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101. Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
     July 01, 2023 - medication instructions are described—and heard—correctly is an important safeguard against potential medication … errors.

102. Risk-Based Patient Safety Metrics (pdf file)
     www.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.

103. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
     July 01, 2024 - 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?

104. About the Toolkit Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication … errors due to the frequent use of high-alert medications.

105. Integration of Medication Information | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure4.html
     June 01, 2018 - between providers and patients, within and across care settings, has been identified as a source of medication … error. … Improving communication is a key aspect of decreasing medication errors and improving patient safety

106. Developing a Community-Wide Electronic Shared Medication List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
     June 15, 2005 - In the outpatient setting, medication errors and subsequent ADEs can result from physician/ provider-related … errors and, therefore, fewer ADEs across the continuum of care. … errors. … errors would be made. … Preventing medication errors.

107. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.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.

108. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
     www.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.

109. Final Progress Report: The National Quality Forum Fall Policy Conference 2008 (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/mcneil-report.pdf
     January 01, 2025 - Error Reporting and Prevention About: NCC MERP is an independent council of more than 20 national … error,” its “Taxonomy of Medication Errors,” and its “Index for Categorizing Medication Errors” has … resulted in standardization of medication error reporting and analysis … • Canada, the UK, Australia, and others have embedded The Taxonomy of Medication Errors and other … errors.

110. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
     www.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.

111. Making Healthcare Safer III | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html
     August 01, 2024 - special hygiene and disinfection interventions to prevent HAIs, and several practices designed to prevent medication … errors and reduce opioid misuse and overdose.

112. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     www.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.

113. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - support; rates of all medication errors fell 83%. (2;3) These findings have been substantiated elsewhere … We adapted methodologies we have previously used in the study of medication errors and adverse drug … The impact of computerized physician order entry on medication error prevention. … Computerized physician order entry and medication errors in a pediatric critical care unit. … Computerized physician order entry and medication errors in a pediatric critical care unit.

114. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - error that led to an unanticipated intensive care unit [ICU] stay but ultimate recovery).10–12 After … We recognized early that too many cases focusing on medication errors, or “systems thinking,” would … Among the published cases, the most common were diagnostic errors (27 percent), medication errors ( … It is worth noting that the comparable percentages for diagnostic and medication errors reflect editorial … decisions: we have received roughly twice as many medication error submissions, but many described

115. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
     April 06, 2008 - errors. … errors. … errors. … The impact of computerized physician order entry on medication error prevention. … Role of computerized physician order entry systems in facilitating medication errors.

116. Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study (pdf file)
     www.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.

117. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
     March 30, 2008 - errors and adverse drug events. … Errors,” the Institute of Medicine (IOM) recommended that all prescriptions be written electronically … Committee on Identifying and Preventing Medication Errors. Preventing medication errors. … Role of computerized physician order entry systems in facilitating medication errors. … Medication errors related to computerized order entry for children.

118. Safety Climate on Hospital Units: A New Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
     January 01, 2004 - inpatient units.26, 27 Perceived reasons that medication errors occur included organizational factors … Factors contributing to medication errors: a literature review. … Medication errors by nurses: contributing factors. AARN Newsletter 1990;46(1):17–22. 23. … Workload and environmental factors in hospital medication errors. … Responses and concerns of health care providers to medication errors.

119. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/neumiller.html
     August 01, 2017 - To reduce safety risks to patients, health systems expend considerable resources to prevent medication … errors in the hospital setting. 1-3 Increasingly, inpatient medication risk management efforts focus … of the medication errors being rated as minor, significant, and serious, respectively. 34 261 In … Institute of Medicine, Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J … Medication Errors: Quality Chasm Series (pp. 1-25), Washington DC: National Academies Press; 2007.

120. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
     www.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.