National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (4)
- Adverse Events (4)
- Caregiving (1)
- Children/Adolescents (3)
- Chronic Conditions (1)
- Clinician-Patient Communication (1)
- Communication (1)
- Community-Based Practice (1)
- COVID-19 (1)
- Elderly (1)
- Electronic Health Records (EHRs) (1)
- Electronic Prescribing (E-Prescribing) (1)
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- Long-Term Care (1)
- Medicaid (1)
- Medical Errors (2)
- Medication (10)
- (-) Medication: Safety (11)
- Nursing Homes (1)
- Opioids (1)
- Outcomes (1)
- Patient Safety (5)
- Provider: Pharmacist (1)
- Quality Measures (1)
- Quality of Care (1)
- Risk (1)
- Screening (1)
- Substance Abuse (1)
- Telehealth (1)
- Women (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 11 of 11 Research Studies DisplayedCarroll AR, Johnson JA, Stassun JC
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
This study’s objective was to test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was conducted from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Observed dosing errors were the main outcome measured, and secondary outcomes included caregiver-reported medication knowledge. Among 198 randomized caregivers (mean age 31.4 years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 percentage points). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group. The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%], and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]).
AHRQ-funded; HS026122.
Citation: Carroll AR, Johnson JA, Stassun JC .
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
JAMA Netw Open 2024 Jan 2; 7(1):e2350969. doi: 10.1001/jamanetworkopen.2023.50969..
Keywords: Children/Adolescents, Health Literacy, Communication, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinician-Patient Communication, Hospital Discharge, Medication: Safety
Jolliff A, Coller RJ, Kearney H
An mHealth design to promote medication safety in children with medical complexity.
This study describes an effort to design a health information technology tool to improve medication safety for children with medical complexity (CMC). The study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a co-design process to identify: 1) medication safety challenges experienced by CMC caregivers and, 2) design requirements for a mobile health application to improve medication safety for CMC in the home. Family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program participated in virtual co-design sessions. During these sessions, the facilitator guided 16 co-designers in generating and converging upon medication safety challenges and design requirements. These sessions were recorded and reviewed after conclusion to confirm that all designer comments had been captured. An analysis yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines.
AHRQ-funded; HS028409.
Citation: Jolliff A, Coller RJ, Kearney H .
An mHealth design to promote medication safety in children with medical complexity.
Appl Clin Inform 2024 Jan; 15(1):45-54. doi: 10.1055/a-2214-8000..
Keywords: Children/Adolescents, Medication: Safety, Medication, Health Information Technology (HIT), Chronic Conditions, Telehealth, Caregiving
MohammadiGorji S, Joseph A, Mihandoust S
Anesthesia workspaces for safe medication practices: design guidelines.
The purpose of this study was to create a set of evidence-based design guidelines for the design of anesthesia workspaces to support safer anesthesia medication tasks in operating rooms (ORs). The researchers collected data through literature review, observation, and coding of prerecorded videos of outpatient surgical procedures to identify challenges encountered by anesthesia providers while performing medication tasks. The study findings were summarized into 7 design guidelines, including: 1) locate critical tasks within a primary field of vision, 2) eliminate other staff travel into and through the anesthesia zone, 3) identify and delineate a clear anesthesia zone with adequate space for the anesthesia provider, 4) maximize the ability to reconfigure the anesthesia workspace, 5) minimize workspace clutter from equipment, 6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and 7) optimize lighting of tasks and surfaces.
AHRQ-funded.
Citation: MohammadiGorji S, Joseph A, Mihandoust S .
Anesthesia workspaces for safe medication practices: design guidelines.
HERD 2024 Jan; 17(1):64-83. doi: 10.1177/19375867231190646..
Keywords: Medication: Safety, Medication, Patient Safety
Cohen TN, Berdahl CT, Coleman BL
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
This study’s objective was to understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. The authors randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. Results showed that among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Seven of these events were linked to COVID-19.
AHRQ-funded; HS027455.
Citation: Cohen TN, Berdahl CT, Coleman BL .
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
J Nurs Care Qual 2024 Jan-Mar; 39(1):51-57. doi: 10.1097/ncq.0000000000000720..
Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors
Berbakov ME, Hoffins EL, Stone JA
AHRQ-funded; HS028475.
A study team collaborated with Aurora Pharmacy, Inc. to develop Senior Safe, a community pharmacy-based intervention designed to increase awareness of safe over-the-counter medication use for older adults. Senior Safe was adapted through pilot testing and a randomized control trial before a finalized version was provided to Aurora Pharmacy to integrate into all its pharmacy sites. The authors concluded that this multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.
AHRQ-funded; HS024490; HS027737.
Citation: Berbakov ME, Hoffins EL, Stone JA .
AHRQ-funded; HS028475.
J Am Pharm Assoc 2024 Jan-Feb; 64(1):159-68. doi: 10.1016/j.japh.2023.11.009.
Keywords: Medication, Medication: Safety, Provider: Pharmacist, Patient Safety, Community-Based Practice
Kyler KE, Hall M, Antoon JW
Major drug-drug interaction exposure among Medicaid-insured children in the outpatient setting.
