National Healthcare Quality and Disparities Report
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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.
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1 to 2 of 2 Research Studies DisplayedCohen TN, Berdahl CT, Coleman BL
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
This study’s objective was to understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. The authors randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. Results showed that among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Seven of these events were linked to COVID-19.
AHRQ-funded; HS027455.
Citation: Cohen TN, Berdahl CT, Coleman BL .
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
J Nurs Care Qual 2024 Jan-Mar; 39(1):51-57. doi: 10.1097/ncq.0000000000000720..
Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors
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