National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (4)
- Adverse Events (16)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (2)
- Clinician-Patient Communication (3)
- Communication (7)
- COVID-19 (1)
- Diagnostic Safety and Quality (7)
- Electronic Health Records (EHRs) (1)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (2)
- Evidence-Based Practice (1)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Health Information Technology (HIT) (3)
- Health Literacy (1)
- Hospital Discharge (2)
- Hospitalization (1)
- Hospitals (2)
- Inpatient Care (2)
- (-) Medical Errors (28)
- Medical Liability (8)
- Medication (4)
- Medication: Safety (4)
- Pain (1)
- Patient-Centered Healthcare (1)
- Patient Safety (22)
- Practice Patterns (3)
- Prevention (1)
- Primary Care (2)
- Provider: Health Personnel (1)
- Quality Improvement (1)
- Quality Measures (1)
- Quality of Care (6)
- Risk (1)
- Stress (1)
- Surgery (3)
- Tools & Toolkits (1)
- Transplantation (1)
- Web-Based (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 25 of 28 Research Studies DisplayedAuerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Newman-Toker DE, Nassery N, Schaffer AC
Burden of serious harms from diagnostic error in the USA.
Americans who experience serious harm from misdiagnosis annually. Serious harm is defined as permanent morbidity or morality. This cross-sectional analysis used nationally representative observational data. The authors estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). US-based cancer registries were used to find annual new cancers. They derived diagnostic errors and serious harms by multiplying by literature-based rates for disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories). Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), they estimated total serious harms annually in the USA to be 795,000 (plausible range 598,000-1,023,000). Using more conservative assumptions they estimated 549,000 serious harms. These results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. Fifteen dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.
AHRQ-funded; HS027614; HS029350.
Citation: Newman-Toker DE, Nassery N, Schaffer AC .
Burden of serious harms from diagnostic error in the USA.
BMJ Qual Saf 2024 Jan 19; 33(2):109-20. doi: 10.1136/bmjqs-2021-014130..
Keywords: Healthcare Cost and Utilization Project (HCUP), Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality of Care, Adverse Events
Carroll 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
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
Mello MM, Greenberg Y, Senecal SK
Case outcomes in a communication-and-resolution program in New York hospitals.
The researchers sought to determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery. They concluded that the bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.
AHRQ-funded; R18 HS019505.
Citation: Mello MM, Greenberg Y, Senecal SK .
Case outcomes in a communication-and-resolution program in New York hospitals.
Health Serv Res 2016 Dec;51 Suppl 3:2583-99. doi: 10.1111/1475-6773.12594.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Surgery
Mello MM, Armstrong SJ, Greenberg Y
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
The researchers sought to implement a communication-and-resolution program (CRP) in a setting in which liability insurers and health care facilities must collaborate to resolve incidents involving a facility and separately insured clinicians. They found that sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP.
AHRQ-funded; HS019531.
Citation: Mello MM, Armstrong SJ, Greenberg Y .
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
Health Serv Res 2016 Dec;51 Suppl 3:2550-68. doi: 10.1111/1475-6773.12580.
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Keywords: Communication, Medical Errors, Medical Liability, Patient Safety
Helmchen LA, Lambert BL, McDonald TB
Changes in physician practice patterns after implementation of a communication-and-resolution program.
The researchers tested if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories. They found that the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.
AHRQ-funded; HS019565.
Citation: Helmchen LA, Lambert BL, McDonald TB .
Changes in physician practice patterns after implementation of a communication-and-resolution program.
Health Serv Res 2016 Dec;51 Suppl 3:2516-36. doi: 10.1111/1475-6773.12610.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Practice Patterns
Gallagher TH, Farrell ML, Karson H
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
The Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. After describing the process, the authors concluded that the CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Farrell ML, Karson H .
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
Health Serv Res 2016 Dec;51 Suppl 3:2569-82. doi: 10.1111/1475-6773.12557.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Patient Safety, Quality of Care
Gallagher TH, Etchegaray JM, Bergstedt B
Improving communication and resolution following adverse events using a patient-created simulation exercise.
The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Etchegaray JM, Bergstedt B .
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Health Serv Res 2016 Dec;51 Suppl 3:2537-49. doi: 10.1111/1475-6773.12601.
