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181. Final Progress Report: Enhanced Patient Safety Intervention to Optimize Medical (EPITOME) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/sirio-report.pdf
     January 01, 2024 - An important unanticipated benefit was identification of medication errors. … tool for providing education and assisting in the promotion of patient safety through decreasing medication … errors and improving medication adherence behaviors. … errors, improve medication delivery system and administration design issues, enhance and improve patient … • Unexpected and significant medication errors were identified in approximately 20% of a subset of

182. Final Progress Report: Improving Quality in Medication Management in Schools (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/grahamlear-report.pdf
     January 01, 2024 - administration practices of school nurses and found that 314 (48.5%) of the respondents “report that a medication … error occurred in the past year in their school(s),” with the most frequent error being missed doses … For example, although medical errors, particularly medication errors, have been recognized as a potential

183. Transforming Hospitals: Designing for Safety and Quality (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/transform.pdf
     January 01, 2020 - and avoidable incidents of patient harm, such as patient falls, hospital- acquired infections, and medication … errors. … time walking to sinks and have more opportunities to sanitize their hands before providing care.12 Medication … errors. … errors.13 3 Patient rooms that can be adapted for the acuity of a patient can also reduce errors

184. Appendix F. Interventions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/envscan-app-f.pdf
     January 01, 2015 - Simple strategies to avoid medication errors Yes Yes Moderate Strategies for patients and providers to … avoid medication errors in practice. … Prevent medication mix-ups Yes Yes Suggestive Guidelines for patients to prevent medication errors.

185. A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality’s Patient Safety Initiative 2000–2004 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
     January 01, 2004 - • Assessing the risks leading to medication errors in various health care settings. … Seven implementation projects were funded that address the following issues: • Reduction of medication … errors using intravenous smart pumps and medication administration using bar codes … Effect of computerized physician order entry and a team intervention on prevention of serious medication … errors.

186. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
     April 01, 2018 - Institute of Medicine, Preventing Medication Errors, Quality Chasm Series .

187. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
     June 02, 2025 - visits 1 in 9 ED admissions are related to an adverse drug event An estimated 160 million medication … errors occur each year in primary care 80% of information shared in a primary care visit is immediately

188. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/patient-safety-issues.pdf
     June 02, 2025 - visits 1 in 9 ED admissions are related to an adverse drug event An estimated 160 million medication … errors occur each year in primary care 80% of information shared in a primary care visit is immediately

189. Personal Health Records to Improve Health Information Exchange and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Fricton_21.pdf
     April 17, 2008 - The Institute of Medicine’s report, Preventing Medication Errors 2007, states that poor communication … errors and up to 20 percent of adverse drug events.1 Each time a patient moves from one clinic or setting … process does not occur in a standardized manner that is designed to ensure complete reconciliation, medication … errors could lead to adverse events and patient harm. … Institute of Medicine, Preventing medication errors.

190. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - Medication errors observed in 36 health care facilities. … Medication errors and pediatric inpatients. JAMA 2001 Apr;285(16):2114–20. 27.

191. Chapter-8 - Diabetes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf
     March 01, 2020 - errors and worked to decrease error rates. … Medication errors common for hospital diabetes. … https://www.nursingtimes.net/clinical-archive/diabetes-clinical-archive/medication-errors- common-for-hospital-diabetes … national-diabetes-statistics-report.pdf https://www.nursingtimes.net/clinical-archive/diabetes-clinical-archive/medication-errors-common-for-hospital-diabetes … -01-04-2011/ https://www.nursingtimes.net/clinical-archive/diabetes-clinical-archive/medication-errors-common-for-hospital-diabetes

192. Transforming Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/transform.html
     December 01, 2017 - Medication errors. … time walking to sinks and have more opportunities to sanitize their hands before providing care. 12 Medication … Errors Poor lighting, frequent interruptions and distractions, and inadequate private space can complicate … quiet, private spaces allow pharmacists to fill prescriptions without the distractions that may lead to medication … errors. 13 Patient rooms that can be adapted for the acuity of a patient can also reduce errors.

193. Final Progress Report: Training Leaders to Improve Healthcare Quality in Emergency Settings for Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/macias-report.pdf
     January 01, 2024 - errors, and pain and sedation. … Errors platform Madhok, Manu Children's Hospitals and Clinics of Minnesota Reducing medication … error strategies. … These focused on medication errors/patient safety issues. … Medication Errors-Zapata Room Moderators: Karen Frush, MD, and Jane Knapp, MD G26.

194. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
     June 01, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action Inpatient-to-Outpatient Transitions Previous Page Next Page Table of Contents Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to A…

195. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
     January 01, 2004 - The medication errors generally involved one of three issues: incorrect dose, time, or port. … For example, when case studies depicted medication errors associated with the wrong dose, time, or port … for this situation: inconsistent and vague guidelines; and narrow definitions that encompass only medication … errors or errors that have caused harm.3 In addition, peer pressure and fear were also mentioned as

196. Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/911.html
     April 01, 2024 - Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors Issue Number 911 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. April 30, 2024 AHRQ Stats: Average Healthcare Expenditures Among Persons With High Expenses In…

197. Appendix E. Category Definitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appe.html
     March 01, 2017 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Appendix E. Category Definitions Previous Page Next Page Table of Contents Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Executive Summary Introduction …

198. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - -Patient has to call back to inquire about a medication error when doctor writes wrong script. … Preventing Medication Errors. Washington DC: National Academy Press; 2007. 18 4. … A prospective hazard and improvement analytic approach to predicting the effectiveness of medication … error interventions. … How can information technology improve patient safety and reduce medication errors in children's health

199. Massachusetts Hospital Improves Medication Reconciliation With AHRQ Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips89.html
     October 01, 2014 - Massachusetts Hospital Improves Medication Reconciliation With AHRQ Toolkit Search All Impact Case Studies March 2012 After participating in AHRQ-sponsored learning sessions and provider support calls, Masspro, the Massachusetts Quality Improvement Organization (QIO), worked with New England Rehabilitation …

200. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - Although much of the patient safety spotlight has focused on medication errors, two recent studies of … malpractice claims reveal that diagnosis errors far outnumber medication errors as a cause of claims … Bates has promulgated a useful model for depicting the relationships between medication errors and outcomes … Assessing the quality of published case reports of look-alike and sound-alike medication errors. … An evaluation of the quality of the USP/ISMP Medication Error Reporting Program.