National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (5)
- Adverse Events (9)
- Ambulatory Care and Surgery (1)
- Back Health and Pain (1)
- Clinical Decision Support (CDS) (3)
- Decision Making (1)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (3)
- Healthcare Costs (1)
- (-) Health Information Technology (HIT) (11)
- (-) Medical Errors (11)
- Medication (5)
- Medication: Safety (1)
- Patient Safety (11)
- Prevention (1)
- Primary Care (1)
- System Design (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 11 of 11 Research Studies DisplayedKang H, Gong Y
Design of a user-centered voluntary reporting system for patient safety events.
A knowledge-based and user-centered patient safety events (PSE) reporting system is needed to organize scattered knowledge and improve user-friendliness. The researchers described the development of a knowledge base for patient falls, the most frequent PSE. Based on the knowledge base, user-centered design features were incorporated into the system to improve the reporting accuracy, completeness, and timeliness.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
Design of a user-centered voluntary reporting system for patient safety events.
Stud Health Technol Inform 2017;245:733-37.
.
.
Keywords: Adverse Events, Medical Errors, Health Information Technology (HIT), Patient Safety
Kushniruk A, Senathirajah Y, Borycki E
Towards a usability and error "safety net": a multi-phased multi-method approach to ensuring system usability and safety.
The researchers describe a multi-phased multi-method approach to integrating usability engineering methods into system testing to ensure both usability and safety of healthcare IT upon widespread deployment. Their approach involves usability testing followed by clinical simulation (conducted in-situ) and "near-live" recording of user interactions with systems. At key stages in this process, usability problems are identified and rectified forming a usability and technology-induced error "safety net.”
AHRQ-funded; HS023708.
Citation: Kushniruk A, Senathirajah Y, Borycki E .
Towards a usability and error "safety net": a multi-phased multi-method approach to ensuring system usability and safety.
Stud Health Technol Inform 2017;245:763-67.
.
.
Keywords: Health Information Technology (HIT), Medical Errors, Patient Safety
Gong Y, Kang H, Wu X
Enhancing patient safety event reporting. a systematic review of system design features.
Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. This paper aimed at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system. Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated. The authors concluded that the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.
AHRQ-funded; HS022895.
Citation: Gong Y, Kang H, Wu X .
Enhancing patient safety event reporting. a systematic review of system design features.
Appl Clin Inform 2017 Aug 30;8(3):893-909. doi: 10.4338/aci-2016-02-r-0023..
Keywords: Adverse Events, Medical Errors, Health Information Technology (HIT), Patient Safety, System Design
Bhise V, Meyer AND, Singh H
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
With this study, the investigators set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement. The investigators found that despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses were common and involved inadequate history, physical examination, and test ordering. They suggested that solutions should include renewed attention to basic clinical skills.
AHRQ-funded; HS022087.
Citation: Bhise V, Meyer AND, Singh H .
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Am J Med 2017 Aug;130(8):975-81. doi: 10.1016/j.amjmed.2017.03.009..
Keywords: Adverse Events, Back Health and Pain, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Patient Safety
Kang H, Gong Y
Developing a similarity searching module for patient safety event reporting system using semantic similarity measures.
In this study, three prevailing algorithms of semantic similarity were implemented to measure the similarities of the 366 patient safety events (PSE) annotated by the taxonomy of AHRQ. The result shows that the similarity scores reflect a higher consistency with the experts' review than those randomly assigned. Moreover, incorporating the algorithms into the reporting system enables a mechanism to learn and update, based upon PSE similarity.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
Developing a similarity searching module for patient safety event reporting system using semantic similarity measures.
BMC Med Inform Decis Mak 2017 Jul 5;17(Suppl 2):75. doi: 10.1186/s12911-017-0467-8.
.
.
Keywords: Patient Safety, Adverse Events, Medical Errors, Health Information Technology (HIT)
Singh H, Schiff GD, Graber ML
The global burden of diagnostic errors in primary care.
In this narrative review, the authors discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. They then synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. Finally, they summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors.
AHRQ-funded; HS022087; HS023602.
Citation: Singh H, Schiff GD, Graber ML .
The global burden of diagnostic errors in primary care.
BMJ Qual Saf 2017 Jun;26(6):484-94. doi: 10.1136/bmjqs-2016-005401.
.
.
Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Medical Errors, Patient Safety, Primary Care
Horsky J, Aarts J, Verheul L
Clinical reasoning in the context of active decision support during medication prescribing.
The purpose of this study was to describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. The investigators found that declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher.
AHRQ-funded; HS021094.
Citation: Horsky J, Aarts J, Verheul L .
Clinical reasoning in the context of active decision support during medication prescribing.
Int J Med Inform 2017 Jan;97:1-11. doi: 10.1016/j.ijmedinf.2016.09.004..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
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.
.
.
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.
.
.
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.
.
.
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