National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (18)
- (-) Adverse Events (64)
- Ambulatory Care and Surgery (1)
- Behavioral Health (2)
- Blood Clots (2)
- Burnout (2)
- Cardiovascular Conditions (5)
- Care Coordination (1)
- Caregiving (1)
- Care Management (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (2)
- Children/Adolescents (9)
- Chronic Conditions (2)
- Clinical Decision Support (CDS) (3)
- Clinician-Patient Communication (3)
- Communication (7)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Critical Care (4)
- Cultural Competence (1)
- Data (2)
- Depression (2)
- Diabetes (1)
- Diagnostic Safety and Quality (4)
- Digestive Disease and Health (2)
- Disparities (1)
- Education: Continuing Medical Education (1)
- Elderly (6)
- Electronic Health Records (EHRs) (3)
- Electronic Prescribing (E-Prescribing) (2)
- Emergency Department (3)
- Evidence-Based Practice (3)
- Falls (5)
- Healthcare-Associated Infections (HAIs) (6)
- Healthcare Cost and Utilization Project (HCUP) (2)
- Healthcare Costs (1)
- Healthcare Delivery (4)
- Health Information Technology (HIT) (11)
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- Health Services Research (HSR) (1)
- Heart Disease and Health (3)
- Hospital Discharge (2)
- Hospitalization (4)
- Hospitals (7)
- Imaging (1)
- Implementation (1)
- Infectious Diseases (3)
- Injuries and Wounds (1)
- Inpatient Care (3)
- Intensive Care Unit (ICU) (6)
- Kidney Disease and Health (2)
- Labor and Delivery (3)
- Long-Term Care (1)
- Maternal Care (2)
- Medical Devices (1)
- Medical Errors (18)
- Medication (21)
- Medication: Safety (12)
- Mortality (1)
- Neonatal Intensive Care Unit (NICU) (1)
- Newborns/Infants (6)
- Nursing (1)
- Nursing Homes (1)
- Organizational Change (1)
- Outcomes (6)
- Patient-Centered Outcomes Research (1)
- Patient and Family Engagement (1)
- (-) Patient Safety (64)
- Practice Patterns (2)
- Pregnancy (2)
- Prevention (2)
- Provider (3)
- Provider: Pharmacist (1)
- Provider: Physician (3)
- Quality Improvement (5)
- Quality of Care (5)
- Racial and Ethnic Minorities (1)
- Registries (2)
- Respiratory Conditions (4)
- Risk (11)
- Shared Decision Making (3)
- Simulation (1)
- Skin Conditions (1)
- Sleep Problems (1)
- Social Determinants of Health (1)
- Social Media (1)
- Surgery (10)
- Surveys on Patient Safety Culture (2)
- Teams (2)
- TeamSTEPPS (2)
- Tools & Toolkits (1)
- Training (2)
- Transitions of Care (2)
- Uninsured (1)
- Urinary Tract Infection (UTI) (1)
- Vaccination (1)
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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 25 of 64 Research Studies DisplayedVenema DM, Skinner AM, Nailon R
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.
AHRQ-funded; HS021429.
Citation: Venema DM, Skinner AM, Nailon R .
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
BMC Geriatr 2019 Dec 11;19(1):348. doi: 10.1186/s12877-019-1368-8..
Keywords: Falls, Injuries and Wounds, Patient Safety, Elderly, Risk, Hospitals, Adverse Events
Napolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Patel SA, Araujo T, Rodriguez LP
Long peripheral catheters: a retrospective review of major complications.
The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, the investigators did a retrospective review of major complications. Among other discoveries, they found LPCs were often placed for the indications of difficult access and long-term antibiotics.
AHRQ-funded; HS025891.
Citation: Patel SA, Araujo T, Rodriguez LP .
Long peripheral catheters: a retrospective review of major complications.
J Hosp Med 2019 Dec;14(12):758-60. doi: 10.12788/jhm.3313..
Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Patient Safety, Central Line-Associated Bloodstream Infections (CLABSI), Blood Clots, Infectious Diseases, Risk
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Gaufberg E, Olmsted MW, Bell SK
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
The authors discuss an AHRQ conference held to establish a research agenda on patient and family emotional harm after medical errors. Topics include implications for quality and safety, educational innovation, and qualitative research.
AHRQ-funded; HS024463.
Citation: Gaufberg E, Olmsted MW, Bell SK .
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
J Med Humanit 2019 Dec;40(4):489-504. doi: 10.1007/s10912-019-09563-z..
Keywords: Medical Errors, Adverse Events, Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety
Khan A, Yin HS, Brach C
AHRQ Author: Brach C
Association between parent comfort with English and adverse events among hospitalized children.
The purpose of this study was to examine the association between parents’ limited comfort with English (LCE) and adverse events in a cohort of hospitalized children. Participants included Arabic-, Chinese-, English-, and Spanish-speaking parents of patients 17 years and younger in the pediatric units of seven North American hospitals. Findings showed that hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.
AHRQ-authored; AHRQ-funded; HS022986.
Citation: Khan A, Yin HS, Brach C .
Association between parent comfort with English and adverse events among hospitalized children.
JAMA Pediatr 2020 Dec;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215..
Keywords: Children/Adolescents, Caregiving, Cultural Competence, Clinician-Patient Communication, Communication, Adverse Events, Patient Safety, Inpatient Care, Hospitalization
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
Lambert BL, Galanter W, Liu KL
Automated detection of wrong-drug prescribing errors.
Investigators assessed the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. They found that automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Additionally, real-time error detection is not possible with the current system. They suggested that further development should replicate their analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
AHRQ-funded; HS021093.
Citation: Lambert BL, Galanter W, Liu KL .
Automated detection of wrong-drug prescribing errors.
BMJ Qual Saf 2019 Nov;28(11):908-15. doi: 10.1136/bmjqs-2019-009420..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Leeds IL, DiBrito SR, Canner JK
Cost-benefit limitations of extended, outpatient venous thromboembolism prophylaxis following surgery for Crohn's disease.
This goal of this study was to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery. A decision tree model was used to assess cost-effectiveness and cost-per-case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery. Results showed that extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment.
AHRQ-funded; HS024547.
Citation: Leeds IL, DiBrito SR, Canner JK .
Cost-benefit limitations of extended, outpatient venous thromboembolism prophylaxis following surgery for Crohn's disease.
Dis Colon Rectum 2019 Nov;62(11):1371-80. doi: 10.1097/dcr.0000000000001461..
Keywords: Prevention, Digestive Disease and Health, Surgery, Healthcare Costs, Adverse Events, Patient Safety, Blood Clots, Shared Decision Making, Medication
Allen JA, Reiter-Palmon R, Kennel V, et al.
Group and organizational safety norms set the stage for good post-fall huddles.
In this study, the investigators explored group and organizational safety norms as antecedents to meeting leader behaviors and achievement of desired outcomes in a special after-action review case-a post-fall huddle. Findings indicated that organizational and group safety norms related to perceived huddle meeting effectiveness through appropriate huddle leader behavior in a partial mediated framework.
AHRQ-funded; HS024630; HS021429.
Citation: Allen JA, Reiter-Palmon R, Kennel V, et al..
Group and organizational safety norms set the stage for good post-fall huddles.
J Leadersh Organ Stud 2019 Nov;26(4):465-75. doi: 10.1177/1548051818781820..
Keywords: Adverse Events, Falls, Organizational Change, Patient Safety
Mathis MR, Duggal NM, Likosky DS
Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.
In this study, the authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery. They identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. Their findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
AHRQ-funded; HS022535.
Citation: Mathis MR, Duggal NM, Likosky DS .
Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.
Anesthesiology 2019 Nov;131(5):1046-62. doi: 10.1097/aln.0000000000002909..
Keywords: Adverse Events, Cardiovascular Conditions, Patient Safety, Respiratory Conditions, Surgery
Goswami E, Ogden RK, Bennett WE
Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children.
