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digital.ahrq.gov/sites/default/files/docs/page/2006LeonhardtPagel_052411comp.pdfJune 01, 2006 - Patient Safety Council Kathy Leonhardt, MD, MPH Patti Pagel, RN Aurora Health Care June 2006 Medication … Medication Safety Patient Role • One out of 4 patients do not follow physician advice, primarily due … Identify and implement interventions through out the community • Measurements: Accuracy of medication … Medication bag 2. Personal medication list 3. Computer programs for providers 4. … medication list = • A • B • C_____________ Inaccurate: • D (on chart but not taken by patient) OR
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Connecting for Health Common Framework Resources for Implementing Secure Health Information Exchange (pdf file)
digital.ahrq.gov/sites/default/files/docs/E-Prescribing%20and%20Medication%20Management%20(1).pdfMarch 31, 2009 - Staff review and call back if needed Select medication; check current medication list for drug interaction … or duplication Select medication; check current medication list for drug interaction or duplication … Pink box means expected change with Medication History. Yellow box for F&B. … Medication History for Hospitals • Provides clinicians convenient access to up-to- date medication … ��dbell@rand.org � Generating Accurate Medication Information Need for Medication Lists Accurate -
digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2010January 01, 2010 - errors occur when a patient receives an incorrect medication because its name is spelled like or sounds … like another medication. … While medication errors have been studied in the pediatric population, the frequency of LASA-specific … The error rates of these 200 medication pairs will then be estimated by reviewing patient medication … To measure the error rates of the final list of medication pairs, the team will review patient medication
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digital.ahrq.gov/sites/default/files/docs/activity/2011_017072_lobach_pdf_3.pdfJanuary 01, 2011 - The clinic-directed intervention generated medication management reports displaying a 1-year list of … (Achieved) • Implement and evaluate the impact of two complementary interventions for medication … because of apparent ineffectiveness, when the actual issue was nonadherence to the medication. … The perceived value of the medication management project intervention led the Medicaid care management … management via the integration and utilization of medication management systems and technologies.
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Slide 1 (ppt file)
digital.ahrq.gov/sites/default/files/docs/page/Strom.pptMay 28, 2005 - Slide 1 CCEB IMPROVING PATIENT SAFETY BY REDUCING MEDICATION ERRORS Brian L. Strom, M.D., M.P.H. … Use Process PRIME: Program for Reduction In Medication Errors CCEB OVERALL APPROACH Focus - the … occurrence of errors anywhere along the entire pathway of medication use Drugs with ubiquitous use … errors To determine if houseofficers’ experience of workplace stress affects the risk of medication … CCEB Center for Excellence in Patient Medication Safety: Investigative Teams Brian L. -
Using Information Technology for Patient-Centered Communication and Decisionmaking about Medications (pdf file)
digital.ahrq.gov/sites/default/files/docs/activity/using_information_technology_for_patient_centered_communication_and_decisionmaking_about_medications_2010_pdf__2.pdfJanuary 01, 2010 - Medication management in primary care is extremely complicated, given the continually expanding array … Patients then review the medication information contained within the system, indicating if there are … The physician will then clarify any issues with the patient and update the patient’s medication list … If a new medication is prescribed, the system will generate a plain-language medication information … (Achieved) • Use the EMR to encourage patient-centered medication management and extend the EMR medication -
digital.ahrq.gov/sites/default/files/docs/publication/r01hs014947-porter-final-report-2007.pdfJanuary 01, 2007 - All medication orders were written on paper. … Outcome: Medication Error The primary outcome was the number of medication errors per 100 patients … Evaluation of ED-Based Medication Actions. … The nurse reviewed all available medication- related evidence, including medication order sheets, medication … The interface design for capture of medication data considers how a patient might recognize a medication
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017248-adams-final-report-2011.pdfJanuary 01, 2011 - Each call also addressed medication safety examining: 1) what medications on the EHR medication list … the child was actually taking; 2) age appropriate medication use; and 3) if taking asthma medication … Fever and cold medication use and dosing of liquid medication (0-11 yrs) Outcome(s) % of families … with inappropriate medication use, Number of medication errors detected by PHP, number of medication … If on a controller medication: Inform family of action of controller medication with clinician and
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018151-smith-final-report-2013.pdfJanuary 01, 2013 - The primary outcome was discharge medication errors. … PCPs wanted a brief description of the hospital course, discharge medication and medication reconciliation … The frequency of unintended medication variances (medication errors) was found to be lower during the … 1,009 (29) 814 (29) Medication error 645 (18) 359 (13) Clinically important medication error … medication errors: a quasi-experimental study.
