Advice Columns from Dr. Carolyn Clancy

July 10 2012 20120710

Revealing Medical Errors Helps Chicago Hospitals Build a Safer Health System 2012

October 21 2008 20081021

Payment Change Puts Spotlight on Preventing Hospital Errors

December 18 2007 20071218

Where Medical Errors Occur and Steps You Can Take to Avoid Them

Audio & Video

May 1 2010 20100501

Where Medical Errors Occur and How to Avoid Them

Other Patient & Consumer Resources

• 20 Tips to Help Prevent Medical Errors
• 20 Tips to Help Prevent Medical Errors in Children - Spanish Transcript
• Automated screening of patient electronic medical records is only the first step to identifying a medication problem
• Detailed, up-to-date medication lists help prevent errors
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• National Survey on Consumer Experiences With Patient Safety and Quality
• Nearly one-third of emergency department visits involve nonideal care events
• Patient Safety/Medical Errors
• Project Overview: Designing Consumer Reporting Systems for Patient Safety Events

Audio & Video

May 1 2010 20100501

Where Medical Errors Occur and How to Avoid Them

Clinicians & Providers

• AHRQ Patient Safety Tools and Resources
• Designing Consumer Reporting Systems for Patient Safety Events
• Detailed, up-to-date medication lists help prevent errors
• Electronic prescribing improves safety, but with a small increase in physician time
• Electronic prescribing with clinical decision support reduces medication errors in community-based practices
• Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• Impact of Working Conditions on Patient Safety
• Medication Adherence Interventions: Comparative Effectiveness
• Oral chemotherapy drugs not immune to medication errors
• Patient Safety/Medical Errors
• Physicians can use 10 strategies to manage abnormal test result alerts in electronic health records
• Pilot study finds a low level of medication errors for look-alike, sound-alike drugs prescribed for children
• Preventing Avoidable Readmissions: Improving the Hospital Discharge Pr
• Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs

Hospital & Health System Resources

• 10 Patient Safety Tips for Hospitals
• AHRQ Patient Safety Tools and Resources
• Additional Tools and Resources
• Additional Tools and Resources
• Appendix 1-A. Suggested Slides for Module 1
• Appendix 1-B. Pre/Post-Test Questions and Answers for Module 1
• Appendix 2-A. Suggested Slides for Module 2
• Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2
• Appendix 3-A: Suggested Slides for Module 3
• Appendix 3-B. Pre/Post-Test Questions and Answers for Module 3
• Appendix. Additional Tools and Resources
• Appendix: Examples of the SBAR and CUS Tools
• Assessment of hospital computerized physician order entry systems finds many medication errors are missed
• Automated screening of patient electronic medical records is only the first step to identifying a medication problem
• Conclusion
• Conclusion
• Conclusion
• Designing Consumer Reporting Systems for Patient Safety Events
• Detailed, up-to-date medication lists help prevent errors
• E-prescribing for managing medication refills has not reached its full potential
• Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
• Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• Hospital risk managers more likely than physicians to recommend error disclosure, but less likely to apologize
• Hospitals face dilemmas about disclosure of large-scale adverse events
• Improving Patient Safety Systems for Patients With Limited English Proficiency
• Improving Patient Safety in Long-Term Care Facilities
• Improving Patient Safety in Long-Term Care Facilities
• Introduction
• Learning Objectives: Knowledge and Performance Objectives
• Learning Objectives: Knowledge and Performance Objectives
• Learning Objectives: Knowledge and Performance Objectives
• Module 1. Detecting Change in a Resident's Condition
• Module 1: Detecting Change in a Resident's Condition
• Module 2. Communicating Change in a Resident's Condition
• Module 2: Communicating Change in a Resident's Condition
• Module 3. Falls Prevention
• Module 3: Falls Prevention and Management
• Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
• Nearly one-third of emergency department visits involve nonideal care events
• Patient Safety/Medical Errors
• Project Overview: Designing Consumer Reporting Systems for Patient Safety Events
• Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs
• Session 1
• Session 1
• Session 1
• Session 2
• Session 2
• Session 2
• Transforming Hospitals
• Various factors affect providers' ability to identify spoken drug names

