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161. 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

162. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
     January 01, 2025 - viii Using Home Visits to Understand Medication Errors in Children Kathleen E. … The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis

163. Final Progress Report: RCT to Reduce Prescribing Errors in Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/soumerai-report.pdf
     January 01, 2024 - Scope: Suboptimal prescribing of antihypertensive medications is one type of medication error that contributes … Key Words: Hypertension, medication errors, patient safety PURPOSE The main objective of the study

164. 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.

165. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
     July 01, 2023 - Safe Medication Administration: Slide Presentation AHRQ Safety Program for Perinatal Care Slide 1: AHRQ Safety Program for Perinatal Care Safe Medication Administration Slide 2: Learning Objectives Image: Four ascending steps show the learning objectives: Define high-alert medications. Identif…

166. 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.

167. 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.

168. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
     January 01, 2024 - Key Words: drug name confusion, nomenclature, patient safety, auditory perception, medication errors … One in six medication errors involves name confusion. … An evaluation of the quality of the USP/ISMP Medication Error Reporting Program. … Medication errors. Washington, DC: American Pharmaceutical Association; 1999. 5. … Preventing medication errors. Washington, DC: The National Academies Press; 2007. 6. Davis NM.

169. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
     February 21, 2008 - Urgency for Interventions Related to Medication Errors Nearly one in every five medication doses in … Medication error rates depend on how these rates are measured. … errors also add to costs. … Medication errors observed in 36 health care facilities. … Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities

170. New Toolkit Can Improve Post-Surgery Complications and Enhance Patient Recovery | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/870.html
     June 01, 2023 - Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Medication errors that occur outside the hospital can be lethal for children with chronic conditions, … Walsh has identified factors that contribute to medication errors and injuries in children with chronic

171. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=84
     January 01, 2024 - errors using patient safety event reports (PSEs). … errors across medication process stages. … Researchers sought to identify the types of medication errors associated with health IT use, whether … They found that health IT usability issues were a prevalent contributing factor to medication errors, … Identifying health information technology usability issues contributing to medication errors across medication

172. Using Technology to Alert Clinicians to Potential Allergy, Drug Interactions | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-zhou.html
     July 01, 2024 - School, Brigham and Women’s Hospital Grantee Since: 2009 Type of Grant: Various Related AHRQ Resources Medication … Errors and Adverse Drug Events Medication Safety Consistent with its mission, AHRQ provides a broad

173. Table of Contents: Volume 1. Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     January 01, 2025 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … xviii Using Home Visits to Understand Medication Errors in Children Kathleen E.

174. Patient Safety Research Summaries | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/research-summaries/index.html
     April 01, 2025 - Medication safety refers to the practices and measures implemented to minimize the risk of medication … errors and adverse drug events in various settings across the healthcare continuum.

175. The PeaceHealth Ambulatory Medication Safety Culture Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
     January 01, 2007 - Errors,4 the IOM notes that developing an organizational culture of medication safety in the health … Medication errors are handled appropriately in this clinic. 3. … errors. 11. … errors.” … Preventing medication errors. Institute of Medicine.

176. 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.

177. 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.

178. 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.

179. 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.

180. 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.