Patient Safety Research Highlights (continued)

Medication Safety

Errors associated with the use of smart infusion pumps. Medication errors and adverse drug events are common among critically ill cardiac surgery patients who receive medications through intravenous infusion pumps. AHRQ researchers studied smart infusion pump data for 735 cardiac surgery patients and found 180 serious medication errors. They concluded that although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety.
Project Title: Improving Medication Safety Across Clinical Settings
Research Area: COE
AHRQ Grant: HS11534
Principal Investigator: David Bates, M.D.
Reference: Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E, Thompson S, Hayes J, Bates DW. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med 2005 Mar;33(3):533-40.

Dosing errors in children are associated with inadequate national standards for medication dosing based on patient weight and age. Although medications are prescribed to millions of children each year in the United States, little is known about medication errors in ambulatory pediatrics. In the process of completing a study to determine the prevalence of outpatient dosing errors, AHRQ researchers identified a number of issues with respect to medication errors in children. These include prescribing medication not labeled for use in children, discrepancies in published dosing recommendations for many medications, unclear guidelines on use of adult dosing recommendations for children of different ages and weights, and the lack of readily available, documented weights to determine appropriate weight-based doses for children. The authors suggest we need better national standards of medication-dosing that are appropriate for children and an improved ability to determine errors through databases that include children's weights as well as prescription information.
Project Title: Pediatric EBM-Getting Evidence Used at the Point of Care
AHRQ Grant: HS10516
Principal Investigator: Robert Davis, M.D., M.P.H.
Reference: McPhillips H, Stille C, Smith D, Pearson J, Stull J, Hecht J, Andrade S, Miller M, Davis R. Methodological challenges in describing medication dosing errors in children. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 2, Concepts and Methodology. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 213-23.

High rates of adverse events in long-term care facilities found during the ordering and monitoring stages of care. There were over 800 adverse drug events, of which more than 40 percent were judged preventable, in two large long-term care facilities during a 9-month period in 2000-2001, according to an AHRQ-funded study. Of the 225 adverse drug events considered to be serious, life-threatening, or fatal, over 60 percent were preventable. The study found that preventable adverse drug events occurred most often during the ordering and monitoring stages of care and that the two drugs most commonly involved were warfarin and atypical antipsychotic agents (olanzapine, risperidone, quetiapine, and clozapine).
Project Title: Reducing Adverse Drug Events in the Nursing Home
Research Area: TRIP
AHRQ Grant: HS10481
Principal Investigator: Jerry Gurwitz, M.D.
Reference: Gurwitz JH, Field TS, Judge J, Rochon P, Harrold LR, Cadoret C, Lee M, White K, LaPrino J, Erramuspe-Mainard J, DeFlorio M, Gavendo L, Auger J, Bates DW. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med 2005 Mar;118(3):251-8.

PDA-based drug information sources improve medication safety. Having drug information sources readily available at the point of care is one practice-improvement intervention that may reduce medication errors. PDAs offer great potential for improving quality in health care and several PDA-based drug information sources are available. AHRQ researchers developed a quality and safety framework and used it to evaluate 11 drug information sources. Three of those sources met the criteria of the framework: Eprocrates Rx Pro, Lexi-Drugs, and mobileMICROMEDEX. Lexi-Drugs was found to be the most specific and complete PDA resource to optimize medication safety by reducing potential errors associated with insufficient or incomplete drug information. However, the researchers found that no resource sufficiently addressed all patient safety information needs for all cases, and it is often necessary to use more than one resource to reduce medication errors and improve patient safety.
Project Title: Training Clinicians to Use a Handheld Device for Electronic Prescribing
Research Area: CLIPS
AHRQ Grant: HS11808
Principal Investigator: Kimberly Galt, Pharm.D., FASHP
Reference: Galt KA, Rule AM, Houghton B, Young DO, Remington G. Personal digital assistant-based drug information sources: potential to improve medication safety. J Med Libr Assoc 2005 Apr;93(2):229-36.

