National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (7)
- Adverse Events (31)
- Behavioral Health (2)
- Burnout (2)
- Cancer (1)
- Care Coordination (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (3)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (2)
- Clinician-Patient Communication (4)
- Communication (10)
- Data (2)
- Depression (1)
- Diagnostic Safety and Quality (8)
- Education: Continuing Medical Education (2)
- Electronic Health Records (EHRs) (3)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (4)
- Evidence-Based Practice (2)
- Healthcare Delivery (4)
- Health Information Technology (HIT) (9)
- Hospital Discharge (2)
- Hospitalization (1)
- Hospitals (2)
- Imaging (1)
- Implementation (1)
- Inpatient Care (2)
- Intensive Care Unit (ICU) (1)
- Medical Devices (1)
- (-) Medical Errors (47)
- Medical Liability (9)
- Medication (8)
- Medication: Safety (4)
- Neonatal Intensive Care Unit (NICU) (1)
- Newborns/Infants (1)
- Pain (1)
- Patient-Centered Healthcare (2)
- Patient and Family Engagement (2)
- Patient Safety (39)
- Practice Patterns (3)
- Prevention (2)
- Primary Care (3)
- Provider (2)
- Provider: Health Personnel (1)
- Provider: Physician (3)
- Quality Improvement (4)
- Quality Measures (1)
- Quality of Care (8)
- Risk (2)
- Shared Decision Making (1)
- Sleep Problems (1)
- Stress (1)
- Surgery (3)
- Tools & Toolkits (2)
- Training (1)
- Transitions of Care (1)
- Transplantation (1)
- Treatments (1)
- Web-Based (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 25 of 47 Research Studies DisplayedShafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Gaufberg E, Olmsted MW, Bell SK
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
The authors discuss an AHRQ conference held to establish a research agenda on patient and family emotional harm after medical errors. Topics include implications for quality and safety, educational innovation, and qualitative research.
AHRQ-funded; HS024463.
Citation: Gaufberg E, Olmsted MW, Bell SK .
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
J Med Humanit 2019 Dec;40(4):489-504. doi: 10.1007/s10912-019-09563-z..
Keywords: Medical Errors, Adverse Events, Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
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
Mixon AS, Kripalani S, Stein J
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
This paper examined evidence-based interventions implemented in five US hospitals to improve inpatient medication reconciliation. The sites implemented one to seven interventions in 791 patients during a 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful reconciliation rates while two interventions were associated with significant increases. The positive interventions included: defining clinical roles and responsibilities, training, and hiring staff to perform discharge medication reconciliation. The negative interventions were training staff to take medication histories and implementing a new electronic health record (EHR) system.
AHRQ-funded; HS019598.
Citation: Mixon AS, Kripalani S, Stein J .
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
J Hosp Med 2019 Oct;14(10):614-17. doi: 10.12788/jhm.3308..
Keywords: Medication, Evidence-Based Practice, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Hospitals, Healthcare Delivery, Inpatient Care
Chang X, Li HH, Kalet AM
Development and validation of a bayesian network method to detect external beam radiation therapy physician order errors.
This study investigated using a Bayesian network (BN)-based method to detect physician order errors in external beam radiation therapy. The authors extracted data from 4331 total external beam radiation orders written from 2008 to 2017 at their institution of origin. The cohort was divided into 3 groups: single prescription, concurrent boost, and sequential boost. True-positive (TPR) and false-positive (FPR) rates were determined. The investigators saw good results using the BN method.
AHRQ-funded; HS022888.
Citation: Chang X, Li HH, Kalet AM .
Development and validation of a bayesian network method to detect external beam radiation therapy physician order errors.
Int J Radiat Oncol Biol Phys 2019 Oct 1;105(2):423-31. doi: 10.1016/j.ijrobp.2019.05.034..
Keywords: Medical Errors, Patient Safety, Cancer, Treatments
Wang E, Kang H, Gong Y
Generating a health information technology event database from FDA MAUDE reports.
This study examined using a health information technology (HIT) event database to identify patient safety events (PSEs) or medical errors. The study used the FDA Manufacturer and User Facility Device Experience (MAUDE) database to extract HIT events. Classic and CNN models were utilized on a test set. The model was capable of identifying HIT event with about a 90% accuracy.
AHRQ-funded; HS022895.
