National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- (-) Adverse Drug Events (ADE) (27)
- Adverse Events (24)
- Ambulatory Care and Surgery (2)
- Antibiotics (1)
- Blood Clots (1)
- Blood Pressure (1)
- Blood Thinners (2)
- Children/Adolescents (2)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (4)
- Communication (2)
- Comparative Effectiveness (1)
- Decision Making (1)
- Diabetes (1)
- Elderly (3)
- Electronic Health Records (EHRs) (5)
- Electronic Prescribing (E-Prescribing) (2)
- Emergency Department (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (15)
- Heart Disease and Health (1)
- Hospital Discharge (1)
- Implementation (1)
- Injuries and Wounds (1)
- Medical Errors (12)
- Medication (26)
- Medication: Safety (18)
- Opioids (2)
- (-) Patient Safety (27)
- Practice Patterns (2)
- Prevention (2)
- Provider (3)
- Provider: Pharmacist (4)
- Quality Improvement (1)
- Respiratory Conditions (1)
- Risk (4)
- Telehealth (2)
- Transitions of Care (1)
- Transplantation (1)
- Vaccination (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 25 of 27 Research Studies DisplayedAdams KT, Pruitt Z, Kazi S
Identifying health information technology usability issues contributing to medication errors across medication process stages.
Researchers sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. They found that health IT usability issues were a prevalent contributing factor to medication errors, many of which reach the patient. They recommended that data entry, workflow support, and alerting be prioritized during usability and safety optimization efforts.
AHRQ-funded; HS025136.
Citation: Adams KT, Pruitt Z, Kazi S .
Identifying health information technology usability issues contributing to medication errors across medication process stages.
J Patient Saf 2021 Dec 1;17(8):e988-e94. doi: 10.1097/pts.0000000000000868..
Keywords: Medication, Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety
McGrath SP, McGovern KM, Perreard IM
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
AHRQ-funded; HS024403.
Citation: McGrath SP, McGovern KM, Perreard IM .
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
J Patient Saf 2021 Dec 1;17(8):557-61. doi: 10.1097/pts.0000000000000696..
Keywords: Respiratory Conditions, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Reese TJ, Del Fiol G, Morgan K
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
Exposure to life-threatening drug-drug interactions (DDIs) occurs despite the widespread use of clinical decision support. The DDI between warfarin and nonsteroidal anti-inflammatory drugs is common and potentially life-threatening. Patients can play a substantial role in preventing harm from DDIs; however, the current model for DDI decision-making is clinician centric. This study aimed to design and examine the usability of DDInteract, a tool to support shared decision-making (SDM) between a patient and provider for the DDI between warfarin and nonsteroidal anti-inflammatory drugs.
AHRQ-funded; HS026198.
Citation: Reese TJ, Del Fiol G, Morgan K .
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
JMIR Hum Factors 2021 Oct 26;8(4):e28618. doi: 10.2196/28618..
Keywords: Blood Thinners, Medication: Safety, Medication, Clinical Decision Support (CDS), Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Patient Safety
Herzig SJ, Anderson TS, Jung Y
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
This retrospective cohort study’s objective was to determine the incidence and risk of post-discharge adverse events among opioid claims in the week after hospital discharge, compared to those with nonsteroidal anti-inflammatory drugs (NSAIDs) claims alone. A national sample of Medicare beneficiaries age 65 and older who were hospitalized in the United States in 2016 was used. Beneficiaries who were admitted from or discharged to a facility were excluded. The authors used 3:1 propensity matching to match beneficiaries with an opioid claim in the week after discharge (13,385) with beneficiaries with NSAID claim alone (4,677). Beneficiaries receiving opioids had a higher incidence of death, healthcare utilization, and any potential adverse effect compared to those with an NSAID claim only. Specific adverse effects included higher relative risk of fall/fracture, nausea/vomiting, and slowed colonic motility.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Jung Y .
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
PLoS Med 2021 Sep 27;18(9):e1003804. doi: 10.1371/journal.pmed.1003804..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Risk, Hospital Discharge
De Oliveira GS, Castro-Alves LJ, Kendall MC
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition-of-care interventions on the reduction of medication errors after hospital discharge. Findings showed that pharmacist transition-of-care intervention is an effective strategy to reduce medication errors after hospital discharge and also reduces subsequent emergency room visits.
AHRQ-funded; HS024158.
Citation: De Oliveira GS, Castro-Alves LJ, Kendall MC .