Medication safety guide for evaluating best practices in ambulatory care is available. AHRQ researchers have developed a quality and safety framework for health providers to evaluate medication safety in their practice. The tool helps providers identify areas for improvement and establish an action plan for various levels of implementation. A key aspect of the tool is its identification of methods to improve the environment for medication safety through individual behavior and policy or system changes. It also identifies implementation plans that need additional financial or expert resources beyond ambulatory care. The tool requires providers to think about safe practices pertaining to medication use, office environment, error management, workplace conditions, safety education, safety perceptions, and most importantly, the patient. The tool can be downloaded and distributed without permission.
Project Title: Impact of Personal Digital Assistant Devices on Medication Errors in Primary Care
Research Area: CLIPS
AHRQ Grant: HS11808
Principal Investigator: Kimberly Galt, Pharm.D., FASHP
Reference: http://chrp.creighton.edu/documents/BestPractices.pdf

*Potential medication dosing errors among children are common in outpatient pediatrics using both hand-written and electronic prescriptions. AHRQ researchers have found that prescriptions for 22 common medications dispensed to children often contain potential dosing errors. Using automated pharmacy data from 3 HMOs—two using hand-written prescriptions and one using CPOE—researchers examined the prevalence of under- and overdosed medications prescribed to 1,933 children. About 15 percent of children were prescribed a potentially wrong dose for a medication: eight percent were potentially overdosed and seven percent were potentially underdosed. Only 67 percent of children weighing less than 35 kg (77 lbs.) received medication doses within recommended ranges, and children prescribed medication outside of a clinic visit were at a 50 percent greater risk for an overdose. Potential error rates were not lower at the site using CPOE.
Project Title: The CERTs Prescribing Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11843
Principal Investigator: Richard Platt, M.D., M.Sc.
Reference: McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J, Stull J, Debellis K, Andrade S, Miller M, Kaushal R, Gurwitz J, Davis RL. Potential medication dosing errors in outpatient pediatrics. J Pediatr 2005 Dec;147(6):761-7.

*Toolkit can help hospitals identify and implement successful techniques for reconciling medications at admission. The Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association recruited 50 hospitals to participate in a statewide patient safety initiative. The goal of the program was to reduce medication errors by implementing a set of safe practice recommendations for reconciling medications at admission. By the end of the 18-month adoption period, 20 percent of the hospitals had diffused the practices throughout their organization and 64 percent reported using a standardized medication reconciliation form. Active clinician and senior administrator involvement, multidisciplinary implementation teams, and small pilot tests of change were key factors in successful implementation of the program. A medication reconciliation toolkit based on the hospitals' experiences is available online (http://www.macoalition.org/Initiatives/RMToolkit.shtml).
Project Title: Evaluate the Effects of Massachusetts Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11928
Principal Investigator: Nancy Ridley, M.S.
Reference: Rogers G, Alper E, Brunelle D, Federico F, Fenn CA, Leape LL, Kirle L, Ridley N, Clarridge BR, Bolcic-Jankovic D, Griswold P, Hanna D, Annas CL. Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies. Jt Comm J Qual Pat Saf 2006 Jan;32(1):37-50. Online toolkit: http://www.macoalition.org/Initiatives/RMToolkit.shtml

*Compliance with the Food and Drug Administration's (FDA's) black box warnings is highly variable in ambulatory care. Black box warnings (BBWs) are the FDA's strongest labeling requirements for high-risk medicines. However, it remains unclear how effective they are at communicating risk. AHRQ researchers used data on 930,000 members in 10 health plans, nationwide to assess overall BBW drug use and prescribing compliance with BBW recommendations in ambulatory care. Among the 42 percent of health plan members receiving at least one BBW drug, use consistent with recommendations varied by the drug. Most noncompliance occurred with lab monitoring—about half of all first-time therapies that should have been accompanied by baseline lab tests were not, and 13 percent of ongoing therapies were not monitored regularly. There was almost no coprescribing of the two contra-indicated QT-interval-prolonging BBW drugs that, in some patients, can lead to cardiac arrhythmia and even sudden death. Pregnant women were rarely prescribed BBW drugs that are contra-indicated during pregnancy. The researchers conclude that, to minimize drug-associated risks, BBWs must be clearly communicated to both clinicians and patients.
Project Title: The CERTs Prescribing Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11832
Principal Investigator: Richard Platt, M.D., M.Sc.
Reference:Wagner AK, Chan KA, Dashevsky I, Raebel MA, Andrade SE, Lafata JE, Davis RL, Gurwitz JH, Soumerai SB, Platt R. FDA drug prescribing warnings: is the black box half empty or half full? Pharmacoepidemiol Drug Saf 2005 Nov 18 [In press, available in electronic form].

