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141. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
     January 01, 2024 - errors of severity category B (p < 0.0001). … that reported 8,087 medication errors and 143 NFCHs that reported 159,519 errors. … Harmful errors (categories E through I) accounted for approximately 2% of reported errors from the … Taxonomy of medication errors. … Medication errors observed in 36 health care facilities.

142. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - The errors and issues described in the cases also were of a diverse nature. … Among the published cases, the most common were diagnostic errors (27 percent), medication errors ( … Thirty-seven errors (67 percent) occurred in hospital, while 8 errors (14.5 percent) occurred in emergency … Discussion of medical errors in morbidity and mortality conferences. … A system of analyzing medical errors to improve GME curricula and programs.

143. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
     January 01, 2024 - Scope Earlier research suggests that medication errors, excluding wrong-time errors, average 10% or … , including wrong-time errors. … Although the ICC was lower when considering medication errors without wrong-time medication errors ( … between the rate of interruptions and medication errors when wrong-time medication errors were included … when considering the variable that only included medication errors excluding wrong-time errors (p=

144. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
     January 01, 2024 - other types of MEs (e.g., prescribing errors due to missing information or errors in spelling). … , including errors in ordering medications (13%) and errors in implementing medication orders (6%).1 … reducing such errors. … monitoring errors. … other types of MEs (e.g., prescribing errors due to missing information or errors in spelling).

145. Development of a Comprehensive Medical Error Ontology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
     June 16, 2008 - An ontology of medical errors is one approach to solving the problem. … • Capture the richness of the domain of errors and adverse events. … A preliminary taxonomy of medical errors in family practice. … A system of analyzing medical errors to improve GME curricula and programs. … Individual, practice, and system causes of errors in nursing: A taxonomy.

146. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - errors (38/1000 doses). … Transcription errors are an important contributor to medication errors,14 but 2 relatively few studies … these transcription errors. … Research on drug-use-system errors. … Calculation and expression of rate errors were found in 17.5% of errors; 13.4%of errors involved incorrect

147. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - 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 … some legitimate concerns that patients and their families: Might be unaware of certain types of errors … recent years. 12,13,14,15,16,17 Investment in learning from patients’ experiences about diagnostic errors … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors

148. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
     January 01, 2005 - Prescribing errors This paper reports on errors observed by evaluation of the face of a prescription … , including legibility errors, errors of omission, errors of commission, and errors of interpretation … The frequency of medication errors was determined by counting the total number of errors attributed … Impact of PDA use on prescribing errors The frequency of medication errors was compared between pre- … Impact of PDA on prescriber medication errors The results of the impact of PDA use on prescribing errors

149. Final Progress Report: Improve Safety, Quality, and Efficiency in Radiotherapy with Automated HIT System (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/yang-report.pdf
     January 01, 2024 - total errors. … , patient setup errors, and treatment plan errors [53, 60]. … However, detecting errors based on manually defined rules is limited. … , for example, prescription errors. … 40% errors, and potentially prevent the most severe errors in real time.

150. Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/crane-report.pdf
     January 01, 2024 - Reducing medical errors 3. Promoting evidence-based care 4. … : both active errors and latent errors • Safety targets: medication prescribing, patient identification … PAs also agreed that making errors in medicine is inevitable. … share information about errors and their causes. … PAs make errors.

151. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
     October 01, 2020 - facilities can minimize such safety problems as health care-associated infections, patient falls, medication errors … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries

152. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
     March 01, 2024 - Among those patients, about 18 percent of errors caused temporary harm, permanent harm, or death. … The urgent need to reduce these errors—which include diagnoses that are either inaccurate, delayed, or … Safety Centers of Excellence are working to better characterize, understand, and measure diagnostic errors … as improving diagnosis in pediatric care, how to best learn from patient experiences, how diagnostic errors … They underscore the imperative to mitigate diagnostic errors and harm.

153. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/preface.html
     May 01, 2016 - feasibility and promise of collecting information from health care professionals about adverse events, errors … structured data about concerns that patients have about the safety of their health care, including errors

154. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
     March 19, 2008 - Given this need, near-miss chemotherapy ordering errors, and research that identifies the prescribing … /ordering step as a significant source of pediatric chemotherapy errors, Memorial Healthcare System … Standardized Pre-B ALL Standard Induction order form 6 errors continues. … Prevention of medication errors in the pediatric inpatient setting. … Prevention of medication errors in the pediatric inpatient setting.

155. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - The most common types of errors were inappropriate abbreviations, followed by dosing errors. … The most frequent cause of errors was illegibility. … of 6.3 serious medication errors per 1000 patient-days. … a high rate of nursing transcription errors (20%). … Overall, we found a total of 219 IV medication errors.

156. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - errors (44 percent); errors in diagnosis (17 percent); failures of prevention (12 percent); and errors … of Errors 1. … TabId=1 Abstract Introduction Dimensions of Medical Errors Preventing Errors in Health Care Errors … System-Change Participation Diagnosis Errors Treatment Errors Monitoring Errors Infection Control … Errors Communication Errors Conclusion Author Affiliations References

157. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
     January 01, 2024 - • What are best practices for identifying errors? … • Can a taxonomy of errors improve error reporting? … How does team participation affect medication errors? … ) and adversely (fatigue can increase errors)? … • Do magnet hospitals have lower rates of medication errors?

158. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
     February 01, 2025 - Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors. … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … , and develop ways hospitals, clinicians, and patients can work together to avoid diagnostic errors and … Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … Project Aims: Characterize the diagnostic journey, focusing on successes, errors, and patient/family

159. Impoving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/Improving_diagnosis_flyer.pdf
     April 01, 2019 - ■ Diagnostic errors affect more than 12 million Americans each year and may seriously harm approximately … ■ Fifty-five percent of patients said diagnostic errors were a chief concern in outpatient visits … AHRQ is also funding research to better understand how diagnostic errors happen, what can be done to … It outlines three key areas of interest: ■ Quantifying the incidence of diagnostic errors. … ■ Understanding what contributes to these errors.

160. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot … Program 223 Identifying, Understanding, and Communicating Medical Device Use Errors: Observations … This typically occurs in organizations that have a “blaming” culture when errors occur. … Medical Device Errors—FDA Pilot Program 227 Further details about a report can be obtained through … Medical Device Errors—FDA Pilot Program 233 Author affiliations Center for Devices and Radiological