National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (6)
- Adverse Events (9)
- Ambulatory Care and Surgery (1)
- Blood Thinners (1)
- Cancer (1)
- Children/Adolescents (2)
- Critical Care (1)
- Dental and Oral Health (1)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (2)
- Electronic Prescribing (E-Prescribing) (2)
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- Evidence-Based Practice (1)
- Health Information Technology (HIT) (4)
- Intensive Care Unit (ICU) (1)
- (-) Medical Errors (11)
- Medication (5)
- Medication: Safety (5)
- Patient Safety (10)
- Provider: Pharmacist (1)
- Surgery (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 11 of 11 Research Studies DisplayedKaufman BG, Holland DE, Vanderboom CE
Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.
The aim of this randomized controlled trial study was to evaluate the effectiveness of a multicomponent intervention for decreasing clinically important medication errors (CIMEs). The researchers included ambulatory patients beginning a DOAC or resuming one after a complication. The intervention included pharmacist evaluation and monitoring based on the implementation of a recently published checklist. The primary measure was anticoagulant-related CIMEs and non-anticoagulant-related CIMEs over 90 days from DOAC initiation. Primary variables included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. A total of 561 patients contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs. The most common anticoagulant-related CIMEs were failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients or non-anticoagulant-related CIMEs.
AHRQ-funded; HS02592401.
Citation: Kaufman BG, Holland DE, Vanderboom CE .
Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.
J Gen Intern Med 2023 Dec; 38(16):3526-34. doi: 10.1007/s11606-023-08315-z..
Keywords: Provider: Pharmacist, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Blood Thinners, Medication: Safety, Patient Safety
Cifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Berdahl CT, Henreid AJ, Cohen TN
Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.
This paper describes the study protocol that will be used for a randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. There are six key attributes to the SAFE Loop: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will be conducted at 20 randomized nursing units at a large academic/community hospital in Los Angeles and will focus on medication errors. The investigators will look for the following outcomes: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. They will use quantitative analysis to compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses to explore nurses' experiences with implementation.
AHRQ-funded; HS027455.
Citation: Berdahl CT, Henreid AJ, Cohen TN .
Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.
Contemp Clin Trials Commun 2023 Oct; 35:101192. doi: 10.1016/j.conctc.2023.101192..
Keywords: Patient Safety, Adverse Events, Medical Errors
Langlieb ME, Sharma P, Hocevar M
The additional cost of perioperative medication errors.
The aim of this study was to calculate the additional annual cost to the U.S. healthcare system attributable to preventable medication errors (MEs) in the operating room. The ME types were grouped into 13 categories by their related harm (or potential harm), and researchers calculated the incidence of operations involving each ME category: 1) delayed or missed required perioperative antibiotic; 2) prolonged hemodynamic swings; 3) untreated postoperative pain; 4) residual neuromuscular blockade; 5) oxygen saturation <90% due to ME; 6) delayed emergence; 7) untreated new onset intraoperative cardiac arrhythmia; 8) medication documentation errors; 9) syringe swaps; 10) presumed hypotension with inability to obtain a blood pressure reading; 11) potential for bacterial contamination due to expired medication syringes; 12) untreated bradycardia <40 beats/min; and 13) other. Through a PubMed search, the researchers established the possibility that the ME category would cause downstream patient harm such as surgical site infection or acute kidney injury, and the additional fully allocated cost of care for each potential downstream patient harm event. The cost of the MEs across the U.S. healthcare system was then calculated by scaling the number of MEs to the total number of annual operations in the United States. The total additional fully allocated annual cost of care due to perioperative MEs was estimated to be $5.33 billion U.S. dollars.
AHRQ-funded; HS024764.
Citation: Langlieb ME, Sharma P, Hocevar M .
The additional cost of perioperative medication errors.
J Patient Saf 2023 Oct 1; 19(6):375-78. doi: 10.1097/pts.0000000000001136..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Surgery, Patient Safety
Kalenderian E, Bangar S, Yansane A
Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.
This study’s objective was to analyze harmful dental adverse events (AEs) to assess potential contributing factors. Harmful AEs were defined as those that resulted in temporary moderate to severe harm, required hospitalization, or resulted in permanent moderate to severe harm. The authors classified potential contributing factors according to (1) who was involved (person), (2) what were they doing (tasks), (3) what tools/technologies were they using (tools/technologies), (4) where did the event take place (environment), (5) what organizational conditions contributed to the event? (organization), (6) patient (including parents), and (7) professional-professional collaboration. A second review was conducted by a blinded panel of dental experts to confirm the presence of an AE. A total of 59 cases at 2 dental institutions had 1 or more harmful AEs. The most common harmful AE was pain (27.1%) followed by nerve injury (16.9%), hard tissue injury (15.2%), and soft tissue injury (15.2%). The most common contribution factor was the care provider (training, supervision, and fatigue at 31.5%) followed by patient ((noncompliance, unsafe practices at home, low health literacy, 17.1%), and professional-professional collaboration (15.3%).