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Communication and Patient Support

Most people have difficulty understanding pharmaceutical label instructions, regardless of their cultural background and level of education. Pharmaceutical labels that give dosage instructions can be difficult to understand. AHRQ researchers investigated the errors in understanding instructions on pharmaceutical labels by subjects of different cultural and educational backgrounds. Labels of three medications of varying complexities were used in the study: oral rehydration therapy, cough medicine, and fever medicine. The results indicated that all subjects had considerable difficulty in interpreting pharmaceutical labels, independent of the cultural background and level of education. The authors suggest that the instructions be presented in a simplified manner and in multiple forms to meet the needs of multiple groups and communities.
Project Title: Mining Complex Clinical Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George Hripcsak, M.D.
Reference: Patel VL, Branch T, Arocha JF. Errors in interpreting quantities as procedures: the case of pharmaceutical labels. Int J Med Inform 2002 Nov 12;65(3):193-211.

Many chronically ill patients limit use of prescription drugs because of cost, but don't tell their doctors. About two-thirds of chronically ill adults who cut back on their medications because of the cost don't tell their doctors in advance. AHRQ researchers surveyed 4,055 adults age 50 years and older taking prescription medication for diabetes, depression, heart problems, or high cholesterol. Of these, 660 patients reported forgoing some medication in the prior year due to cost pressures, and two-thirds of this group reported they did not tell their clinicians in advance. However, less than one-third of the patients who spoke to their clinicians about the cost of prescription drugs reported being given information about programs to assist patients with medication costs or sources of lower-cost refills.
Project Title: Automated Assessments and the Quality of Diabetes Care
AHRQ Grant: HS10281
Principal Investigator: John Piette, M.D.
Reference: Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: Do patients with chronic illnesses tell their doctors? Arch Intern Med 2004 Sept. 13;164(16):1749-55.

Patients develop more positive attitudes toward electronic health care records and Web-based communication. AHRQ researchers found patients are becoming increasingly satisfied by Web-based communication with their health care providers while having online access to their electronic health care records. Researchers conducted an online survey of 4,282 members of the Geisinger Health System who were registered users of an application that allows patients to communicate electronically with their providers and view selected portions of their EHR. They also conducted focus groups with 25 patients using the system and conducted one-on-one interviews with 10 primary care clinicians.
Project Title: Impact of EpiCare on the Management of Diabetes in the Geisinger Health System
Research Area: IDSRN
AHRQ Grant: 290-00-0003 TO#2
Principal Investigator: Andrea Hassol, M.S.P.H.
Reference: Hassol A, Walker JM, Kidder D, Rokita K, Young D, Pierdon S, Deitz D, Kuck S, Ortiz E. Patient experiences and attitudes about access to a patient electronic healthcare record and linked Web messaging. J Am Med Inform Assoc 2004 Nov-Dec;11(6):505-13.

Video available to help providers disclose bad news. AHRQ researchers offer an ethical argument as to why a serious harm-causing medical error must be disclosed. All the mechanics of disclosure, including the initial contact, the meeting setting, who should be present, framing the disclosure, how to talk, empathizing, and follow-up are laid out as a guideline. A video tool to educate physicians and other medical personnel about these guidelines is available free of charge at http://www.gha.org/pha/video/index.asp.
Project Title: Accountability and Health Safety, a Statewide Approach
Research Area: R-DEMO
AHRQ Grant: HS11918
Principal Investigator: Kenneth Thorpe, Ph.D.
Reference: Banja J. Why, what and how ought harmed parties be told? The art, mechanics, and ambiguities of error disclosure. In: Hatlie M and Youngberg B, editors. The Patient Safety Handbook. Sudbury, MA.: Jones and Bartlett Publishers; 2003. pp. 531-48.

