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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015284-reiling-final-report-2008.pdf
January 01, 2008 - errors, and that 1 out of 854 inpatient hospital deaths resulted from a medication error. … Medication errors and near misses. At St. … The medication error rate declined 16.5%; without wrong
technique it declined 21.2%. … The medication error rate increased by 51%, and
without wrong technique decreased by 58%. … The medication error rate declined by 56% and without wrong technique
decreased by 63%.
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digital.ahrq.gov/sites/default/files/docs/activity/2011_018250_vawdrey_pdf_3.pdf
January 01, 2011 - $99,998
Summary: When patients transfer to new health care settings, there is an increased risk of medication … errors due to incomplete or inaccurate medication information.
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2011
January 01, 2011 - Project Period
September 2009 - September 2012
AHRQ Funding Amount
$1,181,628
Summary: Medication … errors account for approximately 20 percent of all medical errors in the United States each year. … Ongoing)
Determine whether electronic facilitation alters medical reconciliation and the incidence of medication … errors in ambulatory care.
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digital.ahrq.gov/ahrq-funded-projects/decreasing-ades-montana-frontier-critical-access-hospitals-through-hit
January 01, 2023 - Populations
Type of Care
Acute Care
Health Care Theme
Adverse Events
Medication … Errors
Medication Management
The Montana Rural Healthcare Performance Improvement Network
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digital.ahrq.gov/ahrq-funded-projects/virtual-continuity-and-its-impact-complex-hospitalized-patients-care/annual-summary/2012
January 01, 2012 - A pre-post study compared the frequency of discharge medication errors before and after initiation of … 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 … Statistically significant decreases in medication errors, in both unadjusted and adjusted analyses, were … Clinically significant medication errors were rare and not significantly different between groups.
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digital.ahrq.gov/sites/default/files/docs/publication/Parisetal_HFES2008.pdf
January 01, 2008 - Cullen et al (1997) showed that the large
number of medication errors and adverse drug events (ADEs … In its 2007 report, “Preventing Medication
Errors,” the Institute of Medicine (IOM) found that latent … errors occur.” … error or ADE. … Preventing Medication
Errors. Washington, DC: National Academy Press.
11. Kumar, A.
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs015274-carayon-final-report-2009.pdf
January 01, 2009 - Adverse drug events related to a medication error (preventable ADEs) significantly
increased after implementation … Medication errors observed in 36
health care facilities. … Using information technology to
reduce rates of medication errors in hospitals. … The impact of computerized
physician order entry on medication error prevention. … Preventing Medication Errors.
Washington, DC: The National Academies Press.
Kohn, L.
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2012
January 01, 2012 - Project Period
September 2009 – July 2013
AHRQ Funding Amount
$1,181,628
Summary: Medication … errors account for approximately 20 percent of all medical errors in the United States each year. … )
Determine whether electronic facilitation alters medication reconciliation and the incidence of medication … errors in ambulatory care.
-
digital.ahrq.gov/health-care-theme/medication-safety
January 01, 2023 - Medication Safety
Identifying Sepsis Phenotypes Associated with Antibiotic-Resistant Pathogens Using Large Language Models and Machine Learning
Description
This research uses large language models and machine learning to retrospectively analyze electronic health records of pa…
-
digital.ahrq.gov/sites/default/files/docs/activity/u18hs016970-bates-annual-summary-2012.pdf
January 01, 2012 - In 2007, recognizing that health information technology (IT) has great potential to reduce medication … errors and improve patient safety, the Agency for Healthcare Research and Quality funded the Brigham … documentation of medications as compared to usual care practices, and a mod-
est decrease in serious medication … errors.
-
digital.ahrq.gov/sites/default/files/docs/medication-without-harm-slides-07242024.pdf
January 12, 2025 - errors in electronic orders.
5
Electronic Communication of Prescription
Discontinuation using CancelRx … errors.
7
Clinical Case
“A 69-year-old woman with a history of epilepsy
presented to the emergency … errors are a
major advancement in patient safety and can help healthcare
systems make ordering even … errors were
further
categorized
and quantified
Error Type No. of RAR Orders
Wrong Dose 20,153 … New RAR measures
identify wrong dose, wrong frequency, and wrong route medication errors.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024945-lambert-final-report-2022.pdf
January 01, 2022 - Scope: Medication errors, incomplete problem lists, and order abandonments are prevalent across health … and 4.6% of all medication errors were wrong-patient.2 Adelman et al. found 5246
wrong-patient orders … error. … error. … Role of Computerized Physician Order Entry Systems in
Facilitating Medication Errors.
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digital.ahrq.gov/sites/default/files/docs/activity/2011_016970_bates_pdf_3.pdf
January 01, 2011 - In 2007, recognizing that health information technology (IT) has great potential to reduce medication … errors and improve patient safety, the Agency for Healthcare Research and Quality funded the Brigham … a post-discharge
medication reconciliation module was created within the ambulatory EHR to reduce medication … errors.
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use
January 01, 2023 - Errors
Medication Reconciliation
Medication Safety
The Centers for Education and Research … errors and improve patient safety. … errors. … errors. … errors, near misses and preventable ADEs.
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digital.ahrq.gov/sites/default/files/docs/activity/health_information_technology_and_improving_medication_use_2010pdf_2.pdf
August 01, 2011 - In 2007, recognizing that information technology (IT) has great potential to reduce medication errors … a post-discharge
medication reconciliation module was created within the ambulatory EHR to reduce medication … errors.
-
digital.ahrq.gov/sites/default/files/docs/Health_IT_and_Safety_070910_comp.pdf
July 13, 2010 - documents this on the MAR
– Monitoring—assessing whether or not the patient had
an adverse effect
• Medication … errors in hospitals are common and can
have serious consequences
– Errors can occur at any stage … Journal of Nursing Administration Dec 2008
Summary: Impact on Serious Medication … Errors
MD
Pharmacist
RN Patient
Medication on
Wards
Medication
Admin Record
Dispensing … Errors
Implementation Factors
Implementation
Implementation (cont'd.)
-
digital.ahrq.gov/medication-reconciliation
January 01, 2023 - points in time; and to use that information to inform prescribing decisions and identify and prevent medication … errors. 1 This report illustrates the different approaches that AHRQ-funded health information technology
-
digital.ahrq.gov/ahrq-funded-projects/medication-safety-primary-care-practice-translating-research-practice
January 01, 2023 - Health Care Theme
Medication Safety
Quality Improvement
Quality Measurement
Medication … errors in primary care practice cause morbidity; therefore, work is needed to specify relevant measures
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digital.ahrq.gov/sites/default/files/docs/page/2006StromPepper_051211comp.pdf
May 23, 2011 - Errors:
Overall Organization
• Four projects
• Four cores:
–Administrative Core
–Data Collection … Core
–Biostatistics and Data
Management Core
–Dissemination Core
CCEB
Project 4: Medication Errors … errors
• To determine if houseofficers’
experience of workplace stress (the
cognitive, behavioral … errors
CCEB
Project 4 Study Design
• A series of cross sectional studies
• Data collection: 1 … Errors:�Overall Organization
Project 4: Medication Errors�Related to Workplace Stressors�(Ross Koppel
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs014947-porter-final-report-2007.pdf
January 01, 2007 - Minimal impact on medication errors and
incorrect actions was found during the intervention. … Key Words: pediatrics; emergency medicine; parent; medical history taking; medication errors;
documentation … Outcome: Medication Error
The primary outcome was the number of medication errors per 100 patients … This outcome
summed all medication error events inclusive of preventable adverse drug events (ADEs), … Consistent with Institute of Medicine definitions, a medication error
was defined as an error in drug