National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (10)
- Adverse Events (5)
- Behavioral Health (1)
- Caregiving (1)
- Children/Adolescents (5)
- Chronic Conditions (1)
- Clinician-Patient Communication (1)
- Communication (2)
- Community-Based Practice (3)
- Comparative Effectiveness (1)
- COVID-19 (1)
- Dementia (1)
- Depression (1)
- Elderly (3)
- Emergency Medical Services (EMS) (1)
- Falls (1)
- Health Information Technology (HIT) (1)
- Health Literacy (1)
- Hospital Discharge (1)
- Injuries and Wounds (1)
- Medicaid (1)
- Medical Errors (2)
- Medication (15)
- (-) Medication: Safety (18)
- Neurological Disorders (2)
- Newborns/Infants (1)
- Nursing Homes (2)
- Opioids (1)
- Patient Adherence/Compliance (2)
- Patient Safety (8)
- Practice-Based Research Network (PBRN) (2)
- Practice Patterns (1)
- Provider: Pharmacist (3)
- Stroke (1)
- Telehealth (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 18 of 18 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
Ahuja V, Sohn MW, Birge JR
Geographic variation in rosiglitazone use surrounding FDA warnings in the Department of Veterans Affairs.
The purpose of this study was to document variation in the use of rosiglitazone and other glucose- lowering drugs across 21 Veterans Integrated Service Networks. It found that aggregate rosiglitazone use increased monotonically from 7.7 percent, in the quarter it was added to the VA formulary, to a peak of 15.3 percent in the quarter when the FDA issued the safety alert.
AHRQ-funded; HS018542.
Citation: Ahuja V, Sohn MW, Birge JR .
Geographic variation in rosiglitazone use surrounding FDA warnings in the Department of Veterans Affairs.
J Manag Care Spec Pharm 2015 Dec;21(12):1214-34. doi: 10.18553/jmcp.2015.21.12.1214.
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Keywords: Adverse Drug Events (ADE), Medication: Safety, Medication, Practice Patterns
Patel P, Hemmeger H, Kozak MA
Community pharmacist participation in a practice-based research network: a report from the Medication Safety Research Network of Indiana (Rx-SafeNet).
The researchers described the experiences and opinions of pharmacists serving as site coordinators for the Medication Safety Research Network of Indiana (Rx-SafeNet). In general, Rx-SafeNet site coordinators appeared to experience increased confidence in research engagement after joining the network. While respondents identified a number of benefits associated with network participation, concerns about potential time constraints remained a key barrier to participation.
AHRQ-funded; HS022119.
Citation: Patel P, Hemmeger H, Kozak MA .
Community pharmacist participation in a practice-based research network: a report from the Medication Safety Research Network of Indiana (Rx-SafeNet).
J Am Pharm Assoc (2003) 2015 Nov-Dec;55(6):649-55. doi: 10.1331/JAPhA.2015.14244.
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Keywords: Community-Based Practice, Medication: Safety, Practice-Based Research Network (PBRN), Provider: Pharmacist
Gagne JJ, Kesselheim AS, Choudhry NK
Comparative effectiveness of generic versus brand-name antiepileptic medications.
The objective of this study was to compare treatment persistence and rates of seizure-related events in patients who initiate antiepileptic drug (AED) therapy with a generic versus a brand-name product. It concluded that patients who initiated generic AEDs had fewer adverse seizure-related clinical outcomes and longer continuous treatment periods before experiencing a gap than those who initiated brand-name versions.
AHRQ-funded; HS018465.
Citation: Gagne JJ, Kesselheim AS, Choudhry NK .
Comparative effectiveness of generic versus brand-name antiepileptic medications.
Epilepsy Behav 2015 Nov;52(Pt A):14-8. doi: 10.1016/j.yebeh.2015.08.014.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Comparative Effectiveness, Medication, Medication: Safety, Neurological Disorders, Patient Safety
Culley CM, Perera S, Marcum ZA
Using a clinical surveillance system to detect drug-associated hypoglycemia in nursing home residents.
The authors determined whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home (NH) residents. Their evaluation found a high incidence of drug-associated hypoglycemia in a general NH population.
AHRQ-funded; HS018721.
Citation: Culley CM, Perera S, Marcum ZA .
Using a clinical surveillance system to detect drug-associated hypoglycemia in nursing home residents.
J Am Geriatr Soc 2015 Oct;63(10):2125-9. doi: 10.1111/jgs.13648.
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Keywords: Adverse Drug Events (ADE), Elderly, Medication: Safety, Medication, Nursing Homes
Kao DP, Haigney MC, Mehler PS
Arrhythmia associated with buprenorphine and methadone reported to the Food and Drug Administration.
The researchers assessed the relative frequency of reporting of adverse events involving ventricular arrhythmia, cardiac arrest, corrected QT interval prolongation or torsade de pointes to the US Food and Drug Administration between buprenorphine and methadone. They found that in spontaneously reported adverse events between 1969 and June 2011 originating in 196 countries, methadone is associated with disproportionate reporting of cardiac arrhythmias, whereas buprenorphine is not.
AHRQ-funded; HS021138.
Citation: Kao DP, Haigney MC, Mehler PS .
Arrhythmia associated with buprenorphine and methadone reported to the Food and Drug Administration.
Addiction 2015 Sep;110(9):1468-75. doi: 10.1111/add.13013.
