National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (8)
- Adverse Events (8)
- Burnout (1)
- Clinical Decision Support (CDS) (2)
- Clinician-Patient Communication (1)
- Communication (1)
- Critical Care (1)
- Diagnostic Safety and Quality (1)
- Education: Patient and Caregiver (1)
- Elderly (1)
- Electronic Health Records (EHRs) (8)
- Electronic Prescribing (E-Prescribing) (2)
- (-) Health Information Technology (HIT) (15)
- Health Literacy (1)
- Hospitals (1)
- Intensive Care Unit (ICU) (2)
- Medical Errors (3)
- Medication (15)
- (-) Medication: Safety (15)
- Newborns/Infants (1)
- Opioids (1)
- (-) Patient Safety (15)
- Patient Self-Management (1)
- Provider (2)
- Provider: Clinician (1)
- Provider: Pharmacist (1)
- Quality of Care (1)
- Shared Decision Making (2)
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 15 of 15 Research Studies DisplayedSalmasian H, Blanchfield BB, Joyce K
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). The purpose of this study was to evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.
AHRQ-funded; HS024713.
Citation: Salmasian H, Blanchfield BB, Joyce K .
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
AMA Netw Open 2020 Nov 2;3(11):e2019652. doi: 10.1001/jamanetworkopen.2020.19652..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Diagnostic Safety and Quality
Co Z, Holmgren AJ, Classen DC
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
This study evaluated the overall performance of hospitals that used the Computerized Physician Order Entry Evaluation Tool in 2017 and 2018 and compared performances for fatal orders and nuisance orders each year. The authors evaluated 1599 hospitals that took the test by using their overall percentage scores along with the percentage of fatal orders appropriately alerted on and the percentage of nuisance orders incorrectly alerted on. Overall hospital scores improved from 58.1% in 2017 to 66.2% in 2018. Fatal order performance improved slightly from 78.8% to 83.0%, but there no very little change in nuisance order performance (89.0% to 89.7%). Conclusions were that perhaps hospitals are not targeting the deadliest orders first and some hospitals may be achieving higher scores by over-alerting. This has the potential to cause clinician burnout and even worsen patient safety.
AHRQ-funded; HS023696.
Citation: Co Z, Holmgren AJ, Classen DC .
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
J Am Med Inform Assoc 2020 Aug;27(8):1252-58. doi: 10.1093/jamia/ocaa098..
Keywords: Medication: Safety, Medication, Patient Safety, Clinical Decision Support (CDS), Shared Decision Making, Burnout, Hospitals, Health Information Technology (HIT), Quality of Care
Banerji A, Lai KH, Li Y
Natural language processing combined with ICD-9-CM codes as a novel method to study the epidemiology of allergic drug reactions.
Researchers sought to develop and validate a novel informatics method based on natural language processing (NLP) in combination with ICD-9-CM codes that identifies allergic drug reactions in the electronic health record. They found that using NLP with ICD-9-CM codes improved identification of allergic drug reactions, and they concluded that the resulting decrease in manual chart review effort will facilitate large epidemiology studies of this understudied area.
AHRQ-funded; HS024264; HS025375.
Citation: Banerji A, Lai KH, Li Y .
Natural language processing combined with ICD-9-CM codes as a novel method to study the epidemiology of allergic drug reactions.
J Allergy Clin Immunol Pract 2020 Mar;8(3):1032-38.e1. doi: 10.1016/j.jaip.2019.12.007..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Holmgren AJ, Co Z, Newmark L
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
The authors tested how well EHRs prevented medication errors with the potential for patient harm. Data from a national, longitudinal sample of 1527 hospitals in the US from 2009-16 who took a safety performance assessment test using simulated medication orders was used. The authors found that hospital medication order safety performance improved over time. They conclude that intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.
AHRQ-funded; HS023696.
Citation: Holmgren AJ, Co Z, Newmark L .
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
BMJ Qual Saf 2020 Jan;29(1):52-59. doi: 10.1136/bmjqs-2019-009609..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Medication, Electronic Prescribing (E-Prescribing), Medication: Safety, Clinical Decision Support (CDS), Shared Decision Making
McCarthy DM, Curtis LM, Courtney DM
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The objective of this study was to evaluate the effect of an Electronic Medication Complete Communication (EMC(2)) Opioid Strategy on patients' safe use of opioids and knowledge about opioids. The study found that the EMC(2) tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.
AHRQ-funded; HS023459.
Citation: McCarthy DM, Curtis LM, Courtney DM .
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Acad Emerg Med 2019 Dec;26(12):1311-25. doi: 10.1111/acem.13860..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Health Literacy, Education: Patient and Caregiver, Clinician-Patient Communication, Communication, Health Information Technology (HIT)
Carayon P, Wetterneck TB, Cartmill R
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
This study examined the impact of electronic health record (EHR) implementation in two intensive care units (ICUs). The authors assessed 1254 consecutive admissions before and after an EHR implementation. They identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). The overall potential for harm due to medication errors decreased post-implementation, but only 2 of the 3 error rates were significantly lower post-implementation. They observed reductions in rates of medication errors per admission at the stages of transcription, dispensing, and administration. In the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information).
AHRQ-funded; HS015274; HS000083.
Citation: Carayon P, Wetterneck TB, Cartmill R .
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
J Patient Saf 2021 Aug 1;17(5):e429-e39. doi: 10.1097/pts.0000000000000358.
AHRQ-funded; HS015274; HS000083..
AHRQ-funded; HS015274; HS000083..