This paper describes an initiative to develop an evidence-based list of nephrotoxic medications to screen for acute kidney injury (AKI) risk in hospitalized children. This initiative, called the Nephrotoxic Injury Negated by Just-in-time Action quality improvement collaborative, convened a Nephrotoxic Medication (NTMx) Subcommittee composed of pediatric nephrologists, a pharmacist, and a pediatric intensivist. The committee reviewed NTMx lists, conducted a literature review of the disputed medications, and assigned an evidence grade based on the association between nephrotoxicity and the quality of the data. The subcommittee then came to a majority consensus to which medications should be included on the list. The list was presented to the larger collaborative and voted on. This list will be continually updated and voted on annually.
AHRQ-funded; HS023763.
Citation: Goswami E, Ogden RK, Bennett WE .
Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children.
Am J Health Syst Pharm 2019 Oct 30;76(22):1869-74. doi: 10.1093/ajhp/zxz203..
Keywords: Children/Adolescents, Medication: Safety, Medication, Patient Safety, Risk, Evidence-Based Practice, Adverse Drug Events (ADE), Adverse Events
Adelman JS, Applebaum JR, Southern WN
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Researchers assessed the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and examined the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). They found that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
AHRQ-funded; HS024538.
Citation: Adelman JS, Applebaum JR, Southern WN .
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
JAMA Pediatr 2019 Oct 10;173(10):979-85. doi: 10.1001/jamapediatrics.2019.2733..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Medication, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
Mixon AS, Kripalani S, Stein J
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
This paper examined evidence-based interventions implemented in five US hospitals to improve inpatient medication reconciliation. The sites implemented one to seven interventions in 791 patients during a 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful reconciliation rates while two interventions were associated with significant increases. The positive interventions included: defining clinical roles and responsibilities, training, and hiring staff to perform discharge medication reconciliation. The negative interventions were training staff to take medication histories and implementing a new electronic health record (EHR) system.
AHRQ-funded; HS019598.
Citation: Mixon AS, Kripalani S, Stein J .
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
J Hosp Med 2019 Oct;14(10):614-17. doi: 10.12788/jhm.3308..
Keywords: Medication, Evidence-Based Practice, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Hospitals, Healthcare Delivery, Inpatient Care
Angraal S, Nuti SV, Masoudi FA
Digoxin use and associated adverse events among older adults.
The authors describe national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over the past two decades. They found that, while digoxin prescriptions have decreased, the drug is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. They concluded that these findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines.
AHRQ-funded; HS025164; HS025402; HS025517.
Citation: Angraal S, Nuti SV, Masoudi FA .
Digoxin use and associated adverse events among older adults.
Am J Med 2019 Oct;132(10):1191-98. doi: 10.1016/j.amjmed.2019.04.022.
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Keywords: Medication, Elderly, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Heart Disease and Health, Cardiovascular Conditions, Hospitalization, Practice Patterns
Jones KJ, Crowe J, Allen JA
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
The purpose of this study was to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture. The investigators concluded that post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles were likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Crowe J, Allen JA .
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
BMC Health Serv Res 2019 Sep 9;19(1):650. doi: 10.1186/s12913-019-4453-y..
Keywords: TeamSTEPPS, Falls, Adverse Events, Surveys on Patient Safety Culture, Patient Safety, Hospitals, Teams
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
AHRQ-funded; HS024596.
Citation: Kapoor A, Field T, Handler S .
Adverse events in long-term care residents transitioning from hospital back to nursing home.
JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Chopra V, Kaatz S, Swaminathan L
Variation in use and outcomes related to midline catheters: results from a multicentre pilot study.
This study examined complication rates from placement of midline vascular catheters. They have become more common in use recently. Complications were analyzed using medical records from hospitalized patients in 12 hospitals from January 2017 to February 2018. Most midline catheters were placed in general ward settings for difficult intravenous access. About half were removed within 5 days of insertion. Major or minor complications occurred in 10.3% of midlines with minor complications accounting for 71% of all adverse events. These minor complications included dislodgement, leaking, and infiltration. Major complications included occlusion, upper-extremity DVT and BSI. Use of midlines and outcomes varied widely across hospitals.
AHRQ-funded; HS025891.
Citation: Chopra V, Kaatz S, Swaminathan L .
Variation in use and outcomes related to midline catheters: results from a multicentre pilot study.