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
J Patient Saf 2021 Aug 1;17(5):375-80. doi: 10.1097/pts.0000000000000283..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Provider: Pharmacist, Transitions of Care
Caballero ML, Krantz MS, Quirce S
Hidden dangers: recognizing excipients as potential causes of drug and vaccine hypersensitivity reactions.
In this paper, the authors provided a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provided strategies for heightened recognition and allergy testing.
AHRQ-funded; HS026395.
Citation: Caballero ML, Krantz MS, Quirce S .
Hidden dangers: recognizing excipients as potential causes of drug and vaccine hypersensitivity reactions.
J Allergy Clin Immunol Pract 2021 Aug;9(8):2968-82. doi: 10.1016/j.jaip.2021.03.002..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Vaccination, Patient Safety
Watterson TL, Stone JA, Brown R
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software.
AHRQ-funded; HS025793.
Citation: Watterson TL, Stone JA, Brown R .
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
J Am Med Inform Assoc 2021 Jul 14;28(7):1526-33. doi: 10.1093/jamia/ocab038..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT), Ambulatory Care and Surgery
Wu P, Nelson SD, Zhao J
DDIWAS: high-throughput electronic health record-based screening of drug-drug interactions.
In this study, the investigators developed and evaluated Drug-Drug Interaction Wide Association Study (DDIWAS). This novel method detected potential drug-drug interactions (DDIs) by leveraging data from the electronic health record (EHR) allergy list. The investigators concluded that they demonstrated the value of incorporating information mined from existing allergy lists to detect DDIs in a real-world clinical setting. They indicate that since allergy lists are routinely collected in EHRs, DDIWAS has the potential to detect and validate DDI signals across institutions.
AHRQ-funded; HS026395.
Citation: Wu P, Nelson SD, Zhao J .
DDIWAS: high-throughput electronic health record-based screening of drug-drug interactions.
J Am Med Inform Assoc 2021 Jul 14;28(7):1421-30. doi: 10.1093/jamia/ocab019..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety
King CR, Abraham J, Fritz BA
Predicting self-intercepted medication ordering errors using machine learning.
Current approaches to understanding medication ordering errors rely on relatively small manually captured error samples. These approaches are resource-intensive, do not scale for computerized provider order entry (CPOE) systems, and are likely to miss important risk factors associated with medication ordering errors. Previously, the investigators described a dataset of CPOE-based medication voiding accompanied by univariable and multivariable regression analyses. In this paper, they updated the analysis using machine learning (ML) models to predict erroneous medication orders and identify its contributing factors.
AHRQ-funded; HS025443.
Citation: King CR, Abraham J, Fritz BA .
Predicting self-intercepted medication ordering errors using machine learning.
PLoS One 2021 Jul 14;16(7):e0254358. doi: 10.1371/journal.pone.0254358..
Keywords: Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
Worsham CM, Woo J, Jena AB
Adverse events and emergency department opioid prescriptions in adolescents.
Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, the investigators exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transitioned from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events.
AHRQ-funded; HS026753.
Citation: Worsham CM, Woo J, Jena AB .
Adverse events and emergency department opioid prescriptions in adolescents.
Health Aff 2021 Jun;40(6):970-78. doi: 10.1377/hlthaff.2020.01762..
Keywords: Children/Adolescents, Emergency Department, Opioids, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Practice Patterns
Stolldorf DP, Ridner SH, Vogus TJ
Implementation strategies in the context of medication reconciliation: a qualitative study.
Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, the authors report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit).
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Ridner SH, Vogus TJ .
Implementation strategies in the context of medication reconciliation: a qualitative study.
Implement Sci Commun 2021 Jun 10;2(1):63. doi: 10.1186/s43058-021-00162-5..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Medical Errors, Adverse Events, Patient Safety, Implementation, Communication
Harben AL, Kashy DA, Esfahanian S
Using change detection to objectively evaluate whether novel over-the-counter drug labels can increase attention to critical health information among older adults.
Over-the-counter (OTC) drugs have many benefits but also carry risks, such as adverse drug reactions, which are more prevalent in older adults. Because these products do not require the oversight of a physician or pharmacist, labeling plays a key role in communicating information required for their safe and effective use. In two experiments, the investigators used a change detection task to objectively evaluate how novel label designs that employ highlighting and a warning label placed on the package's front impact attention to critical information among older participants (65 and older).
AHRQ-funded; HS025386.
Citation: Harben AL, Kashy DA, Esfahanian S .
Using change detection to objectively evaluate whether novel over-the-counter drug labels can increase attention to critical health information among older adults.
Cogn Res Princ Implic 2021 May 26;6(1):40. doi: 10.1186/s41235-021-00307-z..
