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Search results for "United States of America"
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Agency for Healthcare Research and Quality. Health Care Innovations Exchange. March 16, 2011.
This collection provides information on programs and tools to improve medication safety.
Journal Article > Study
Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients.
Sarkar U, Handley MA, Gupta R, et al. J Gen Intern Med. 2008;23:459-465.
Chronic disease care increasingly involves patients engaging in self-management activities outside of discrete clinical encounters—for example, diabetics must monitor their blood sugars at home. This study used retrospective analysis of data from an interactive telephone-based diabetes self-management system to characterize the types and severity of adverse events occurring between physician visits in a low health literacy patient population. The vast majority of patients experienced at least one adverse event, most of which were considered preventable. Most events were detected by prompts generated by the telephone-based system. This study is one of the first to address adverse events in ambulatory patients outside the context of clinician visits and provides a model for addressing patient safety in chronic disease management.
Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.