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Keywords: Adverse Events, Clinician-Patient Communication, Medical Errors, Medical Liability, Patient-Centered Healthcare, Patient Safety
Battles JB, Reback KA, Azam I
AHRQ Author: Battles JB, Reback KA, Azam I
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
AHRQ launched the Patient Safety and Medical Liability (PSML) initiative in 2009. The papers in this issue cover a breadth of topics related to the PSML initiative. Members of the individual Demonstration project teams have authored the majority of the papers. Seven of these papers report outcomes associated with the individual Demonstrations and another four describe tools generated as a part of the interventions.
AHRQ-funded; 233201500029P.
Citation: Battles JB, Reback KA, Azam I .
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
Health Serv Res 2016 Dec;51 Suppl 3:2401-13. doi: 10.1111/1475-6773.12632.
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Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety, Prevention
Ridgely MS, Greenberg MD, Pillen MB
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
This article identifies lessons learned from the experience of AHRQ’s Patient Safety and Medical Liability (PSML) Demonstration Program. The demonstration lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm.
AHRQ-funded; 290200710073T.
Citation: Ridgely MS, Greenberg MD, Pillen MB .
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
Health Serv Res 2016 Dec;51 Suppl 3:2414-30. doi: 10.1111/1475-6773.12625.
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Keywords: Patient Safety, Medical Liability, Adverse Events, Medical Errors
Lambert BL, Centomani NM, Smith KM
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
This study's objective was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes. It found that the intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs. The study found that a communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.
AHRQ-funded; HS019565.
Citation: Lambert BL, Centomani NM, Smith KM .
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2491-515. doi: 10.1111/1475-6773.12548.
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Keywords: Adverse Events, Medical Liability, Medical Errors, Communication, Patient Safety
Singh H, Zwaan L
Annals for hospitalists inpatient notes - Reducing diagnostic error-a new horizon of opportunities for hospital medicine.
The authors argue that given the importance of diagnoses in the hospital, hospitalists are well-positioned to lead efforts to promote correct and timely diagnosis. However, to reduce harms from diagnostic errors, hospitalists must first understand how these errors occur and then develop practical strategies to avoid them.
AHRQ-funded; HS022087; HS023602.
Citation: Singh H, Zwaan L .
Annals for hospitalists inpatient notes - Reducing diagnostic error-a new horizon of opportunities for hospital medicine.
Ann Intern Med 2016 Oct 18;165(8):HO2-HO4. doi: 10.7326/m16-2042.
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Keywords: Medical Errors, Diagnostic Safety and Quality, Patient Safety, Health Information Technology (HIT), Inpatient Care
Mueller SK, Yoon C, Schnipper JL
Association of a web-based handoff tool with rates of medical errors.
The researchers implemented a web-based handoff tool and training for health care professionals and evaluated the association of the tool with rates of medical errors in adult medical and surgical patients. They found that implementation of this tool was associated with a significant reduction in rates of medical errors, driven largely by a reduction in errors attributable to communication failure and errors that occurred during end-of-shift handoffs.
AHRQ-funded; HS023331.
Citation: Mueller SK, Yoon C, Schnipper JL .
Association of a web-based handoff tool with rates of medical errors.
JAMA Intern Med 2016 Sep;176(9):1400-2. doi: 10.1001/jamainternmed.2016.4258.
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Keywords: Medical Errors, Patient Safety, Surgery, Tools & Toolkits, Web-Based
Lavin JM, Boss EF, Brereton J
Responses to errors and adverse events: the need for a systems approach in otolaryngology.
The authors reported otolaryngologists' reactions to errors and adverse events and determined if temporal changes in physician efforts to assume responsibility; ameliorate patients' conditions; or change personal, group-wide, or hospital practices have occurred. Members of the American Academy of Otolaryngology-Head and Neck Surgery were surveyed. The undertaking of corrective actions was reported, and these events led to changes in personal, group/departmental, and hospital practice. The authors found that efforts to change personal practice were much more common than efforts to improve systems.
AHRQ-funded; HS022932.
Citation: Lavin JM, Boss EF, Brereton J .
Responses to errors and adverse events: the need for a systems approach in otolaryngology.
