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501. Aetna Informs Members With AHRQ Materials | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/multicenter-0702-cp3-ockt.html
     October 01, 2014 - Aetna Informs Members With AHRQ Materials Search All Impact Case Studies March 2007 Aetna, one of the Nation's largest health care benefits companies, uses AHRQ information to help its members become better informed and more involved in their own health care and that of their families. Aetna cites AHRQ reso…

502. State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
     January 17, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults PATIENT SAFETY e Issue Brief 22 State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults This page intentionally left blank. e Issue Brief 22 State of the Science and Future Directions…

503. Development and Implementation of The University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
     March 01, 2004 - A systems approach to the reduction of medication error on the hospital ward.

504. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=4
     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…

505. 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…

506. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=201
     January 01, 2024 - Health, Practice Improvement Yao B , Kang H , Gong Y Data quality assessment of narrative medication … error reports. … Data quality assessment of narrative medication error reports.

507. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - Second, a review of medication errors (1 of the 18 ACEs identified) in 2 health care facilities led … Improving patient safety and restructuring medical liability using ACEs: Medication errors.

508. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
     May 01, 2016 - Second, a review of medication errors (1 of the 18 ACEs identified) in 2 health care facilities led … Improving patient safety and restructuring medical liability using ACEs: Medication errors.

509. Improving Safety for Patients with Limited English Proficiency: TeamSTEPPS
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
     January 01, 2013 - follow-up Inaccurate and incomplete medical history Ineffective or improper use of medications or serious medication … errors Improper preparation for tests and procedures Poor or inadequate informed consent TEAMSTEPPS

510. Research Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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…

511. 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…

512. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/15818-Fairbanks-draft-1.pdf
     September 08, 2008 - is perplexing, given that the ED is known to be a particularly high-risk environment with frequent medication … errors.3 The 1999 Institute of Medicine report To Err is Human reported that the ED had the highest … Errors 90 0.88% 21 0.99% 69 0.85% ns Quality Measures Several quality measures were also assessed, … inventory based on formulary status 51 99 52 41-62% Drug or toxicology information 47 99 47 37-58% Medication-error … Medication errors in the emergency department: a systems approach to minimizing risk.

513. AHRQ Releases Best Practices for Safe COVID-19 Vaccine Administration in Nursing Homes | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/775.html
     August 01, 2021 - AHRQ Releases Best Practices for Safe COVID-19 Vaccine Administration in Nursing Homes Issue Number 775 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. August 10, 2021 AHRQ Stats Access more data on this topic in the associated statistical brief , plus …

514. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/liability/preface.html
     August 01, 2017 - Advances in Patient Safety and Medical Liability Preface 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…

515. 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…

516. Tool 3O: Postfall Assessment for Root Cause Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
     January 01, 2013 - Preventing Falls in Hospitals Tool 3O: Postfall Assessment for Root Cause Analysis Previous Page Next Page Table of Contents Preventing Falls in Hospitals Roadmap Acknowledgments Overview Icons 1. Are you ready for this change? 2. How will you manage change? 3. Which fall prevention pr…

517. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/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.

518. 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.

519. 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.

520. 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.