Policymaker Resources

• AHRQ Patient Safety Tools and Resources
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• Hospitals face dilemmas about disclosure of large-scale adverse events
• Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
• Patient Safety/Medical Errors
• Study recommends disclosure of medical mistakes that affect multiple patients

Fact Sheets

September 1 2012 20120901

20 Tips to Help Prevent Medical Errors

en español

September 1 2012 20120901

Impact of Working Conditions on Patient Safety

September 1 2012 20120901

Improving Patient Safety Through Simulation Research

September 1 2012 20120901

Patient Safety Challenge Grants

September 1 2012 20120901

Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs

Full Research Reports

September 1 2012 20120901

Designing Consumer Reporting Systems for Patient Safety Events

September 1 2012 20120901

Transforming Hospitals

Other Research & Data

• Assessment of hospital computerized physician order entry systems finds many medication errors are missed
• Automated screening of patient electronic medical records is only the first step to identifying a medication problem
• Detailed, up-to-date medication lists help prevent errors
• E-prescribing for managing medication refills has not reached its full potential
• Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
• Electronic prescribing improves safety, but with a small increase in physician time
• Electronic prescribing with clinical decision support reduces medication errors in community-based practices
• Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• Georgia Hospital Association
• Hospital risk managers more likely than physicians to recommend error disclosure, but less likely to apologize
• Hospitals face dilemmas about disclosure of large-scale adverse events
• Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
• National Survey on Consumer Experiences With Patient Safety and Quality
• Nearly one-third of emergency department visits involve nonideal care events
• Oral chemotherapy drugs not immune to medication errors
• Patient Safety/Medical Errors
• Physicians can use 10 strategies to manage abnormal test result alerts in electronic health records
• Pilot study finds a low level of medication errors for look-alike, sound-alike drugs prescribed for children
• Preventing Avoidable Readmissions: Improving the Hospital Discharge Pr
• Project Overview: Designing Consumer Reporting Systems for Patient Safety Events
• Study recommends disclosure of medical mistakes that affect multiple patients
• Various factors affect providers' ability to identify spoken drug names

Press Releases

September 10 2012 20120910

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent

September 1 2010 20100901

Study Recommends Disclosure of Medical Mistakes That Affect Multiple Patients

May 30 2010 20100530

AHRQ Study Shows Using Bar-Code Technology with eMAR Reduces Medication Administration and Transcription Errors

Advice Columns from Dr. Carolyn Clancy

July 10 2012 20120710

Revealing Medical Errors Helps Chicago Hospitals Build a Safer Health System 2012

