National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (133)
- Adverse Events (92)
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- Ambulatory Care and Surgery (5)
- Antibiotics (9)
- Antimicrobial Stewardship (2)
- Asthma (1)
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- Implementation (4)
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- Intensive Care Unit (ICU) (7)
- Kidney Disease and Health (9)
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- Medicaid (1)
- Medical Errors (33)
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- Medication (225)
- (-) Medication: Safety (233)
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- Opioids (27)
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- Pain (6)
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- Racial and Ethnic Minorities (3)
- Registries (1)
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- Risk (20)
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- Sleep Problems (1)
- Social Determinants of Health (1)
- Stroke (4)
- Substance Abuse (10)
- Surgery (12)
- Telehealth (4)
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- Transitions of Care (6)
- Transplantation (3)
- Treatments (2)
- Vaccination (1)
- Vulnerable Populations (1)
- Women (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
101 to 125 of 233 Research Studies DisplayedYang AD, Hewitt DB, Blay E
Multi-institution evaluation of adherence to comprehensive postoperative VTE chemoprophylaxis.
The aims of this study were to: (1) measure the rate of failure to provide defect-free postoperative venous thromboembolism (VTE) chemoprophylaxis, (2) identify reasons for failure to provide defect-free VTE chemoprophylaxis, and (3) examine patient- and hospital-level factors associated with failure. The investigators concluded that in contrast to SCIP-VTE-2, their novel quality measure unmasked VTE chemoprophylaxis failures in 18% of colectomies. They found that most failures were due to patient refusals or ordering errors.
AHRQ-funded; HS024516.
Citation: Yang AD, Hewitt DB, Blay E .
Multi-institution evaluation of adherence to comprehensive postoperative VTE chemoprophylaxis.
Ann Surg 2020 Jun;271(6):1072-79. doi: 10.1097/sla.0000000000003124..
Keywords: Patient Adherence/Compliance, Guidelines, Blood Clots, Blood Thinners, Medication, Medication: Safety, Patient Safety, Adverse Events
Wolff C, Dowd WN, Ali MM
AHRQ Author: McClellan C
The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation.
The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. In this study, the investigators used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse.
AHRQ-authored.
Citation: Wolff C, Dowd WN, Ali MM .
The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation.
Addict Behav 2020 Jun;105:106268. doi: 10.1016/j.addbeh.2019.106268..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Prevention, Pain, Substance Abuse
Rowe TA, Linder JA
Delayed antibiotic prescriptions in ambulatory care: reconsidering a problematic practice.
In this paper, the authors discuss delayed or backup antibiotic prescriptions, which are given to ambulatory patients with the expectation that the patient will pick up or fill the prescription if he or she is not improving within a few days. They discuss the drawbacks of delayed antibiotic prescriptions and the options for clinicians.
AHRQ-funded; HS024930; HS026506; 2332015000201.
Citation: Rowe TA, Linder JA .
Delayed antibiotic prescriptions in ambulatory care: reconsidering a problematic practice.
JAMA 2020 May 12;323(18):1779-80. doi: 10.1001/jama.2020.2325..
Keywords: Antibiotics, Medication, Ambulatory Care and Surgery, Medication: Safety, Patient Safety, Antimicrobial Stewardship
Johnson MD, Zorc JJ, Nelson DS
Intravenous magnesium in asthma pharmacotherapy: variability in use in the PECARN Registry.
Researchers examined the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. They found that, in PECARN Registry EDs, administration of IVMg occurred late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggested the current clinical role for IVMg in preventing hospitalization was limited. Discharge after IVMg administration would likely be safe. They recommended further research to assess the efficacy and safety of early IVMg administration.
AHRQ-funded; HS020270.
Citation: Johnson MD, Zorc JJ, Nelson DS .
Intravenous magnesium in asthma pharmacotherapy: variability in use in the PECARN Registry.
J Pediatr 2020 May;220:165-74.e2. doi: 10.1016/j.jpeds.2020.01.062..
Keywords: Children/Adolescents, Asthma, Medication, Emergency Department, Registries, Treatments, Patient Safety, Medication: Safety
Mastarone GL, Wyse JJ, Wilbur ER
Barriers to utilization of prescription drug monitoring programs among prescribing physicians and advanced practice registered nurses at Veterans Health Administration facilities in Oregon.
The authors sought to identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon. They found that physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety, but issues regarding organizational processes and software design impede optimal use of these resources.
AHRQ-funded; HS026370.
Citation: Mastarone GL, Wyse JJ, Wilbur ER .
Barriers to utilization of prescription drug monitoring programs among prescribing physicians and advanced practice registered nurses at Veterans Health Administration facilities in Oregon.
