching-clinical-decision/section-5-how-key-terms-are-used-book
Medication errors. … " [9] [10] NCC MERP has developed a taxonomy for categorizing medication errors and the associated … are used in a manner that minimizes, to the greatest extent possible, preventable harm caused by both errors
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaushal-r-et-al-2003
January 01, 2003 - and if the measured outcomes were clinical (e.g. adverse drug events) or surrogate (e.g. medication errors … isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors … or adverse drug events and 1 an improvement in theophylline-associated 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/ahrq-funded-projects/current-health-it-priorities/clinical-decision-support-cds/chapter-1-approaching-clinical-decision/section-1-introduction
recent report from The Institute of Medicine (IOM) (see Summary of the 2006 IOM Report on Medication Errors … We conclude this chapter with a literature sampling on medication errors and CDS in medication management
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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/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/sites/default/files/docs/implementation/REILING_8_V.ppt
January 01, 2005 - Joseph’s Hospital
Latent Conditions
Errors in the design, organization, training or maintenance … that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods … , con’t
Active Failures
Operative/Post-Op Complications/Infections
Events Relating to Medication Errors