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61. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
    January 01, 2024 - Key Words: drug name confusion, nomenclature, patient safety, auditory perception, medication errors … One in six medication errors involves name confusion. … An evaluation of the quality of the USP/ISMP Medication Error Reporting Program. … Medication errors. Washington, DC: American Pharmaceutical Association; 1999. 5. … Preventing medication errors. Washington, DC: The National Academies Press; 2007. 6. Davis NM.

62. A System to Describe and Reduce Medical Errors in Primary Care (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-Kaprielian_9.pdf
    January 01, 2007 - relating to diagnostic studies—are different from the category most commonly cited in prior studies—i.e., medication … errors.8 Some of the issues with diagnostic studies have related to the complexities of a teaching … Medication errors may occur less frequently due to an emphasis in the electronic medical record on medication … medication error deaths between 1983 and 1993. Lancet 1998; 351: 643-644. 5. Gaba DM.

63. AHRQ-Funded Patient Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
    June 01, 2023 - When compared with paper order entry, CPOE was associated with half as many pADEs and medication errors … Key Findings/Impact: Investigators sought to reduce medication errors for three high-risk groups: patients … All three projects resulted in a measurable decrease in medication errors and these improvements were … errors. … Errors?

64. Clinical Inertia and Outpatient Medical Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
    January 01, 2003 - Medication errors observed in 36 health care facilities.

65. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
    ce.effectivehealthcare.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 - of chemotherapy to hospitalized children.3 , 4 , 5 e There is a consensus that most general medication … errors, and pediatric chemotherapy errors in particular, occur at the prescribing/ordering step.6 , … Prevention of medication errors in the pediatric inpatient setting. … Prevention of medication errors in the pediatric inpatient setting.

66. Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
    January 01, 2004 - One preliminary study5 examined the effect of basic computerized prescribing on medication errors in … Of these studies, two demonstrated a marked decrease in the serious medication error rate, one showed … errors. … The impact of computerized physician order entry on medication error prevention. … Impact of basic computerized prescribing on outpatient medication errors and adverse drug events.

67. Development of a Comprehensive Medical Error Ontology (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-Mokkarala_103.pdf
    June 16, 2008 - error reporting,10 primary care error taxonomy8), such application-specific and oft organization-specific … Errors has a very detaile classification of product labeling issues as a cause of error that is not … errors • Lack of intervention on the patient’s behalf • Lack of prevention • Missed or mistaken … National Coordinating Council on Medication Error Reporting and Prevention. … Taxonomy of medication errors. Available at: www.nccmerp.org/pdf/taxo2001- 07-31.pdf.

68. Chapter 1. Building the Project Foundation: Gaining Leadership Support Within the Organization | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/chapter-1.html
    July 01, 2022 - Justification for Medication History Collection and Reconciliation on Admission Average # of discrepancies/medication … errors per patient 2.2 Number of inpatient admissions per year 43,312 (2006) Potential medication … errors per year that can be avoided 95,286 (2.2 x 43,312) Percent of medications that were potentially … harmful to patient during hospitalization * 2.5% Number of harmful medication errors avoided per

69. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
    January 01, 2003 - error (ME), medication error that leads to an adverse drug event (ADE/ME), or no event. … A medication error was defined as any error that occurred in the medication use process (including ordering … Medication errors that caused an injury were called preventable ADEs. … Increase in US medication-error deaths between 1983 and 1993. The Lancet 1998;351:643–44. 2. … Relationship between medication errors and adverse drug events.

70. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
    January 01, 2020 - of researchers at AHRQ have published studies on patient safety, such as documenting the impact of medication … errors.

71. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
    April 23, 2004 - medication errors and close calls. … A full one-third of the offices had no outlined procedure for responding to a serious medication error … However, it is encouraging that when a staff member actually experienced a medication error, 45 percent … Medication errors in ambulatory care. … Impact of hand- held technologies on medication errors in primary care.

72. Chapter 7. High-Risk Situations for Medication Reconciliation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/chapter-7.html
    July 01, 2022 - not understand prescription instructions and warning labels, and they may be at increased risk for medication … errors and non-compliance. … they have basic or below basic health literacy levels. 11 Limited health literacy is associated with medication … errors, increased health care costs, and inadequate knowledge of and care for chronic health conditions

73. Chapter 1. Building the Project Foundation: Gaining Leadership Support Within the Organization | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-1.html
    July 01, 2022 - Justification for Medication History Collection and Reconciliation on Admission Average # of discrepancies/medication … errors per patient 2.2 Number of inpatient admissions per year 43,312 (2006) Potential medication … errors per year that can be avoided 95,286 (2.2 x 43,312) Percent of medications that were potentially … harmful to patient during hospitalization * 2.5% Number of harmful medication errors avoided per

74. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (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-Simmons_66.pdf
    April 03, 2008 - Voluntary medication error reporting program in a Japanese national university hospital. … One hospital’s journey toward reducing medication errors. … Medication errors. Washington, DC: APhA Publications; 2006. 10. Institute of Medicine. … Medication error identification is a key to prevention: A performance improvement approach. … Reduction of adverse drug events and medication errors in a community hospital setting.

75. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/references.html
    July 01, 2022 - Preventing Medication Errors: Quality Chasm Series , 2006. … http://iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx .

76. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - Events relating to medication errors Medication related errors are one of the most common types of … errors and that 1 out of every 854 inpatient hospital deaths resulted from a medication error. … While not all medication errors result in harm, those that do can be costly. … errors and adverse events caused by latent conditions and active failures. … A USP study on medication errors at U.S. hospitals. Rockville, MD: Pharmacopeia; 2002. 4.

77. Adverse Drug Events (ADE) | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/topics/adverse-drug-events-ade.html
    Recent Research Studies Health literacy-informed communication to reduce discharge medication … errors in hospitalized children: a randomized clinical trial. … Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory

78. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncilref.html
    April 01, 2018 - Institute of Medicine, Preventing Medication Errors , Quality Chasm Series. … Medication Errors . 2nd edition. Washington, DC: American Pharmacists Association; 2007.

79. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
    February 21, 2008 - Urgency for Interventions Related to Medication Errors Nearly one in every five medication doses in … Medication error rates depend on how these rates are measured. … errors also add to costs. … Medication errors observed in 36 health care facilities. … Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities

80. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
    May 01, 2023 - Errors Reporting Program, this web page provides a comprehensive list of commonly confused medication … Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions … Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primers/primer … Errors and Adverse Drug Events Patient Safety Primer: Teamwork Training Plan-Do-Study-Act (PDSA) Steps … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.