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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
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Table of Contents
State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
Introduction
Uniqu…
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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
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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
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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.
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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
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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.
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www.ahrq.gov/patient-safety/about/areas/improve-discharge.html
August 01, 2024 - PSNet Primer: Improving Patient Safety and Team Communication Through Daily Huddles AHRQ PSNet Primer: Medication … Errors and Adverse Drug Events AHRQ PSNet Primer: Medication Reconciliation AHRQ PSNet Perspective:
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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
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Table of Contents
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Executive Summary
Introduction
Limitations of the Enviro…
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www.ahrq.gov/topics/m.html
June 12, 2025 - Topics Browse A - Z
M
Maternal Health Medicaid Medical Errors Medical Expenditure Panel Survey (MEPS) Medical Liability Medicamentos Medicare Medication Medication: Safety Men's Health Methicillin-Resistant Staphylococcus aureus (MRSA) Mortality
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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.
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www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
January 01, 2024 - Final Progress Report: Safety Advancement in the Emergency Department
FINAL PROGRESS REPORT
PROJECT TITLE: SAFETY ADVANCEMENT IN THE EMERGENCY DEPARTMENT*
PRINCIPAL INVESTIGATOR: KENDALL K. HALL, MD, MS (AHRQ, formerly of UNIV of MARYLAND)
KEY PERSONNEL: YAN XIAO, PhD (BAYLOR, formerly of UNIV of MARYLAND)
ANTHO…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.pdf
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Safe Medication Administration
AHRQ Safety Program for Perinatal Care
Safe Medication Administration
AHRQ Publication No. 17-0003-19-EF
May 2017
SAY:
The Safe Medication Administration bundle
provides information on high-alert medications
commonly used in labor and d…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/mch-ref.html
April 01, 2018 - Reducing the risk of harm from medication errors in children. … Strategies to Reduce Medication Errors: Working to Improve Medication Safety. 2013.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - Treatment
(1995 – 2004)
Root Causes of Sentinel Events
(All Categories, 1994 – 2005)
Root Causes of Medication … Errors
(1995 – 2004)
Science of
Improving Patient Safety ‹#›
AHRQ Safety Program … errors, delays in treatment, ventilator events, and healthcare-associated infections.
16
Basic Process … 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
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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
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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
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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
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www.ahrq.gov/patient-safety/reports/hotline/refs.html
May 01, 2016 - Consumers can prevent medication errors (Web site).
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
January 01, 2018 - New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi)
Optimizing
the Use of HIT
to Improve
Safety
Tejal Gandhi
Handwriting
16
Ways IT Can Improve Safety
• Prevent errors and adverse events
• Facilitating a more rapid response after an
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
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