This study’s objective was to determine the prevalence of major drug-drug interactions (DDI) exposure and factors associated with higher DDI exposure rates among children in an outpatient setting. The authors performed a cross-sectional study of children aged 0 to 18 years with ≥1 ambulatory encounter, and ≥2 dispensed outpatient prescriptions using the 2019 Marketscan Medicaid database. Primary outcomes were the prevalence and rate of major DDI exposure. Out of 781,019 children with ≥2 medication exposures, 21.4% experienced ≥1 major DDI exposure. The odds of exposure increased with age and with medical and mental health complexity. Frequently mentioned drugs included Clonidine, psychiatric medications, and asthma medications. The highest adverse physiologic effect exposure rate per 100 children included: increased drug concentrations (14.6), central nervous system depression (13.6), and heart rate-corrected QT interval prolongation (9.9).
AHRQ-funded; HS028979.
Citation: Kyler KE, Hall M, Antoon JW .
Major drug-drug interaction exposure among Medicaid-insured children in the outpatient setting.
Pediatrics 2024 Jan; 153(2):e2023063506. doi: 10.1542/peds.2023-063506.
Keywords: Children/Adolescents, Adverse Drug Events (ADE), Adverse Events, Medicaid, Medication: Safety
Fain K, Alexander GC
Are Food and Drug Administration prescription drug safety plans working? A case study of isotretinoin.
The authors comment on a case study analyzing pharmacy claims in order to examine the impact of the iPledge program (an FDA restricted distribution plan that included electronic registration of patients, physicians, and pharmacists plus monitoring of contraceptive use) on contraceptive use for women of childbearing age taking isotretinoin (Accutane). This drug, used for acute acne, could affect fetal development. The limited effectiveness of the program shows the difficulty of changing patient behavior.
AHRQ-funded; HS0189960
Citation: Fain K, Alexander GC .
Are Food and Drug Administration prescription drug safety plans working? A case study of isotretinoin.
Pharmacoepidemiol Drug Saf. 2013 Dec;22(12):1258-62. doi: 10.1002/pds.3514..
Keywords: Patient Safety, Medication: Safety, Medication, Health Information Technology (HIT), Women
Abramson EL, Pfoh ER, Barron Y
The effects of electronic prescribing by community-based providers on ambulatory medication safety.
This study was conducted to assess the effect of implementing a commercial electronic health record with e-prescribing on rates and types of prescribing errors. Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100) prescriptions).
AHRQ-funded; HS016970.
Citation: Abramson EL, Pfoh ER, Barron Y .
The effects of electronic prescribing by community-based providers on ambulatory medication safety.
Jt Comm J Qual Patient Saf 2013 Dec;39(12):545-52..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Medication: Safety, Medication, Electronic Health Records (EHRs)
Hanlon JT, Schmader KE
The medication appropriateness index at 20: where it started, where it has been, and where it may be going.
The objective of this narrative review is to describe finding regarding the reliability of the Medication Appropriateness Index (MAI), a comparison of the MAI with other quality measures of potentially inappropriate prescribing, the predictive value of the MAI with important health outcomes, and the responsiveness of the MAI to change within the framework of randomized controlled trials.
AHRQ-funded; HS018721
Citation: Hanlon JT, Schmader KE .
The medication appropriateness index at 20: where it started, where it has been, and where it may be going.
Drugs Aging. 2013 Nov;30(11):893-900. doi: 10.1007/s40266-013-0118-4..
Keywords: Quality of Care, Medication, Outcomes, Quality Measures, Medication: Safety
Katz DF, Sun J, Khatri V
QTc interval screening in an opioid treatment program.
This pilot study supports the feasibility of implementing a population-based electrocardiographic monitoring program in order to decrease the QTc interval in high-risk patients undergoing methadone maintenance in an opioid treatment program. Clinical characteristics alone were inadequate to identify patients in need of electrocardiographic screening.
AHRQ-funded; HS021138
Citation: Katz DF, Sun J, Khatri V .
QTc interval screening in an opioid treatment program.
Am J Cardiol. 2013 Oct 1;112(7):1013-8. doi: 10.1016/j.amjcard.2013.05.037..
Keywords: Opioids, Medication, Substance Abuse, Screening, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Risk, Implementation
Moga DC, Carnahan RM, Lund BC
Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living Centers.
This study evaluated the risks and benefits of drugs to reduce urinary incontinence that were used by elderly VA nursing home residents. It found that the use of these drugs, known as bladder antimuscarinics, resulted in improved continence rates and better social engagement but also led to a higher risk of fractures in new users.
AHRQ-funded; HS016094
Citation: Moga DC, Carnahan RM, Lund BC .
Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living Centers.
J Am Med Dir Assoc. 2013 Oct;14(10):749-60. doi: 10.1016/j.jamda.2013.03.008..
Keywords: Elderly, Medication, Medication: Safety, Nursing Homes, Long-Term Care, Injuries and Wounds, Patient Safety