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digital.ahrq.gov/sites/default/files/docs/publication/guide-to-reducing-unintended-consequences-of-electronic-health-records.pdf
August 01, 2011 - the issue as well as information about potential risks that the issue poses or
incidents that have occurred … The Issues Log should contain valuable information about the
problem (for example, when and where it occurred … The evidence collected in the Issues Log will help you formulate hypotheses about
why the problem occurred … For problems that resulted from a series of events that occurred over time
it may be helpful to construct … Use specific and accurate descriptors for what occurred, rather than negative and vague
words.
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digital.ahrq.gov/ahrq-funded-projects/improving-sickle-cell-transitions-care-through-health-information-technology/annual-summary/2012
January 01, 2012 - Improving Sickle Cell Transitions of Care through Health Information Technology - 2012
Project Name
Improving Sickle Cell Transitions of Care Through Health Information Technology
Principal Investigator
Jain, Anjali
Organization
The Lewin Group, Inc.
Funding Mechanism…
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digital.ahrq.gov/ahrq-funded-projects/assessment-pediatric-look-alike-sound-alike-substitution-errors/annual-summary/2012
January 01, 2012 - Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors - 2012
Project Name
Assessment of Pediatric Look-Alike, Sound-Alike Substitution Errors
Principal Investigator
Basco, William
Organization
Medical University of South Carolina
Funding Mechanism
PAR:…
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digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
January 01, 2019 - Using Aviation Technology to Prevent Healthcare Errors: The Health IT Black Box
Similar to the airline industry’s use of a “black box” that captures actions leading up to a near miss or error, the health IT black box captures mouse movements and keystrokes made by users of EHRs. This allows for a robust analysis of…
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digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-slides-081811.pdf
August 18, 2011 - per year
438,046 preventable ADEs
• This is likely to be an underestimate
Stages In Which Errors Occurred … Study Design, Population, and Setting
ADEs in the Ambulatory Setting - Rates
Stages In Which Errors Occurred
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digital.ahrq.gov/location/usa-il-evanston
January 01, 2023 - USA, IL, Evanston
Preventing Wrong-Drug and Wrong-Patient Errors With Indication Alerts in CPOE Systems
Description
This research implemented indication alerts, which occur when an ordered or prescribed medication lacks a corresponding problem on the patient’s problem list. Th…
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digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015182-bentley-final-report-2008.pdf
January 01, 2008 - A successful “go live”
occurred there the first week of December, 2006. … implementation also went very well even though many things continued to be learned as this
transformation occurred … A successful implementation occurred there on August 6,
2007. … different members of the hospital staff before they reach the physician,
the likelihood that an error has occurred
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digital.ahrq.gov/ahrq-funded-projects/facilitators-and-barriers-adoption-successful-urban-telemedicine-model
January 01, 2023 - The HeA program completed 13,566 visits between May 2001 and June 2013, of which 4,985 visits occurred
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017258-gardner-final-report-2010.pdf
January 01, 2010 - changes in type or
dose of medication and being able to continue monitoring after the changes have occurred … family was interested, the team scheduled a baseline visit where a signed
informed consent process occurred … semi-structured interviews (e.g. suicidality assessment) that documented
whether adverse events had occurred
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digital.ahrq.gov/sites/default/files/docs/publication/p20hs014949-branscombe-final-report-2005.pdf
January 01, 2005 - Most of the work of the Leadership Team occurred over the first quarter of the Planning
Project. … activities were as stated above, mention should be made regarding the
growth of understanding that occurred … Further learning occurred within the project staff as technology options were
researched.
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt
January 01, 2009 - How Do I Evaluate Workflow?
What is Workflow?
Defining workflow
Definitions of workflow vary. Here are a couple:
The flow of work through space and time, where work is comprised of three components: inputs are transformed into outputs.[1]
The activities, tools, and processes needed to produce or modify work, pr…
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digital.ahrq.gov/ahrq-funded-projects/novel-it-create-patient-integrated-quality-improvement
January 01, 2023 - Novel IT To Create Patient-Integrated Quality Improvement
Project Final Report ( PDF , 1.44 MB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ.…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/idea
January 01, 2023 - Idea Generation
Benchmarking
Description
Benchmarking is a process of evaluating metrics or best practices from other organizations (either related or unrelated to your own) and then applying them to your organization.
Brainwriting
Description
B…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/examples/finalize
January 01, 2023 - Finalize Workflows
1. Examples of flowcharts
Patient Check In ( PDF , 18KB)
Patient Check Out ( PDF , 18KB)
Post-Appointment Lab Visit ( PDF , 17KB)
2. Why and how do we use the flowcharts we previously developed again, at this point?
By now your flowcharts will provide a…
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digital.ahrq.gov/medication-reconciliation
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixC_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - Likelihood 28.1%
(n=135)
Moderate Likelihood 17.9%
(n=86)
High Likelihood 9.2%
(n=44)
Has Occurred … – Here 31.5%
(n=151)
Has Occurred – Elsewhere 2.9%
(n=14)
Type of potential care-process
compromise
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digital.ahrq.gov/sites/default/files/docs/page/delrahim-howlett-podcast-transcript.pdf
June 16, 2021 - Delrahim Howlett Podcast Transcript
Podcast 1
Web‐Based Assessment and Brief Intervention for Alcohol Use in Women of Childbearing Age
(Dr. Katia Delrahim Howlett)
Narrator: Welcome to Health IT Spotlight from the Agency for Healthcare Research and Quality.
Fetal Alcohol Spectrum Disorders result from prenatal e…
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017157-carrow-final-report-2012.pdf
January 01, 2012 - This occurred when prescribers were registered in the EPCS system by the
Project Liaison as being authorized … e-prescribing, the DrFirst
monitoring staff were available as instances of prescription rejection occurred … The first
occurred in November, 2009 after it was determined an EPCS was transmitted without a hard … The second occurred in July, 2010, after the prescribing
vendor became aware providers were able to … Providers using EPCS reported that several safety problems occurred less often after
implementation of
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/examples/flowcharts
January 01, 2023 - Flowcharts
1. Examples of flowcharts
In-Office Prescribing - Paper System ( PDF , 22KB)
Prescription Renewal Request - Paper System ( PDF , 25KB)
2. Why and how do we assess workflow using flowcharts when we are determining our clinic’s health it system requirements?
A flow…
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digital.ahrq.gov/ahrq-funded-projects/closing-feedback-loop-improve-diagnostic-quality/annual-summary/2011
January 01, 2011 - Closing the Feedback Loop to Improve Diagnostic Quality - 2011
Project Name
Closing the Feedback Loop to Improve Diagnostic Quality
Principal Investigator
Weiss, Eta
Organization
University of Alabama at Birmingham
Funding Mechanism
RFA: HS07-002: Ambulatory Safety …