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401. Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
     January 01, 2024 - Effect of computerized physician order entry and a team intervention on prevention of serious medication … errors. … Improving quality: how a hospital reduced medication errors. 2008. 30.

402. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 - Skills Leadership Structures and Systems Lean Six Sigma Medical Knowledge and Patient Safety Medication … Error Reporting Mock Tracers Patient Safety Manager Certification Program Patient Safety Standards … Pressure Ulcers 5 430 -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety 126 416 -- Medication … Errors/Preventable Adverse Drug Events 96 420 ---- Administration Errors 14 419 ---- Dispensing

403. The CAHPS Ambulatory Care Improvement Guide: Open Notes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6c.pdf
     March 01, 2017 - The CAHPS Ambulatory Care Improvement Guide: Open Notes The CAHPS Ambulatory Care Improvement Guide Practical Strategies for Improving Patient Experience Section 6: Strategies for Improving Patient Experience with Ambulatory Care 6.C. OpenNotes Visit the AHRQ Website for the full Guide. March 2017 https:/…

404. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - Advances in Patient Safety and Medical Liability Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commenta…

405. Understand the Science of Safety for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
     July 01, 2023 - Slide 3: Health Care Defects In the U.S. health care system— 7 percent of patients suffer a medication … error. 1 In 1999, it was estimated that 44,000 to 99,000 people die in hospitals each year as the

406. AHRQ Report Identifies Strategies To Reduce Emergency Department Boarding | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/951.html
     March 01, 2025 - AHRQ Report Identifies Strategies To Reduce Emergency Department Boarding Issue Number 951 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. March 25, 2025 AHRQ Stats: MRSA Rates by Payer Type The rate of MRSA diagnoses on admission among expected self-pay hosp…

407. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
     January 01, 2004 - Medication error reports from primary care, for example, could be repackaged and shared with the Food … and Drug Administration and other medication error-reporting processes.

408. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - Patient Safety Primer: Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primers/primer … Education and Training Catalog Patient Safety Essentials Toolkit: Huddles Patient Safety Primer: Medication … Errors and Adverse Drug Events Person-Centered Care Plan-Do-Study-Act (PDSA) Steps Worksheet Pioneer … Patient Safety Primer: Medication Errors and Adverse Drug Events 18. Person-Centered Care 19.

409. Final progress Report: Improving Over-the-Counter Medication Safety for Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/chui-report.pdf
     January 01, 2024 - Final progress Report: Improving Over-the-Counter Medication Safety for Older Adults Improving Over-the-Counter Medication Safety for Older Adults Project Dates: 04/01/2016 – 01/31/2020 R18HS024490 Institution: University of Wisconsin - Madison PI: Michelle Chui Team Members: Pascale Carayon, Roger Brown, Nora Jac…

410. Chartbook on Care Coordination: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination-slides.html
     June 01, 2018 - error. … Improving communication is a key aspect of decreasing medication errors and improving patient safety … Notes: Importance: CPOE is associated with a 13% to 99% reduction in medication errors and a 30% … Importance: CPOE is associated with a 13% to 99% reduction in medication errors and a 30% to 84% reduction … The effect of electronic prescribing on medication errors and adverse drug events: a systematic review

411. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing 1. Title Page Title: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing PI: Lewis Lipsitz, MD Team Members: Amber Moore, MD, MPHa,b; Julie C. Lima, MPH, PhDc; Sweta Patel, BD…

412. Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
     January 01, 2024 - Final Progress Report: Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) 1 | P a g e Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety (MARQUIS2) Principal Investigator: Jeffrey L. Schnipper, MD, MPH Team Members: Harry Reyes Nieva, MAS; Me…

413. Final Progress Report: EHR-Based Medication Complete Communication Strategy to Promote Safe Opioid Use (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/mccarthy-report.pdf
     January 01, 2024 - Final Progress Report: EHR-Based Medication Complete Communication Strategy to Promote Safe Opioid Use Title Page EHR-Based Medication Complete Communication Strategy to Promote Safe Opioid Use Principal Investigator: Danielle M. McCarthy, MD, MS Co-Investigators: Mike S. Wolf, PhD, MPH, Kenzie A. Cameron, PhD, MP…

414. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - errors is especially high. … Medication errors were highlighted in the report and were stated to account for over 7000 deaths and … error rates. … although the “use of CPOE and isolated clinical decision support systems can substantially reduce medication … error rates, studies have not been powered to detect differences in adverse drug events and have evaluated

415. The Science of Improving Patient Safety and Identifying Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
     December 01, 2017 - Breakdowns 6 Images: Four bar graphs showing root causes of adverse events including sentinel events, medication … errors, delays in treatment, and infection-associated events from 1995 to 2004.

416. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
     January 01, 2002 - 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 … Organizational culture and medication error reporting.

417. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - Medication error prevention: profiling one of pharmacy’s foremost advocacy efforts for advice on error … CQI case study: reducing medication errors. Jt Comm J Qual Improv 1995;21 (5):232–7. 37. … Developing a proactive approach to medication error prevention.

418. Chapter 6. Measure Maps and Profiles (continued, 20) | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6s.html
     June 01, 2014 - or Health System Characteristics: In a Swedish study, the risk of negative clinical outcomes due to medication … errors was significantly reduced for elderly individuals who were given comprehensive and structured

419. Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
     January 01, 2024 - Analysis: The main outcome variables were nonpreventable AWEs and potential and preventable AWEs due to medication … errors.

420. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - Advances in Patient Safety and Medical Liability Silence A Commentary Previous Page Next Page Table of Contents Advances in Patient Safety and Medical Liability Preface Acknowledgments Prologue Silence A Commentary Reforming the Medical Liability System in Massachusetts: Communication, Apo…