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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.
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1 to 3 of 3 Research Studies DisplayedLanglieb ME, Sharma P, Hocevar M
The additional cost of perioperative medication errors.
The aim of this study was to calculate the additional annual cost to the U.S. healthcare system attributable to preventable medication errors (MEs) in the operating room. The ME types were grouped into 13 categories by their related harm (or potential harm), and researchers calculated the incidence of operations involving each ME category: 1) delayed or missed required perioperative antibiotic; 2) prolonged hemodynamic swings; 3) untreated postoperative pain; 4) residual neuromuscular blockade; 5) oxygen saturation <90% due to ME; 6) delayed emergence; 7) untreated new onset intraoperative cardiac arrhythmia; 8) medication documentation errors; 9) syringe swaps; 10) presumed hypotension with inability to obtain a blood pressure reading; 11) potential for bacterial contamination due to expired medication syringes; 12) untreated bradycardia <40 beats/min; and 13) other. Through a PubMed search, the researchers established the possibility that the ME category would cause downstream patient harm such as surgical site infection or acute kidney injury, and the additional fully allocated cost of care for each potential downstream patient harm event. The cost of the MEs across the U.S. healthcare system was then calculated by scaling the number of MEs to the total number of annual operations in the United States. The total additional fully allocated annual cost of care due to perioperative MEs was estimated to be $5.33 billion U.S. dollars.
AHRQ-funded; HS024764.
Citation: Langlieb ME, Sharma P, Hocevar M .
The additional cost of perioperative medication errors.
J Patient Saf 2023 Oct 1; 19(6):375-78. doi: 10.1097/pts.0000000000001136..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Surgery, Patient Safety
Samost-Williams A, Nanji KC
A systems theoretic process analysis of the medication use process in the operating room.
While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room.
AHRQ-funded; HS024764.
Citation: Samost-Williams A, Nanji KC .
A systems theoretic process analysis of the medication use process in the operating room.
Anesthesiology 2020 Aug;133(2):332-41. doi: 10.1097/aln.0000000000003376..
Keywords: Medication, Surgery, Medical Errors, Adverse Drug Events (ADE), Adverse Events
Banerjee A, Burden A, Slagle JM
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
This study analyzed performance gaps of practicing anesthesiologists, and used 4 different scenarios that illustrate those gaps and how they contribute to hazards in anesthesiology and proposals for addressing them. The authors used 4 standardized simulated scenarios of common events that anesthesiologists would expect to see in their practice. The 4 perioperative crisis events are: (1) local anesthetic systemic toxicity (LAST) leading to hemodynamic collapse; (2) retroperitoneal bleeding from insertion of a laparoscopic surgery trocar leading to hemorrhagic shock; (3) malignant hyperthermia (MH) presenting in the postanesthesia care unit; and (4) acute atrial fibrillation with hemodynamic instability, followed by signs of a ST-elevation myocardial infarction (AFib-MI). These scenarios came from a 2017 paper by Weinger, et al. A group of subject matter experts defined a set of clinical performance elements (CPEs) that they would expect to be performed in the scenarios. Only 4% of encounters in these scenarios had perfect performance by anesthesiologists where all prescribed CPEs were performed. Recommendations for improvement included providing high-fidelity simulation training, incorporating clinical lessons about gaps, fostering regular use by anesthesiologists and OR teams of clinical guidance, modifying organizational arrangements at clinical sites to ensure backup help is readily available, and implementing periodic formative performance assessments.
AHRQ-funded; HS020415.
Citation: Banerjee A, Burden A, Slagle JM .
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
Int Anesthesiol Clin 2020 Winter;58(1):13-20. doi: 10.1097/aia.0000000000000262..
Keywords: Medical Errors, Adverse Events, Adverse Drug Events (ADE), Patient Safety, Provider Performance, Provider: Physician, Provider, Surgery