National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (11)
- (-) Adverse Events (15)
- Ambulatory Care and Surgery (1)
- Care Coordination (1)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (5)
- Communication (1)
- Data (1)
- Electronic Health Records (EHRs) (4)
- Electronic Prescribing (E-Prescribing) (2)
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- (-) Health Information Technology (HIT) (15)
- Hospital Discharge (1)
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- Medical Errors (9)
- Medication (12)
- Medication: Safety (6)
- Newborns/Infants (1)
- (-) Patient Safety (15)
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- Provider (1)
- Provider: Pharmacist (1)
- Surgery (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 15 of 15 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
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)
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
Nguyen BP, Reese T, Decker S
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
The authors report on the implementation and evaluation of CDS Services which represent potential drug-drug interactions knowledge with Clinical Quality Language (CQL). Their suggested solution is based on emerging standards including CDS Hooks, FHIR, and CQL. They selected two use cases, implemented them with CQL rules, and tested them.
AHRQ-funded; HS023826; HS025984.
Citation: Nguyen BP, Reese T, Decker S .
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
Stud Health Technol Inform 2019 Aug 21;264:724-28. doi: 10.3233/shti190318..
Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Medication, Adverse Events, Patient Safety, Health Information Technology (HIT)
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
Bucher BT, Ferraro JP, Finlayson SRG
Use of computerized provider order entry events for postoperative complication surveillance.
The purpose of this study was to determine if a surveillance system using computerized provider order entry (CPOE) events for selected medications as well as laboratory, microbiologic, and radiologic orders can decrease the manual medical record review burden for surveillance of postoperative complications. Results showed that a CPOE-based surveillance of postoperative complications has high negative predictive value, demonstrating that this approach can augment the currently used, resource-intensive manual medical record review process.
AHRQ-funded; HS025776.
Citation: Bucher BT, Ferraro JP, Finlayson SRG .
Use of computerized provider order entry events for postoperative complication surveillance.
JAMA Surg 2019 Apr;154(4):311-18. doi: 10.1001/jamasurg.2018.4874..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Adverse Events, Surgery, Patient Safety
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
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