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digital.ahrq.gov/2018-year-review/research-spotlights/prototype-computerized-provider-order-entry-system-reduced
January 01, 2018 - Medication errors may also occur during the prescribing process, including prescribing the wrong medication … , wrong dose, or the wrong frequency of taking the medication.
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digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
January 01, 2005 - Events
– Correct Tube-Correct Connector-Correct Hole
– Patient Falls
– Deaths Related to Surgery at Wrong … & post-op
–op & post-op
infections
•Falls
•Transfusion events
•Deaths in restraints
•IP suicides
•Wrong … since ’02 to 0.8% in ’05
•No instances of:
–Transfusion
events
–Deaths in
restraints
–Suicides
–Wrong … tube-
connector-hole
events
–Wrong site
surgeries
–MRI hazards
Hospital
Outcomes:
•Patient
satisfaction
-
digital.ahrq.gov/organization/columbia-university
January 01, 2023 - HS023963
Principal Investigator(s)
Schnall, Rebecca
Assess Risk of Wrong-Patient … Multiple Records Open
Description
This project compared the risk of orders placed on the wrong
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digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds
January 01, 2023 - selected and dosed improperly; confusion around the names of medications may cause patients to receive the wrong … ×
Disclaimer
Disclaimer details
Close
Automated detection of wrong-drug … Automated detection of wrong-drug prescribing errors. … Technology: Electronic Health Record/Electronic Medical Record
Indication-based prescribing prevents wrong-patient … Indication-based prescribing prevents wrong-patient medication errors in computerized provider order
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_4_ADE_Incident_Identification_Form.pdf
June 16, 2021 - Substitution If yes:
____ 14.01 Wrong drug given
____ 14.02 Wrong patient received
drug … ____ 14.03 Wrong drug ordered
____ 14.04 Other __________
____ 15.
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digital.ahrq.gov/program-overview/research-reports/2021-year-review/research-dissemination
January 01, 2021 - Patient-Generated Health Data Integration
Yuyang Yang (presenter), Bruce Lambert (PI)
Preventing Wrong-Drug … and Wrong-Patient Errors With Indication Alerts in CPOE Systems
Poster: Implementation of Medication … Alerts to Reduce Wrong-Drug and Wrong-Patient Errors in CPOE Systems
AHRQ-Funded
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digital.ahrq.gov/track-9-emerging-approaches-drive-change-healthcare
January 01, 2023 - Track 4 | Track 5 | Track 6 | Track 7 | Track 8 | Track 9
Track 9-I Plausibly correct, but wrong … instances when the lack of a human intermediary led to conclusions that were plausibly correct, but wrong
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digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
December 01, 2005 - Questions
Advancing Excellence in Health Care
What is wrong with Healthcare today? … Advancing Excellence in Health Care
What is wrong with Healthcare? … When the docs tried to do this
themselves they were lost and ordered the wrong test. … Someone had to manually look at all of these results
and check what was wrong! … Popping up irrelevant
alerts at the wrong time will ensure they are ignored.
-
digital.ahrq.gov/research-method/chart-review
January 01, 2023 - Notifying Clinicians About Epilepsy Surgery Patients
Automated detection of wrong-drug … Automated detection of wrong-drug prescribing errors.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/potential-problem-analysis
January 01, 2023 - Description
A potential problem analysis (PPA) is a systematic method for determining what could go wrong
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/survey
January 01, 2023 - 28419267
Principal Investigator
Adelman, Jason Stuart
Project Name
Assess Risk of Wrong-Patient
-
digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/effect
January 01, 2023 - 37011638/
Principal Investigator
Adelman, Jason Stuart
Project Name
Assess Risk of Wrong-Patient
-
digital.ahrq.gov/sites/default/files/docs/resource/PCC_Schillinger_Q4_UCSF_verbal_consent_9_4_08.pdf
June 16, 2021 - _________________
Phone Number Dialed
VERIFY1
I’m sorry; I must have dialed or been given the wrong … If Yes: I’m sorry, I was given a wrong number. Thank you for your time. Goodbye.
(END)
2.
-
digital.ahrq.gov/sites/default/files/docs/resource/PCC_Schillinger_Q2_EnrollmentOutreachCallSFHP.pdf
June 16, 2021 - The information we received must have been wrong. We will
correct it. Thank you for your time. … The information we received must have been wrong. We will correct it.
Thank you.
-
digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open/citation/goldmine
January 01, 2023 - Project Name
Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open
Develop
-
digital.ahrq.gov/sites/default/files/docs/medication-without-harm-qas-07242024.pdf
July 24, 2024 - There is no standard that says thirty is right and thirty-one is wrong. … providers describe situations that
were so subtle, you could see that there is no subtlety in being on the wrong … We worked out the measure for the wrong patient, which
is a 1,000 of the 3,060 and dosing for 20,000 … It seems
quite clear that photos help prevent orders on the wrong patient, and I strongly endorse that
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015284-reiling-final-report-2008.pdf
January 01, 2008 - dose, extra dose, wrong route,
wrong form, wrong time. … The medication error rate declined 16.5%; without wrong
technique it declined 21.2%. … The medication error rate increased by 51%, and
without wrong technique decreased by 58%. … The medication error rate declined by 56% and without wrong technique
decreased by 63%. … Wrong time errors accounted for 81% (9.2% error rate) pre
and 54% (2.7% error rate) post.
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digital.ahrq.gov/medical-condition/pregnancy
January 01, 2023 - Investigator(s)
Fareed, Naleef
Joseph, Joshua J
Venkatesh, Kartik Kailas
Wrong-patient … Wrong-patient orders in obstetrics.
-
digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
January 01, 2019 - EHR “bloat”
For example, one analysis done was around acetaminophen (Tylenol) errors involving the wrong … These ‘wrong route’ errors can be catastrophic in some circumstances and are a focus of patient safety
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaushal-r-et-al-2003
January 01, 2003 - "Finally, physicians can electronically write an order in the wrong patient's record, analogous to handwriting … an order in the wrong patient's medical chart."