Keywords: Elderly, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Gonzales HM, Fleming JN, Gebregziabher M
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
The goal of this study was to examine the efficacy of improving medication safety through a pharmacist-led, mobile health-based intervention. In this single-center study of adult kidney recipients 6-36 months post-transplant, findings showed that participants receiving the intervention experienced a significant reduction in medication errors and a significantly lower incidence risk of Grade 3 or higher adverse events. The intervention arm also demonstrated significantly lower rates of hospitalizations.
AHRQ-funded; HS023754.
Citation: Gonzales HM, Fleming JN, Gebregziabher M .
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Clin J Am Soc Nephrol 2021 May 8;16(5):776-84. doi: 10.2215/cjn.15911020..
Keywords: Medication: Safety, Medication, Patient Safety, Transplantation, Telehealth, Health Information Technology (HIT), Provider: Pharmacist, Provider, Medical Errors, Adverse Drug Events (ADE), Adverse Events
Herrin J, Abraham NS, Yao X
Comparative effectiveness of machine learning approaches for predicting gastrointestinal bleeds in patients receiving antithrombotic treatment.
The purpose of this retrospective cross-sectional study was to compare the performance of 3 machine learning approaches with the commonly-used HAS-BLED (hypertension, abnormal kidney and liver function, stroke, bleeding, labile international normalized ratio, older age, and drug or alcohol use) risk score in predicting antithrombotic-related gastrointestinal bleeding (GIB). The machine-learning models were regularized Cox proportional hazards regression (RegCox), random survival forests, and extreme gradient boosting (XGBoost). Findings showed that the machine learning models revealed similar performance in identifying patients at high risk for GIB after being prescribed antithrombotic agents. Two models (RegCox and XGBoost) performed modestly better than the HAS-BLED score.
AHRQ-funded; HS025402.
Citation: Herrin J, Abraham NS, Yao X .
Comparative effectiveness of machine learning approaches for predicting gastrointestinal bleeds in patients receiving antithrombotic treatment.
JAMA Netw Open 2021 May;4(5):e2110703. doi: 10.1001/jamanetworkopen.2021.10703..
Keywords: Blood Thinners, Medication, Risk, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Patient Safety, Comparative Effectiveness
Gurwitz JH, Kapoor A, Garber L
Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.
The purpose of this study was to determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes: anticoagulants, diabetes agents, and opioids. The randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older. Findings showed that there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention.
AHRQ-funded; HS023774.
Citation: Gurwitz JH, Kapoor A, Garber L .
Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.
JAMA Intern Med 2021 May;181(5):610-18. doi: 10.1001/jamainternmed.2020.9285..
Keywords: Elderly, Medication: Safety, Medication, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Provider: Pharmacist, Provider
Kane-Gill SL, Wong A, Culley CM
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for nursing home (NH) residents using medication reconciliation and prospective medication regimen reviews (MRRs) on admission plus ongoing clinical decision support alerts throughout the residents' stay. Studying residents in four NHs in Southwestern Pennsylvania, findings showed that the intervention group had a 92% lower incidence of alert-specific ADEs than usual care, and all-cause hospitalization was similar between groups, as were 30-day readmissions.
AHRQ-funded; HS02420.
Citation: Kane-Gill SL, Wong A, Culley CM .
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
J Am Geriatr Soc 2021 Feb;69(2):530-38. doi: 10.1111/jgs.16946..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Telehealth, Health Information Technology (HIT), Provider: Pharmacist, Provider, Clinical Decision Support (CDS), Prevention
Horton DB, Xie F, Chen L
Oral glucocorticoids and incident treatment of diabetes mellitus, hypertension, and venous thromboembolism in children.
The purpose of this study was to quantify rates of incident treatment for diabetes mellitus, hypertension, and venous thromboembolism (VTE) associated with oral glucocorticoid exposure in children aged 1-18 years. Participants were identified using US Medicaid claims data and included more than 930,000 children diagnosed with autoimmune diseases or a nonimmune comparator condition. Findings showed strong dose-dependent relationships between current glucocorticoid exposure and all outcomes, suggesting strong relative risks, but low absolute risks, of newly-treated VTE, diabetes, and especially hypertension in children taking high-dose oral glucocorticoids.
AHRQ-funded; HS021110.
Citation: Horton DB, Xie F, Chen L .
Oral glucocorticoids and incident treatment of diabetes mellitus, hypertension, and venous thromboembolism in children.
Am J Epidemiol 2021 Feb 1;190(3):403-12. doi: 10.1093/aje/kwaa197..
