National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (5)
- Children/Adolescents (1)
- COVID-19 (1)
- Diagnostic Safety and Quality (3)
- Elderly (1)
- Electronic Health Records (EHRs) (1)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (4)
- Health Information Technology (HIT) (1)
- Kidney Disease and Health (1)
- Labor and Delivery (1)
- Long-Term Care (1)
- (-) Medical Errors (10)
- Medical Liability (1)
- Medication (2)
- Medication: Safety (2)
- Nursing Homes (1)
- Patient-Centered Outcomes Research (1)
- Patient Safety (8)
- Provider: Pharmacist (1)
- Quality Improvement (1)
- Quality of Care (2)
- (-) Risk (10)
- Sepsis (1)
- Transplantation (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 10 of 10 Research Studies DisplayedGonzales HM, Fleming JN, Gebregziabher M
A critical analysis of the specific pharmacist interventions and risk assessments during the 12-month TRANSAFE Rx randomized controlled trial.
The objective of this study was to describe frequency and types of interventions made during a pharmacist-led, mobile health-based intervention of high-risk kidney transplant (KTX) recipients and to assess impact on patient risk levels. Primary pharmacist intervention types were medication reconciliation, patient education, and medication changes. The authors concluded that pharmacist-led mHealth may enhance opportunities for interventions and mitigate risk levels in KTX recipients.
AHRQ-funded; HS023754.
Citation: Gonzales HM, Fleming JN, Gebregziabher M .
A critical analysis of the specific pharmacist interventions and risk assessments during the 12-month TRANSAFE Rx randomized controlled trial.
Ann Pharmacother 2022 Jun; 56(6):685-90. doi: 10.1177/10600280211044792..
Keywords: Provider: Pharmacist, Medication: Safety, Medication, Risk, Transplantation, Kidney Disease and Health, Adverse Drug Events (ADE), Medical Errors, Patient Safety
Cifra CL, Westlund E, Ten Eyck P
An estimate of missed pediatric sepsis in the emergency department.
AHRQ-funded; HS025753.
Citation: Cifra CL, Westlund E, Ten Eyck P .
An estimate of missed pediatric sepsis in the emergency department.
Diagnosis 2021;8(2):193-98. doi: 10.1515/dx-2020-0023..
Keywords: Children/Adolescents, Sepsis, Emergency Department, Diagnostic Safety and Quality, Medical Errors, 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
Mangrum R, Stewart MD, Gifford DR
Omissions of care in nursing homes: a uniform definition for research and quality improvement.
The goal of this study was to create a uniform definition of omission of care in US nursing homes. Lack of a uniform definition has made efforts to prevent them challenging. Subject matter experts and a broad range of nursing home stakeholders were brought together in iterative rounds of engagement to identify key concepts and aspects of omissions of care and develop a consensus-based definition. The concise definition decided on was: “Omissions of care in nursing homes encompass situations when care–either clinical or nonclinical–is not provided for a resident and results in additional monitoring or intervention or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident."
AHRQ-funded; 233201500014I.
Citation: Mangrum R, Stewart MD, Gifford DR .
Omissions of care in nursing homes: a uniform definition for research and quality improvement.
J Am Med Dir Assoc 2020 Nov;21(11):1587-91.e2. doi: 10.1016/j.jamda.2020.08.016..
Keywords: Elderly, Nursing Homes, Long-Term Care, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety, Risk, Patient-Centered Outcomes Research
Griffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: a novel approach to screening for quality and safety events.
The goal of this study was to develop an automated version of a previously developed emergency department (ED) trigger tool to track the likelihood of an adverse event. Thirty triggers were associated with risk of harm. The authors identified 1,726 records out of 76,894 ED visits with greater than or equal to 1 trigger. They compared the results of the automated tool to the previous version and found it performed well. They began with a broad set of candidate triggers and validated a computerized query that eliminates the need for manual screening of triggers and also identified a refined set of triggers associated with adverse events in the ED.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: a novel approach to screening for quality and safety events.
Ann Emerg Med 2020 Aug;76(2):230-40. doi: 10.1016/j.annemergmed.2019.07.032..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors, Quality of Care, Risk
Gandhi TK, Singh H
Reducing the risk of diagnostic error in the COVID-19 era.
This perspective article discusses anticipated diagnoses errors for positive or negative COVID-19 results. The errors are classified using user-friendly nomenclature. Mitigation strategies are discussed including technology for cognitive support, optimized workflow and communication, people-focused interventions, organizational strategies, and state/federal policies and regulations.
AHRQ-funded; HS027363.
Citation: Gandhi TK, Singh H .
Reducing the risk of diagnostic error in the COVID-19 era.
J Hosp Med 2020 Jun;15(6):363-66. doi: 10.12788/jhm.3461..
Keywords: Diagnostic Safety and Quality, Risk, Medical Errors, COVID-19
Griffey RT, Schneider RM, Todorov AA
Critical review, development, and testing of a taxonomy for adverse events and near misses in the emergency department.
Researchers created and tested a taxonomy for adverse events (AEs) and near misses for use in the emergency department (ED). This taxonomy is patient-centered, as opposed to most taxonomies which fail to describe harm experienced by patients and focus instead on errors and uses too broad categorizations. The authors reviewed candidate taxonomies using an iterative process and selected the Adventist Health Systems AE taxonomy and modified it for use in the ED. After testing with reviewers, agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Performance from individual raters ranged from very good (88%) to near perfect (98%) at the main category level.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Critical review, development, and testing of a taxonomy for adverse events and near misses in the emergency department.
Acad Emerg Med 2019 Jun;26(6):670-79. doi: 10.1111/acem.13724..
Keywords: Adverse Events, Emergency Department, Medical Errors, Patient Safety, Risk
Howe JL, Adams KT, Hettinger AZ
Electronic health record usability issues and potential contribution to patient harm.
Researchers analyzed reports of possible patient harm that explicitly mentioned a major EHR vendor or product. They concluded that EHR usability may have been a contributing factor to some possible patient harm events. Only a small percentage of potential harm events were associated with EHR usability, but the analysis was conservative because safety reports only capture a small fraction of the actual number of safety incidents.
AHRQ-funded; HS023701.
Citation: Howe JL, Adams KT, Hettinger AZ .
Electronic health record usability issues and potential contribution to patient harm.
JAMA 2018 Mar 27;319(12):1276-78. doi: 10.1001/jama.2018.1171.
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Keywords: Adverse Events, Electronic Health Records (EHRs), Medical Errors, Patient Safety, Risk
Okafor N, Payne VL, Chathampally Y
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
The researchers analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Among the 209 incidents, they identified 214 diagnostic errors associated with 65 unique diseases/conditions. Most diagnostic errors in ED appeared to relate to common disease conditions.
AHRQ-funded; HS017586; HS022087.
Citation: Okafor N, Payne VL, Chathampally Y .
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
Emerg Med J 2016 Apr;33(4):245-52. doi: 10.1136/emermed-2014-204604.
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Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Risk, Patient Safety
Santos P, Ritter GA, Hefele JL
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
The researchers conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births), while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births).
AHRQ-funded; HS019608.
Citation: Santos P, Ritter GA, Hefele JL .
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
J Healthc Risk Manag 2015;34(4):20-7. doi: 10.1002/jhrm.21168..
Keywords: Labor and Delivery, Patient Safety, Risk, Medical Liability, Medical Errors