Pain Med 2020 Apr;21(4):695-703. doi: 10.1093/pm/pnz289..
Keywords: Opioids, Medication: Safety, Medication, Patient Safety
Kurani S, Jeffery MM, Thorsteinsdottir B
Use of potentially nephrotoxic medications by U.S. adults with chronic kidney disease: NHANES, 2011-2016.
This study looked at the prevalence of potentially inappropriate medication (PIM) use by US adults by chronic kidney disease (CKD) stage and self-reported CKD awareness. A cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011-2016 was conducted using a cohort of non-pregnant CKD adults with stages 3a, 3b, or 4-5 CKD. Analyses were adjusted for sex, age, race/ethnicity, education, comorbidities, and insurance type. More than 50% of US adults were taking PIM(s) for all CKD stages and awareness categories, but rates were highest among CKD-unaware patients with stages 4-5 CKD. Proton pump inhibitors, opioids, metformin, sulfonylureas, and NSAIDS were used frequently in all CKD stages. NSAIDS were used less frequently when the patient was CKD-aware.
AHRQ-funded; HS025164; HS025402; HS025517.
Citation: Kurani S, Jeffery MM, Thorsteinsdottir B .
Use of potentially nephrotoxic medications by U.S. adults with chronic kidney disease: NHANES, 2011-2016.
J Gen Intern Med 2020 Apr;35(4):1092-101. doi: 10.1007/s11606-019-05557-8..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Kidney Disease and Health, Chronic Conditions, Patient Safety
Fashaw S, Chisholm L, Mor V
Inappropriate antipsychotic use: the impact of nursing home socioeconomic and racial composition.
Researchers examined how nursing home characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics, using national data from Long-Term Care: Facts on Care. They found an overall decline in the use of antipsychotics. Although findings indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among nursing homes. They recommended that policy interventions focusing on reimbursement be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant nursing homes.
ARHQ-funded; HS000011.
Citation: Fashaw S, Chisholm L, Mor V .
Inappropriate antipsychotic use: the impact of nursing home socioeconomic and racial composition.
J Am Geriatr Soc 2020 Mar;68(3):630-36. doi: 10.1111/jgs.16316..
Keywords: Nursing Homes, Long-Term Care, Elderly, Medication, Medication: Safety, Social Determinants of Health, Disparities, Racial and Ethnic Minorities
Hayden JD, Horter L, Parsons T
Metabolic monitoring rates of youth treated with second-generation antipsychotics in usual care: results of a large US national commercial health plan.
Researchers examined metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. They concluded that, given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. They recommended determining barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring.
AHRQ-funded; HS026001.
Citation: Hayden JD, Horter L, Parsons T .
Metabolic monitoring rates of youth treated with second-generation antipsychotics in usual care: results of a large US national commercial health plan.
J Child Adolesc Psychopharmacol 2020 Mar;30(2):119-22. doi: 10.1089/cap.2019.0087..
Keywords: Children/Adolescents, Medication, Behavioral Health, Medication: Safety, Patient Safety
Banerji A, Lai KH, Li Y
Natural language processing combined with ICD-9-CM codes as a novel method to study the epidemiology of allergic drug reactions.
Researchers sought to develop and validate a novel informatics method based on natural language processing (NLP) in combination with ICD-9-CM codes that identifies allergic drug reactions in the electronic health record. They found that using NLP with ICD-9-CM codes improved identification of allergic drug reactions, and they concluded that the resulting decrease in manual chart review effort will facilitate large epidemiology studies of this understudied area.
AHRQ-funded; HS024264; HS025375.
Citation: Banerji A, Lai KH, Li Y .
Natural language processing combined with ICD-9-CM codes as a novel method to study the epidemiology of allergic drug reactions.
J Allergy Clin Immunol Pract 2020 Mar;8(3):1032-38.e1. doi: 10.1016/j.jaip.2019.12.007..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Probst MA, Gupta M, Hendey GW
Prevalence of intracranial injury in adult patients with blunt head trauma with and without anticoagulant or antiplatelet use.
In this study, the investigators determined the prevalence of significant intracranial injury among adults with blunt head trauma who are receiving preinjury anticoagulant or antiplatelet medications. The investigators concluded that patients receiving preinjury warfarin or a combination of aspirin and clopidogrel were at increased risk for significant intracranial injury, but not those receiving aspirin alone. They suggested that clinicians should have a low threshold for neuroimaging when evaluating patients receiving warfarin or a combination of aspirin and clopidogrel.
AHRQ-funded; HS009699.
Citation: Probst MA, Gupta M, Hendey GW .
Prevalence of intracranial injury in adult patients with blunt head trauma with and without anticoagulant or antiplatelet use.
Ann Emerg Med 2020 Mar;75(3):354-64. doi: 10.1016/j.annemergmed.2019.10.004..
