National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (32)
- Adverse Events (24)
- Ambulatory Care and Surgery (2)
- Blood Thinners (2)
- Cancer (1)
- Cardiovascular Conditions (1)
- Children/Adolescents (3)
- Clinical Decision Support (CDS) (1)
- Clinician-Patient Communication (1)
- Communication (2)
- COVID-19 (1)
- Diagnostic Safety and Quality (2)
- Elderly (1)
- Electronic Health Records (EHRs) (5)
- Electronic Prescribing (E-Prescribing) (5)
- Emergency Department (1)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (13)
- Health Literacy (1)
- Heart Disease and Health (1)
- Hospital Discharge (2)
- Hospitals (2)
- Implementation (2)
- Kidney Disease and Health (1)
- Long-Term Care (1)
- (-) Medical Errors (33)
- Medication (31)
- (-) Medication: Safety (33)
- Nursing Homes (1)
- Patient Safety (28)
- Practice Patterns (1)
- Prevention (2)
- Provider (2)
- Provider: Pharmacist (6)
- Quality Improvement (1)
- Risk (2)
- Surgery (1)
- Telehealth (2)
- Transitions of Care (2)
- Transplantation (2)
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
26 to 33 of 33 Research Studies DisplayedKannampallil TG, Manning JD, Chestek DW
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
The authors examined the effect of number of open charts on intercepted wrong-patient medication orders in an emergency department using an interrupted time series analysis of intercepted wrong-patient medication orders in an emergency department during 2010-2016.
AHRQ-funded; HS024945.
Citation: Kannampallil TG, Manning JD, Chestek DW .
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
J Am Med Inform Assoc 2018 Jun;25(6):739-43. doi: 10.1093/jamia/ocx099..
Keywords: Adverse Drug Events (ADE), Emergency Department, Medical Errors, Medication, Medication: Safety, Patient Safety
Zhou S, Kang H, Yao B
Unveiling originated stages of medication errors: an automated pipeline approach.
Medication error reports collected by Patient Safety Organizations provide an opportunity to analyze and learn from previous cases. However, the current process of analyzing the reports is labor-intensive and time-consuming. To improve the efficiency, the investigators used automated text classification techniques to develop a pipeline for medication error report pre-analysis.
AHRQ-funded; HS022895.
Citation: Zhou S, Kang H, Yao B .
Unveiling originated stages of medication errors: an automated pipeline approach.
Stud Health Technol Inform 2018;250:182-86..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Medication: Safety, Patient Safety
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care
Miller GE, Sarpong EM, Davidoff AJ
AHRQ Author: Miller GE, Sarpong EM
Determinants of potentially inappropriate medication use among community-dwelling older adults.
The researchers examined the determinants of potentially inappropriate medication (PIM) use. The multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use
AHRQ-authored.
Citation: Miller GE, Sarpong EM, Davidoff AJ .
Determinants of potentially inappropriate medication use among community-dwelling older adults.
Health Serv Res 2017 Aug;52(4):1534-49. doi: 10.1111/1475-6773.12562.
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Keywords: Medication, Elderly, Medication: Safety, Adverse Drug Events (ADE), Medical Errors
Schroeder SR, Salomon MM, Galanter WL
Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
The researchers conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. They found that across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception.
AHRQ-funded; HS021093.
Citation: Schroeder SR, Salomon MM, Galanter WL .
Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
BMJ Qual Saf 2017 May;26(5):395-407. doi: 10.1136/bmjqs-2015-005099.
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Keywords: Adverse Drug Events (ADE), Medical Errors, Medication: Safety, Medication, Provider: Pharmacist
Beeler PE, Orav EJ, Seger DL
Provider variation in responses to warnings: do the same providers run stop signs repeatedly?
Variation in the use of tests and treatments has been demonstrated to be substantial between providers and geographic regions. This study assessed variation between outpatient providers in overriding electronic prescribing warnings. It concluded that the decision to override prescribing warnings shows variation between providers, and the magnitude of variation differs among the clinical domains of the warnings; more variation was observed in areas with more inappropriate overrides.
AHRQ-funded; HS021094.
Citation: Beeler PE, Orav EJ, Seger DL .
Provider variation in responses to warnings: do the same providers run stop signs repeatedly?
J Am Med Inform Assoc 2016 Apr;23(e1):e93-8. doi: 10.1093/jamia/ocv117.
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Keywords: Adverse Drug Events (ADE), Electronic Prescribing (E-Prescribing), Medication: Safety, Medical Errors, Practice Patterns
Zhong W, Feinstein JA, Patel NS
Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years.
This paper evaluated rates of potential look-alike sound-alike (LA-SA) drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007. The authors found no statistically significant change in error rate for each of the 11 drug pairs studied. Also, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards. They concluded that implementation of Tall Man lettering was not associated with a reduction in the potential LA-SA error rate.
AHRQ-funded; HS018425.
Citation: Zhong W, Feinstein JA, Patel NS .
Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years.
BMJ Qual Saf 2016 Apr;25(4):233-40. doi: 10.1136/bmjqs-2015-004562.
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Keywords: Adverse Drug Events (ADE), Medication, Medication: Safety, Medical Errors, 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