National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (5)
- Adverse Events (5)
- Case Study (1)
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- Diabetes (1)
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- (-) Electronic Prescribing (E-Prescribing) (12)
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- Medication: Safety (8)
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- Provider: Clinician (1)
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- Shared Decision Making (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 12 of 12 Research Studies DisplayedTaft 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
Holmgren AJ, Co Z, Newmark L
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
The authors tested how well EHRs prevented medication errors with the potential for patient harm. Data from a national, longitudinal sample of 1527 hospitals in the US from 2009-16 who took a safety performance assessment test using simulated medication orders was used. The authors found that hospital medication order safety performance improved over time. They conclude that intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.
AHRQ-funded; HS023696.
Citation: Holmgren AJ, Co Z, Newmark L .
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
BMJ Qual Saf 2020 Jan;29(1):52-59. doi: 10.1136/bmjqs-2019-009609..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Medication, Electronic Prescribing (E-Prescribing), Medication: Safety, Clinical Decision Support (CDS), Shared Decision Making
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
Adams KT, Howe JL, Fong A
An analysis of patient safety incident reports associated with electronic health record interoperability.
The study’s objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports. It found that the majority of EHR interoperability patient safety event (PSE) reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems.
AHRQ-funded; HS023701.
Citation: Adams KT, Howe JL, Fong A .
An analysis of patient safety incident reports associated with electronic health record interoperability.
Appl Clin Inform 2017 Feb;8(2):593-602. doi: 10.4338/ACI-2017-01-RA-0014.
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Keywords: Healthcare Delivery, Electronic Health Records (EHRs), Electronic Prescribing (E-Prescribing), Medication: Safety, Patient Safety
Powers C, Gabriel MH, Encinosa W
AHRQ Author: Encinosa W
Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.
The authors investigated whether physicians who meet the meaningful use stage 2 threshold for e-prescribing (50 percent of prescriptions e-prescribed) have lower rates of ADEs among their diabetic patients. They found that physician e-prescribing to Medicare beneficiaries was associated with reduced risk of ADEs among their diabetes patients, as were several prescriber and panel characteristics.
AHRQ-authored
Citation: Powers C, Gabriel MH, Encinosa W .
Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.
J Am Med Inform Assoc 2015 Sep;22(5):1094-8. doi: 10.1093/jamia/ocv036..
Keywords: Electronic Prescribing (E-Prescribing), Diabetes, Medication, Patient Safety
Abbott AA, Fuji KT, Galt KA
A qualitative case study exploring nurse engagement with electronic health records and e-prescribing.
The purpose of this qualitative case study was to describe how nurses adapt to using an electronic health record with electronic prescribing (e-Rx) system in a rural ambulatory care practice. Findings showed that nurses adjust their routine in response to providers' preferential behavior yet retained focus on the patient and care coordination. e-Rx adoption increased workload and introduced safety risks.
AHRQ-funded; HS018625.
Citation: Abbott AA, Fuji KT, Galt KA .
A qualitative case study exploring nurse engagement with electronic health records and e-prescribing.
West J Nurs Res 2015 Jul;37(7):935-51. doi: 10.1177/0193945914567359.
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Keywords: Case Study, Electronic Health Records (EHRs), Electronic Prescribing (E-Prescribing), Nursing, Patient Safety