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digital.ahrq.gov/2019-year-review/research-summary/improving-delivery-health-services-health-systems-level
January 01, 2019 - This research applied NLP and machine-learning methods to detect errors in speech-recognition notes. … of medical documents, but further work is needed to reduce false positives and the identification of errors
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digital.ahrq.gov/2019-year-review/executive-summary
January 01, 2019 - Factors in Healthcare
Aaron Zachary Hettinger
Using Aviation Technology to Prevent Healthcare Errors … captures actions leading up to an incident, the health IT black box allows for root cause analysis of EHR errors … information exchange capability between a poison control center and emergency department to reduce errors
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs017201-simon-final-report-2012.pdf
January 01, 2012 - Purpose
Objectives of Study
Medication errors and preventable adverse drug events occur commonly … The Institute of Medicine report “Prevention of Medication Errors,” highlights the
problem of medication … In addition to errors in medication ordering, dispensing, or
administration, patients may be at risk … Challenges
The research study evaluated two important domains of patient safety: reduction of errors … related to the monitoring of medication therapy and the reduction of errors related to delayed or
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digital.ahrq.gov/track-8-patient-and-family-centered-health-it-and-safety
January 01, 2023 - Participants will learn how to recognize some of the causal factors linked to medication errors and develop
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digital.ahrq.gov/technology/audit-log
January 01, 2023 - Project Name
Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open
Develop
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digital.ahrq.gov/sites/default/files/docs/medicaid/NY_CaseStudy.pdf
July 01, 2010 - developing an electronic prescribing (e-prescribing)
incentive program aimed at reducing medication errors … The
committee looked exclusively at the cost savings associated with avoiding medication errors … transmitted electronically would save the agency $1.82, which includes the decrease in
medication errors
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digital.ahrq.gov/sites/default/files/docs/page/NY_CaseStudy_0.pdf
July 01, 2010 - developing an electronic prescribing (e-prescribing)
incentive program aimed at reducing medication errors … The
committee looked exclusively at the cost savings associated with avoiding medication errors … transmitted electronically would save the agency $1.82, which includes the decrease in
medication errors
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digital.ahrq.gov/sites/default/files/docs/page/2006PattersonGeisWears_051611comp.pdf
March 01, 2006 - Pressured environment to expeditiously problem
solve on limited information
Emergency Department Errors … gradient and assertive statements
-Challenging the authority gradient
Mitigation and trapping of errors … Disclosure Statement
Emergency Department Risk Factors for Patient Safety
Emergency Department Errors
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digital.ahrq.gov/ahrq-funded-projects/care-transitions-app-patients-multiple-chronic-conditions
January 01, 2023 - transitions are a vulnerable period for patients, leading to post-discharge adverse events, falls, medication errors … Complications, such as falls or medication errors, could lead to readmissions.
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digital.ahrq.gov/ahrq-funded-projects/human-factors-considerations-design-and-implementation-telemedicine-integrated
January 01, 2023 - Errors that were predicted included miscommunication, omitted or incomplete steps, incorrect data entry … However, the researchers felt that knowledge of types of errors that occur pre-arrival to the hospital
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digital.ahrq.gov/ahrq-funded-projects/improving-lab-follow-delivering-enhanced-medication-list-outpatient-physician/annual-summary/2010
January 01, 2010 - Completion of Contract
Target Population: General
Summary: Medication errors … Although outpatient providers could detect and prevent many of these errors, their limited time with
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digital.ahrq.gov/ahrq-funded-projects/context-aware-knowledge-delivery-electronic-health-records
January 01, 2023 - Care
Health Care Theme
Clinical Workflow
Human Factors
A main cause of errors … Electronic Medical Record , Knowledge System
Can prospective usability evaluation predict data errors … Can prospective usability evaluation predict data errors?
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-support-safe-nursing-care
January 01, 2023 - Health Care Theme
Care Coordination
To enhance safety culture and reduce errors … extreme variation in the ways clinicians share information with each other causes an untold number of errors … Ackron says that having this type of information can help prevent medical errors.
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digital.ahrq.gov/sites/default/files/docs/page/tool-3-1-goals-worksheet-poster.pptx
June 16, 2021 - INSTRUCTION: Review what goals can be achieved with e-prescribing, Here are examples:
Reduce medication errors
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digital.ahrq.gov/ahrq-funded-projects/community-shared-clinical-abstract-improve-care-mn
January 01, 2023 - major barrier to effective care transitions and can lead to redundant work, conflicted recommendations, errors
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digital.ahrq.gov/sites/default/files/docs/page/Electronic%20Prescribing%20Using%20A%20Community%20Utility%20-%20The%20ePrescribing%20Gateway_0.pdf
January 31, 2007 - Suspected medication errors (MEs) and adverse drug events (ADEs)
were rated by physicians. … ; no amount dispensed errors; no prn errors no
frequency or route abbreviation errors- all other abbreviation … errors were included; no
combinations (i.e Tylenol # 3) strength w/out units, or any strength without … Medication errors are errors during ordering, transcribing,
dispensing, administering, or monitoring … Not all medication errors have the potential to harm a patient.
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digital.ahrq.gov/ahrq-funded-projects/technology-exchange-cancer-health-network-tech-net/annual-summary/2008
January 01, 2008 - Analysis of other study measures (medical errors, medication errors, treatment success/failure, adverse
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digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics/annual%20summary/2010
January 01, 2010 - essential to: 1) establish a baseline performance metric to measure improvement; 2) separate medication errors … Despite extensive literature on medication safety, medication errors, and adverse drug events in adult
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digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
December 01, 2005 - Fragmentation leads to miscommunication and errors
– Duplicate Testing
– Medication Lists not reconciled … pre-maturely
– Poor documentation, illegible handwriting and other
mis-communication causing errors … Some references on medical errors:
– “To Err is Human” – IOM report
• http://books.nap.edu/books/0309068371 … National Patient Safety Conference
• http://healthit.ahrq.gov/conf2005/
– JCAHO Taxonomy of Medical Errors … This can introduce all kinds of errors
that you may not even hear about until its too late.
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digital.ahrq.gov/technology/emergency-department-information-system
January 01, 2023 - rural hospital, and three private primary care physician practices; evaluated the reduction in medical errors