National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Access to Care (1)
- Adverse Drug Events (ADE) (5)
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- Community-Based Practice (1)
- Electronic Health Records (EHRs) (2)
- (-) Electronic Prescribing (E-Prescribing) (11)
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- Medication: Safety (6)
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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 11 of 11 Research Studies DisplayedPitts SI, Olson s, Yanek LR
Pharmacy e-prescription dispensing before and after CancelRx implementation.
The objective of this study was to evaluate the association of implementation of e-prescription cancellation messaging (CancelRx) with medication dispensing after discontinuation of e-prescriptions in electronic health records (EHRs). Patients who had at least one medication e-prescribed in ambulatory care to a health system pharmacy and discontinued within the study period participated in a case series with interrupted time series analysis. Findings indicated that CancelRx implementation was associated with an immediate and sustained reduction in the proportion of e-prescriptions sold after discontinuation in the EHR. The authors concluded that widespread implementation of CancelRx could significantly improve medication safety through the reduction of medication dispensing after discontinuation by prescribers.
AHRQ-funded; HS026584.
Citation: Pitts SI, Olson s, Yanek LR .
Pharmacy e-prescription dispensing before and after CancelRx implementation.
JAMA Intern Med 2023 Oct; 183(10):1120-26. doi: 10.1001/jamainternmed.2023.4192..
Keywords: Medication, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Provider: Pharmacist
Taft T, Rudd EA, Thraen I
"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.
The objectives of this study were to characterize persistent hazards and inefficiencies in inpatient medication administration, to explore cognitive attributes of medication administration tasks, and to discuss strategies to reduce technology-related hazards. Researchers interviewed nurses at two urban US health systems. Persistent safety hazards and inefficiencies related to medication administration technology were organized around the perception-action cycle (PAC) cycle. The researchers concluded that errors may persist in medication administration despite successful deployment of Bar Code Medication Administration and Electronic Medication Administration Record. Opportunities to improve would require a deeper understanding of high-level reasoning in medication administration.
AHRQ-funded; HS025136.
Citation: Taft T, Rudd EA, Thraen I .
"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.
J Am Med Inform Assoc 2023 Apr 19; 30(5):809-18. doi: 10.1093/jamia/ocad031..
Keywords: Medication, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Patient Safety, Adverse Drug Events (ADE), Medical Errors, Medication: Safety
Grauer A, Rosen A, Applebaum JR
Examining medication ordering errors using AHRQ network of patient safety databases.
Research on the impact of Computerized Physician Order Entry (CPOE) systems on drug order inaccuracies has shown inconsistent results, with CPOE not reliably preventing such mistakes. The study utilized the Network of Patient Safety Databases (NPSD) from the Agency for Healthcare Research and Quality (AHRQ) to explore the frequency and degree of harm associated with reported events during the ordering stage, and to classify them by error type.
The researchers conducted a retrospective analysis of reported safety incidents provided by healthcare systems associated with patient safety organizations from June 2010 to December 2020. All errors related to medication and other substance orders reported to the NPSD using the common format v1.2 during this period were assessed. The researchers grouped and categorized the prevalence of reported medication order errors by error type, harm levels, and demographic data. The study found that during the study period, 12,830 mistakes were reported. Incorrect dosage accounted for 3,812 errors (29.7%), followed by incorrect medicine 2,086 (16.3%), and incorrect duration 765 (6.0%). Out of 5,282 incidents that affected the patient and had a known severity level, 12 resulted in fatalities, 4 led to severe harm, 45 caused moderate harm, 341 led to minor harm, and 4,880 resulted in no harm. The study concluded that the most frequently reported and damaging types of medication order errors were incorrect dose and incorrect medication orders.
The researchers conducted a retrospective analysis of reported safety incidents provided by healthcare systems associated with patient safety organizations from June 2010 to December 2020. All errors related to medication and other substance orders reported to the NPSD using the common format v1.2 during this period were assessed. The researchers grouped and categorized the prevalence of reported medication order errors by error type, harm levels, and demographic data. The study found that during the study period, 12,830 mistakes were reported. Incorrect dosage accounted for 3,812 errors (29.7%), followed by incorrect medicine 2,086 (16.3%), and incorrect duration 765 (6.0%). Out of 5,282 incidents that affected the patient and had a known severity level, 12 resulted in fatalities, 4 led to severe harm, 45 caused moderate harm, 341 led to minor harm, and 4,880 resulted in no harm. The study concluded that the most frequently reported and damaging types of medication order errors were incorrect dose and incorrect medication orders.
AHRQ-funded; HS026121.
Citation: Grauer A, Rosen A, Applebaum JR .
Examining medication ordering errors using AHRQ network of patient safety databases.
J Am Med Inform Assoc 2023 Apr 19; 30(5):838-45. doi: 10.1093/jamia/ocad007..
Keywords: Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Medication: Safety
Iqbal AR, Parau CA, Kazi S
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.
This study investigated the contribution of usability challenges associated with the electronic medication administration record (eMAR) to medication errors using patient safety event reports (PSEs). The authors analyzed free-text descriptions of 849 medication-related PSEs selected from 2.3 million reports. Specific health IT components, usability challenge categories, and nuanced usability themes that contributed to each PSE were identified by coders. Usability challenges included workflow support, alerting, and display/visual clutter.
AHRQ-funded; HS025136.
Citation: Iqbal AR, Parau CA, Kazi S .
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.
Jt Comm J Qual Patient Saf 2021 Dec;47(12):793-801. doi: 10.1016/j.jcjq.2021.09.004..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Medication, Medical Errors, 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)
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
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
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)
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
Lindau ST
CommunityRx, an e-prescribing system connecting people to community resources.
CommunityRx is an e-prescribing system that make it easier for patients in communities to connect with health resources. NowPow, LLC is an information technology enterprise that is part of CommunityRx. NowPow participated in AHRQ’s EvidenceNow grants program and worked with hundreds of small Midwestern primary care practices in the Healthy Hearts in the Heartland study. By 2018, over 1600 youths had been employed (many for the first-time) and generated annual asset census for Chicago, New York, and two rural areas of North Carolina. CommunityRx has been successful in providing health resource information to lower-income communities such as Chicago’s South Side. They also found that half of people who received a HealtheRx e-prescription use the information to help others.
AHRQ-funded; HS023921.
Citation: Lindau ST .
CommunityRx, an e-prescribing system connecting people to community resources.
Am J Public Health 2019 Apr;109(4):546-47. doi: 10.2105/ajph.2019.304986..
Keywords: Access to Care, Community-Based Practice, Electronic Prescribing (E-Prescribing), Evidence-Based Practice, Health Information Technology (HIT), Medication, Vulnerable Populations
Garabedian PM, Wright A, Newbury I
Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.
The objective of this study was to evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing systems, the efficiency, error rate, and satisfaction with a new computerized provider order entry prototype for the outpatient setting that allows clinicians to initiate prescribing using the indication. The investigators found that reengineering prescribing to start with the drug indication allowed indications to be captured in an easy and useful way, which may be associated with saved time and effort, reduced medication errors, and increased clinician satisfaction.
AHRQ-funded; HS023694.
Citation: Garabedian PM, Wright A, Newbury I .
Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems.
JAMA Netw Open 2019 Mar;2(3):e191514. doi: 10.1001/jamanetworkopen.2019.1514..
Keywords: Electronic Health Records (EHRs), Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Medication