Citation: Wang E, Kang H, Gong Y .
Generating a health information technology event database from FDA MAUDE reports.
Stud Health Technol Inform 2019 Aug 21;264:883-87. doi: 10.3233/shti190350..
Keywords: Health Information Technology (HIT), Medical Devices, Adverse Events, Data, Medical Errors, 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)
Yao B, Kang H, Gong Y
Data quality assessment of narrative medication error reports.
This study examined the data quality of patient safety event (PSE) reports that are used to analyze the root causes of PSE. If the data quality is poor then the reporting and root cause analysis (RCA) will also be poor. Incomplete or missing data is the most prevalent problem in these reports. The researchers used an adapted taxonomy to assess the data quality of PSE reports, and extracted sample reports based on eight error types. The extracts were scored by experts. They found that most structured fields were ignored by reporters, but the narrative parts of the reports contained rich and valuable information. The results show that the adapted taxonomy could be a promising tool for report quality assessment and improvement.
AHRQ-funded; HS022895.
Citation: Yao B, Kang H, Gong Y .
Data quality assessment of narrative medication error reports.
Stud Health Technol Inform 2019 Aug 9;265:101-06. doi: 10.3233/shti190146..
Keywords: Adverse Drug Events (ADE), Medication, Medical Errors, Adverse Events, Data, Patient Safety
Brunsberg KA, Landrigan CP, Garcia BM
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
The objective of this paper was to determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. Results of this prospective cohort study showed that resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors, indicating the importance of determining what interventions might mitigate the patient safety risk.
AHRQ-funded; HS019456.
Citation: Brunsberg KA, Landrigan CP, Garcia BM .
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
Acad Med 2019 Aug;94(8):1150-56. doi: 10.1097/acm.0000000000002778..
Keywords: Children/Adolescents, Provider: Physician, Provider, Medical Errors, Adverse Events, Burnout, Patient Safety, Depression, Behavioral Health
Dossett L, Miller J, Jagsi R
A modified communication and optimal resolution program for intersystem medical error discovery: protocol for an implementation study.
AHRQ’s Communication and Optimal Resolution (CANDOR) Toolkit facilitates transparent communication, error prevention, and achieving optimal resolution with patients and families; how medical errors should be addressed when they are discovered between systems-intersystem medical error discovery (IMED)-remains unclear. This study aims to develop and test implementation of a modified CANDOR process for application to IMED scenarios. Step 1 of aim 1 is currently underway. This work is expected to provide important insights into the potential utility of an implementation toolkit to improve transparent communication and optimal resolution of IMED scenarios.
AHRQ-funded; HS026030.
Citation: Dossett L, Miller J, Jagsi R .
A modified communication and optimal resolution program for intersystem medical error discovery: protocol for an implementation study.
JMIR Res Protoc 2019 Jul 2;8(7):e13396. doi: 10.2196/13396..
Keywords: Adverse Events, Communication, Clinician-Patient Communication, Medical Errors, Patient Safety, Tools & Toolkits
Gupta K, Lisker S, Rivadeneira NA
Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM).
Researchers characterized events contributing to the second-victim effect among a diverse sample of physician mothers, described the impact on both provider and patient, and sought to determine the association between experiencing a mistake and burnout. They found that physician mothers involved in errors experience negative outcomes and may be at increased risk for burnout. They recommended additional research focusing on strategies to mitigate burnout associated with the second victim effect, particularly among women physicians and those with family responsibilities.
AHRQ-funded; HS023558.
Citation: Gupta K, Lisker S, Rivadeneira NA .
Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM).
BMJ Qual Saf 2019 Jul;28(7):564-73. doi: 10.1136/bmjqs-2018-008372..
Keywords: Adverse Events, Burnout, Medical Errors, Patient Safety, Provider: Physician
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Schoenfeld EM, Mader S, Houghton C
The effect of shared decisionmaking on patients' likelihood of filing a complaint or lawsuit: a simulation study.
This study examined the effect of shared decisionmaking on the likelihood of a patient filing a complaint or lawsuit after an adverse event. A simulation experiment using clinical vignettes was conducted. The participants, adults from the US were recruited from an online crowd-sourcing platform. They were randomized to vignettes with 1-3 levels of shared decision making. A total of 804 participants were recruited. Those who were exposed to shared decisionmaking were 80% less like to report a plan to contact a lawyer than those not exposed. They also showed higher levels of physician trust, and less likely to fault their physicians for an adverse outcome.
