National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (3)
- Adverse Events (3)
- Children/Adolescents (2)
- Clinician-Patient Communication (2)
- (-) Communication (11)
- Education: Patient and Caregiver (2)
- Elderly (1)
- Electronic Health Records (EHRs) (2)
- Electronic Prescribing (E-Prescribing) (1)
- Evidence-Based Practice (1)
- Guidelines (1)
- Health Information Technology (HIT) (2)
- Health Literacy (2)
- Hospital Discharge (1)
- Implementation (1)
- Medical Errors (2)
- Medication (10)
- (-) Medication: Safety (11)
- Opioids (3)
- Patient Safety (8)
- Policy (1)
- Provider (3)
- Provider: Clinician (1)
- Provider: Pharmacist (2)
- Risk (1)
- Substance Abuse (1)
- Tools & Toolkits (1)
- Training (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
Becker MW, Kashy DA, Harben A
A novel strategy to optimize critical information on over the counter labels for older adults.
In this article, the authors described two experiments in which they evaluated the impact of over-the-counter (OTC) medication label designs that employ highlighting and warning labels placed on package fronts on the attention and use of critical information by older consumers. In both experiments. participants aged 65 or over were required to access and use critical label information to respond correctly to questions. Highlighting or placing critical information on the front of packaging significantly improved response accuracy. The authors concluded that these results are relevant for regulations which dictate label design to further ease and safety of use of medications for older adults.
AHRQ-funded; HS025386.
Citation: Becker MW, Kashy DA, Harben A .
A novel strategy to optimize critical information on over the counter labels for older adults.
Health Sci Rep 2023 Jan 25; 6(1):e1062. doi: 10.1002/hsr2.1062..
Keywords: Elderly, Medication: Safety, Medication, Patient Safety, Communication
Stolldorf DP, Ridner SH, Vogus TJ
Implementation strategies in the context of medication reconciliation: a qualitative study.
Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, the authors report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit).
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Ridner SH, Vogus TJ .
Implementation strategies in the context of medication reconciliation: a qualitative study.
Implement Sci Commun 2021 Jun 10;2(1):63. doi: 10.1186/s43058-021-00162-5..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Medical Errors, Adverse Events, Patient Safety, Implementation, Communication
Kandaswamy S, Pruitt Z, Kazi S
Clinician perceptions on the use of free-text communication orders.
The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information. The investigators concluded that clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks.
AHRQ-funded; HS025136; HS024755.
Citation: Kandaswamy S, Pruitt Z, Kazi S .
Clinician perceptions on the use of free-text communication orders.
Appl Clin Inform 2021 May;12(3):484-94. doi: 10.1055/s-0041-1731002..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Electronic Health Records (EHRs), Medication: Safety, Medication, Patient Safety, Communication, Provider: Clinician, Provider, Risk
Alley L, Novak K, Havlin T
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
The authors developed the Resources Encouraging Safe Prescription Opioid and Naloxone Dispensing (RESPOND) Toolkit to enhance community pharmacists' understanding of their role in addressing opioid safety; to improve integration of prescription drug monitoring program (PDMP) into daily workflow; and to enhance communication between pharmacists, prescribers, and patients. In this paper, they described the development of the RESPOND Toolkit and summarized their findings from initial pilot testing. They concluded that the RESPOND Toolkit has promise as an effective and scalable approach to providing community pharmacist-tailored training to promote behavioral shifts supporting opioid safety for patients.
AHRQ-funded; HS024227.
Citation: Alley L, Novak K, Havlin T .
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
Res Social Adm Pharm 2020 Oct;16(10):1422-30. doi: 10.1016/j.sapharm.2019.12.023..
Keywords: Opioids, Substance Abuse, Medication, Medication: Safety, Patient Safety, Tools & Toolkits, Communication, Provider: Pharmacist, Provider, Training
Gilson AM, Xiong KZ, Stone JA
Improving patient-pharmacist encounters with over-the-counter medications: a mixed-methods pilot study.
This study evaluated the impact of having an abbreviated medication section in pharmacies specifically for older adults (Senior Section™) on the frequency and content of over-the-counter (OTC) medication encounters between pharmacy staff and patients. An intervention mixed-methods design was created to generate data from patient OTC encounters, and interviews with two pharmacists and two technicians, throughout the study. The interview transcripts were coded, and frequencies and chi-square analyses demonstrated pre/post-intervention comparisons for the OTC encounter variables. After implementation, pharmacy staff were more likely to initiate (and be involved in) patient encounters, address more topics or problem/symptoms, provide details about OTC products, discuss appropriateness of OTC use, and discuss medication classes highlighted in the Senior Section. Pharmacy staff were less likely to need to leave the prescription counter for extended periods, and they also had fewer prolonged encounters or encounters about product location.
