National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (6)
- Adverse Events (9)
- Ambulatory Care and Surgery (1)
- Care Coordination (1)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (4)
- Communication (2)
- Data (1)
- Diagnostic Safety and Quality (1)
- Electronic Health Records (EHRs) (4)
- Healthcare Costs (1)
- Healthcare Delivery (2)
- (-) Health Information Technology (HIT) (13)
- Hospital Discharge (2)
- Inpatient Care (1)
- Medical Devices (1)
- (-) Medical Errors (13)
- Medication (8)
- Medication: Safety (2)
- Patient Safety (12)
- Prevention (1)
- Quality Measures (1)
- Transitions of Care (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 13 of 13 Research Studies DisplayedLambert BL, Galanter W, Liu KL
Automated detection of wrong-drug prescribing errors.
Investigators assessed the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. They found that automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Additionally, real-time error detection is not possible with the current system. They suggested that further development should replicate their analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
AHRQ-funded; HS021093.
Citation: Lambert BL, Galanter W, Liu KL .
Automated detection of wrong-drug prescribing errors.
BMJ Qual Saf 2019 Nov;28(11):908-15. doi: 10.1136/bmjqs-2019-009420..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Wang E, Kang H, Gong Y
Generating a health information technology event database from FDA MAUDE reports.
This study examined using a health information technology (HIT) event database to identify patient safety events (PSEs) or medical errors. The study used the FDA Manufacturer and User Facility Device Experience (MAUDE) database to extract HIT events. Classic and CNN models were utilized on a test set. The model was capable of identifying HIT event with about a 90% accuracy.
AHRQ-funded; HS022895.
Citation: Wang E, Kang H, Gong Y .
Generating a health information technology event database from FDA MAUDE reports.
Stud Health Technol Inform 2019 Aug 21;264:883-87. doi: 10.3233/shti190350..
Keywords: Health Information Technology (HIT), Medical Devices, Adverse Events, Data, Medical Errors, Patient Safety
Liang C, Miao Q, Kang H
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
The present study sought to explore the associations between federal incentives of patient safety research and the outcomes from 1995 to 2014, in which two historical events - the release of To Err Is Human and the American Recovery and Reinvestment Act - were considered in the analysis. They concluded that their findings suggested a positive outcome in patient safety research.
AHRQ-funded; HS022895.
Citation: Liang C, Miao Q, Kang H .
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
Stud Health Technol Inform 2019 Aug 21;264:983-87. doi: 10.3233/shti190371..
Keywords: Patient Safety, Medical Errors, Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT)
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Adelman JS, Applebaum JR, Schechter CB
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
This study assessed whether the belief that having only 1 electronic health record (EHR) open at a time as opposed to 4 will reduce the number of wrong-patient orders by clinicians. A randomized clinical trial was conducted with 3356 clinicians in a large New York Health system from October 2015 to April 2017. Outcomes from emergency department, inpatient, and outpatient settings showed that there seemed to be no difference in the number of wrong-patient order errors. However, most clinicians in the unrestricted group placed orders with a single-record open anyway which limited the power of the study.
AHRQ-funded; HS023704.
Citation: Adelman JS, Applebaum JR, Schechter CB .
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
JAMA 2019 May 14;321(18):1780-87. doi: 10.1001/jama.2019.3698..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Healthcare Delivery, Medical Errors, Patient Safety
Wang J, Liang H, Kang H
Understanding health information technology induced medication safety events by two conceptual frameworks.
While health information technology (health IT) is able to prevent medication errors in many ways, it may also potentially introduce new paths to errors. To understand the impact of health IT induced medication errors, this study aimed to conduct a retrospective analysis of medication safety reports. The investigators concluded that the two frameworks provided an opportunity to understand a comprehensive context of safety event and the impact of health IT induced errors on medication safety.
AHRQ-funded; HS022895.
Citation: Wang J, Liang H, Kang H .
Understanding health information technology induced medication safety events by two conceptual frameworks.
Appl Clin Inform 2019 Jan;10(1):158-67. doi: 10.1055/s-0039-1678693..
Keywords: Health Information Technology (HIT), Medication: Safety, Medication, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors
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
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
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
Ranji SR, Rennke S, Wachter RM
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
The authors searched AHRQ's Patient Safety Net to identify reviews of the effect of computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) on adverse drug event (ADE) rates in inpatient and outpatient settings. They found that CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, often leading to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects.
AHRQ-funded; 2902007100621.
Citation: Ranji SR, Rennke S, Wachter RM .
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
BMJ Qual Saf 2014 Sep;23(9):773-80. doi: 10.1136/bmjqs-2013-002165.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinical Decision Support (CDS), Health Information Technology (HIT), Medication, Patient Safety
Pohl JM, Tanner C, Hamilton A
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
This study, conducted in five safety-net practices, examined the impact of implementing a commercial electronic health records system on medication safety. The authors found 130 "true" drug-drug interaction (DDI) pairs, representing 149,087 visits and 62 providers, with the largest DDI categories being related to antihypertensive medications, which are often prescribed together. They found no significant differences between physicians and nurse practitioners on the rate of DDI pairs.
AHRQ-funded; HS017191.
Citation: Pohl JM, Tanner C, Hamilton A .
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
J Am Assoc Nurse Pract 2014 Aug;26(8):438-44. doi: 10.1002/2327-6924.12089.
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Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety
Galanter WL, Bryson ML, Falck S
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
The authors measured whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. They found that indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts and recommended that institutions with CPOE consider using indication prompts to intercept drug name confusion errors.
AHRQ-funded; HS021093.
Citation: Galanter WL, Bryson ML, Falck S .
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
PLoS One 2014 Jul 15;9(7):e101977. doi: 10.1371/journal.pone.0101977.
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Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Health Information Technology (HIT), Medication, Patient Safety
Forrester SH, Hepp Z, Roth JA
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
The study objective was to estimate the cost-effectiveness of computerized provider order entry versus traditional paper-based prescribing in reducing medications errors and adverse drug events in the ambulatory setting of mid-sized medical group. Using a decision-analytic model, the researchers found that the adoption of CPOE in the ambulatory setting provides excellent value for the investment.
AHRQ-funded; HS014739
Citation: Forrester SH, Hepp Z, Roth JA .
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
Value Health. 2014 Jun;17(4):340-9. doi: 10.1016/j.jval.2014.01.009..
Keywords: Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Patient Safety, Healthcare Costs, Ambulatory Care and Surgery, Prevention