Keywords: Brain Injury, Injuries and Wounds, Blood Thinners, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Risk
De Roo AC, Vu JV, Regenbogen SE
Statewide utilization of multimodal analgesia and length of stay after colectomy.
This study examined statewide utilization of multimodal analgesia after colectomy. Multimodal analgesia shortens length of stay and hastens recovery. The researchers conducted a statewide, 72-hospital collaborative quality initiative and evaluated postoperative analgesia regimens among adult elective colectomy patients between 2012 and 2015. One-third of patients received opioids alone, and 2.8% received one nonopioid pain medication alone. The researchers suggest that these numbers must be improved particularly with the current opioid crisis.
AHRQ-funded; HS000053.
Citation: De Roo AC, Vu JV, Regenbogen SE .
Statewide utilization of multimodal analgesia and length of stay after colectomy.
J Surg Res 2020 Mar;247:264-70. doi: 10.1016/j.jss.2019.10.014..
Keywords: Surgery, Opioids, Medication, Medication: Safety, Practice Patterns, Pain
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
Abraham NS
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
This article is a review of current best practice recommendations focusing on the risk of immediate and delayed postpolypectomy bleeding in the context of drug discontinuation or continuation of antiplatelet and anticoagulant drugs. Data was assessed whether cold snare vs conventional thermal-based polypectomy technology and prophylactic placement of hemostatic clips are endoscopic techniques that are beneficial in reducing polypectomy bleeding. Clinical takeaways are also provided to facilitate safer polypectomy among patients on antiplatelet and anticoagulant agents.
AHRQ-funded; HS025402.
Citation: Abraham NS .
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
Gastrointest Endosc 2020 Feb;91(2):257-65. doi: 10.1016/j.gie.2019.09.033..
Keywords: Blood Thinners, Medication, Medication: Safety, Colonoscopy, Adverse Drug Events (ADE), Adverse Events, Guidelines, Prevention, Patient Safety
Greene RA, Zullo AR, Mailloux CM
Effect of best practice advisories on sedation protocol compliance and drug-related hazardous condition mitigation among critical care patients.
This study’s goal was to determine whether best practice advisories improved sedation protocol compliance and could mitigate propofol-related hazardous conditions in adult ICUs. Two adult ICUs at two academic medical centers that shared the same sedation protocol were used to identify adults admitted between 2016 to January 31 2018 who received a continuous infusion of propofol. A total of 1,394 patients were included in the study cohort. The best practice advisory improved sedation protocol compliance and resulted in providers discontinuing propofol an average of 16.6 hours sooner than pre-best practice advisory.
AHRQ-funded; HS022998.
Citation: Greene RA, Zullo AR, Mailloux CM .
Effect of best practice advisories on sedation protocol compliance and drug-related hazardous condition mitigation among critical care patients.
Crit Care Med 2020 Feb;48(2):185-91. doi: 10.1097/ccm.0000000000004116..
Keywords: Critical Care, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Guidelines, Intensive Care Unit (ICU)
Abraham NS, Noseworthy PA, Inselman J
Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age.
This study investigated whether age of patient and time frame increased the risk of gastrointestinal bleeding (GIB) in elderly patients being treated with anticoagulants, antiplatelets, or a combination of both therapies. This retrospective analysis used nationwide claims data from privately insured and Medicare Advantage enrollees who received anticoagulant and/or antiplatelet agents from October 1, 2010, through May 31, 2017. The final cohort included 311,211 patients who had a primary diagnosis of atrial fibrillation, ischemic heart disease, or venous thromboembolism. There was no significant different in the proportion of patients with GIB after anticoagulant or antiplatelet monotherapy, but combination therapy increased GIB risk. Advancing age was also associated with increasing 1-year probability of FIB, especially patients older than 75 years taking combination therapy.
AHRQ-funded; HS025402.
Citation: Abraham NS, Noseworthy PA, Inselman J .
Risk of gastrointestinal bleeding increases with combinations of antithrombotic agents and patient age.
Clin Gastroenterol Hepatol 2020 Feb;18(2):337-46.e19. doi: 10.1016/j.cgh.2019.05.017..
Keywords: Adverse Drug Events (ADE), Medication, Adverse Events, Medication: Safety, Elderly, Blood Thinners, Blood Clots, Digestive Disease and Health
Holmgren AJ, Co Z, Newmark L
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
The authors tested how well EHRs prevented medication errors with the potential for patient harm. Data from a national, longitudinal sample of 1527 hospitals in the US from 2009-16 who took a safety performance assessment test using simulated medication orders was used. The authors found that hospital medication order safety performance improved over time. They conclude that intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.
AHRQ-funded; HS023696.