AHRQ-funded; HS027268.
Citation: Kalenderian E, Bangar S, Yansane A .
Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.
J Patient Saf 2023 Aug 1; 19(5):305-12. doi: 10.1097/pts.0000000000001122..
Keywords: Dental and Oral Health, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Patient Safety
Liberman AL, Wang Z, Zhu Y
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
The purpose of this paper was to clarify features of the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach to accurately measure diagnostic errors to assure that researchers utilize this method to yield valid results, as well as improve the validity of SPADE and related approaches to quantify diagnostic error in medicine. The researchers describe four types of comparators (intra-group and inter-group), detailing the reason for selecting one over the other and conclusions that can be drawn from these comparative analyses.
AHRQ-funded; HS027614.
Citation: Liberman AL, Wang Z, Zhu Y .
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
Diagnosis 2023 Aug 1; 10(3):225-34. doi: 10.1515/dx-2022-0130..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
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
Wong CI, Vannatta K, Gilleland Marchak J
Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.
The goal of this longitudinal study was to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over seven months of treatment. The study included children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Ten percent experienced adverse drug events because of outpatient medication errors. Twenty-six percent of caregivers reported miscommunication leading to missed doses or overdoses. The authors concluded that improvements addressing communication with and among caregivers should be based on human-factors engineering and codeveloped with families.
AHRQ-funded; HS024390.
Citation: Wong CI, Vannatta K, Gilleland Marchak J .
Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.
Cancer 2023 Apr 1;129(7):1064-74. doi: 10.1002/cncr.34651.
Keywords: Children/Adolescents, Cancer, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Ambulatory Care and Surgery, Medication: Safety, Patient Safety
Hansten PD, Tan MS, Horn JR
Colchicine drug interaction errors and misunderstandings: recommendations for improved evidence-based management.
Colchicine serves as an effective therapy for the management and prevention of gout and various other medical conditions. As a substrate for CYP3A4 and P-glycoprotein (P-gp), its simultaneous use with CYP3A4/P-gp inhibitors can lead to critical drug-drug interactions (DDIs) that may result in pancytopenia, multiorgan dysfunction, and cardiac irregularities. Additionally, colchicine's potential for myotoxicity could elevate the risk of myopathy and rhabdomyolysis when combined with other myotoxic medications. Numerous sources of DDI information, encompassing journal articles, product labels, and online resources, contain inaccuracies or vague statements regarding colchicine's interactions with other drugs and subpar guidance on managing DDIs to minimize patient harm. Moreover, assessments of the clinical significance of specific colchicine DDIs can differ substantially between sources. The purpose of this study was to present an evidence-based analysis of drugs that are likely to interact with colchicine, as well as those that have been cited to interact but are improbable to do so. Based on these assessments, the researchers proposes strategies to mitigate the risk of severe adverse consequences from colchicine DDIs. The frequent recommendation to decrease colchicine dosage when administered with CYP3A4/P-gp inhibitors may, in some cases, lead to colchicine toxicity or therapeutic failure. An exhaustive evaluation of nearly 100 documented instances of colchicine DDIs is provided in a table within the electronic supplementary material. While colchicine is a beneficial medication, enhancements to the available information on colchicine DDIs are necessary to reduce the risk of serious adverse events.
AHRQ-funded; HS025984
Citation: Hansten PD, Tan MS, Horn JR .
Colchicine drug interaction errors and misunderstandings: recommendations for improved evidence-based management.
Drug Saf 2023 Mar;46(3):223-42. doi: 10.1007/s40264-022-01265-1.
Keywords: Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Evidence-Based Practice
Griffey RT, Schneider RM, Todorov AA
Near-miss events detected using the emergency department trigger tool.
The purpose of this study was to explore near misses and their significance for quality and safety in the emergency department (ED). This study presents a secondary analysis of data from a retrospective investigation of the ED Trigger Tool (EDTT) at an urban, academic ED. The EDTT, a computerized query for triggers, was applied to 13 months of ED visit data, and 5582 selected records were reviewed using a two-tiered approach. Events were categorized by occurrence (ED vs. present on arrival [POA]), severity, omission/commission, and type, employing a taxonomy featuring categories, subcategories, and cross-cutting modifiers. The researchers identified 1458 ED near misses in 1269 of the 5582 records and 80 near misses that were POA. Patient care events constituted the majority of ED near misses, including diagnostic delays, treatment delays, and monitoring failures, primarily influenced by ED boarding and overcrowding. Medication events ranked second in frequency (17%), with 80 medication administration errors identified. Among the 80 POA events, 42% were linked to overanticoagulation. It was estimated that 19.3% of all ED visits involved a near miss.
AHRQ-funded; HS027811; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Near-miss events detected using the emergency department trigger tool.
J Patient Saf 2023 Mar 1; 19(2):59-66. doi: 10.1097/pts.0000000000001092..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors