Medical Errors

Research Findings

Research Activities, February 2012:
E-prescribing systems within electronic health records reduce ambulatory prescribing errors in community-based practices
Recommendations on rounding pediatric doses may improve e-prescribing while reducing risk of adverse drug events

Research Activities, January 2012:
Clinical informatics monitoring tool helps reduce adverse drug events in nursing home settings
Duplicate medication order errors increase after computerized provider order entry is implemented

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Research Activities, December 2011:
Transitioning to new electronic health records can result in potential safety problems
Volume of paid outpatient malpractice claims underscores need for greater patient safety efforts in this area
Pharmacy, medical, and nurse practitioner students need more education on drug-drug interactions

Research Activities, November 2011:
Blacks and patients at hospitals with a high percentage of black patients more likely to suffer adverse events
Nearly 1 in 10 outpatient computerized prescriptions contains errors

Research Activities, October 2011:
MONAHRQ gains momentum
Less than half of pharmacy computer systems studied correctly identified drug-drug interactions
Medical students, interns, and residents need training to disclose medical errors
Certain factors increase risk of medication errors in the neonatal intensive care unit (NICU)

Research Activities, August 2011:
Trigger tools have potential to detect adverse events following outpatient surgery
Mental demands of pediatric hospital pharmacy staff have varying effects on likelihood of medication errors and adverse events

Research Activities, July 2011:
Delays in reporting medical errors at Japanese hospital nearly triple that of United States hospital

Research Activities, June 2011:
An automated phone response system can help track adverse drug events in primary care patients
Medication side effects, injuries up dramatically

Research Activities, May 2011:
Systems to detect adverse drug events need buy-in from leaders and staff to become part of hospital routine
Laboratory monitoring of high-risk medications varies greatly
Specific primary care strategies may improve medication safety

Research Activities, April 2011:
Medication safety indicators can guide improvement in primary care drug selection, dosing, and monitoring
Adverse drug event surveillance tailored to hospitalized children

Research Activities, March 2011:
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
Automated screening of patient electronic medical records is only the first step to identifying a medication problem

Research Activities, February 2011:
Flawed State apology and disclosure laws dilute their intended impact on malpractice suits
Nearly one-third of emergency department visits involve nonideal care events
Pilot study finds a low level of medication errors for look-alike, sound-alike drugs prescribed for children

Research Activities, January 2011:
E-prescribing for managing medication refills has not reached its full potential

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Research Activities, December 2010:
Physicians can use 10 strategies to manage abnormal test result alerts in electronic health records

Research Activities, November 2010:
Oral chemotherapy drugs not immune to medication errors
Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup
Various factors affect providers' ability to identify spoken drug names

Research Activities, October 2010:
Timely followup remains an issue with abnormal lab results in electronic health records
Study recommends disclosure of medical mistakes that affect multiple patients

Research Activities, September 2010:
Assessment of hospital computerized physician order entry systems finds many medication errors are missed
Detailed, up-to-date medication lists help prevent errors
Electronic prescribing with clinical decision support reduces medication errors in community-based practices
Electronic prescribing improves safety, but with a small increase in physician time

Research Activities, August 2010:
Emergency physicians suggest ways to reduce errors in patient handoffs during shift changes
Hospital risk managers more likely than physicians to recommend error disclosure, but less likely to apologize

Research Activities, July 2010:
HIV patients are at risk for being prescribed wrong drug combinations
Computerized provider order entry significantly reduces medication errors in an ambulatory setting
Using bar-code technology with eMAR reduces medication administration and transcription errors

Research Activities, May 2010:
Adverse events occurring during pediatric sedation are recorded in charts but not always reported
Drug monitoring may be improved by the use of health information technology and clinical pharmacists

Research Activities, April 2010:
Physicians need to be better educated about FDA-approved indications for drugs and evidence for off-label drug use
FACE cards have a small positive effect on hospital patients' ability to identify their physicians
Outpatient advice on pediatric medication safety is inadequate
Medication review technique may help identify drug-related problems in the elderly

Research Activities, March 2010:
One patient safety indicator may offer a glimpse at a hospital's overall safety record

Research Activities, February 2010:
Vaccines with names that look and sound alike can lead to vaccination errors

Research Activities, January 2010:
Simulating equipment failures can be useful to hone anesthesia providers' skills
Failure to order and follow up medical tests are leading causes of diagnostic errors
Medication changes are not always documented properly in physician notes or the electronic medical record
Criteria used to identify "drugs to avoid" in the elderly are not very accurate
Physicians aren't confident they can recognize infections from anthrax and other bioterrorism disease threats
Computerized decisionmaking systems improve physician prescribing for long-term-care residents

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Research Activities, December 2009:
Specimens from multiple body sites are needed to accurately test for MRSA
Staff willingness to change and adapt is important when implementing electronic pharmacy systems

Research Activities, November 2009:
Children are commonly harmed by adverse events in intensive care units
Infants are at the highest risk for errors involving cardiovascular drugs
Evaluating team member perceptions can help guide future failure mode and effects analysis activities
Instituting patient safety rounds can boost adverse event reporting in outpatient cancer clinics
Inappropriate medications raise the risk of adverse drug events among older adults

Research Activities, October 2009:
Electronic prescriptions help community pharmacists recognize prescribing errors

Research Activities, September 2009:
Shift workers suffer fatigue and poor performance
Out-of-hospital endotracheal intubation errors are not linked to deaths, but failed attempts may boost pneumonitis risk
Ambulance stretcher-related injuries are not uncommon

Research Activities, August 2009:
Specialists are less likely than generalists to spot clinically important drug-drug interactions
Hospitals with better safety climates have fewer events that can potentially harm patients
Medicare claims data identify hospital-acquired catheter-associated urinary tract infections with limited accuracy
Making medication administration a dedicated activity free of interruptions could improve long-term care drug safety
Study finds high medication error rates among adults and children receiving outpatient cancer treatment
Performance obstacles negatively affect how ICU nurses perceive the quality and safety of care they deliver
Diagnostic codes alone may misclassify bacterial infections among hospitalized patients with rheumatoid arthritis

Research Activities, July 2009:
Anesthesiologists who read during operations are as vigilant as those who do not read
Examining processes, not outcomes, improves patient safety in hospitals
Nurses feel left out of the medical error disclosure process

Research Activities, June 2009:
Patient-centered health information technology has little impact on reducing pediatric medication errors in emergency departments
Emergency departments need to do more to maximize patient safety
Patient safety events make hospital stays longer and more costly
Staff perceptions of hospital patient safety differ by department and position
WalkRounds program enhances the patient safety climate in hospitals
The cost and impact of medical errors continue long after hospital discharge

Research Activities, May 2009:
AHRQ sponsors issue of Health Services Research that examines the implementation, assessment, and evaluation of patient safety initiatives
Hospital reports on patient safety incidents can be useful in identifying the contributing factors, but often need more detail
Physicians correctly identify fewer than half of drug pairs with potentially dangerous interactions

Research Activities, April 2009:
Perception of patient safety climate in hospitals varies by management level and clinical discipline
Voluntary reporting and computerized surveillance work best together to identify adverse drug events
Quality improvement collaborative fails to improve infection prevention in surgical patients
Focused review is more effective than random review in discovering errors in surgical pathology cases
ICU nurses handle medical errors differently than they say they do on survey
Simulation exercise for hospital resuscitation teams pinpoints training and patient safety issues
Antibiotic use and diarrhea are factors in hospital room contamination with vancomycin-resistant organisms
AHRQ releases a new tool to help improve patient safety

Research Activities, March 2009:
Mandatory public reporting of care performance did not affect quality of care for Medicare managed care patients
Nurses and office staff can help report prescribing errors in primary care offices
Some pediatricians would disclose errors only if harm is evident
10-State project to study methods to reduce central line-associated blood stream infections in hospital ICUs

Research Activities, February 2009:
Quality of care and working conditions influence job satisfaction of surgical residents
Multiple approaches are needed to reduce hospital prescribing errors
Veterans Administration hospitals have a generally positive safety climate, but there is room for improvement

Research Activities, January 2009:
Rates of adverse medical events and motor vehicle incidents are unchanged among U.S. resident pediatric physicians despite duty hour limit standards
Statewide collaborative effort to improve patient safety in intensive care units greatly enhanced unit safety culture
Patients reveal adverse events in the hospital that are not documented in the medical records
Final rule issued for Patient Safety Organizations
New report recommends strategies to reduce medical resident fatigue-related errors and improve training

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