National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (6)
- Adverse Events (20)
- Ambulatory Care and Surgery (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (3)
- Clinical Decision Support (CDS) (2)
- Clinician-Patient Communication (3)
- Communication (7)
- Diagnostic Safety and Quality (7)
- Electronic Health Records (EHRs) (2)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (2)
- Evidence-Based Practice (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (8)
- Health Insurance (1)
- Hospital Discharge (1)
- Hospitalization (2)
- Hospitals (1)
- Inpatient Care (1)
- Labor and Delivery (1)
- (-) Medical Errors (39)
- Medical Liability (11)
- Medication (8)
- Medication: Safety (3)
- Pain (1)
- Patient-Centered Healthcare (1)
- Patient Safety (31)
- Policy (2)
- Practice Patterns (3)
- Pregnancy (1)
- Prevention (3)
- Primary Care (3)
- Provider: Health Personnel (1)
- Quality Improvement (3)
- Quality Indicators (QIs) (1)
- Quality Measures (1)
- Quality of Care (6)
- Risk (1)
- Rural Health (1)
- Stress (1)
- Surgery (4)
- Teams (1)
- Telehealth (1)
- Tools & Toolkits (2)
- Transplantation (1)
- Web-Based (1)
- Women (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 39 Research Studies DisplayedMello 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
Edrees H, Brock DM, Wu AW
The experiences of risk managers in providing emotional support for health care workers after adverse events.
The authors surveyed members of the American Society for Health Care Risk Management (ASHRM) about their training, experience, competence, and comfort with providing emotional support to health care workers. Risk managers who were comfortable listening to and supporting health care workers were more likely to report prior training. Most respondents expressed a preference to receive additional training.
AHRQ-funded; HS019531.
Citation: Edrees H, Brock DM, Wu AW .
The experiences of risk managers in providing emotional support for health care workers after adverse events.
J Healthc Risk Manag 2016 Apr;35(4):14-21. doi: 10.1002/jhrm.21219.
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Keywords: Adverse Events, Medical Errors, Stress, Patient Safety
Okafor N, Payne VL, Chathampally Y
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
The researchers analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Among the 209 incidents, they identified 214 diagnostic errors associated with 65 unique diseases/conditions. Most diagnostic errors in ED appeared to relate to common disease conditions.
AHRQ-funded; HS017586; HS022087.
Citation: Okafor N, Payne VL, Chathampally Y .
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
Emerg Med J 2016 Apr;33(4):245-52. doi: 10.1136/emermed-2014-204604.
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Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Risk, Patient Safety
Rabatin J, Williams E, Baier Manwell L
Predictors and outcomes of burnout in primary care physicians.
This study assessed relationships between primary care work conditions, physician burnout, quality of care, and medical errors. It found that burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians.
AHRQ-funded; HS011955.
Citation: Rabatin J, Williams E, Baier Manwell L .
Predictors and outcomes of burnout in primary care physicians.
J Prim Care Community Health 2016 Jan;7(1):41-3. doi: 10.1177/2150131915607799.
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Keywords: Provider: Health Personnel, Primary Care, Medical Errors, Patient Safety, Quality of Care
Meeks DW, Meyer AN, Rose B
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
The researchers described outcomes of peer review within the Department of Veterans Affairs (VA) healthcare system and identified opportunities to leverage peer review data for measurement and improvement of safety. Results showed that the most common process contributing to substandard care was 'timing and appropriateness of treatment'; approximately 16% had diagnosis-related performance concerns. The authors concluded that peer review may be a useful tool for healthcare organizations to assess their sharp end clinical performance, particularly safety events related to diagnostic and treatment errors.
AHRQ-funded; HS022087.
Citation: Meeks DW, Meyer AN, Rose B .
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
BMJ Qual Saf 2014 Dec;23(12):1023-30. doi: 10.1136/bmjqs-2014-003239.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Quality Improvement
Dollarhide AW, Rutledge T, Weinger MB
A real-time assessment of factors influencing medication events.
This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. It found that medication events were associated with 36.1 percent higher perceived workload, 8.6 percent higher inpatient caseloads and 55.9 percent higher emotional stress scores. Also, there was a trend for reported events to be associated with less sleep.
AHRQ-funded; HS014283.
Citation: Dollarhide AW, Rutledge T, Weinger MB .
A real-time assessment of factors influencing medication events.
J Healthc Qual 2014 Sep-Oct;36(5):5-12. doi: 10.1111/jhq.12012..
Keywords: Medication, Medical Errors, Patient Safety, Quality of Care