Laryngoscope 2016 Sep;126(9):1999-2002. doi: 10.1002/lary.25837.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Practice Patterns
Smith KJ, Handler SM, Kapoor WN
Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.
This study examines a health care system’s implementation of a broader set of automated primary care physician communication tools, including computerized medication reconciliation, and its impact on discharge medication errors. It found that implementation of automated health system–based tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.
AHRQ-funded; HS018151.
Citation: Smith KJ, Handler SM, Kapoor WN .
Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.
Am J Med Qual 2016 Jul;31(4):315-22. doi: 10.1177/1062860615574327..
Keywords: Health Information Technology (HIT), Communication, Medication, Medical Errors, Hospital Discharge
Al-Mutairi A, Meyer AN, Thomas EJ
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
The researchers aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews. They found that their Safer Dx Instrument helped quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence.
AHRQ-funded; HS022087.
Citation: Al-Mutairi A, Meyer AN, Thomas EJ .
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
J Gen Intern Med 2016 Jun;31(6):602-8. doi: 10.1007/s11606-016-3601-x.
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Keywords: Primary Care, Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality Improvement
Pronovost PJ, Cleeman JI, Wright D
AHRQ Author: Cleeman JI
Fifteen years after to Err is Human: a success story to learn from.
This paper provides a historical profile of the central line-associated bloodstream infection (CLABSI) success story, comparing infection rates before and 15 years after the IOM report. It discusses the five elements essential to the national success in reducing CLABSI rates: a reliable and valid measurement system, evidence-based care practices, investment in implementation sciences, local ownership and peer learning communities, and coordination and alignment of CLABSI reduction efforts.
AHRQ-authored.
Citation: Pronovost PJ, Cleeman JI, Wright D .
Fifteen years after to Err is Human: a success story to learn from.
BMJ Qual Saf 2016 Jun;25(6):396-9. doi: 10.1136/bmjqs-2015-004720.
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Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Patient Safety, Medical Errors, Evidence-Based Practice, Quality of Care
Khan A, Furtak SL, Melvin P
Parent-reported errors and adverse events in hospitalized children.
The researchers sought to determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). They found that parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record.
AHRQ-funded; HS022986.
Citation: Khan A, Furtak SL, Melvin P .
Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr 2016 Apr 4;170(4):e154608. doi: 10.1001/jamapediatrics.2015.4608..
Keywords: Children/Adolescents, Hospitalization, Patient Safety, Adverse Events, Medical Errors
McElroy LM, Woods DM, Yanes AF
Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population.
The researchers aimed to test the applicability of the International Classification for Patient Safety to a surgical population by developing a codebook for future use by researchers. They found that the most common severity classification was 'reportable circumstance' and that the most common incident type was 'resources/organizational management.' They noted that several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions, and handoffs. They concluded that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data.
AHRQ-funded; HS000078.
Citation: McElroy LM, Woods DM, Yanes AF .
Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population.
Int J Qual Health Care 2016 Apr;28(2):166-74. doi: 10.1093/intqhc/mzw001.
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Keywords: Surgery, Patient Safety, Transplantation, Adverse Events, Medical Errors
Medford-Davis L, Park E, Shlamovitz G
Diagnostic errors related to acute abdominal pain in the emergency department.
This study reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results).
AHRQ-funded; HS022087.
Citation: Medford-Davis L, Park E, Shlamovitz G .
Diagnostic errors related to acute abdominal pain in the emergency department.
Emerg Med J 2016 Apr;33(4):253-9. doi: 10.1136/emermed-2015-204754.
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Keywords: Pain, Emergency Department, Diagnostic Safety and Quality, Medical Errors, Clinician-Patient Communication
Singh H, Sittig DF
Measuring and improving patient safety through health information technology: the Health IT Safety Framework.
The authors propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns. A long term framework goal is to enable rigorous measurement that helps achieve the safety benefits of health IT in real-world clinical settings.
AHRQ-funded; HS022087.
Citation: Singh H, Sittig DF .
Measuring and improving patient safety through health information technology: the Health IT Safety Framework.
BMJ Qual Saf 2016 Apr;25(4):226-32. doi: 10.1136/bmjqs-2015-004486.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Health Information Technology (HIT), Patient Safety, Quality Measures
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