Keywords: Medication: Safety, Medication, Intensive Care Unit (ICU), Critical Care, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Adelman JS, Applebaum JR, Southern WN
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Researchers assessed the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and examined the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). They found that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
AHRQ-funded; HS024538.
Citation: Adelman JS, Applebaum JR, Southern WN .
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
JAMA Pediatr 2019 Oct 10;173(10):979-85. doi: 10.1001/jamapediatrics.2019.2733..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Medication, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
P Dellsperger, KC Fallaw, D
AHRQ Author: Rangachari
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
This study sought to identify issues related to electronic health record (EHR) medication reconciliation (MedRec) from the perspective of practitioners directly involved in the EHR MedRec process, with the goal of reducing medication discrepancies during transitions of care and improving the accuracy of patient medication lists. The study was conducted in two rounds: individual interviews, then a survey of physicians, nurses, and pharmacists based in the outpatient and inpatient medicine service at AU Health. The survey elicited practitioner ratings of the importance of issues identified during the interviews. Issues that were rated as important by more than 70 percent of respondents include care coordination, patient education, ownership and accountability, processes-of-care, IT-related issues, and workforce training. From these issues, the authors conclude that there is an absence of shared understanding among practitioners regarding the value of EHR MedRec in promoting patient safety, which contributes to work-arounds and the suboptimal use of the EHR MedRec system, and there is also a sociotechnical dimension to many of these issues which creates an additional layer of complexity.
AHRQ-funded; HS024335.
Citation: P Dellsperger, KC Fallaw, D .
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
Qual Manag Health Care 2019 Apr/Jun;28(2):84-95. doi: 10.1097/qmh.0000000000000208..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety, Provider, Provider: Clinician
Wong A, Seger DL, Lai KH
Drug hypersensitivity reactions documented in electronic health records within a large health system.
The goal of this study was to examine the epidemiology of hypersensitivity reactions (HSRs) using EHR data from the Partners Enterprise-wide Allergy Repository for two large tertiary care hospitals. HSRs were categorized as immediate or delayed and the causative drugs and drug groups assessed. Prevalence of HSRs was determined, and the sex and race of patients analyzed. Penicillins were associated with the most immediate and delayed reactions. Nearly half of the reported immediate HSRs manifested as hives. HSRs were more prevalent in females and white patients, but differences were identified for specific, rare HSRs.
AHRQ-funded; HS022728; HS025375.
Citation: Wong A, Seger DL, Lai KH .
Drug hypersensitivity reactions documented in electronic health records within a large health system.
J Allergy Clin Immunol Pract 2019 Apr;7(4):1253-60.e3. doi: 10.1016/j.jaip.2018.11.023..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety
Wolfson AR, Zhou L, Li Y
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome identified in the electronic health record allergy module.
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but severe hypersensitivity reaction that remains poorly characterized in the United States. The objective of this study was to identify and describe DRESS syndrome cases in an integrated health care system using electronic health record (EHR) allergy module free-text searches.
AHRQ-funded; HS022728; HS025375.
Citation: Wolfson AR, Zhou L, Li Y .
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome identified in the electronic health record allergy module.
J Allergy Clin Immunol Pract 2019 Feb;7(2):633-40. doi: 10.1016/j.jaip.2018.08.013..
Keywords: Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Schiff GD, Klinger E, Salazar A
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
In this study, the investigators evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist- to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, depression, and insomnia. Systematic automated telephone outreach monitoring coupled with real-time phone referral to a pharmacist identified a substantial number of previously unidentified potentially drug-related symptoms, many of which were validated as probably or possibly related to the drug by the pharmacist or their physicians.
AHRQ-funded; HS021094.
Citation: Schiff GD, Klinger E, Salazar A .
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
J Gen Intern Med 2019 Feb;34(2):285-92. doi: 10.1007/s11606-018-4672-7..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Health Information Technology (HIT), Provider: Pharmacist, Provider, 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
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
Chrischilles EA, Hourcade JP, Doucette W
Personal health records: a randomized trial of effects on elder medication safety.
The purpose of this study was to compare patient-reported medication self-management behaviors and safety indicators among older adult participants invited to use an electronic personal health record (PHR). Among the 16.1 percent of participants who used the PHR frequently, there were significantly more changes in medication use, improved medication reconciliation behaviors, and more recognition of side effects.
AHRQ-funded; HS017034
Citation: Chrischilles EA, Hourcade JP, Doucette W .
Personal health records: a randomized trial of effects on elder medication safety.
J Am Med Inform Assoc. 2014 Jul-Aug;21(4):679-86. doi: 10.1136/amiajnl-2013-002284..
Keywords: Elderly, Medication, Medication: Safety, Health Information Technology (HIT), Patient Safety, Patient Self-Management
Gagne JJ, Wang SV, Rassen JA
A modular, prospective, semi-automated drug safety monitoring system for use in a distributed data environment.
The purpose of this study was to develop and test a semi-automated process for conducting routine active safety monitoring for new drugs in a network of electronic health care databases. The system identified serious risks due to some drugs, which were eventually removed from the market years later.
AHRQ-funded; HS018088; HS022193
Citation: Gagne JJ, Wang SV, Rassen JA .
A modular, prospective, semi-automated drug safety monitoring system for use in a distributed data environment.
Pharmacoepidemiol Drug Saf. 2014 Jun;23(6):619-27. doi: 10.1002/pds.3616..
Keywords: Medication: Safety, Health Information Technology (HIT), Patient Safety, Medication