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121. Veinte consejos para ayudar a evitar errores médicos | Agency for Healthcare Research and Quality
     www.ahrq.gov/patients-consumers/care-planning/errors/20tips/20tipssp.html
     August 01, 2018 - Veinte consejos para ayudar a evitar errores médicos Los errores médicos pueden ocurrir en cualquier parte del sistema de atención médica: en hospitales, clínicas, centros de cirugía, consultorios médicos, hogar de ancianos, farmacias y en el hogar de los pacientes. Estos consejos le indican qué pue…

122. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
     January 01, 2024 - that are potential ADEs Entire pharmacy Pre & post Review of medication dispensing errors by … that are potential ADEs and ii) ADEs due to medication transcribing and administering errors 2 ➢ … Measures included target dispensing errors, defined as dispensing errors that barcode technology was … Gandhi 4.16.07 6 pharmacy with undetected errors. … How many hospital pharmacy medication dispensing errors go undetected?

123. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis … of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, … nature of nurses’ work and the relationship interruptions and cognitive load may have on omissions and errors … Introduction The occurrence of medical errors within the acute care environment, as reported in To … Individual, practice and system causes of errors in nursing: a taxonomy.

124. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
     January 01, 2004 - These could be administrative or clinical errors. … The most commonly reported health process errors in all three studies were office administration errors … Errors in the first two studies were reported only by physicians, but errors in the third study were … AAFP study, all errors were coded. … that might avert testing process errors.

125. Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/ambulatory-pediatric-long-desc.html
     January 01, 2025 - Period: 09/30/18-09/29/23 Description: The overarching goal of this research was to reduce medication errors … medication dosing based on clinical information gathered by the patient/family to prevent medication errors … For example, more than half of the T1D patients involved in home visits had medication errors, at a rate

126. Final Progress Report: Staff Nurse Fatigue and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
     January 01, 2024 - The most common errors were dosing errors (28%) followed by the wrong choice of drug and errors of … any errors or near errors that might have occurred during their work periods. … All errors, near misses, and discovered errors (errors made by others and discovered by nurses) were … did not make errors. … The frequency and type of errors and near errors reported by critical care nurses.

127. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - Detecting and reporting medical errors: why the dilemma? BMJ 2000;320(7237):794–6. 7. … Medication errors. Causes prevention, and risk management. … House passes bill to track medical errors. The Washington Post; Mar 12, 2003. … Taxonomy of medication errors. … Ranked top 10 inpatient products involved in errors that reached the patient, Table 4.

128. Final Progress Report: Application of Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/singh-report.pdf
     January 01, 2025 - Progress in reducing diagnostic errors is slow partly due to poorly defined methods to identify errors … cases of ED-based diagnostic errors.2,9,10,11 About half of all diagnostic errors have potential for … limitations of lower reviewer agreement for diagnostic errors. … Triggers such as those used in this study inevitably missed some errors, especially errors related to … in addition to diagnostic errors.

129. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - Reported events are only a subset of all medical errors that occur. … Case example: diagnostic testing errors We selected diagnostic testing errors for analysis because … by communication errors, especially to the clinician of record; missing information; procedural errors … Although reported medical errors, like errors in general, typically involve a series of actions gone … , communication errors, and errors involving clinicians and nonclinicians.

130. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - • Insight into causes, cascades, and consequences of errors. … and opportunities for errors, including errors that may occur in transitions between different parts … in rates of errors but may merely represent differences in reporting behavior. … necessarily the errors that occur most frequently. … and discourage blame and punishment for errors that are due to systemic problems.

131. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
     January 01, 2016 - Quality Measures xxVoluntary Reporting Chart Reviews Trigger Tools Automated Measures • 1% of errors … reported • Good for analysis of errors • Not useful as an outcome measure to test interventions … Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … Medication Errors in Pediatric Inpatients Charts reviewed of 1120 patients.

132. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - in the prevention of medical errors, 4) disclosure of medical errors, and 5) physician support following … Medical errors in the outpatient setting: Ethics in practice. … Patients’ concerns about medical errors during hospitalization. … Physicians’ Need for Support Following Medical Errors. … Physicians’ need for support following medical errors.

133. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role-references.html
     September 01, 2024 - Learning from patients’ experiences related to diagnostic errors is essential for progress in patient … Americans’ Experiences With Medical Errors and Views on Patient Safety. … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Types and origins of diagnostic errors in primary care settings.

134. Final Report: Improving Drug Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/magid-report.pdf
     January 01, 2024 - The primary outcome of the study will be the occurrence of medication errors. … Any strategy employed alone, however, cannot eliminate medication errors (Ballentine et al 2003). … , administration route errors, drug substitution errors, and errors involving drug allergies (Bates … When potential errors are detected, alerts are triggered. … All three projects resulted in a measurable decrease in medication errors.

135. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - Errors have structures that can be described using a systems approach to errors and using a cognitive … it would be uncommon to see errors documented explicitly as errors. … Case-based reasoning on an errors database Reported errors are collected into an errors database. … When new errors are reported, patient safety personnel need to determine whether similar errors have … Errors terminology Identifying and characterizing medical errors requires an error terminology.

136. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety1.html
     September 01, 2022 - To Improve Diagnosis and Suggested Questions for Debriefing Case Studies Diagnostic errors … problem solving, to recognize and encourage nurses as important contributors to reducing diagnostic errors

137. AHRQ’s Work Helps Convince Army Medical Center to Reinstate E.D. Clinical Pharmacist | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201519.html
     July 01, 2015 - Influenced by AHRQ-sponsored research showing how clinical pharmacy services can reduce medication-related errors … Cartwright to start a clinical pharmacy program in the ED in order to reduce medication-related errors

138. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
     May 01, 2016 - Summary Report Director's Update Health Information Technology Real World Use of MEPS Diagnostic Errors … Return to Contents Diagnostic Errors Elizabeth A. … the results of a large study, conducted by the Institute of Medicine (IOM), on reducing diagnostic errors … AHRQ and others should encourage and facilitate the voluntary reporting of diagnostic errors and near … is focusing on three goals from the IOM report—goal 6 concerning improving learning from diagnostic errors

139. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - 21% more serious medication errors (p=0.03) and over five times as many serious diagnostic errors … In this study, we focused on procedural and diagnostic errors in addition to medication errors. … This includes preventable adverse events, nonintercepted serious errors, and intercepted serious errors … Errors with little or no potential for harm are not serious errors, nor are nonpreventable adverse … Analysis of the types of all errors (intern errors plus errors in which interns were not involved) showed

140. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Prescribing errors. … In Medication Errors. 2nd ed. … Root cause analysis of medication errors. In Cohen MR ed. Medication Errors. 2nd ed. … In Medication Errors. 2nd ed. … In Medication Errors. 2nd ed.