Patients and physicians view disclosure of medical errors differently. AHRQ researchers undertook to determine patients' and physicians' attitudes about error disclosure. Thirteen focus groups were organized, including six groups of adult patients, four groups of academic and community physicians, and three groups of both physicians and patients. A total of 52 patients and 46 physicians participated. Patients wanted disclosure of all harmful errors. Physicians agreed that harmful errors should be disclosed but that they should "choose their words carefully." Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians may not be providing the information or emotional support that patients seek following harmful medical errors.
Project Title: Surveillance, Analysis, and Interventions to Improve Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11898
Principal Investigator: Victoria Fraser, M.D.
Reference: Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003 Feb 26;289(8):1001-7.

Visual aids may improve the accuracy of medication assessment and may be especially beneficial for patients with communication barriers. AHRQ researchers performed a study among long-term warfarin users in an anticoagulation clinic to assess concordance between patient and clinician reports of patient warfarin regimens. Bilingual research assistants asked patients to verbalize their prescribed weekly warfarin regimen, and identify this regimen from a digitized color menu of warfarin pills. Fifty percent of patients achieved verbal concordance, and 66 percent achieved visual concordance with clinicians regarding the weekly warfarin regimen. Clinician/patient discordance regarding patients' warfarin regimen was common, but occurred less frequently when patients identified their regimen with a visual aid. Visual aids may improve the accuracy of medication assessment and may be especially beneficial for patients with communication barriers.
Project Title: Promoting Effective Communication and Decisionmaking in Diverse Populations
AHRQ Grant: HS10856
Principal Investigator: Eugene Washington, M.D., M.Sc.
Reference: Schillinger D, Machtinger EL, Wang F, Chen L-L, Win K, Palacios J, Rodriguez M, Bindman A. Language, literacy, and communication regarding medication in an anticoagulation clinic: are pictures better than words? In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 2, Concepts and Methodology. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 191-212.

*Patient-provider communication influences the resolution of adverse medical events. Patient-provider communication is essential to whether patients and providers continue their relationships, and it affects whether patients perceive adverse events as "mistakes" or "malpractice." AHRQ researchers explored real-life patient-provider communication after patients experienced adverse medical events. Prompt action and repeated reassurance and support from providers helped patients cope with the physical, emotional, and financial trauma—and the worries and frustration that follow adverse events. All of the patients who perceived providers as caring and concerned reported positive post-incident communication with providers. Health organizations, providers, investigators, and policymakers should consider the patient experience when developing training for providers or evaluating adverse event resolution processes.
Project Title: Applied Strategies for Improving Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11878
Principal Investigator: Wilson Pace, M.D.
Reference: Duclos CW, Eichler M, Taylor L, Quintela J, Main DS, Pace W, Staton EW. Patient perspectives of patient-provider communication after adverse events. Int J Qual Health Care 2005 Dec;17(6):479-86.

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Clinical Practice Change

Techniques to reduce the incidence of retained instruments and sponges after surgery include counting instruments and sponges before and after the procedure, and x-raying patients after surgery. A surgical instrument or sponge is left in more than 1,500 patients during surgery each year. AHRQ researchers studied 54 patients who had a total of 61 foreign bodies left inside them after surgery. Of the 61 foreign bodies, 69 percent were sponges and 31 percent were surgical instruments. They found that patients who had emergency surgery were nine times as likely to have a sponge or surgical instrument left in their body as patients undergoing the same procedure on a nonemergency basis. The risk increased by four times for patients who had unplanned changes in their procedure. The researchers note that a number of techniques are available to reduce these incidences, including counting instruments and sponges before and after the procedure, and x-raying patients after surgery.
Project Title: Malpractice Insurers' Medical Error Prevention Study
Research Area: R-DEMO
AHRQ Grant: HS11886
Principal Investigator: David M. Studdert, M.D.
Reference: Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003 Jan 16;348(3):229-35.

Chlorhexidine gluconate reduces the risk of catheter-related blood stream infections by one-half compared to povidone iodine and can lead to reduced costs. More than 150 million intravascular devices are used annually in the United States, including more than 5 million central vascular catheter sites. However, intravascular catheters can lead to complications, such as catheter-related bloodstream infection. AHRQ researchers report that use of chlorhexidine gluconate solution to disinfect the central vascular catheter insertion site reduces the risk of catheter-related bloodstream infection by one-half compared with povidone iodine, and also leads to cost savings of $113 per catheter used. They suggest that the use of chlorhexidine in place of povidone for vascular catheter site disinfection is a simple and cost-effective method of improving patient safety.
Project Title: Targeting Interventions to Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Chaiyakunapruk N, Veenstra DL, Lipsky BA, Sullivan SD, Saint S. Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis 2003 Sep 15;37(6):764-71.

