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digital.ahrq.gov/sites/default/files/docs/page/2006FriedmanSantinonFormica_052411comp.pdf
June 16, 2021 - MD
Yale University School of Medicine
Why should
surgeons care about
medication errors? … Why should surgeons care about medication errors? … Transplant Recipients Take Many Medications (mean = 10 meds)
Medication Errors Observed in Transplant … Slide No. 19 (No title)
Slide No. 20 (No title)
Slide No. 21 (No title)
Types of Medication Errors … Errors
Slide No. 34 (No title)
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaushal-r-et-al-2003
January 01, 2003 - error rates. … errors) markers. … Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement … errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. … Conclusions: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most
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digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
January 01, 2008 - Medication errors can
be classified into three groups – adverse drug events (ADEs), medication errors … errors by the National Coordinating Council for Medication Error
10
http:Zoomerang.com … While overall medication error rates started low, the trend in overall medication error rates
declined … Errors and ADE’s in the Medication Error
Outcome Evaluations
• Naloxone
• Antiemetics (ondansetron … Errors and ADE’s in the Medication Error Outcome Evaluations
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018151-smith-final-report-2013.pdf
January 01, 2013 - The primary outcome was discharge medication errors. … error 645 (18) 359 (13)
Clinically important medication error 9 (1.4) 11 (3.1) 0.10
30-day Follow-up … medication errors or in patient outcomes. … Interestingly, our clinically important medication error rates were much lower than typically
reported … Low and unchanged medication error rates suggest that patient outcomes would be no
different with or
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digital.ahrq.gov/ahrq-funded-projects/medication-management-closed-computerized-loop
January 01, 2023 - Inpatient
Population
Rural Populations
Health Care Theme
Adverse Events
Medication … Errors
Medication Management
Patient Safety
This project implemented and evaluated an … Observations of medication administration yielded a 45 percent reduction in observed medication errors
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digital.ahrq.gov/sites/default/files/docs/page/johnson-success-story.pdf
June 16, 2021 - IQHIT
Pediatric Medication Prescribing
Made Simpler and Safer
Children are particularly vulnerable to medication … errors that can have significant health consequences;
too little can render medication ineffective … Medication errors
pose a greater threat to children than to adults for a
number of reasons. … In an effort to reduce outpatient pediatric medication
errors and to save time calculating doses, Dr … errors in pediatrics.
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digital.ahrq.gov/ahrq-funded-projects/evaluating-impact-acpoecds-system-outcomes/annual-summary/2009
January 01, 2009 - It also evaluated the impact of the system on medication errors and downstream preventable adverse drug … The characteristics and severity of medication errors were described, and the relationship between these … Medication Errors
Results of the medication error and ADE study revealed that the frequency of errors … ACPOE use was associated with a reduction in medication errors and potential ADEs, thereby contributing … The impact of computerized provider order entry on medication errors in a multispecialty group practice
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digital.ahrq.gov/ahrq-funded-projects/understanding-cancelrx-impact-clinical-workflows-medication-safety-risks-and
January 01, 2023 - errors if the patient continues to take those medications. … errors. … errors are a leading cause of injury and avoidable harm in healthcare, with an estimated 1.3 million … Preventable medication errors cost the nation more than $21 billion annually across all care settings … errors.
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015319-sullivan-final-report-2007.pdf
January 01, 2007 - error. … error. … Importantly, the pilot data from the
medication error study revealed over a 60% reduction in medication … National Coordinating Council for Medication Error
and Reporting and Prevention. … The impact of
computerized physician order entry on medication
error prevention.
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs025136-ratwani-final-report-2024.pdf
January 01, 2024 - Prevalence
Medication errors are one of the most frequent types of error impacting patients. … Analyses focused on
determining: (1) the type of medication error, medication process stage, and health … Of the 2700 events, 1508 (55.9%)
described a medication error that was associated with health IT use … Most health IT-
associated medication error reports described usability issues (n = 1468 of 1508, 97.3% … Nearly half
of health IT related medication errors are reaching the patient.
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digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems
January 01, 2023 - Staff/Clinician
Patient
Type of Care
Acute Care
Health Care Theme
Medication … Errors
Patient Safety
Despite the widespread use of computerized prescriber order entry … alert fatigue – against the benefits – more complete problem lists and an increase in self-intercepted medication … errors.
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digital.ahrq.gov/ahrq-funded-projects/conducting-measurement-activities-health-information-technology-initiative
January 01, 2023 - errors due to adoption of electronic prescribing systems. … Reduction of medication errors due to the adoption of electronic prescribing (e-prescribing). … The use of e-prescribing systems was estimated to avert approximately 14.3 million medication errors … Further, it was estimated that as many as 86 million medication errors could have been averted in 2008 … Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems
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digital.ahrq.gov/technology/medication-management-system
January 01, 2025 - Identifying health information technology usability issues contributing to medication … errors across medication process stages. … Identifying health information technology usability issues contributing to medication errors across medication
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digital.ahrq.gov/principal-investigator/friedman-amy
January 01, 2023 - Project Name
Web-based Renal Transplant Patient Medication System
Medication … errors in the outpatient setting: classification and root cause analysis. … Medication errors in the outpatient setting: classification and root cause analysis. … evaluated Web-enabled education tools in hospitals and homes for renal transplant patients to reduce medication … errors and improve safety and compliance using wireless portable computers.
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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/sites/default/files/docs/publication/p20hs015325-hartzema-final-report-2005.pdf
January 01, 2005 - error. … Where errors originate
The National Coordinating Council for Medication Error and Reporting and Prevention … defines a medication
error as “ any preventable event that may cause or lead to inappropriate medication … This system can track the number and type of medication errors prevented. … error flags.
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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.
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digital.ahrq.gov/organization/university-mississippi-medical-center
January 01, 2023 - University of Mississippi Medical Center
Detecting Med (Medication) … Errors in Rural Hospitals Using Technology - 2008
Principal Investigator
Brown, Andrew … Project Name
Detecting Med (Medication) Errors in Rural Hospitals Using Technology … Detecting Med (Medication) Errors in Rural Hospitals Using Technology
Description
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digital.ahrq.gov/ahrq-funded-projects/computer-based-provider-order-entry-cpoe-implementation-intensive-care-units
January 01, 2023 - Care
Acute Care
Pediatrics
Specialty Care
Health Care Theme
Human Factors
Medication … Errors
Patient Safety
Sociotechnical Aspects
Health care technologies can be used … errors, adverse drug events, infection rates, protocol compliance, length of stay, mortality rates, … errors in two ICUs. … EHR-related medication errors in two ICUs. J Healthc Risk Manag 2017 Jan;36(3):6-15.
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digital.ahrq.gov/sites/default/files/docs/publication/u18hs016970-bates-final-report-2012.pdf
January 01, 2012 - Key Words: clinical decision support, adverse events, medication errors, patient safety, pharmacovigilance … Medication Errors and Adverse Drug Events
Medical errors and problems in patient safety are as common … error prevention[4]. … To avoid double
counting, each medication was attributed to one serious medication error per patient … Aspden, P., et al., Preventing Medication Errors, T.I.o.