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361. Making Healthcare Safer III Patient Safety Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/practices.html
     April 01, 2020 - Making Healthcare Safer III Patient Safety Practices Below is a list of the 47 patient safety practices examined in Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices . The practices are listed among the report’s 17 chapters, which represent harm areas researched…

362. Final Progress Report: Medication Management at Home: Patient-Identified Processes and Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
     January 01, 2024 - enlighten health systems and medical providers seeking effective methods for reducing the incidence of medication … errors and ADEs that occur outside the control of traditional healthcare environments. … through eight major pathways: medication nonadherence, prescriber-patient miscommunication, patient medication … error, failure to read medication label/insert, polypharmacy, patient characteristics, pharmacist-patient

363. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
     June 04, 2008 - A recent study correlated the relationship of medication errors to lighting levels. … As lighting intensity approaches 1,500 lux,7 the incidence of medication errors dramatically decreases … Poor lighting and the lack of daylight are linked to depression, increased need for pain medication, medication … errors, and order entry errors.8 Health care-acquired infections are related to air quality, ventilation

364. AHRQ Impact Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/index.html
     June 01, 2025 - Impact Case Studies AHRQ’s evidence-based tools and resources are used by organizations nationwide to improve the quality, safety, effectiveness, and efficiency of health care. The Agency’s Impact Case Studies highlight these successes, describing the use and impact of AHRQ-funded tools by State and Federal policy ma…

365. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     May 01, 2017 - • 7 percent of patients suffer from a medication error.

366. Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
     March 01, 2020 - same time.3,4 Broadly defined as injuries that result from drug-related medical interventions (e.g., medication … errors, adverse drug reactions, allergic reactions, or overdoses), ADEs have been associated with thousands … Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug … Aging%20and%20Disability%20in%20America/2017OlderAmericansProfile.pdf https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events … https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://health.gov/hcq/pdfs/

367. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
     January 01, 2025 - surprising that, with intense pressure for action, attention has centered on “low-hanging fruit,” such as medication … errors, wrong-site surgery, and hospital-acquired infections. … judged from the eventual appreciation of more definitive information.(2) Compared with procedural and medication … errors, diagnostic errors are more difficult to recognize and understand and therefore harder to confidently

368. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - errors, and only after the institutions meet the statutory requirement to develop CPOE. … The California medication error reporting system requires the Office of Statewide Health Planning and … Studies show that CPOE may reduce medication errors by 86 percent; at the present time, however, only … Effect of computerized physician order entry and a team intervention on prevention of serious medication … errors.

369. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=12
     January 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…

370. Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
     April 20, 2008 - Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management Ranjit Singh, MA, MB, BChir (Cantab), MBA; Bruce Naughton, MD; Diana Anderson, EdM; Donna McCourt, RN, BSN; Gurdev Singh, MScEng, PhD Abstrac…

371. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - Inpatient team to PCP Community services with PCP Lapse of communication Indadequate Patient Education Medication … Error Lack of timely follow-up Lapse in community services Health Care System New Medical Problem … The use of failure mode effect and criticality analysis in a medication error subcommittee.

372. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
     January 01, 2024 - frequency of errors or shortcomings over the past year in five areas: incomplete discussion of treatment, medication … errors, lack of attention to illness impact, minimal reaction to a patient’s death, and guilt about

373. Guide for Developing a Community-Based Patient Safety Advisory Council (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/advisorycouncil/advisorycouncil.pdf
     April 01, 2008 - Institute of Medicine, Preventing Medication Errors, Quality Chasm Series. … Institute of Medicine, Preventing Medication Errors, Quality Chasm Series. … Institute of Medicine, Preventing Medication Errors, Quality Chasm Series. … Medication Errors. 2nd edition. Washington, DC: American Pharmacists Association; 2007.

374. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action ICU-to-Ward Transitions Previous Page Next Page Table of Contents Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action Intr…

375. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Inaccurate and incomplete medical history; • Ineffective or improper use of medications or serious medication … errors; • Improper preparation for tests and procedures; and • Poor or inadequate informed consent … • Ineffective or improper use of medications or serious medication errors.

376. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - information and hindsight and outcome biases.60,61 We used the modified National Coordinating Council for Medication … Errors Reporting and Prevention (NCC MERP) Index to rate severity, following IHI and OIG guidelines … Error Reporting and Prevention). … National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing … *_ga_45NDTD15CJ*MTczNjk3MjUzMS4zLjAuMTczNjk3MjUzMS42MC4wLjA. https://www.nccmerp.org/categorizing-medication-errors-index-color

377. Final Progress Report: The Impact of Shift-Accumulated Fatigue on Patient Care and Risk of Post-Shift Driving Collisions among 12-Hour Day and Night Shift Nurses (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/james-report.pdf
     January 01, 2024 - Final Progress Report: The Impact of Shift-Accumulated Fatigue on Patient Care and Risk of Post-Shift Driving Collisions among 12-Hour Day and Night Shift Nurses Title: “The Impact of Shift-Accumulated Fatigue on Patient Care and Risk of Post-Shift Driving Collisions among 12-Hour Day and Night Shift Nurses” Pri…

378. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - Planning Grants Final Evaluation Report Findings Previous Page Next Page Table of Contents Planning Grants Final Evaluation Report Executive Summary Introduction Methodology Findings Appendix A. Grantee Profiles Appendix B. References Improving Communication Four planni…

379. Research Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science Research Agenda Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Chi…

380. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
     January 01, 2024 - The most commonly reported types of events were “retention of a foreign object” (22%), “medication errors … Patient death or serious disability associated with a medication error (e.g., errors involving the wrong … error-web-based reporting system. … The advantage of having a web-enabled medication error reporting system integrated with existing systems … error data from hospitals.