National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- (-) Adverse Drug Events (ADE) (7)
- Adverse Events (7)
- Ambulatory Care and Surgery (1)
- Clinical Decision Support (CDS) (2)
- Diagnostic Safety and Quality (2)
- (-) Electronic Health Records (EHRs) (7)
- Health Information Technology (HIT) (7)
- (-) Medical Errors (7)
- Medication (7)
- Medication: Safety (4)
- Patient Safety (7)
- Prevention (1)
- Shared Decision Making (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 7 of 7 Research Studies DisplayedWatterson TL, Stone JA, Brown R
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software.
AHRQ-funded; HS025793.
Citation: Watterson TL, Stone JA, Brown R .
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
J Am Med Inform Assoc 2021 Jul 14;28(7):1526-33. doi: 10.1093/jamia/ocab038..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT), Ambulatory Care and Surgery
Salmasian H, Blanchfield BB, Joyce K
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). The purpose of this study was to evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.
AHRQ-funded; HS024713.
Citation: Salmasian H, Blanchfield BB, Joyce K .
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
AMA Netw Open 2020 Nov 2;3(11):e2019652. doi: 10.1001/jamanetworkopen.2020.19652..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Diagnostic Safety and Quality
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
Wright A, Aaron S, Seger DL
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
This study examined the effects of conversion from a homegrown electronic health record (EHR) system to a commercial system on the effectiveness of drug-drug interaction (DDI) alert. The EHR system included 3277 clinicians in the before and after studies. There was a marked decrease in the acceptance rate (100 to 8.4% for severe alerts, 29.3 to 7.5% for medium severity) at first. The least severe alerts were then disabled, which lowered the alert burden by 50.5% which rose the acceptance of Tier 1 alerts to 12.7%. However, there was no clear explanation after that why the acceptance rate remained so much lower. The authors believe that workflow factors were probably the predominant reasons.
AHRQ-funded; HS016970.
Citation: Wright A, Aaron S, Seger DL .
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
J Gen Intern Med 2018 Nov;33(11):1868-76. doi: 10.1007/s11606-018-4415-9..
Keywords: Adverse Drug Events (ADE), Medication, Adverse Events, Medical Errors, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
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
Horsky J, Aarts J, Verheul L
Clinical reasoning in the context of active decision support during medication prescribing.
The purpose of this study was to describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. The investigators found that declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher.
AHRQ-funded; HS021094.
Citation: Horsky J, Aarts J, Verheul L .
Clinical reasoning in the context of active decision support during medication prescribing.
Int J Med Inform 2017 Jan;97:1-11. doi: 10.1016/j.ijmedinf.2016.09.004..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Shared Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Pohl JM, Tanner C, Hamilton A
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
This study, conducted in five safety-net practices, examined the impact of implementing a commercial electronic health records system on medication safety. The authors found 130 "true" drug-drug interaction (DDI) pairs, representing 149,087 visits and 62 providers, with the largest DDI categories being related to antihypertensive medications, which are often prescribed together. They found no significant differences between physicians and nurse practitioners on the rate of DDI pairs.
AHRQ-funded; HS017191.
Citation: Pohl JM, Tanner C, Hamilton A .
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
J Am Assoc Nurse Pract 2014 Aug;26(8):438-44. doi: 10.1002/2327-6924.12089.
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Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety