Results

Total Results: 4,347 records

Showing results for "errors".
Users also searched for: medication errors

41. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - Introduction The Risk from Medication Errors Medication errors are the most common source of risk … The index has a reported kappa value of κ = 0.62.19 Category B errors are actual errors that were intercepted … CAHs that reported 8,087 medication errors and 143 NFCHs that reported 159,519 errors (Table 2). … Harmful errors (Categories E - I) accounted for approximately 2 percent of reported errors from the … Reporting of Errors by Pharmacy Personnel Of the 156,089 actual errors reported (Categories B - I)

42. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14283-Dresselhaus-draft-1.pdf
    September 29, 2005 - is key to preventing or reducing many such errors. … Nurse ¥ Infusion errors ¥ Self-reported errors ¥ Pharmacist interventions Adverse Drug Events Data … medication errors. … Real-time assessment of risk factors for medication errors. … is key to preventing or reducing many such errors.

43. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
    March 21, 2008 - Errors were identified in 84 of the cases (34.1 percent). … Not all errors result in harm to a patient; some errors are discovered before harm takes place. … Errors were identified for 84 of the medication management encounters (34.1 percent); 67 errors (80 … percent) were chart documentation errors. … The chart review identified 66 additional errors, mostly documentation errors; 16 of the errors (19.1

44. S2: Using EHR-Based Simulations to Reduce Diagnostic Errors in Ambulatory Care Settings | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s2-gold-ratwani.html
    May 01, 2024 - Investments in Primary Care Research for 2021 and 2022 S2: Using EHR-Based Simulations to Reduce Diagnostic Errors … Use of electronic health records (EHRs) can contribute to diagnostic errors, often because of system … powerful tool that can be used to both systematically study the ways EHRs contribute to diagnostic errors … data to identify diagnoses at risk for diagnostic error in ambulatory care settings and the EHR use errors … associated with those errors.

45. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
    January 01, 2004 - Discussion: Approaches to classifying medical errors vary widely. … errors. … , errors involving patient care outside of the office, and errors in the referral Advances in Patient … Discussion Approaches to classifying medical errors vary widely. … A preliminary taxonomy of medical errors in family practice.

46. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/Pace.pdf
    January 01, 2004 - Discussion: Approaches to classifying medical errors vary widely. … errors. … , errors involving patient care outside of the office, and errors in the referral Advances in Patient … Discussion Approaches to classifying medical errors vary widely. … A preliminary taxonomy of medical errors in family practice.

47. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
    June 01, 2023 - ED-Specific Contributors to Diagnostic Challenges and to Diagnostic Errors and Uncertainty EDs are … in the ED are generally considered multifactorial. 19 In addition to being common, diagnostic errors … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … . 12 , 15 ED-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Because of … In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors.

48. A Conceptual Model for Disclosure of Medical Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
    January 01, 2004 - Results: All groups believed that errors should be disclosed. … And medical errors, we could dialogue with in a pretty decent way.” … of Medical Errors 493 more common and less frequently revealed. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors. … A study of the ethical duty of physicians to disclose errors.

49. The Use of Surgical Simulators to Reduce Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
    January 01, 2003 - The Use of Surgical Simulators to Reduce Errors 165 The Use of Surgical Simulators to Reduce Errors … As with flight simulation, near miss detection capabilities anticipate potential errors before they … Some errors, such as “wrong tool choice,” were assigned simple “yes” or “no” measures. … Surgical Simulators for Reducing Errors 173 Table 1. … Surgical Simulators for Reducing Errors 177 28. Gallagher AG, Satava, RM.

50. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
    September 01, 2020 - among LEP Patients Improve Reporting of Medical Errors for LEP Patients Routinely Monitor Patient … Safety for LEP Patients Address Root Causes to Prevent Medical Errors among LEP Patients … among Patients with LEP Improve Reporting of Medical Errors for LEP Patients Routinely Monitor … Patient Safety for LEP Patients Address Root Causes to Prevent Medical Errors among LEP Patients … Errors in medical interpretation and their potential clinical consequences in pediatric encounters.

51. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
    March 01, 2020 - Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating … errors. … Patient Identification Errors. 2016. … One evidence review examined errors in intensive care units. … Patient Identification Errors in the Operating Room PRISMA Diagram Appendix B.

52. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - Of the medication errors reviewed, errors resulting in permanent harm accounted for 18 percent, near-death … errors accounted for 48 percent, and errors resulting in death accounted for 23 percent of the reports … Analysis of New York Medication Errors 135 Figure 1. … This finding is not unexpected, as 90 percent of the errors involved administration of a drug (errors … The pharmacist or nurse may intercept prescribing errors and the nurse may catch dispensing errors.

53. Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/issue-brief-diagnostic-error.html
    September 01, 2023 - Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … describes strategies for improving clinician psychological safety in reporting and discussing diagnostic errors … The brief highlights specific barriers and challenges to reporting and learning from diagnostic errors

54. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
    January 01, 2025 - Most studies on patient safety focus on errors of commission rather than errors of omission. … Errors of omission are difficult to identify and measure. … ECOS is a survey tool designed to measure errors of omission in primary care. … System-related factors contributing to diagnostic errors. … Reducing errors of omission in chronic disease management.

55. Final Progress Report: Reducing Harm to Patients from Diagnostic Errors (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/berner-report.pdf
    January 01, 2025 - Final Progress Report: Reducing Harm to Patients from Diagnostic Errors Final Progress Report Reducing … Harm to Patients from Diagnostic Errors Eta S. … A second diagnostic errors conference, led by Dr. … Dual processing and diagnostic errors. … Diagnostic errors in ambulatory care: dimensions and preventive strategies.

56. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - errors that are harmful. … , not in all errors that occurred. … Outpatient errors involved significantly more dispensing errors (p < 0.001) and more errors due to … Family notification of medication errors was reported in only 12% of errors. … errors; most of these errors involved patients <6 months of age.

57. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
    January 01, 2024 - Final Progress Report: Putting a Face on Hospital Medical Errors: Communication FINAL REPORT Putting … a Face on Hospital Medical Errors: Communication Project funded by: Agency for Healthcare Research … Patient’s and Physicians Attitude Regarding the Disclosure of Medical Errors. … Health Plan members’ Views about Disclosure of Medical Errors. … Communicating with Patients about Medical Errors.

58. The Potential of Psychological Safety and Organizational Safety Culture To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-psychological-safety-2.html
    September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors … concept is generally used in patient safety to encourage transparent and open discussion of hazards and errors … The goal of reporting and analyzing errors should be to promote insight, create solutions, and enable … firmly embedded in patient safety, but evidence is limited around their role in addressing diagnostic errors

59. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
    June 01, 2020 - Overcoming Barriers and Taking Next Steps Conclusion References Defining Diagnostic Errors … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. … Valid and reliable measurement of diagnostic errors results in collective mindfulness, organizational … The Safer Dx framework underscores that diagnostic errors can emerge across multiple episodes of care … Unknown scope and frequency of errors.

60. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.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 … Perceptions of Safety and Medical Errors from Patients’ Perspectives Four past findings have relevance … They were, in fact, directly related to the hole in my new valve….No one spoke to me about the errors … Types and prevalence of patient/family-reported diagnostic errors Type of Diagnostic Error