October 21 2008 20081021

Payment Change Puts Spotlight on Preventing Hospital Errors

December 18 2007 20071218

Where Medical Errors Occur and Steps You Can Take to Avoid Them

Other News & Events

• 1 in 10 computer-generated prescriptions include at least one error
• AHRQ expert discusses trends and challenges in health information technology
• AHRQ-funded medical liability and patient safety initiative shows promise for reducing patient harm, lawsuits, and costs
• Adverse drug event surveillance tailored to hospitalized children
• Adverse drug reactions a major cause of unplanned hospitalizations of elderly veterans
• Adverse events occurring during pediatric sedation are recorded in charts but not always reported
• An automated phone response system can help track adverse drug events in primary care patients
• Assessment of hospital computerized physician order entry systems finds many medication errors are missed
• Automated screening of patient electronic medical records is only the first step to identifying a medication problem
• Blacks and patients at hospitals with a high percentage of black patients more likely to suffer adverse events
• Certain factors increase risk of medication errors in the neonatal intensive care unit (NICU)
• Clinical informatics monitoring tool helps reduce adverse drug events in nursing home settings
• Computerized Provider Order Entry Cuts Medication Error Likelihood in Half
• Computerized decisionmaking systems improve physician prescribing for long-term-care residents
• Criteria used to identify "drugs to avoid" in the elderly are not very accurate
• Delays in reporting medical errors at Japanese hospital nearly triple that of United States hospital
• Detailed, up-to-date medication lists help prevent errors
• Drug interaction decision support software has limitations and pharmacists' knowledge of support features is limited
• Drug monitoring may be improved by the use of health information technology and clinical pharmacists
• Duplicate medication order errors increase after computerized provider order entry is implemented
• E-prescribing for managing medication refills has not reached its full potential
• Electronic health record-based medication monitoring improves patient compliance in primary care clinics
• Electronic health records can help detect diagnostic errors in primary care
• Electronic health records improve nursing care, coordination, and patient safety
• Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
• Electronic medical records reduce negative outcomes and related costs after patient safety events occur
• Electronic prescribing improves safety, but with a small increase in physician time
• Electronic prescribing with clinical decision support reduces medication errors in community-based practices
• Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
• FACE cards have a small positive effect on hospital patients' ability to identify their physicians
• Failure to order and follow up medical tests are leading causes of diagnostic errors
• Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
• Guide helps consumers reduce medication errors
• HIV patients are at risk for being prescribed wrong drug combinations
• High rates of paper-based prescribing errors found among community-based primary care providers
• High-volume hospitals have low rates of adverse events for high-risk surgeries
• Hospital risk managers more likely than physicians to recommend error disclosure, but less likely to apologize
• Hospitals face dilemmas about disclosure of large-scale adverse events
• Infrequent physician use of implantable cardioverter-defibrillators presents potential risks to patient safety
• Laboratory monitoring of high-risk medications varies greatly
• Less than half of pharmacy computer systems studied correctly identified drug-drug interactions
• Medical students, interns, and residents need training to disclose medical errors
• Medication changes are not always documented properly in physician notes or the electronic medical record
• Medication review technique may help identify drug-related problems in the elderly
• Medication safety indicators can guide improvement in primary care drug selection, dosing, and monitoring
• Medication side effects, injuries up dramatically
• Mental demands of pediatric hospital pharmacy staff have varying effects on likelihood of medication errors and adverse events
• More safeguards needed to prevent adverse drug events caused by medication administration errors
• Most process-of-care events do not harm transplant patients, but they boost costs and lengthen hospital stays
• Nearly 1 in 10 outpatient computerized prescriptions contains errors
• Nearly one-third of emergency department visits involve nonideal care events
• New tools help improve patient safety for those with limited English
• One patient safety indicator may offer a glimpse at a hospital's overall safety record
• Oral chemotherapy drugs not immune to medication errors
• Outpatient advice on pediatric medication safety is inadequate
• Overcrowding in emergency departments increases the risk of preventable medical errors
• Patient Safety/Medical Errors
• Patient surveys are an additional useful tool for identifying adverse events occurring during hospital stays
• Pharmacy, medical, and nurse practitioner students need more education on drug-drug interactions
• Physicians aren't confident they can recognize infections from anthrax and other bioterrorism disease threats
• Physicians can use 10 strategies to manage abnormal test result alerts in electronic health records
• Physicians need to be better educated about FDA-approved indications for drugs and evidence for off-label drug use
• Pilot study finds a low level of medication errors for look-alike, sound-alike drugs prescribed for children
• Provision of personal digital assistants alone does not help providers avoid drug-drug interactions
• Recommendations on rounding pediatric doses may improve e-prescribing while reducing risk of adverse drug events
• Simulating equipment failures can be useful to hone anesthesia providers' skills
• Specific primary care strategies may improve medication safety
• Studies link adverse drug interactions to elevated risk for hospitalization among the elderly
• Study recommends disclosure of medical mistakes that affect multiple patients
• Surgeons are more reluctant to withdraw postoperative life support for patients with complications from surgeon error
• Systems to detect adverse drug events need buy-in from leaders and staff to become part of hospital routine
• Transitioning to new electronic health records can result in potential safety problems
• Trigger tools have potential to detect adverse events following outpatient surgery
• Using bar-code technology with eMAR reduces medication administration and transcription errors
• Vaccines with names that look and sound alike can lead to vaccination errors
• Various factors affect providers' ability to identify spoken drug names
• Volume of paid outpatient malpractice claims underscores need for greater patient safety efforts in this area