For impregnated catheters, minocycline/rifampin is more effective and economical for longer-term catheterization. Central venous catheters impregnated with minocycline/rifampin are known to be clinically superior to chlorhexidine/silver sulfadiazine impregnated catheters but are more expensive. AHRQ researchers reported that central venous catheters coated with minocycline/rifampin are cost-effective, compared with chlorhexidine/silver sulfadiazine impregnated catheters, for patients catheterized for at least 1 week. They also lead to overall cost savings when patients are catheterized for 2 weeks or longer. The expected duration of catheterization should serve as a guiding tool for the use of antimicrobial catheters in high-risk patients.
Project Title: Targeting Interventions to Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Marciante KD, Veenstra DL, Lipsky BA, Saint S. Which antimicrobial impregnated central venous catheter should we use? Modeling the costs and outcomes of antimicrobial catheter use. Am J Infect Control 2003 Feb;31(1):1-8.

Various methods can reduce ventilator-associated pneumonia in selected patients. Pneumonia severe enough to require mechanical ventilation is a common and highly morbid condition occurring in about 10 to 25 percent of critically ill patients. AHRQ researchers have done a systematic review and synthesis of the studies to prevent ventilator-associated pneumonia. After evaluation of potential benefits and risks, the authors recommend several specific interventions to reduce the incidence of this condition: putting patients in a semi-recumbent position, using sucralfate rather than H2-antagonists to prevent stress ulcers, aspirating subglottic secretions, and using oscillating beds to increase mobility of lung secretions in selected patients.
Project Title: Targeting Interventions to Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med 2003 Mar 18;138(6): 494-501.

Understanding barriers to clinician use of PDAs is vital in evaluating ways to overcoming those barriers. PDAs can be a valuable resource for ambulatory care, but many physicians avoid using them at the point of care due to their fear of patients' perceptions. Although many physicians perceive that patients disapprove of physicians' use of PDAs, AHRQ researchers found that most patients are not averse to doctors using handheld devices. Rather, patients hold favorable attitudes toward physicians' use of PDAs, even among patients who are not computer literate. However, AHRQ researchers found that providing these survey data to physicians did not lead to significant increases in physicians' use of handhelds in the presence of patients.
Project Title: Improving Primary Care Patient Safety with Handheld Decision Support Systems
Research Area: CLIPS
AHRQ Grant: HS11820
Principal Investigator: Eta Berner, Ed.D.
Reference: Berner ES, Savage GT, Houston TK, Williams ES, Crawford MA, Ray MN. Impact of patient feedback on residents' handheld computer use: a multi-site study. Medinfo 2004;11(Pt 1):582-6.

*Missing clinical information may lead to adverse events and delays in services in outpatient primary care. AHRQ researchers collected point-of-care data during patient visits from 253 clinicians across 32 primary care practices on the type, frequency, and consequences of missing clinical information. Among 1,614 clinical visits, clinicians reported that important information was missing in 13.6 percent of cases (220 visits). Among these visits, the most common types of missing information were lab and radiology results (45% and 28.2%, respectively), letters or dictation containing clinical information (39.5%), and patient history or physical exam findings (26.8%). Clinicians reported that potential adverse outcomes due to missing clinical information were at least somewhat likely in 44 percent of these visits, and clinicians with completely electronic medical records ("full EMRs") were significantly less likely to report missing clinical information than their peers with paper-based or partially electronic records.
Project Title: Applied Strategies for Improving Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11878
Principal Investigator: Wilson Pace, M.D.
Reference: Smith PC, Araya-Guerra R, Bublitz C, Parnes B, Van Vorst R, Westfall JM, Pace WD. Missing clinical information during primary care visits. JAMA 2005 Feb 2;293(5):565-71.

Current as of June 2009
Internet Citation: Patient Safety Research Highlights (continued). June 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/errors-safety/psresearch/psresearch2.html