National Healthcare Quality and Disparities Report
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Topics
- (-) Adverse Drug Events (ADE) (9)
- (-) Adverse Events (9)
- Ambulatory Care and Surgery (1)
- Blood Thinners (1)
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- Children/Adolescents (1)
- Clinical Decision Support (CDS) (1)
- Colonoscopy (1)
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- Health Information Technology (HIT) (4)
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- Kidney Disease and Health (1)
- Medical Errors (3)
- Medication (9)
- Medication: Safety (6)
- Newborns/Infants (1)
- Patient and Family Engagement (1)
- Patient Safety (8)
- (-) Prevention (9)
- Provider (1)
- Provider: Pharmacist (1)
- Quality Improvement (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 9 of 9 Research Studies DisplayedKane-Gill SL, Wong A, Culley CM
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for nursing home (NH) residents using medication reconciliation and prospective medication regimen reviews (MRRs) on admission plus ongoing clinical decision support alerts throughout the residents' stay. Studying residents in four NHs in Southwestern Pennsylvania, findings showed that the intervention group had a 92% lower incidence of alert-specific ADEs than usual care, and all-cause hospitalization was similar between groups, as were 30-day readmissions.
AHRQ-funded; HS02420.
Citation: Kane-Gill SL, Wong A, Culley CM .
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
J Am Geriatr Soc 2021 Feb;69(2):530-38. doi: 10.1111/jgs.16946..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Telehealth, Health Information Technology (HIT), Provider: Pharmacist, Provider, Clinical Decision Support (CDS), Prevention
Earl TR, Katapodis ND, Schneiderman SR
Using deprescribing practices and the screening tool of older persons' potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults.
This paper is a systematic review of the literature published between 2008 to 2018 that studies the effect of interventions to reduce preventable adverse drug effects (ADEs) for adults who are prescribed multiple medications. Two safety practices were examined: 1) deprescribing interventions to reduce polypharmacy; and 2) use of the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) to reduce potentially inappropriate medications (PIMS). A total of 26 studies and 1 systematic review were included (14 for deprescribing and 12 for STOPP). Deprescribing interventions included decision support tools, educational interventions, and medication reviews. The STOPP tool most reported changes in PIMS, as well as some economic outcomes. Both methods were found to be effective.
AHRQ-funded; HHSP233201500013I.
Citation: Earl TR, Katapodis ND, Schneiderman SR .
Using deprescribing practices and the screening tool of older persons' potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults.
J Patient Saf 2020 Sep;16(3S Suppl 1):S23-s35. doi: 10.1097/pts.0000000000000747..
Keywords: Elderly, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Screening, Prevention
Abraham NS
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
This article is a review of current best practice recommendations focusing on the risk of immediate and delayed postpolypectomy bleeding in the context of drug discontinuation or continuation of antiplatelet and anticoagulant drugs. Data was assessed whether cold snare vs conventional thermal-based polypectomy technology and prophylactic placement of hemostatic clips are endoscopic techniques that are beneficial in reducing polypectomy bleeding. Clinical takeaways are also provided to facilitate safer polypectomy among patients on antiplatelet and anticoagulant agents.
AHRQ-funded; HS025402.
Citation: Abraham NS .
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
Gastrointest Endosc 2020 Feb;91(2):257-65. doi: 10.1016/j.gie.2019.09.033..
Keywords: Blood Thinners, Medication, Medication: Safety, Colonoscopy, Adverse Drug Events (ADE), Adverse Events, Guidelines, Prevention, Patient Safety
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
Shaker M, Lindholm C, Low J
Summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
Epinephrine is first-line treatment for anaphylaxis. The Food and Drug Administration reported that adverse events from epinephrine are infrequent. This paper provides a summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
AHRQ-funded; HS024599.
Citation: Shaker M, Lindholm C, Low J .
Summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
J Allergy Clin Immunol Pract 2018 Nov - Dec;6(6):2143-45.e4. doi: 10.1016/j.jaip.2018.04.006..
Keywords: Adverse Events, Adverse Drug Events (ADE), Medication, Patient Safety, Prevention
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Bates DW, Singh H
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
This paper comments on the progress made in improving patient safety since the 1999 report from The Institute of Medicine titled “To Err is Human” was published. This landmark report highlighted problem areas, and since then there has been a number of effective interventions to prevent hospital-acquired infections and improve medication safety. Additional areas for improvement have also been identified in the past two decades, including outpatient care, diagnostic, errors and the use of health information technology. The authors believe that electronic data developments can help increase patient safety even further.
AHRQ-funded; HS022087; HS017820.
Citation: Bates DW, Singh H .
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Health Aff 2018 Nov;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738..
Keywords: Adverse Drug Events (ADE), Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Prevention
Freedman JL, Faerber JI, Kang TI
Predictors of antiemetic alteration in pediatric acute myeloid leukemia.
The purpose of this study was to gain better knowledge of patient and cancer treatment factors associated with nausea/vomiting (NV) in order to enhance prophylaxis in children being treated for acute myeloid leukemia (AML). It found that treatment-related NV, as evidenced by antiemetic alterations, is more prevalent with increasing age.
AHRQ-funded; HS018425
Citation: Freedman JL, Faerber JI, Kang TI .
Predictors of antiemetic alteration in pediatric acute myeloid leukemia.
Pediatr Blood Cancer. 2014 Oct;61(10):1798-805. doi: 10.1002/pbc.25108..
Keywords: Adverse Drug Events (ADE), Adverse Events, Cancer, Children/Adolescents, Medication, Prevention
Forrester SH, Hepp Z, Roth JA
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
The study objective was to estimate the cost-effectiveness of computerized provider order entry versus traditional paper-based prescribing in reducing medications errors and adverse drug events in the ambulatory setting of mid-sized medical group. Using a decision-analytic model, the researchers found that the adoption of CPOE in the ambulatory setting provides excellent value for the investment.
AHRQ-funded; HS014739
Citation: Forrester SH, Hepp Z, Roth JA .
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
Value Health. 2014 Jun;17(4):340-9. doi: 10.1016/j.jval.2014.01.009..
Keywords: Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Patient Safety, Healthcare Costs, Ambulatory Care and Surgery, Prevention