Keywords: Children/Adolescents, Diabetes, Chronic Conditions, Blood Clots, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Risk, Patient Safety, Blood Pressure
Alvarez-Arango S, Yerneni S, Tang O
Vancomycin hypersensitivity reactions documented in electronic health records.
This study’s objective is to describe vancomycin hypersensitivity reaction (HSR) epidemiology in hospitals documented in electronic health records. Vancomycin is the most commonly prescribed antimicrobial in US hospitals. A cross-sectional study of patients with 1 or more encounter from 2017 to 2019 and an electronic health record vancomycin drug allergy label (DAL) in 2 US health care systems was conducted. Prevalence and trends of vancomycin DALs and assessed active DALs by HSR phenotype was determined. Out of almost 4.5 million patients, 14,426 (0.3%) had a vancomycin DAL with 18,761 documented reactions. Out of those 18,761 vancomycin HSRs, 42.1% were immediate phenotypes and 20.7% were delayed phenotypes. Common reactions were rash and red man syndrome (RMS). Anaphylaxis occurred in 6% of HSRs. RMS reaction was more likely for males and less likely for Blacks.
AHRQ-funded; HS025375.
Citation: Alvarez-Arango S, Yerneni S, Tang O .
Vancomycin hypersensitivity reactions documented in electronic health records.
J Allergy Clin Immunol Pract 2021 Feb;9(2):906-12. doi: 10.1016/j.jaip.2020.09.027..
Keywords: Antibiotics, Medication, Medication: Safety, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Patient Safety
Abraham J, Galanter WL, Touchette D
Risk factors associated with medication ordering errors.
This study’s goal was to collect data on “voided” orders in computerized order entry systems for medication to 1) identify the nature and characteristics of medication ordering errors; 2) investigate the risk factors associated with these errors and; 3) explore potential strategies to mitigate these risk factors. Data was collected using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. During the 16-month study period 1074 medication orders were voided, with 842 being true medication errors. A total of 22% reached the patient, with at least a single administration, but without causing patient harm. Interviews were conducted on 355 voided orders (33%). Errors were associated with multiple factors not just a single risk factor. The causal contributors included a combination of technological-, cognitive-, environment-, social-, and organization-level factors.
AHRQ-funded; HS025443.
Citation: Abraham J, Galanter WL, Touchette D .
Risk factors associated with medication ordering errors.
J Am Med Inform Assoc 2021 Jan 15;28(1):86-94. doi: 10.1093/jamia/ocaa264..
Keywords: Medication: Safety, Electronic Prescribing (E-Prescribing), Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Risk, Health Information Technology (HIT), Patient Safety
Hennessy S, Strom BL
Improving postapproval drug safety surveillance: getting better information sooner.
There are often long delays between when a drug is approved and when serious adverse drug events are identified. This article discusses ways to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
AHRQ-funded; HS018372.
Citation: Hennessy S, Strom BL .
Improving postapproval drug safety surveillance: getting better information sooner.
Annu Rev Pharmacol Toxicol 2015;55:75-87. doi: 10.1146/annurev-pharmtox-011613-135955.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Communication, Medication, Medication: Safety, 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
Wang SV, Schneeweiss S, Rassen JA
Optimal matching ratios in drug safety surveillance.
The researchers used a simulation design to generate 48 scenarios varying in the baseline outcome rate, proportion of exposed, true effect size (without effect modification), and strength of unmeasured residual confounding. They found that except for the most extreme combination of rare outcome and exposure, in scenarios with no residual confounding, 1:1 matching removed 98% to 99% of the bias.
AHRQ-funded; HS022193.
Citation: Wang SV, Schneeweiss S, Rassen JA .
Optimal matching ratios in drug safety surveillance.
Epidemiology 2014 Sep;25(5):772-3. doi: 10.1097/ede.0000000000000148..
Keywords: Adverse Drug Events (ADE), Health Information Technology (HIT), Patient Safety, Medication
Brown JR, Solomon RJ, Sarnak MJ
Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.
The researchers sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary interventions. They found that benchmark hospitals had no significant changes in CI-AKI, while rates of CI-AKI were significantly reduced in hospitals receiving the intervention. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration.
AHRQ-funded; HS018443.
Citation: Brown JR, Solomon RJ, Sarnak MJ .
Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.
Circ Cardiovasc Qual Outcomes 2014 Sep;7(5):693-700. doi: 10.1161/circoutcomes.114.000903.
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Keywords: Adverse Drug Events (ADE), Injuries and Wounds, Patient Safety, Heart Disease and Health, Quality Improvement
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