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  1. Layout 1 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/08-0085_bcma.pdf
    August 01, 2008 - These errors can occur at any stage in the process of medication use (e.g., prescribing, dispensing,
  2. digital.ahrq.gov/ahrq-funded-projects/understanding-complex-clinical-decision-tasks-better-health-information
    January 01, 2023 - Complexity-contributing factors (CCF) may occur when 1) the overall clinical picture does not match the
  3. digital.ahrq.gov/ahrq-funded-projects/improving-sickle-cell-transitions-care-through-health-information-technology
    January 01, 2023 - For youths with SCD there are two important transitions that occur: the transition from home to the emergency
  4. digital.ahrq.gov/ahrq-funded-projects/multi-site-trial-test-benefits-adding-personalized-risk-calculator-online
    January 01, 2025 - Usability testing will occur among patients, caregivers, LVAD coordinators, and physicians to collect
  5. digital.ahrq.gov/sites/default/files/docs/page/improving-provider-communication-to-improve-transitions-in-patient-care.pdf
    June 16, 2021 - Adverse events occur in approxi­ mately one in five adult patients within 3 weeks of dis­ charge.1 The
  6. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
    January 01, 2023 - Fault Tree Analysis Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures using a tree diagram . The process can be used to study a failure that actually occurred, or it could study a potential failure. The technique starts with the failure an…
  7. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017010-bailey-final-report-2011.pdf
    January 01, 2011 - high-alert medications – particularly anticoagulants – are a frequent cause of hospitalization.(4) ADEs occur … pharmacists frequently need to repackage adult preparations, thus adding more opportunities for errors to occur … Narcotics overdoses occur in both inpatient and outpatient settings with some frequency due to clinician
  8. digital.ahrq.gov/ahrq-funded-projects/scaling-and-spreading-electronic-capture-patient-reported-outcomes-leveraging
    January 01, 2024 - Scaling and Spreading Electronic Capture of Patient-Reported Outcomes Leveraging a National Surgical Quality Improvement Program Project Final Report ( PDF , 983.41 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are respons…
  9. digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015319-sullivan-final-report-2007.pdf
    January 01, 2007 - error” (NCC MERP Level A14 A priori, we had posited that the error characteristics most likely to occur
  10. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/pareto-chart
    January 01, 2023 - Pareto Chart Also Known As Pareto Diagram Description A pareto chart is a bar graph where the bars appear in decreasing length from left to right. The bar length corresponds to time, frequency, or amount. Uses When you want to find the most significant causes or problems from a l…
  11. digital.ahrq.gov/2018-year-review/research-summary/emerging-innovative-newly-funded-research/engaging-patients-and-families-their-health-care
    January 01, 2018 - Engaging Patients and Families in Their Health Care Research shows that patient and family engagement in healthcare leads to measureable improvements in safety, quality, and satisfaction of care. Health IT can facilitate patient engagement via the use of patient portals, social media, and…
  12. digital.ahrq.gov/decisionmaker-brief-computerized-provider-order-entry-cpoe
    January 01, 2023 - Order entry errors can occur, for example, when providers order medications that adversely interact with
  13. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/decision-tree
    January 01, 2023 - Decision Tree Also Known As Decision Process Flowchart Logic Diagram Description Decision trees are tools that can be utilized to navigate several courses of action to arrive on one choice. Their structure allows one to evaluate multiple options and explore what the potential outcomes ar…
  14. digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual
    January 01, 2023 - Contextual errors occur when a care plan is inappropriate because of inattention to patient context.
  15. digital.ahrq.gov/ahrq-funded-projects/development-and-evaluation-patient-reported-outcome-score-visualization-improve
    January 01, 2023 - Development and Evaluation of Patient-Reported Outcome Score Visualization to Improve Their Utilization (PROVIZ) Project Final Report ( PDF , 1.06 MB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its conte…
  16. digital.ahrq.gov/sites/default/files/docs/citation/r01hs024538-adelman-final-report-2022.pdf
    January 01, 2022 - events in near-real time and providing the unique opportunity to investigate events shortly after they occur … action is executed incorrectly.35 Planning Errors were further classified as Knowledge Errors, which occur … because of practical or clinical knowledge gaps, and Rule- Based Errors, which occur as a result of
  17. digital.ahrq.gov/2018-year-review/research-summary/emerging-innovative-newly-funded-research/using-ehealth-expand-access-behavioral-healthcare-non%E2%80%93english
    January 01, 2018 - Using eHealth to Expand Access to Behavioral Healthcare for non–English-Proficient Hispanic Patients Significance and Potential Impact Adoption of this research will expand access to evidence-based alternatives to medication for the management of chronic insomnia and may narrow existing racial and ethnic disp…
  18. digital.ahrq.gov/sites/default/files/docs/page/Materials%20Management%20and%20Production%20Processes%20Group%20Report.pdf
    June 16, 2021 - that a linear path of care often is mandated toward the end of life, ignoring complexities that can occur
  19. digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/process-0
    January 01, 2023 - Process Mapping Use Case Description A use case is a set of instructions that an individual in a process completes to go through one single step in that process. It describes what the user does to interact with a system. Value Stream Mapping Descr…
  20. digital.ahrq.gov/sites/default/files/docs/page/the-personal-health-partner-using-health-information-technology-to-promote-better-pediatric-primary-care.pdf
    June 16, 2021 - assessing a child’s exposure to secondhand smoke and counseling a parent to make a quit plan, could occur

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