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Appendix A to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations (pdf file)
digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixA.pdfJanuary 01, 2010 - More than 80% of patients have at least one entry recorded as structured data Maintain active medication … lists, medication allergies) More than 50% of requesting patients receive electronic copy within … orders More than 30% of patients with at least one medication in their medication list have at least … one medication ordered through computer provider order entry Implement drug-drug and drug-allergy … reconciliation between care settings Medication reconciliation is performed for more than 50%of -
National Teleconference February 2011 (pdf file)
digital.ahrq.gov/sites/default/files/docs/better-medication-management-slides-021611.pdfFebruary 16, 2011 - Preventing Medication Errors: Quality Chasm Series. … Adverse drug events causes by medication errors in medical inpatients. … Retrospective analysis of mortalities associated with medication errors. … Develop a set of medication safety indicators relevant to primary care 2. … Safety Measures Over Time Medication Error Prevention Strategies Practice Strategies Accurate Medication -
digital.ahrq.gov/sites/default/files/docs/publication/r18hs017072-lobach-final-report-2011.pdfJanuary 01, 2011 - Demonstrate the ability to produce medication management reports and medication alert notices in the … Evaluate Economic Impact of Medication Management System. … Sample medication report Figure 3. … adherence rates by medication and medication class and to detect probable low medication adherence. … discussing medication adherence issues with a patient.
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National Web-Based Teleconference on Health IT: Putting the Patient Back in Patient-Centered Care (pdf file)
digital.ahrq.gov/sites/default/files/docs/patient-centered-care-slides-033011.pdfMarch 30, 2011 - PHR medication screen Medication warnings on home page IowaPHR tracking health information … inventory, medication management behaviors, SF-12 v2, demographics • ACOVE-3 measures of medication … list 219 (42.9) 574 Previous Medication List 36 (7.1) 52 Medication Warnings 24 (4.7) 34 Wallet Sized … M. and Avorn, J. (2007), Quality Indicators for Medication Use in Vulnerable Elders. … Iowa PHR Iowa PHR login screen Iowa PHR welcome screen Iowa PHR medication screen Iowa PHR medication -
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015400-brown-final-report-2008.pdfJanuary 01, 2008 - The goal is to increase the number of medication errors reported. … Count of severity levels for reported medication errors Figure 1c. … Count of where in process the reported medication error occurred Figure 2b. … Count of severity levels for reported medication errors Figure 4c. … C ount o f st aff who d is covered the rep orted medication error Figure 9a.
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digital.ahrq.gov/ahrq-funded-projects/evaluation-effectiveness-health-information-technology-based-care-transition/annual-summary/2011January 01, 2011 - Patient clinical outcomes include patient adherence to medication instructions after discharge, patient … receipt of reconciled medication lists, hospital readmission rates, ambulatory followup visits, and … The final medication reviews, to verify the accuracy of patient-friendly medication lists distributed … at discharge and EHR medication lists at time of telephone call were conducted via telephone and chart … reconciliation, and medication correctness (i.e., whether medications are being taken correctly).
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digital.ahrq.gov/sites/default/files/docs/activity/r18hs017864-ciemins-annual-summary-2012.pdfJanuary 01, 2012 - receipt of reconciled medication lists, hospital readmission rates, ambulatory followup visits, and … A second intervention modified the EHR-based medication reconciliation process. … Secondary outcomes included medication reconciliation, patient medication adherence and accuracy, and … medication list, and patient report. … of information collected at admission, and completeness of patient discharge medication list.
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digital.ahrq.gov/principal-investigator/farris-karenSeptember 13, 2018 - Artificial Intelligence-Adapted Text Messages Role of Health IT to Improve Medication … September 13, 2018 - 2:30pm This AHRQ webinar addressed the potential of health IT to improve medication … monitoring, adherence, and medication therapy management for patients with complex conditions. … system for patients with chronic conditions, the effects of a smart pillbox intervention on patient medication … discharge, and recommendations for clinical decision support used by community pharmacists delivering medication
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digital.ahrq.gov/ahrq-funded-projects/virtual-continuity-and-its-impact-complex-hospitalized-patients-care/annual-summary/2012January 01, 2012 - A pre-post study compared the frequency of discharge medication errors before and after initiation of … Primary care physicians wanted a brief description of the hospital course, discharge medication and medication … Differences in medication errors remained statistically significant on multivariable analysis adjusting … No significant differences were seen between groups in clinically important medication errors or in 30 … Clinically significant medication errors were rare and not significantly different between groups.
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digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety/annual-summary/2009January 01, 2009 - management via the integration and utilization of medication management systems and technologies. … However, due to the complicated nature of pediatric medication administration, CPOE would bring greater … During August 2005, smart pump technology for syringes was implemented to prevent medication errors at … Also, in summer 2006, the pharmacy completed a Six Sigma project targeting a reduction in medication … ADE rates, since they include known, expected medication side effects, were more variable across the
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015430-gurwitz-final-report-2008.pdfJanuary 01, 2008 - administration process, from arranging the medication cart to completion of medication administration … All residents who were scheduled to receive medication during the observed medication administration … Morning medication time periods took place between approximately 7:30 am and 9:30 am, noon medication … The steps in the medication administration process were: 1) organize medication cart and obtain supplies … ), 4) prepare resident to receive medication, 5) provide medication to resident, 6) observe resident
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