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121. Final Progress Report: Medication Safety in Primary Care Practice Translating Research Into Practice (MS-TRIP) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/ornstein-report.pdf
     January 01, 2024 - Scope: Medication errors in primary care practice cause morbidity, but work is needed to specify relevant … Scope Medication errors in primary care practice are an important cause of morbidity, but the extent

122. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
     January 01, 2024 - Medication ordering and administration processes – Medication errors harm an estimated 1.5 million people … Medication reconciliation – Medication reconciliation is a process designed to prevent medication errors … Failure Mode and Effects Analysis: An Interdisciplinary Way to Analyze and Reduce Medication Errors … Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology. … The Use Of Failure Mode Effect And Criticality Analysis In A Medication Error Subcommittee.

123. Final Progress Report: Multi-Method Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/pace-report.pdf
     January 01, 2024 - Lab-related errors actually have a lower chance of causing harm than all errors combined, while medication … errors have a relative risk of causing harm over five times greater than all errors combined. … Medication errors overall were fairly common, accounting for over 20% of all error reports, while referral … Thus, from the ASIPS dataset, medication errors clearly have the highest overall risk when frequency

124. Discussion of Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/findings.html
     March 01, 2017 - the most widely studied sources of medical error in both acute and nonacute health care settings is medication … errors. 39 , 70 , 97–101 Errors occur at the prescribing, filling, and administration stages of medication … Efforts to reduce medication errors in the ambulatory care setting, including primary care, have focused … reviews of safe medication use in primary care acknowledged that much of the research aimed at reducing medication … errors has focused on single interventions.

125. 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.

126. Appendix, Medication Reconciliation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-7.html
     July 01, 2022 - are already doing many of these clinical steps, we have internal and external data to support that medication … errors, and in many cases patient harm, are occurring.

127. Appendix, Medication Reconciliation | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-7.html
     July 01, 2022 - are already doing many of these clinical steps, we have internal and external data to support that medication … errors, and in many cases patient harm, are occurring.

128. 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.

129. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=17
     January 01, 2024 - Settings Publication Date: June 2007 Show Your Work: Do Prescription Annotations Impact Near-Miss Medication … Errors? … Design, Human Factors Approaches To Improve Patient Safety Publication Date: December 2006 Medication … Error Reduction, Technologies, and Human Factors Final Report ( application/pdf 399514 ) Principal

130. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Health Information Technology and Health Information Exchange (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-2025.pdf
     January 01, 2025 - Key Findings/Impact: Investigators sought to reduce medication errors for three high-risk groups: patients … All three projects resulted in a measur- able decrease in medication errors and these improvements were … Compared with paper order entry, CPOE was associated with half as many pADEs and medication errors. … Errors? … errors.

131. Development of a Comprehensive Medical Error Ontology (pdf file)
     www.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.

132. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
     April 20, 2004 - Introduction Medication errors are a serious public health threat. … error. … a “deidentified, fair, and just reporting system for errors and near misses.”23 A medication error … Following root-cause analysis of the barriers to the BCMA software implementation, the medication error … Veterans Affairs: eliminating medication errors through point- of-care devices.

133. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
     www.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.

134. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
     www.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.

135. 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.

136. Appendix A | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-apa.html
     April 01, 2018 - Leadership Structures and Systems Lean Six Sigma Medical Knowledge and Patient Safety Medication … Error Reporting Mock Tracers Patient Safety Manager Certification Program Patient

137. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - Extensive work has been done in the area of medication errors, including a recent comprehensive evaluation … errors. … Preventing medication errors: Quality chasm series. … Strategies to reduce medication errors in ambulatory practice. … EPITOME program educates patient to help reduce medication errors.

138. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
     January 01, 2024 - The 10 key actions to help patients detect and prevent medication errors were derived from reports of … Five Scorecards are available in the application, each for use with a specific type of medication error … The report includes: • An estimate of how often the specific type of medication error with the chosen … Preventing medication errors: quality chasm series. … Institute of Medicine, Committee on Identifying and Preventing Medication Errors.

139. 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.

140. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Using Home Visits to Understand Medication Errors in Children (   PDF , 622 KB ) Kathleen E.