-
digital.ahrq.gov/sites/default/files/docs/page/AHRQ_CDS_TEP_Teleconference_8_15_12.pdf
August 15, 2012 - • What are common mistakes CDS
implementers make?
• How can we minimize the impact? … What are the mistakes CDS developers
usually make?
3. … What are the mistakes CDS implementers
usually make?
4. … What are the mistakes CDS developers usually make? … What are the mistakes CDS implementers usually make?
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/SurveyOnPatientSafetyCulture.doc
January 01, 2008 - Staff feel like their mistakes are held against them.
8. .
(1
(2
(3
(4
(5
(9
8. … Staff are willing to report mistakes they observe in this office
(1
(2
(3
(4
(5
(9
SECTION … They overlook patient care mistakes that happen over and over
(1
(2
(3
(4
(5
(9
3. … Our office processes are good at preventing mistakes that could affect patients
(1
(2
(3
(4
(5 … Mistakes happen more than they should in this office
(1
(2
(3
(4
(5
(9
4.
-
digital.ahrq.gov/sites/default/files/docs/implementation/Bellamy.ppt
April 01, 2005 - It is just by chance that more serious
mistakes don’t happen around here. (A10)
R4. … Staff feel like their mistakes are held
against them. (A8)
R2. … Staff worry that mistakes they make are
kept in their personnel file.
-
digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/privacy-and-security/ethical-issues-and
October 04, 2021 - Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft.
-
digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/nursing-informatics/patient-and-nurse-safety
For nursing, information
technology plays a key role in protecting patients by eliminating
nursing mistakes
-
digital.ahrq.gov/sites/default/files/docs/AHRQ2007STSConferenceCall-Final.pdf
March 28, 2007 - absurd)
Presented by Ross Koppel, PhD
33
If you did all that...you would:
• Make far fewer mistakes … Presented by Ross Koppel, PhD
47
The best HIT reflects learning from mistakes
All commercial HIT represents … embedded choices
of others who have made thousands of mistakes
Safe HIT benefited from those mistakes
-
digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/arreola-m-et-al-2003
January 01, 2003 - Workflow-Related Findings
"A significant number of mistakes and low-quality images were identified
-
digital.ahrq.gov/key-topics/interface-engines
August 30, 2021 - mechanism to handle those instances where source systems transmit invalid codes or make other common mistakes
-
digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/Post-UsabilityEvaluationQuestionnaire.pdf
November 08, 2010 - Correcting your mistakes Difficult 0 1 2 3 4 5 6 7 8 9 Easy
17.
-
digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2011
January 01, 2011 - Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2011
Project Name
Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors
Principal Investigator
Basco, William
Organization
Medical University of South Carolina
Funding Mechanism…
-
digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-lasa-substitution-errors/annual-summary/2010
January 01, 2010 - Assessment of Pediatric Look-Alike, Sound-Alike (LASA) Substitution Errors - 2010
Project Name
Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors
Principal Investigator
Basco, William
Organization
Medical University of South Carolina
Funding Mechanism…
-
digital.ahrq.gov/sites/default/files/docs/activity/2011_018841_basco_pdf_3.pdf
January 01, 2011 - Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors
1 | Assessment of PediAtric Look-ALike, sound-ALike substitution errors
Small ReSeaRch GRant to ImpRove health caRe QualIty thRouGh health
InfoRmatIon technoloGy (It) (R03)
Assessment of Pediatric Look-Alike,
Sound-Alike Substitution Errors
Pri…
-
digital.ahrq.gov/sites/default/files/docs/activity/assessment_of_pediatric_look_alike__sound_alike__lasa__substitution_errors_2010pdf_2.pdf
March 01, 2012 - Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors
1 | Assessment of PediAtric Look-ALike, sound-ALike substitution errors
2010 GrAnt summAry
Assessment of Pediatric Look-Alike, Sound-Alike
Substitution Errors
Principal Investigator: Basco, William, M.D.
Organization: Medical University of So…
-
digital.ahrq.gov/2018-year-review/research-spotlights/prototype-computerized-provider-order-entry-system-reduced
January 01, 2018 - Mistakes made by patients and providers can lead to medication errors.
-
digital.ahrq.gov/ahrq-funded-projects/enhancing-emr-based-real-time-sepsis-alert-system-performance-through-machine
January 01, 2023 - First, they lack mechanisms to learn from past errors and, therefore, make the same mistakes on new patients
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-hazard-manager/annual-summary/2011
January 01, 2011 - Hazard Manager focuses on the missing safeguards in IT systems that fail to protect users from making mistakes
-
digital.ahrq.gov/health-information-exchange-policy-issues
January 01, 2023 - other health care professionals have access to the information they need at the time they need it, mistakes … questions, and how to communicate what is being learned to the health care community so that the same mistakes
-
digital.ahrq.gov/2020-year-review/research-summary/designing-intelligent-systems-support-cognitive-work-clinical
January 01, 2020 - providers find themselves adapting their cognitive work and workflow to meet the system’s requirements, mistakes
-
digital.ahrq.gov/sites/default/files/docs/activity/2011_290200600011i14_walker_pdf_3.pdf
January 01, 2011 - Hazard Manager focuses on the missing
safeguards in IT systems that fail to protect users from making mistakes
-
digital.ahrq.gov/2018-year-review/research-spotlights/leveraging-health-it-test-solutions-are-replicable-scalable-and
January 01, 2018 - While capturing the instance of retracting and reordering mistakes does not correct or prevent errors