BMJ Qual Saf 2019 Sep;28(9):714-20. doi: 10.1136/bmjqs-2018-008554..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Infectious Diseases, Adverse Events, Practice Patterns, Outcomes, Hospitals
Wang E, Kang H, Gong Y
Generating a health information technology event database from FDA MAUDE reports.
This study examined using a health information technology (HIT) event database to identify patient safety events (PSEs) or medical errors. The study used the FDA Manufacturer and User Facility Device Experience (MAUDE) database to extract HIT events. Classic and CNN models were utilized on a test set. The model was capable of identifying HIT event with about a 90% accuracy.
AHRQ-funded; HS022895.
Citation: Wang E, Kang H, Gong Y .
Generating a health information technology event database from FDA MAUDE reports.
Stud Health Technol Inform 2019 Aug 21;264:883-87. doi: 10.3233/shti190350..
Keywords: Health Information Technology (HIT), Medical Devices, Adverse Events, Data, Medical Errors, Patient Safety
Nguyen BP, Reese T, Decker S
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
The authors report on the implementation and evaluation of CDS Services which represent potential drug-drug interactions knowledge with Clinical Quality Language (CQL). Their suggested solution is based on emerging standards including CDS Hooks, FHIR, and CQL. They selected two use cases, implemented them with CQL rules, and tested them.
AHRQ-funded; HS023826; HS025984.
Citation: Nguyen BP, Reese T, Decker S .
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
Stud Health Technol Inform 2019 Aug 21;264:724-28. doi: 10.3233/shti190318..
Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Medication, Adverse Events, Patient Safety, Health Information Technology (HIT)
Liang C, Miao Q, Kang H
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
The present study sought to explore the associations between federal incentives of patient safety research and the outcomes from 1995 to 2014, in which two historical events - the release of To Err Is Human and the American Recovery and Reinvestment Act - were considered in the analysis. They concluded that their findings suggested a positive outcome in patient safety research.
AHRQ-funded; HS022895.
Citation: Liang C, Miao Q, Kang H .
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
Stud Health Technol Inform 2019 Aug 21;264:983-87. doi: 10.3233/shti190371..
Keywords: Patient Safety, Medical Errors, Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT)
Yao B, Kang H, Gong Y
Data quality assessment of narrative medication error reports.
This study examined the data quality of patient safety event (PSE) reports that are used to analyze the root causes of PSE. If the data quality is poor then the reporting and root cause analysis (RCA) will also be poor. Incomplete or missing data is the most prevalent problem in these reports. The researchers used an adapted taxonomy to assess the data quality of PSE reports, and extracted sample reports based on eight error types. The extracts were scored by experts. They found that most structured fields were ignored by reporters, but the narrative parts of the reports contained rich and valuable information. The results show that the adapted taxonomy could be a promising tool for report quality assessment and improvement.
AHRQ-funded; HS022895.
Citation: Yao B, Kang H, Gong Y .
Data quality assessment of narrative medication error reports.
Stud Health Technol Inform 2019 Aug 9;265:101-06. doi: 10.3233/shti190146..
Keywords: Adverse Drug Events (ADE), Medication, Medical Errors, Adverse Events, Data, Patient Safety
Sobieraj DM, Martinez BK, Hernandez AV
Adverse effects of pharmacologic treatments of major depression in older adults.
The objective of this study was to assess adverse effects of pharmacologic antidepressants for treatment of major depressive disorder (MDD) in adults 65 years of age or older. The investigators found, among other conclusions, that in patients 65 years of age or older with MDD, treatment of the acute phase of MDD with serotonin norepinephrine reuptake inhibitors (SNRIs), but not selective serotonin reuptake inhibitors (SSRIs), was associated with a statistically greater number of overall adverse events vs placebo.
AHRQ-funded; 290201500012I.
Citation: Sobieraj DM, Martinez BK, Hernandez AV .
Adverse effects of pharmacologic treatments of major depression in older adults.
J Am Geriatr Soc 2019 Aug;67(8):1571-81. doi: 10.1111/jgs.15966..
Keywords: Depression, Behavioral Health, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Elderly