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Keywords: Adverse Drug Events (ADE), Medication: Safety, Medication, Patient Safety
Basco WT, Ebeling M, Garner SS
Opioid prescribing and potential overdose errors among children 0 to 36 months old.
This study estimated the frequency of potential overdoses among outpatient opioid-containing prescriptions. It found that, overall, 2.7 percent of the prescriptions contained potential overdose quantities, and the average excess amount dispensed was 48% above expected. Younger ages were associated with higher frequencies of potential overdose.
AHRQ-funded; HS015679.
Citation: Basco WT, Ebeling M, Garner SS .
Opioid prescribing and potential overdose errors among children 0 to 36 months old.
Clin Pediatr 2015 Jul;54(8):738-44. doi: 10.1177/0009922815586050..
Keywords: Adverse Drug Events (ADE), Children/Adolescents, Newborns/Infants, Medication, Medication: Safety, Newborns/Infants, Opioids, Patient Safety
Samples H, Mojtabai R
Antidepressant self-discontinuation: results from the collaborative psychiatric epidemiology surveys.
The authors examined the extent and correlates of self-discontinuation of antidepressant medications without physician advice using the Collaborative Psychiatric Epidemiology Surveys. They concluded that physicians prescribing antidepressants need to communicate clearly about the expected benefits of treatment, the minimum duration of use required to experience benefits, and the potential side effects of these medications, particularly to younger patients, those with anxiety disorders, and patients treated in general medical settings, all of whom have increased odds of self-discontinuation.
AHRQ-funded; HS000029.
Citation: Samples H, Mojtabai R .
Antidepressant self-discontinuation: results from the collaborative psychiatric epidemiology surveys.
Psychiatr Serv 2015 May;66(5):455-62. doi: 10.1176/appi.ps.201400021.
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Keywords: Medication, Depression, Medication: Safety, Behavioral Health, Patient Adherence/Compliance
Marcum ZA, Gurwitz JH, Colon-Emeric C
Pills and ills: methodological problems in pharmacological research.
This letter summarizes critical points from a methodology workshop, Pills and Ills: Methodologic Issues in Pharmacologic Research, presented at the 2013 American Geriatrics Society Annual Scientific Meeting. It focuses on two of the most important medication errors in older adults: potentially inappropriate medication use and medication nonadherence.
AHRQ-funded; HS020831.
Citation: Marcum ZA, Gurwitz JH, Colon-Emeric C .
Pills and ills: methodological problems in pharmacological research.
J Am Geriatr Soc 2015 Apr;63(4):829-30. doi: 10.1111/jgs.13371..
Keywords: Medication, Medication: Safety, Elderly, Patient Adherence/Compliance
Radecki RP, Azam A, Doshi PB
Iodinated contrast prior to thrombolysis was not associated with worse intracranial hemorrhage.
The investigators' objective was to assess relative incidence of clinical adverse effects between patients receiving, and not receiving, iodinated contrast prior to thrombolysis. They found that no consistent harms were observed in association with intravenous iodinated contrast prior to recombinant tissue-type plasminogen activator administration, concluding that it is reasonable to continue computed tomographic angiography prior to thrombolysis as clinically indicated.
AHRQ-funded; HS017586.
Citation: Radecki RP, Azam A, Doshi PB .
Iodinated contrast prior to thrombolysis was not associated with worse intracranial hemorrhage.
Acad Emerg Med 2015 Mar;22(3):259-63. doi: 10.1111/acem.12603.
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Keywords: Adverse Drug Events (ADE), Emergency Medical Services (EMS), Medication, Medication: Safety, Stroke
Aspinall SL, Zhao X, Semia TP
Epidemiology of drug-disease interactions in older veteran nursing home residents.
The objective of this study was to assess the prevalence of and factors associated with potentially inappropriate drug– disease combinations according to the AGS 2012 Beers criteria that are clinically important in elderly adults residing in Veterans Affairs Community Living Centers. It found that drug-disease interactions were common in older residents with dementia or cognitive impairment or a history of falls or hip fracture.
AHRQ-funded; HS018721.
Citation: Aspinall SL, Zhao X, Semia TP .
Epidemiology of drug-disease interactions in older veteran nursing home residents.
J Am Geriatr Soc 2015 Jan;63(1):77-84. doi: 10.1111/jgs.13197..
Keywords: Adverse Drug Events (ADE), Adverse Events, Dementia, Elderly, Falls, Injuries and Wounds, Medication, Medication: Safety, Neurological Disorders, Nursing Homes, Patient Safety
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
Kozak MA, Gernant SA, Hemmeger HM
Lessons learned in the growth and maturation stages of a community pharmacy practice-based research network: experiences of the Medication Safety Research Network of Indiana (Rx-SafeNet).
In 2012, the authors reported on their early experiences developing the Medication Safety Research Network of Indiana (Rx-SafeNet) after establishing the Network in 2010. In this article, they report on lessons learned over the past 3 years.
AHRQ-funded; HS022119.
Citation: Kozak MA, Gernant SA, Hemmeger HM .
Lessons learned in the growth and maturation stages of a community pharmacy practice-based research network: experiences of the Medication Safety Research Network of Indiana (Rx-SafeNet).
Innov Pharm 2015;6(2).
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Keywords: Community-Based Practice, Medication: Safety, Medication, Provider: Pharmacist, Practice-Based Research Network (PBRN)