National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (5)
- Adverse Events (8)
- Ambulatory Care and Surgery (1)
- Clinical Decision Support (CDS) (2)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (4)
- Emergency Department (1)
- Healthcare Costs (1)
- (-) Health Information Technology (HIT) (8)
- (-) Medical Errors (8)
- Medication (5)
- Medication: Safety (2)
- Patient Safety (7)
- Prevention (1)
- Quality Improvement (1)
- Quality 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 8 of 8 Research Studies DisplayedGriffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: validation and testing to optimize yield.
Researchers validated the emergency department trigger tool (EDTT) in an independent sample and compared record selection approaches to optimize yield for quality improvement. In this single-site study of the EDTT, they observed high levels of validity in trigger selection, yield, and representativeness of adverse events, with yields that are superior to estimates for traditional approaches to adverse event detection. Record selection using weighted triggers outperformed a trigger count threshold approach and far outperformed random sampling from records with at least one trigger. They concluded that the EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the emergency department.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: validation and testing to optimize yield.
Acad Emerg Med 2020 Dec;27(12):1279-90. doi: 10.1111/acem.14101..
Keywords: Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Events, Patient Safety, Quality Improvement, Quality of Care
Salmasian 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
Kang H, Gong Y
Creating a database for health IT events via a hybrid deep learning model.
The authors of this study propose a hybrid learning model to identify health information technology (HIT) events to prevent risks from poorly designed and improperly implemented HIT. Events from the FDA MAUDE database was employed from 6994 samples (3521 HIT and 3473 non-HIT events). Nine individual and 120 hybrid models were employed. Error causes included lack of root cause (72.3%), short descriptions (19.7%) and model undertrained (8.0%). The optimal model was applied to the entire MAUDE database (1991-2018) and generated a HIT event database with 48,997 reports with an annual growth rate of 10%.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
Creating a database for health IT events via a hybrid deep learning model.
J Biomed Inform 2020 Oct;110:103556. doi: 10.1016/j.jbi.2020.103556..
Keywords: Health Information Technology (HIT), Medical Errors, Adverse Events
Soleimani J, Pinevich Y, Barwise AK
Feasibility and reliability testing of manual electronic health record reviews as a tool for timely identification of diagnostic error in patients at risk.
Although diagnostic error (DE) is a significant problem, it remains challenging for clinicians to identify it reliably and to recognize its contribution to the clinical trajectory of their patients. The purpose of this work was to evaluate the reliability of real-time electronic health record (EHR) reviews using a search strategy for the identification of DE as a contributor to the rapid response team (RRT) activation. Early and accurate recognition of critical illness is of paramount importance.
AHRQ-funded; HS026609.
Citation: Soleimani J, Pinevich Y, Barwise AK .
Feasibility and reliability testing of manual electronic health record reviews as a tool for timely identification of diagnostic error in patients at risk.
Appl Clin Inform 2020 May;11(3):474-82. doi: 10.1055/s-0040-1713750..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Medical Errors, Adverse Events, 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.
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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