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221. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
     December 29, 2022 - associated Received September 8, 2022 Accepted December 29, 2022 with a significant increase in medication … errors.2 Prior re- search has found individuals fail to return to the original task 13–18% of the time

222. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
     January 01, 2004 - These constructs included communication from another office, mistimed procedures, medication errors … Taxonomies designed to evaluate specific domains of errors, such as the National Coordinating Council for Medication … Error Reporting and Prevention,1 may apply across care settings, but are designed to specifically describe … National Coordinating Council for Medication Error Reporting and Prevention. … NCC MERP taxonomy of medication errors. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf.

223. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
     January 01, 2004 - These constructs included communication from another office, mistimed procedures, medication errors … Taxonomies designed to evaluate specific domains of errors, such as the National Coordinating Council for Medication … Error Reporting and Prevention,1 may apply across care settings, but are designed to specifically describe … National Coordinating Council for Medication Error Reporting and Prevention. … NCC MERP taxonomy of medication errors. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf.

224. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
     April 01, 2003 - such as California’s S.B. 1875 (2000), which required hospitals to implement a formal plan to reduce medication … errors in their facilities. … Remember, implementation matters Medication errors received significant attention among consortium … errors, implementation of computerized physician order entry (CPOE) systems was the most significant … errors, falls, and skin breakdown, measured by chart review.

225. Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
     April 14, 2008 - error might be a component), direct contact reports (MedWatch),12 reports from the U.S. … Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP) USP-ISMP Medication Errors … Preventing medication errors: Quality chasm series. … Committee on Identifying and Preventing Medication Errors. … Medication error reporting systems. In: Medication errors. 2nd ed.

226. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/ambulatory/index.html
     June 01, 2025 - resources for implementing a DOAC checklist for ambulatory care pharmacists to reduce clinically important medication … errors for patients newly starting or resuming DOAC therapy.

227. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - breakdowns are a significant, if not leading, cause of many undesirable outcomes, including sentinel events, medication … errors, delays in treatment, ventilator events, and healthcare-associated infections. … you would not want to happen again—an unsafe condition, a patient fall, a venous thromboembolism, a medication … error, a surgical site infection, wrong-site surgery, missing equipment, nursing time spent away from

228. Implementation Quick Start Guide: Medication Mangement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medmanage_quickstartfull.pdf
     December 15, 2016 - Implementation Quick Start Guide: Medication Mangement Implementation Quick Start Guide Medication Management The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Implementation Quick Start Guide: Medication Management Table of Contents What Is the Medication Man…

229. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - errors. … The impact of computerized physician order entry on medication error prevention. … The effect of computerized physician order entry on medication errors and adverse drug events in pediatric … Computerized physician order entry and medication errors in a pediatric critical care unit. … Effective strategies to increase reporting of medication errors in hospitals.

230. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=0
     December 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…

231. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
     January 01, 2024 - Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care O’Connor, Patrick J. Final Report MOVES: Patient-Based Strategy to Reduce Errors in Diabetes Care Patrick J. O’Connor MD MPH, Principal Investigator Research Team Members: JoAnn Sperl-Hillen MD, Paul E. Johnson PhD†, William A. …

232. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/strategies.html
     April 01, 2018 - Together : Creates a complete and accurate medicine list, which is the first line of defense against medication … errors.

233. Implications for Practice Improvement, Research, and Policy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults3.html
     August 01, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults Implications for Practice Improvement, Research, and Policy Previous Page Next Page Table of Contents State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults Introduction Uniqu…

234. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
     January 01, 2004 - Inadequate planning when introducing new technology designed to decrease medication errors in health

235. Create a Safe Medicine List Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
     June 02, 2025 - One clinician observed, “It closes the gaps, reduces medication errors, offers the opportunity to reduce

236. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - Errors Reporting Program [MER]; MEDMARxSM, a national database for medication errors). … errors • Aspirations • IV-related • Embolic and related disorders • Laparoscopic complications … error 282 11.5 Delay in treatment 161 6.6 Patient death/injury in restraints 112 4.6 Patient fall … The medication error subcommittee develops medication error reporting categories and the medication … error supplemental form.16 This committee has analyzed 108 medication errors and associated root- cause

237. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/results.html
     March 01, 2017 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Results Previous Page Next Page Table of Contents Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Executive Summary Introduction Limitations of the Enviro…

238. Final Progress Report: Enhancing the Detection and Management of Adverse Drug Events in the Nursing Home (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/handler-report.pdf
     January 01, 2024 - Monitors and reports medication errors……………... 1 2 3 4 5 1 2 3 4 5 19. …  Error Reporting and Prevention (NCC‐MERP) ADE Classification The NCC‐MERP adopted a Medication Error … National Coordinating Council for Medication Error Reporting and Prevention ADE Classification NCC‐MERP …  Errors.   … Preventing Medication Errors. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, editors. 

239. AHRQ-Funded Research Highlights Impact of Private Equity in Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/927.html
     August 01, 2024 - 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.

240. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
     May 01, 2024 - The care transition intervention will have the potential to prevent DOAC-related medication errors, improve