National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- (-) Adverse Drug Events (ADE) (12)
- Adverse Events (10)
- Ambulatory Care and Surgery (1)
- Clinical Decision Support (CDS) (3)
- Diagnostic Safety and Quality (1)
- Electronic Health Records (EHRs) (3)
- Emergency Department (1)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Healthcare Costs (2)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (8)
- Hospital Discharge (1)
- Hospitals (1)
- Long-Term Care (1)
- (-) Medical Errors (12)
- Medication (12)
- Medication: Safety (7)
- Nursing Homes (1)
- Patient Safety (11)
- Prevention (2)
- 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 12 of 12 Research Studies DisplayedWright A, Aaron S, Seger DL
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
This study examined the effects of conversion from a homegrown electronic health record (EHR) system to a commercial system on the effectiveness of drug-drug interaction (DDI) alert. The EHR system included 3277 clinicians in the before and after studies. There was a marked decrease in the acceptance rate (100 to 8.4% for severe alerts, 29.3 to 7.5% for medium severity) at first. The least severe alerts were then disabled, which lowered the alert burden by 50.5% which rose the acceptance of Tier 1 alerts to 12.7%. However, there was no clear explanation after that why the acceptance rate remained so much lower. The authors believe that workflow factors were probably the predominant reasons.
AHRQ-funded; HS016970.
Citation: Wright A, Aaron S, Seger DL .
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
J Gen Intern Med 2018 Nov;33(11):1868-76. doi: 10.1007/s11606-018-4415-9..
Keywords: Adverse Drug Events (ADE), Medication, Adverse Events, Medical Errors, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Schiff G, Mirica MM, Dhavle AA
A prescription for enhancing electronic prescribing safety.
The authors review six areas in which electronic prescribing areas can be improved to transform medication ordering quality and safety. They recommend incorporating medication indications into electronic prescribing, establishing a single shared online medication list, implementing an electronic cancellation mechanism for pharmacies, implementing standardized structured and codified prescription instruction, reengineering clinical decision support, and redesigning electronic prescribing to facilitate ordering of nondrug alternatives.
AHRQ-funded; HS023694.
Citation: Schiff G, Mirica MM, Dhavle AA .
A prescription for enhancing electronic prescribing safety.
Health Aff 2018 Nov;37(11):1877-83. doi: 10.1377/hlthaff.2018.0725..
Keywords: Adverse Drug Events (ADE), Adverse Events, Health Information Technology (HIT), Healthcare Delivery, Medical Errors, Medication, Medication: Safety, Patient Safety
Bates DW, Singh H
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
This paper comments on the progress made in improving patient safety since the 1999 report from The Institute of Medicine titled “To Err is Human” was published. This landmark report highlighted problem areas, and since then there has been a number of effective interventions to prevent hospital-acquired infections and improve medication safety. Additional areas for improvement have also been identified in the past two decades, including outpatient care, diagnostic, errors and the use of health information technology. The authors believe that electronic data developments can help increase patient safety even further.
AHRQ-funded; HS022087; HS017820.
Citation: Bates DW, Singh H .
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Health Aff 2018 Nov;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738..
Keywords: Adverse Drug Events (ADE), Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Prevention
Slight SP, Seger DL, Franz C
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
Investigators worked to determine the national cost of adverse drug events (ADEs) in the United States in 2014. They used three different regression models. They used a random sample of 40,990 adult inpatients at the Brigham and Women’s Hospital in Boston with over 1.6 million medication orders. They extrapolated the medication orders using 2014 National Inpatient Sample (NIS) data. They estimated that out of 78.8 million total medication alerts, 5.5 million medication alerts would have been inappropriately overridden resulting in 196,660 ADEs. They estimated it would have cost between $871 million and $1.8 billion for treating these preventable ADEs in the United States.
AHRQ-funded; HS021094.
Citation: Slight SP, Seger DL, Franz C .
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
J Am Med Inform Assoc 2018 Sep;25(9):1183-88. doi: 10.1093/jamia/ocy066..
Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT), Healthcare Costs, Medical Errors, Medication
Wang J, Ali E, Gong Y
An information enhanced framework for reporting medication events.
In this article, the authors describe a proposed framework to discover supportive information from the FDA Adverse Event Reporting System (FAERS), an open data source, to enhance the reporting of insulin-use events. The framework represents a paradigm for developing an information enhanced electronic reporting system.
AHRQ-funded; HS022895.
Citation: Wang J, Ali E, Gong Y .
An information enhanced framework for reporting medication events.
Stud Health Technol Inform 2018;250:169-73..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Medication: Safety, Patient Safety
Kannampallil TG, Manning JD, Chestek DW
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
The authors examined the effect of number of open charts on intercepted wrong-patient medication orders in an emergency department using an interrupted time series analysis of intercepted wrong-patient medication orders in an emergency department during 2010-2016.
AHRQ-funded; HS024945.
Citation: Kannampallil TG, Manning JD, Chestek DW .
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
J Am Med Inform Assoc 2018 Jun;25(6):739-43. doi: 10.1093/jamia/ocx099..
Keywords: Adverse Drug Events (ADE), Emergency Department, Medical Errors, Medication, Medication: Safety, Patient Safety
Zhou S, Kang H, Yao B
Unveiling originated stages of medication errors: an automated pipeline approach.
Medication error reports collected by Patient Safety Organizations provide an opportunity to analyze and learn from previous cases. However, the current process of analyzing the reports is labor-intensive and time-consuming. To improve the efficiency, the investigators used automated text classification techniques to develop a pipeline for medication error report pre-analysis.
AHRQ-funded; HS022895.
Citation: Zhou S, Kang H, Yao B .
Unveiling originated stages of medication errors: an automated pipeline approach.
Stud Health Technol Inform 2018;250:182-86..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Medication: Safety, Patient Safety
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care
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