Citation: Holmgren AJ, Co Z, Newmark L .
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
BMJ Qual Saf 2020 Jan;29(1):52-59. doi: 10.1136/bmjqs-2019-009609..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Medication, Electronic Prescribing (E-Prescribing), Medication: Safety, Clinical Decision Support (CDS), Shared Decision Making
Flory JH, Hennessy S, Bailey CJ
Reports of lactic acidosis attributed to metformin, 2015-2018.
This study examined the effects of allowing patients with mild-moderate chronic kidney disease to use metformin. The researchers examined rates of reports of metformin-associated lactic acidosis (MALA) to FDA’s Adverse Event Reporting System (FAERS). Publicly available data from 2015 to 2018 was analyzed. Reports from the US increased from 111 in 2015 to 243 in 2018. However due to a lack of a denominator or control group they could not conclude US MALA rates have increased. The authors also concluded that while the increased reports deserve attention, further study is needed.
AHRQ-funded; HS023898.
Citation: Flory JH, Hennessy S, Bailey CJ .
Reports of lactic acidosis attributed to metformin, 2015-2018.
Diabetes Care 2020 Jan;43(1):244-46. doi: 10.2337/dc19-0923.
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Keywords: Kidney Disease and Health, Medication, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events
Neill LA, Kim HS, Cameron KA
Who is keeping their unused opioids and why?
The purpose of this study was to gain a better understanding of patients' reasoning for keeping unused opioid pills. This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.
AHRQ-funded; HS023459.
Citation: Neill LA, Kim HS, Cameron KA .
Who is keeping their unused opioids and why?
Pain Med 2020 Jan;21(1):84-91. doi: 10.1093/pm/pnz025..
Keywords: Opioids, Medication, Medication: Safety, 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)
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Ailabouni NJ, Marcum ZA, Schmader KE
Medication use quality and safety in older adults: 2018 update.
This study identified four key articles from 2018 that address medication use quality and safety for older adults. The first study highlighted a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and doctors to deprescribe four types of inappropriate medications. The second study from the UK examined the association between anticholinergic exposure, overall and by medication class, and dementia risk in 40,770 older adults. The third study was a Swedish longitudinal cohort study examining the association between antihypertensive medications and incident dementia. The fourth and last study was a randomized, double-blind, placebo-controlled trial and examined the effect of daily low-dose aspirin for primary prevention of cardiac events and hemorrhage in 19,144 community-dwelling older adults.
AHRQ-funded; HS022982.
Citation: Ailabouni NJ, Marcum ZA, Schmader KE .
Medication use quality and safety in older adults: 2018 update.
J Am Geriatr Soc 2019 Dec;67(12):2458-62. doi: 10.1111/jgs.16243..
Keywords: Elderly, Medication, Medication: Safety, Patient Safety, Quality of Care, Provider: Pharmacist, Provider
Bushnell GA, Crystal S, Olfson M
Prescription benzodiazepine use in privately insured U.S. children and adolescents.
The goal of this cohort study was to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use. Investigators found that U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. They concluded that long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.
AHRQ-funded; HS026001; HS021112; HS023258.
Citation: Bushnell GA, Crystal S, Olfson M .
Prescription benzodiazepine use in privately insured U.S. children and adolescents.
Am J Prev Med 2019 Dec;57(6):775-85. doi: 10.1016/j.amepre.2019.07.006..
Keywords: Children/Adolescents, Medication, Medication: Safety, Patient Safety
Carayon P, Wetterneck TB, Cartmill R
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
This study examined the impact of electronic health record (EHR) implementation in two intensive care units (ICUs). The authors assessed 1254 consecutive admissions before and after an EHR implementation. They identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). The overall potential for harm due to medication errors decreased post-implementation, but only 2 of the 3 error rates were significantly lower post-implementation. They observed reductions in rates of medication errors per admission at the stages of transcription, dispensing, and administration. In the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information).
AHRQ-funded; HS015274; HS000083.
Citation: Carayon P, Wetterneck TB, Cartmill R .
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
J Patient Saf 2021 Aug 1;17(5):e429-e39. doi: 10.1097/pts.0000000000000358.
AHRQ-funded; HS015274; HS000083..
AHRQ-funded; HS015274; HS000083..
Keywords: Medication: Safety, Medication, Intensive Care Unit (ICU), Critical Care, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
Kurian S, Baloy B, Baird J
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.
AHRQ-funded; HS024021.
Citation: Kurian S, Baloy B, Baird J .
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.
J Am Pharm Assoc 2019 Nov-Dec;59(6):824-31. doi: 10.1016/j.japh.2019.08.009..
Keywords: Medication, Medication: Safety, Opioids, Substance Abuse, Provider: Pharmacist, Provider, Patient Safety