National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (6)
- Adverse Events (8)
- (-) Clinical Decision Support (CDS) (8)
- Data (1)
- Electronic Health Records (EHRs) (2)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (8)
- (-) Medical Errors (8)
- Medication (6)
- Medication: Safety (1)
- Patient Safety (7)
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- Provider (1)
- Provider: Pharmacist (1)
- Public Reporting (1)
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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 8 of 8 Research Studies DisplayedKane-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
Lambert BL, Galanter W, Liu KL
Automated detection of wrong-drug prescribing errors.
Investigators assessed the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. They found that automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Additionally, real-time error detection is not possible with the current system. They suggested that further development should replicate their analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
AHRQ-funded; HS021093.
Citation: Lambert BL, Galanter W, Liu KL .
Automated detection of wrong-drug prescribing errors.
BMJ Qual Saf 2019 Nov;28(11):908-15. doi: 10.1136/bmjqs-2019-009420..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Liang C, Miao Q, Kang H
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
The present study sought to explore the associations between federal incentives of patient safety research and the outcomes from 1995 to 2014, in which two historical events - the release of To Err Is Human and the American Recovery and Reinvestment Act - were considered in the analysis. They concluded that their findings suggested a positive outcome in patient safety research.
AHRQ-funded; HS022895.
Citation: Liang C, Miao Q, Kang H .
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
Stud Health Technol Inform 2019 Aug 21;264:983-87. doi: 10.3233/shti190371..
Keywords: Patient Safety, Medical Errors, Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT)
Slight SP, Seger DL, Franz C
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
Investigators worked to determine the national cost of adverse drug events (ADEs) in the United States in 2014. They used three different regression models. They used a random sample of 40,990 adult inpatients at the Brigham and Women’s Hospital in Boston with over 1.6 million medication orders. They extrapolated the medication orders using 2014 National Inpatient Sample (NIS) data. They estimated that out of 78.8 million total medication alerts, 5.5 million medication alerts would have been inappropriately overridden resulting in 196,660 ADEs. They estimated it would have cost between $871 million and $1.8 billion for treating these preventable ADEs in the United States.
AHRQ-funded; HS021094.
Citation: Slight SP, Seger DL, Franz C .
The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.
J Am Med Inform Assoc 2018 Sep;25(9):1183-88. doi: 10.1093/jamia/ocy066..
Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT), Healthcare Costs, Medical Errors, Medication
Horsky J, Aarts J, Verheul L
Clinical reasoning in the context of active decision support during medication prescribing.
The purpose of this study was to describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. The investigators found that declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher.
AHRQ-funded; HS021094.
Citation: Horsky J, Aarts J, Verheul L .
Clinical reasoning in the context of active decision support during medication prescribing.
Int J Med Inform 2017 Jan;97:1-11. doi: 10.1016/j.ijmedinf.2016.09.004..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Shared Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Liang C, Gong Y
Enhancing patient safety event reporting by K-nearest neighbor classifier.
The debate on structured or unstructured data entry reveals not only a trade-off problem among data accuracy, completeness, and timeliness, but also a technical gap on text mining. The reesarchers suggested a text classification method for predicting subject categories. Their results demonstrated the feasibility of their system and indicated the advantage of such an application to raise data quality and clinical decision support in reporting patient safety events.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
Enhancing patient safety event reporting by K-nearest neighbor classifier.
Stud Health Technol Inform 2015;218:40603.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Public Reporting, Clinical Decision Support (CDS), Health Information Technology (HIT), Data
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
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