-
digital.ahrq.gov/sites/default/files/docs/activity/electronic_records_to_improve_2009_update_2.pdf
January 01, 2009 - An unexpectedly high level of continuity of information errors and continuity of followup
errors in … electronically between
emergency departments and primary care providers has the potential to diminish these errors
-
digital.ahrq.gov/sites/default/files/docs/page/Keenan.ppt
January 01, 2004 - ,
Pre-HANDS, 12 mo post, 24 mo post
Culture survey,
Pre-HANDS, 12 mo post, 24 mo post
Nursing errors … and near errors;
Pre-HANDS, and 3, 6, 12, 18, 24 months post
Preliminary Findings
Observations … patient
problems, interventions
and outcomes
SAFETY
CULTURE
Improved
communication
Reduced errors
-
digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
May 23, 2011 - Helpful to use multiple methods (quantitative, qualitative,
self-report, observation) to detect errors … All events identified as errors may not represent true safety
problems (false positives)
Using … Joseph’s Hospital)
Key Challenges in Reducing
Medication Errors
Maintain a complete, accurate, … improving safety and efficiency
Key Challenges Identified by
Participants
It is hard to detect errors … Overview of Patient-and Family-Centered Health IT and Safety
Key Challenges in Reducing Medication Errors
-
digital.ahrq.gov/sites/default/files/docs/biblio/AHRQ_Webcast011207.pdf
January 12, 2007 - ICUs
– Computerized physician order entry (CPOE) to reduce serious
on of
4P
medication ordering errors … software
– Demonstrate that their CPOE system can intercept at least 50% of
common serious prescribing errors … Principle #3: Accentuate the positive
– Encourage care quality, as well as ADE reduction
�Address errors … taking the test (detailed feedback)
Test orders representing nine categories of potentially dangerous errors … Key questions to consider:
� What are the highest priority targets in our
organization (types of errors
-
digital.ahrq.gov/sites/default/files/docs/page/THQITvalue020612.pdf
June 01, 2010 - o Increasing the identification and reporting of medical errors and adverse events. … o Decreasing the number of actual errors and adverse events. … The article topics ranged from identification of
factors contributing to medical errors to an analysis … Impact
of a patient-centered technology on medication
errors during pediatric emergency care. … Medication errors in the outpatient setting;
Classification and root cause analysis.
-
digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge/annual-summary/2010
January 01, 2010 - Summary: Nearly half of the hospital patients discharged with pending test results experience medical errors … These errors largely arise from poor methods of managing test results and poor communication with the
-
digital.ahrq.gov/organization/upper-peninsula-health-care-network
January 01, 2023 - access to patient data, eliminate duplicate tests and exams, deliver high-quality care, reduce medical errors
-
digital.ahrq.gov/ahrq-funded-projects/e-prescribing-impact-patient-safety-use-and-cost/annual-summary/2009
January 01, 2009 - Business Goal: Synthesis and Dissemination
Summary: Medication errors can occur at every step in … Medication errors that occur in the earlier stages of the process are more likely than others to be intercepted … A systems-focused, multidisciplinary approach has been useful for preventing serious errors.
-
digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/effect
January 01, 2023 - Principal Investigator
Lambert, Bruce
Project Name
Preventing Wrong-Drug and Wrong-Patient Errors
-
digital.ahrq.gov/organization/west-virginia-medical-institute
January 01, 2023 - Partnering to Improve Patient Safety in Rural WV
Description
Expanded the reporting of medical errors
-
digital.ahrq.gov/location/usa-wv-charleston
January 01, 2023 - Partnering to Improve Patient Safety in Rural WV
Description
Expanded the reporting of medical errors
-
digital.ahrq.gov/track-1-patient-safety-and-health-it-across-settings-and-populations
January 01, 2023 - Presenters will also describe how to monitor health care quality and the incidence of medical errors … Throughout the session, presenters will describe the nature of errors occurring in the ED.
-
digital.ahrq.gov/principal-investigator/gold-jeffrey-allen
January 01, 2023 - Rounds
Description
This research identified the data domains at greatest risk of communication errors … real-time simultaneous reviewing of data by all members of the rounding team to reduce communication errors
-
digital.ahrq.gov/principal-investigator/singh-hardeep
January 01, 2023 - Technology Settings
Learning from patients' experiences related to diagnostic errors … Learning from patients' experiences related to diagnostic errors is essential for progress in patient
-
digital.ahrq.gov/technology/clinical-messaging
January 01, 2023 - communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors … communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors
-
digital.ahrq.gov/funding-mechanism/demonstrating-value-health-information-technology
January 01, 2023 - (CPOE) Implementation in Intensive Care Units (ICUs)
EHR-related medication errors … EHR-related medication errors in two ICUs. J Healthc Risk Manag 2017 Jan;36(3):6-15.
-
digital.ahrq.gov/sites/default/files/docs/publication/r03hs018288-zhou-final-report-2011.pdf
January 01, 2011 - Clinicians may be unaware of errors due to episodic and
often hurried interactions between clinicians … annually.10
3
While medication errors are common and can cause injuries, they are often … such as omissions, duplications, dosing errors,
or drug-drug interactions. … annually.10
While medication errors are common and can cause injuries, they are often avoidable. … such as omissions, duplications, dosing errors, or drug-drug interactions.
-
digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/indication
January 01, 2023 - Principal Investigator
Lambert, Bruce
Project Name
Preventing Wrong-Drug and Wrong-Patient Errors
-
digital.ahrq.gov/sites/default/files/docs/activity/e_prescribing_impact_2009_update_2.pdf
January 01, 2009 - Business Goal: Synthesis and Dissemination
Summary: Medication errors can occur at every step in the … Medication errors that occur in the earlier stages of the process are more likely than others to be … A systems-focused, multidisciplinary approach has been useful for
preventing serious errors.
-
digital.ahrq.gov/ahrq-funded-projects/using-electronic-data-improve-care-patients-known-or-suspected-cancer
January 01, 2023 - Clinical Decision Support System , Electronic Health Record/Electronic Medical Record
Diagnostic errors … Diagnostic errors: moving beyond 'no respect' and getting ready for prime time. … Electronic Health Record/Electronic Medical Record
Defining health information technology-related errors … Defining health information technology-related errors: new developments since to err is human.