AHRQ-funded; HS024490.
Citation: Gilson AM, Xiong KZ, Stone JA .
Improving patient-pharmacist encounters with over-the-counter medications: a mixed-methods pilot study.
Innov Pharm 2020 Feb 14;11(1). doi: 10.24926/iip.v11i1.2295..
Keywords: Provider: Pharmacist, Medication, Medication: Safety, Communication, Patient Safety
McCarthy DM, Curtis LM, Courtney DM
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The objective of this study was to evaluate the effect of an Electronic Medication Complete Communication (EMC(2)) Opioid Strategy on patients' safe use of opioids and knowledge about opioids. The study found that the EMC(2) tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.
AHRQ-funded; HS023459.
Citation: McCarthy DM, Curtis LM, Courtney DM .
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Acad Emerg Med 2019 Dec;26(12):1311-25. doi: 10.1111/acem.13860..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Health Literacy, Education: Patient and Caregiver, Clinician-Patient Communication, Communication, Health Information Technology (HIT)
Meisel ZF, Metlay JP, Sinnenberg L
A randomized trial testing the effect of narrative vignettes versus guideline summaries on provider response to a professional organization clinical policy for safe opioid prescribing.
The authors compared whether narrative vignettes embedded in the American College of Emergency Physicians (ACEP) daily e-newsletter improved dissemination of the clinical policy to ACEP members, and engagement of members with the clinical policy, compared with traditional summary text. They found that the vignettes outperformed traditional guideline text in promoting engagement with an evidence-based clinical guideline related to opioid prescriptions.
AHRQ-funded; HS021956.
Citation: Meisel ZF, Metlay JP, Sinnenberg L .
A randomized trial testing the effect of narrative vignettes versus guideline summaries on provider response to a professional organization clinical policy for safe opioid prescribing.
Ann Emerg Med 2016 Dec;68(6):719-28. doi: 10.1016/j.annemergmed.2016.03.007.
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Keywords: Communication, Evidence-Based Practice, Guidelines, Opioids, Medication, Medication: Safety, Policy, Provider
Curtis LM, Mullen RJ, Russell A
An efficacy trial of an electronic health record-based strategy to inform patients on safe medication use: the role of written and spoken communication.
The researchers tested the feasibility and efficacy of an electronic health record (EHR) strategy that automated the delivery of print medication information at the time of prescribing. They found that written information and physician counseling were independently associated with patient understanding of risk information and that receiving both was most beneficial. They concluded that although an EHR can be a reliable means to deliver tangible, print medication education to patients, it cannot replace physician-patient communication, and that offering both written and spoken information resulted in a synergistic effect for informing patients.
AHRQ-funded; HS017220.
Citation: Curtis LM, Mullen RJ, Russell A .
An efficacy trial of an electronic health record-based strategy to inform patients on safe medication use: the role of written and spoken communication.
Patient Educ Couns 2016 Sep;99(9):1489-95. doi: 10.1016/j.pec.2016.07.004.
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Keywords: Electronic Health Records (EHRs), Communication, Education: Patient and Caregiver, Medication: Safety, Medication
Benjamin JM, Cox ED, Trapskin PJ
Family-initiated dialogue about medications during family-centered rounds.
The researchers sought to further understand the potential for family-centered rounds (FCRs) to foster pediatric medication safety. To that end, their study describes and quantifies medication-related topics raised by families during FCR and how this dialogue affects the children’s treatment plans. The families raised topics that altered treatment and were important for medication safety, adherence, and satisfaction.
AHRQ-funded; HS018680
Citation: Benjamin JM, Cox ED, Trapskin PJ .
Family-initiated dialogue about medications during family-centered rounds.
Pediatrics. 2015 Jan;135(1):94-101. doi: 10.1542/peds.2013-3885..
Keywords: Children/Adolescents, Communication, Medication: Safety, Patient Safety
Hennessy S, Strom BL
Improving postapproval drug safety surveillance: getting better information sooner.
There are often long delays between when a drug is approved and when serious adverse drug events are identified. This article discusses ways to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
AHRQ-funded; HS018372.
Citation: Hennessy S, Strom BL .
Improving postapproval drug safety surveillance: getting better information sooner.
Annu Rev Pharmacol Toxicol 2015;55:75-87. doi: 10.1146/annurev-pharmtox-011613-135955.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Communication, Medication, Medication: Safety, Patient Safety