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digital.ahrq.gov/2018-year-review/research-spotlights
January 01, 2018 - Safety—Especially for Children
A Prototype Computerized Provider Order Entry System Reduced Medication … Errors
Leveraging Health IT to Test Solutions that are Replicable, Scalable, and Improve
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digital.ahrq.gov/2018-year-review/research-spotlights/leveraging-health-it-test-solutions-are-replicable-scalable-and
January 01, 2018 - Leveraging Health IT to Test Solutions That Are Replicable, Scalable, and Improve Patient Safety
Impact
“Studies like that by Adelman and colleagues point the way to the creation of a digital learning health care system, in which the results of the interactions between clinicians (and, increasingly, patients …
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digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
June 16, 2021 - Joseph’s Hospital)
Key Challenges in Reducing
Medication Errors
Maintain a complete, accurate, … and Safety
Overview of Patient-and Family-Centered Health IT and Safety
Key Challenges in Reducing Medication … Errors
What Did We Learn?
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digital.ahrq.gov/ahrq-funded-projects/medication-safety-primary-care-practice-translating-research-practice/annual-summary/2010
January 01, 2010 - Medication Safety in Primary Care Practice - Translating Research Into Practice - 2010
Project Name
Medication Safety in Primary Care Practice - Translating Research into Practice
Principal Investigator
Ornstein, Steven
Organization
Medical University of South Carolina
…
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digital.ahrq.gov/principal-investigator/reiling-john
January 01, 2023 - Implemented an Epic health IT system and diffused the system community-wide; identified the prevalence of medication … errors, near misses, and preventable adverse drug events; assessed costs and customer satisfaction both
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digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
January 01, 2005 - Recommendations,
con’t
• Active Failures
– Operative/Post-Op Complications/Infections
– Events Relating to Medication … Errors
– Deaths of Patients in Restraints
– Inpatient Suicides
– Transfusion Related Events
– Correct
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digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics/annual%20summary/2010
January 01, 2010 - environments is essential to: 1) establish a baseline performance metric to measure improvement; 2) separate medication … errors and system failures that result in harm to patients from those that do not; and 3) accurately … Despite extensive literature on medication safety, medication errors, and adverse drug events in adult
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digital.ahrq.gov/organization/medical-university-south-carolina
January 01, 2023 - Medical University of South Carolina
Leveraging Health System Telehealth and Informatics Infrastructure to Create a Continuum of Services for COVID-19 Screening, Testing, and Treatment: A Learning Health System Approach
Description
This research aims to examine a health system…
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digital.ahrq.gov/2018-year-review/research-dissemination/conference-proceedings/ahrq-funded-research-2018-amia-annual-symposium
January 01, 2018 - AHRQ-Funded Research at the 2018 AMIA Annual Symposium
Investigator Name
AHRQ Research Profile
AMIA Title
Type
Abraham, Joanna
An Etiology for Medication Ordering Errors in Computerized Provider Order Entry Systems
Clinician Perspectives on Duplicate Medication Ordering…
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digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/annual-summary/2012
January 01, 2012 - Tools for Optimizing Medication Safety (TOP-MEDS) - 2012
Project Name
Tools for Optimizing Medication Safety (TOP-MEDS)
Principal Investigator
Lambert, Bruce
Organization
University of Illinois at Chicago
Funding Mechanism
RFA: HS11-004: Centers for Education and Re…
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digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/citation/cognitive-tests-predict
January 01, 2023 - Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
Citation
Schroeder SR, Salomon MM, Galanter WL, et al. Cognitive tests predict real-world errors: the r…
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digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing/citation/enhancing
January 01, 2023 - Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors.
Citation
Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf 2017 Oct;…
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digital.ahrq.gov/sites/default/files/docs/page/ahrq-dhr-2022-year-in-review.pdf
January 01, 2022 - Complications, such as falls or
medication errors, could lead to readmissions. … https://digital.ahrq.gov/ahrq-funded-projects/preventing-perioperative-medication-errors-and-adverse-drug-events-through-use … Near-miss medication errors are difficult to identify and are
underreported but can be opportunities … to make electronic
ordering safer
Medication errors are the most common and preventable cause
of … Near-miss medication
errors, such as when clinicians realize they’ve ordered the wrong
dose or frequency
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digital.ahrq.gov/ahrq-funded-projects/systems-engineering-approach-improving-medication-safety-clinician-use-health
January 01, 2023 - Logging Tool
Primary Care Visual Error Reporting Tool Description:
The Primary Care Visual Medication … Error Reporting Tool is a tool using pictures/diagrams to be used in the reporting of errors.
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digital.ahrq.gov/sites/default/files/docs/medicaid/NY_CaseStudy.pdf
July 01, 2010 - Medicaid began developing an electronic prescribing (e-prescribing)
incentive program aimed at reducing medication … errors, encouraging practices that support better
patient care and outcomes, and reducing costs. … The
committee looked exclusively at the cost savings associated with avoiding medication errors … prescription
transmitted electronically would save the agency $1.82, which includes the decrease in
medication … errors and costs of printing official New York paper prescriptions, which are
currently distributed
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digital.ahrq.gov/sites/default/files/docs/page/NY_CaseStudy_0.pdf
July 01, 2010 - Medicaid began developing an electronic prescribing (e-prescribing)
incentive program aimed at reducing medication … errors, encouraging practices that support better
patient care and outcomes, and reducing costs. … The
committee looked exclusively at the cost savings associated with avoiding medication errors … prescription
transmitted electronically would save the agency $1.82, which includes the decrease in
medication … errors and costs of printing official New York paper prescriptions, which are
currently distributed
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digital.ahrq.gov/ahrq-funded-projects/demonstration-project-assessing-significance-and-impact-utilizing-novel
January 01, 2023 - Type of Care
Hospice Care
Health Care Theme
Medication Management
Medication … Errors
Telehealth
The rising prevalence of serious illness has increased the need for
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digital.ahrq.gov/sites/default/files/docs/page/Electronic%20Prescribing%20Using%20A%20Community%20Utility%20-%20The%20ePrescribing%20Gateway_0.pdf
January 31, 2007 - Suspected medication errors (MEs) and adverse drug events (ADEs)
were rated by physicians. … Medication errors are errors during ordering, transcribing,
dispensing, administering, or monitoring … During this study, medication errors associated
with transcribing and dispensing were most likely impacted … Not all medication errors have the potential to harm a patient. … A
near miss or potential adverse drug event (PADE) is a medication error that has the
potential to
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digital.ahrq.gov/health-care-theme/human-factors
January 01, 2023 - Human Factors
Artificial Intelligence and Human Factors in Healthcare Quality & Safety
Description
Using a conference model, this study convenes a multidisciplinary group of experts to explore the integration of human factors engineering approaches in the implementation of art…
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014965-schmidt-final-report-2007.pdf
January 01, 2007 - safe
use of medications.3
IOM estimates that a patient in the hospital is subject to at least one medication … error per day;
fully one-quarter of all of these medication errors are preventable.
4 The National … Preventing Medication Errors.