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41. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
    January 01, 2007 - WVMI produced statewide aggregated reports of numerator data (e.g., How many medication errors were … error Wrong drug name 15 1.71 2.20 0 – 2.67 2.48 Wrong dose of drug Medication error Wrong dose 16 … Medication errors compared with doses dispensed or prescriptions written have generally been reported … QI efforts focused on falls, patient flow through the emergency room, and medication errors. … Medication errors and adverse drug events in pediatric inpatients.

42. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/corbett.html
    August 01, 2017 - Full disclosure when harm occurs from a medication error is a best practice. … Introduction Health systems expend considerable resources to reduce medication errors in hospital settings … error, there are generally multiple layers of responsibility. … When harm resulted from a medication error, the second sub-theme of full disclosure emerged. 27,28 There … Stakeholders in our focus groups recognized that medication errors resulting in harm are generally multi-focal

43. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/chapter-6.html
    July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … (NCC MERP)   NCC MERP developed categories for classifying medication errors. … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below. … For more information about the classification of medication errors visit http://www.nccmerp.org .

44. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Both medication errors and procedural errors, such as performing the wrong test on a patient, were included … The most frequent type of medication error was giving the wrong dose of medication to the patient ( … Other types of medication errors included wrong medication (12 percent), wrong patient (20 percent), … Nurses’ perceptions: when is it a medication error? J Nurs Adm 1999;29(4):33–8.

45. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/medlist.html
    October 01, 2022 - This strategy helps to improve documentation because we can see the medications and decrease medication … errors. … Studies show that 5 to 7 percent of prescriptions result in a medication error. … That’s at least 160 million medication errors annually .

46. Translating Patient Safety Research into Clinical Practice (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
    January 01, 2004 - Medication errors are the primary outcome. … Introduction The Institute of Medicine has identified medication error prevention as a priority area … Efficacy or effectiveness The degree to which the medication errors have been reduced Did medication … Relationship between medication errors and adverse drug events. … The impact of computerized physician order entry on medication error prevention.

47. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
    January 01, 2004 - error. … Variables associated with medication errors in pediatric emergency medicine. … Medication error research. In: M. R Cohen (Ed.) … The impact of computerized physician order entry on medication error prevention. … Learning from medication errors. The Pharmaceutical Journal 2001 (267):287. 42.

48. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
    November 01, 2022 - Medication errors that occur at home, especially during transitions of care such as patient discharge … The preventable harms for these medication errors include adverse drug events (ADEs), unscheduled hospital … There is an increased potential for medication errors as more responsibilities of medication management

49. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-12.html
    July 01, 2022 - Medication errors are the most common health care errors. … for Safe Medication Practices (ISMP) is the Nation's only nonprofit organization devoted entirely to medication … error prevention and safe medication use.

50. Efficiency Gains with Computerized Provider Order Entry (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
    March 18, 2008 - errors. … Although much has been written about using CPOE to reduce medication errors,7, 8, 9 there is limited … Their primary endpoint was the reduction in medication errors, with secondary endpoints, such as reductions … error rate increase did not measure error rates prior to CPOE installation; the study compiled impressions … Role of computerized physician order entry systems in facilitating medication errors.

51. Appendix, Sample Letter to Discipline-Specific Leaders on Meeting Regarding Training and Implementation Strategy for Medication Reconciliation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-8.html
    July 01, 2022 - Plan [Insert Organization Logo Here] [Insert date] To [Insert Stakeholder] , Medication … errors are one of the highest single-volume sources of medical errors. … Unfortunately, many of these medication errors are associated with direct harm to patients.

52. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
    April 08, 2004 - Medication error course work was categorized under six domains: human factors research, medical errors … , medication errors, quality or process improvement, root-cause analysis, and failure mode and effects … This was chosen to be a core course because medication errors are one of the leading risks to patient … Centers for Education and Research on Therapeutics report: survey of medication errors education during … Medication error instruction in schools of pharmacy curricula: a descriptive study.

53. Medication: Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/topics/medication-safety.html
    Recent Research Studies Health literacy-informed communication to reduce discharge medication … errors in hospitalized children: a randomized clinical trial.

54. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
    March 01, 2002 - Medication error reporting is an essential component of achieving these goals. … Relationship between medication errors and adverse drug events. … Severity- indexed, incident report-based medication error- reporting program. … Comparison of medication- error detection methods in the long term care facility. … Medication errors observed in 36 health care facilities.

55. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
    June 15, 2003 - Although evidence suggests that regionwide progress has been made in increasing medication error reporting … medication errors in the Nation and is used by more than 400 hospitals.3, 11 The NNIS system is the … For MEDMARXSM, the methods used to identify potential medication errors vary across hospitals. … Some hospitals also keep separate, customized medication error databases, while other hospitals use … Medication errors: experience of the United States Pharmacopeia (USP) MEDMARXSM reporting system.

56. Risk-Based Patient Safety Metrics (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
    March 25, 2008 - Comparison of medication errors in an American and British hospital. … Medication error prevention by clinical pharmacists in two children's hospitals. … Medication errors observed in 36 health care facilities. … The problems of detecting medication errors in hospitals. … National Coordinating Council for Medication Error Reporting and Prevention; 2002.

57. Medication Management (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanagement_webinar_slides.pdf
    January 01, 2015 - Medication Management 1 Medication Management AHRQ Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Speaker Kelly Smith, PhD Scientific Director, Quality & Safety Co-PI, AHRQ Guide to Improve Patient Safety in Primary Care Settings by Engaging Patients …

58. Discussion of Findings | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/findings.html
    March 01, 2017 - the most widely studied sources of medical error in both acute and nonacute health care settings is medication … errors. 39 , 70 , 97–101 Errors occur at the prescribing, filling, and administration stages of medication … Efforts to reduce medication errors in the ambulatory care setting, including primary care, have focused … reviews of safe medication use in primary care acknowledged that much of the research aimed at reducing medication … errors has focused on single interventions.

59. Clinical Pharmacists in Emergency Medicine (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
    February 21, 2008 - Evidence to Support the Value of a Clinical Pharmacist Medication Errors in the ED Data suggest that … Medication errors in emergency department settings – 5 year review [abstract]. … Medication errors in the emergency department: A systems approach to minimizing risk. … Variables associated with medication errors in pediatric emergency medicine. … Justifying a pediatric critical-care satellite pharmacy by medication-error reporting.

60. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201509.html
    January 01, 2018 - The Institute of Medicine has identified medication errors as the most common type of error in health