National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (5)
- Adverse Events (6)
- Ambulatory Care and Surgery (1)
- Antibiotics (1)
- Blood Thinners (1)
- Clinical Decision Support (CDS) (1)
- Communication (1)
- Decision Making (1)
- Diagnostic Safety and Quality (2)
- (-) Electronic Health Records (EHRs) (13)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (3)
- Emergency Medical Services (EMS) (1)
- Health Information Technology (HIT) (12)
- Imaging (1)
- Intensive Care Unit (ICU) (1)
- Medical Errors (3)
- Medicare (1)
- Medication (7)
- Medication: Safety (6)
- (-) Patient Safety (13)
- Provider (1)
- Provider: Clinician (1)
- Quality of Care (1)
- Risk (2)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 13 of 13 Research Studies DisplayedPruitt ZM, Howe JL, Hettinger AZ
Emergency physician perceptions of electronic health record usability and safety.
Investigators sought to identify emergency physicians' perceived electronic health record (EHR) usability and safety strengths and shortcomings across major EHR vendor products. They found that the 3 most commonly discussed usability topics were Workflow Support (shortcoming), Visual Display (strength), and Data Entry. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes emerged as well.
AHRQ-funded; HS025136.
Citation: Pruitt ZM, Howe JL, Hettinger AZ .
Emergency physician perceptions of electronic health record usability and safety.
J Patient Saf 2021 Dec 1;17(8):e983-e87. doi: 10.1097/pts.0000000000000849..
Keywords: Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), 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
Fong A, Adams K, Samarth A
AHRQ Author: Chappel T, Grace E, Terrillion S
Assessment of automating safety surveillance from electronic health records: Analysis for the quality and safety review system.
Researchers provided a heuristic assessment of the feasibility of automatically populating the Quality and Safety Review System (QSRS) questions from electronic health record (EHR) data. They developed the Relative Abstraction Complexity Framework to assess relative complexity of data abstraction questions. Their results suggested that Blood and Hospital Acquired Infections-Clostridium Difficile Infection (HAI-CDI) modules would be relatively easier to automate, whereas Surgery and HAI-Surgical Site Infection would be more difficult to automate.
AHRQ-authored; AHRQ-funded; 290201400008I.
Citation: Fong A, Adams K, Samarth A .
Assessment of automating safety surveillance from electronic health records: Analysis for the quality and safety review system.
J Patient Saf 2021 Sep 1;17(6):e524-e28. doi: 10.1097/pts.0000000000000402..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), 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
Enayati M, Sir M, Zhang X
Monitoring diagnostic safety risks in emergency departments: protocol for a machine learning study.
This study’s objective will be to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques. It will use trigger algorithms with electronic health record (EHR) data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on if they meet certain criteria. This study will be conducted by 2 academic medical centers with affiliated community hospitals.
AHRQ-funded; HS027363; HS026622.
Citation: Enayati M, Sir M, Zhang X .
Monitoring diagnostic safety risks in emergency departments: protocol for a machine learning study.
JMIR Res Protoc 2021 Jun 14;10(6):e24642. doi: 10.2196/24642..
Keywords: Emergency Department, Diagnostic Safety and Quality, Patient Safety, Risk, Electronic Health Records (EHRs), Health Information Technology (HIT)
Kandaswamy S, Pruitt Z, Kazi S
Clinician perceptions on the use of free-text communication orders.
The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information. The investigators concluded that clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks.
AHRQ-funded; HS025136; HS024755.
Citation: Kandaswamy S, Pruitt Z, Kazi S .
Clinician perceptions on the use of free-text communication orders.
Appl Clin Inform 2021 May;12(3):484-94. doi: 10.1055/s-0041-1731002..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Electronic Health Records (EHRs), Medication: Safety, Medication, Patient Safety, Communication, Provider: Clinician, Provider, Risk
Classen DC, Munier W, Verzier N
AHRQ Author: Munier W, Eldridge N, Brady PJ, Helwig A, Battles J
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
This review article discusses the development, strengths and limitations, and future of the Medicare Patient Safety Monitoring System (MPSMS), which was created more than 10 years ago. MPSMS is a chart review-based national patient safety surveillance system that provides rates of 21 specific hospital inpatient adverse event measures, which are divided into 4 clinical domains (general, hospital-acquired infections, post-procedure adverse events, and adverse drug events). The 2014 MPSMS national sample was drawn from 1109 hospitals and includes approximately 20,000 medical records of patients admitted to the hospital for at least 1 of 4 conditions: congestive heart failure, acute myocardial infarction, pneumonia, and major surgical procedures as defined by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. The MSPMS is now undergoing a major transformation to capture additional types of adverse events, and is being renamed the Quality and Safety Review System (QSRS). Data will be electronically imported and will be updated and evolved over time to incorporate expanded standardized data available from electronic health records.
AHRQ-authored.
Citation: Classen DC, Munier W, Verzier N .
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
J Patient Saf 2021 Apr 1;17(3):e234-3240. doi: 10.1097/pts.0000000000000322..
Keywords: Patient Safety, Medicare, Medical Errors, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT)
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
Lacson R, Cochon L, Ching PR
Integrity of clinical information in radiology reports documenting pulmonary nodules.
Researchers sought to quantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports, and to assess impact on making follow-up recommendations. Their retrospective cohort study was performed at an academic medical center and natural language processing was used on radiology reports of CT scans of chest, abdomen, or spine to assess presence of pulmonary nodules. They found that essential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up. They concluded that the lack of documentation of pulmonary nodule characteristics in radiology reports was common, with the potential for compromising patient care and clinical decision support tools.
AHRQ-funded; HS024722.
Citation: Lacson R, Cochon L, Ching PR .
Integrity of clinical information in radiology reports documenting pulmonary nodules.
J Am Med Inform Assoc 2021 Jan 15;28(1):80-85. doi: 10.1093/jamia/ocaa209..
Keywords: Imaging, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Collinsworth AW, Masica AL, Priest EL
Modifying the electronic health record to facilitate the implementation and evaluation of a bundled care program for intensive care unit delirium.
This case study describes how an integrated health care delivery system modified its inpatient electronic health record to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative for the prevention of delirium in intensive care unit patients.
AHRQ-funded; HS021459
Citation: Collinsworth AW, Masica AL, Priest EL .
Modifying the electronic health record to facilitate the implementation and evaluation of a bundled care program for intensive care unit delirium.
eGEMS. 2014;2(1):1121. doi: 10.13063/2327-9214.1121..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Intensive Care Unit (ICU), Patient Safety, Quality of Care
Peterson SM, Gurses AP, Regan L
Resident to resident handoffs in the emergency department: an observational study.
This study aimed to identify hazards to patient safety and barriers to efficiency related to resident handoffs in the ED. It found that residents were interrupted, on average, every 8.5 min. The most common deficit in relaying the plan of care strategy was failing to relay medications administered (32 percent). In addition, there were ambiguities related to medication administration.
AHRQ-funded; HS018762.
Citation: Peterson SM, Gurses AP, Regan L .
Resident to resident handoffs in the emergency department: an observational study.
J Emerg Med 2014 Nov;47(5):573-9. doi: 10.1016/j.jemermed.2014.06.027..
Keywords: Emergency Department, Emergency Medical Services (EMS), Patient Safety, Electronic Health Records (EHRs), Medication
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.
.
.
Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety