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www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
January 01, 2024 - Although improved, documentation of advanced directives and medication lists remains challenging. … reconciliation, and communication strategies) and process improvement options were identified and
implemented … Accurate reconciliation of medications, infection status or potential, patient-centered
directives and … reconciliation, and handoff communication. … Although improved,
documentation of advanced directives and medication lists remains a challenge.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_8.pdf
October 01, 2016 - Medication
reconciliation
LVN performs medication reconciliation and documents in EHR. … Provider
reviews reconciliation with patient. … Medication titration Health educators (RN, CDE) work with provider on titrating insulin. … Medication
management
Onsite pharmacist assists provider in medication management. … RN works with
provider on medication adjustments.
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-8.html
July 01, 2019 - Medication reconciliation
LVN performs medication reconciliation and documents in EHR. … Provider reviews reconciliation with patient. … Medication titration
Health educators (RN, CDE) work with provider on titrating insulin. … Medication management
Onsite pharmacist assists provider in medication management. … RN works with provider on medication adjustments.
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psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk
November 08, 2013 - July 29, 2020
Improving reconciliation following medical injury: a qualitative study
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psnet.ahrq.gov/issue/reframing-morbidity-and-mortality-conference-impact-just-culture
November 15, 2018 - May 15, 2024
Patient, carer and family experiences of seeking redress and reconciliation
-
psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - It is well accepted that poorly executed care transitions are associated with
increased adverse medication … telemedicine visit utilizing self-taken blood pressure measurements,
augmented by clinical pharmacist-led medication … reconciliation, prior to the outpatient visit.
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - She realized that they were fentanyl patches—a potent opioid medication. … The nurse asked a pharmacy technician to perform medication reconciliation, which revealed that the patient's … Resources
WebM&M Cases
The Impact of Communication on Medication … WebM&M Cases
Misleading Complaint
July 1, 2012
Medication … See More About The Topic
Hospitals
Physicians
Neurology
Clinical Misdiagnosis
Medication
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psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
February 06, 2018 - September 27, 2023
Patient, carer and family experiences of seeking redress and reconciliation
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digital.ahrq.gov/sites/default/files/docs/improve-medication-management-qa-091318.pdf
September 13, 2018 - A National Conference on the Role of Health IT to Improve Medication Management - Q&A … Optimizing medication use. … Yes, various CDS exist in the context of medication therapy management
(MTM). … It's feasible to bring in medication
information from many electronic sources. … reconciliation.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-section-5-table-8-9.pdf
January 01, 2013 - readmissions if they
include the following components:
(1) early assessment of discharge
needs and medication … reconciliation; (2) enhanced
patient education; (3) early post-
acute follow-up within 24 to 72
hours … reconciliation, and provide patient
education with an individualized
instruction booklet that was … reconciliation; (4) arranging
follow-up appointments before
discharge; (5) having a process in
place … and contained standard hospital
discharge data, plus a date-
stamped record of all material
and medication
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - safety around hospital discharge.( 10 ) Hospital accreditation requires discharge planning to include medication … reconciliation, patient education, and communication to outpatient providers. … details have been shown to increase patient understanding of their diagnosis from 77% to 100%, and medication … December 31, 2014
Effect of an electronic medication reconciliation application and process … Reconciliation: Whose Job Is It?
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - labeling lead to fewer medication errors. 1 Each correctly labeled medication becomes a distinct entity … The handoff at a provider change is a safety prompt that encourages medication reconciliation and individual … In this patient’s case, the medication error was recognized by reviewing the medication process intraoperatively … Reducing medication errors: teaching strategies that increase nursing students’ awareness of medication … Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - The surgeon injected the medication to stain the eye. … administrations and found a total of 153 medication errors or roughly one error in every 20 medication … Understanding medication compounding issues. … Back to basics: medication safety. … Reconciliation Mishap
January 1, 2018
Implementation of the I-PASS handoff
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - specific focus on early illness detection, acute illness management, reduction of polypharmacy through
medication … for improvement.3 For example, QI may focus on improving
advance directive completion or conducting medication … INTERACT are educational
trainings for providers as well as clinical and education tools, such as a medication … reconciliation
worksheet, a “stop and watch” early warning tool, and templates for progress notes and … APRN-conducted
medication reviews for long-stay nursing home residents.
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psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - potential risk for patient harm, fraud, or tort claim, have been reported in 10% of patient EMRs.( 4 ) Medication … reconciliation discrepancies are particularly noteworthy, since such errors are noted in almost 40% … of EMR patient medication lists.( 5 ) There are also reports of incredible copy-and-paste persistence … Medication history taking in emergency department triage is inaccurate and incomplete. … Follow-up
June 14, 2023
WebM&M Cases
Refused Medication
-
psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - or an incorrect report or handoff between staff, and can result in errors such as missed or delayed medication … administration or orders. 5 Such medication, treatment, and equipment errors can have potentially … Ventilator and intravenous medication administration tubing may not be long enough to maneuver into and … The checklist included patient demographic, procedural, medication and overall status data and required … Reconciliation Mishap
January 1, 2018
HIM functions in healthcare quality
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Institutions hoped to leverage this technology to reduce verbal order use and prevent medication prescribing … However, a survey conducted by the Institute for Safe Medication Practices in 2017 indicated that for … (For example, pharmacists assess the dose, route, and indication for medication orders and radiology … Additionally, unlike verification for medication or imaging orders, the standard protocol for verifying … Reconciliation
August 5, 2022
WebM&M Cases
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psnet.ahrq.gov/issue/exploring-situational-awareness-diagnostic-errors-primary-care
September 20, 2011 - January 19, 2012
Medicines reconciliation using a shared electronic health care record
-
psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - life-threatening-infant-overdose-sodium-chloride
infant’s family and attending physician met regularly for discussions and reconciliation … Four main system errors contributed to the medication error made in the care of
this patient. … Systemic Causes of In-Hospital Intravenous
Medication Errors: A Systematic Review. … Technology utilization to prevent medication errors. Curr Drug Saf.
2010;5(1):13-8.
16. … Interventions to reduce
pediatric medication errors: a systematic review.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ambulatory-safety_research-protocol.pdf
July 24, 2015 - safety” OR harm* OR accident* OR complication*
OR error* OR discontinuit* OR continuity OR hand-off* OR medication … literature reviewers
against established inclusion criteria, and all selections will be accepted without
reconciliation