AHRQ-funded; HS024311.
Citation: Schoenfeld EM, Mader S, Houghton C .
The effect of shared decisionmaking on patients' likelihood of filing a complaint or lawsuit: a simulation study.
Ann Emerg Med 2019 Jul;74(1):126-36. doi: 10.1016/j.annemergmed.2018.11.017..
Keywords: Adverse Events, Shared Decision Making, Medical Errors, Patient-Centered Healthcare, Patient and Family Engagement
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
Umberfield E, Ghaferi AA, Krein SL
Using incident reports to assess communication failures and patient outcomes.
Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes. The investigators found that incident reports could identify specific types of communication failures and patient outcomes.
AHRQ-funded; HS023621; HS024403; HS022305; HS024760.
Citation: Umberfield E, Ghaferi AA, Krein SL .
Using incident reports to assess communication failures and patient outcomes.
Jt Comm J Qual Patient Saf 2019 Jun;45(6):406-13. doi: 10.1016/j.jcjq.2019.02.006..
Keywords: Communication, Medical Errors, Adverse Events, Patient Safety
Adelman JS, Applebaum JR, Schechter CB
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
This study assessed whether the belief that having only 1 electronic health record (EHR) open at a time as opposed to 4 will reduce the number of wrong-patient orders by clinicians. A randomized clinical trial was conducted with 3356 clinicians in a large New York Health system from October 2015 to April 2017. Outcomes from emergency department, inpatient, and outpatient settings showed that there seemed to be no difference in the number of wrong-patient order errors. However, most clinicians in the unrestricted group placed orders with a single-record open anyway which limited the power of the study.
AHRQ-funded; HS023704.
Citation: Adelman JS, Applebaum JR, Schechter CB .
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
JAMA 2019 May 14;321(18):1780-87. doi: 10.1001/jama.2019.3698..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Healthcare Delivery, Medical Errors, Patient Safety
St Hilaire MA, Anderson C, Anwar J
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
This study examines the impact of reinstating extended duration (24-28) work shifts (EDWS) for postgraduate year 1 resident physicians. The performance of residents was studied for 23 male residents between 2002-2004 during a three-week on-call rotation schedule at the Medical and Intensive Care Units at Brigham and Women’s Hospital in Boston. If the sleep episodes were four hours or less then the odds of >1 attentional failure was 2.72 times higher during post-call compared to matched sessions during non-EDWS.
AHRQ-funded; HS012032.
Citation: St Hilaire MA, Anderson C, Anwar J .
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
Sleep 2019 May;42(5):pii: zsz041. doi: 10.1093/sleep/zsz041..
Keywords: Adverse Events, Education: Continuing Medical Education, Medical Errors, Patient Safety, Provider, Provider: Physician, Quality of Care, Sleep Problems, Training
Terp S, Wang B, Burner E
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
This study analyzed civil monetary penalties resulting from Emergency Medical and Treatment Act (EMTALA) violations involving psychiatric emergencies from 2002 to 2018. Psychiatric treatment settlements are larger with the average settlement being $85,488 compared to $32,004 for non-psychiatric-related cases. Five of six of the largest settlements during the study period were psychiatric-related. The penalties were for failure to provide appropriate medical screening examinations, receive stabilizing treatment, or arrange appropriate transfer. Almost half (41%) occurred in the Southeast Region and 20% in the Central region.
AHRQ-funded; HS022402; HS025281.
Citation: Terp S, Wang B, Burner E .
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
Acad Emerg Med 2019 May;26(5):470-78. doi: 10.1111/acem.13710..
Keywords: Emergency Department, Medical Errors, Medical Liability, Behavioral Health, Quality of Care
Bundy DG, Singh H, Stein RE
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
This paper discusses the results of Project RedDE, which was a virtual collaborative quality improvement study to reduce diagnostic errors in pediatric primary care practices. Forty-three practices were initially recruited, with a total of 31 practices left at the end due to practice dropout and two participating practices merging. This study was a randomized controlled trial targeting three common diagnostic errors (missed diagnoses of adolescent depression, abnormal blood pressure, and lack of followup for abnormal laboratory results). Contamination across study groups was a recurring problem, but risk mitigations were used. Electronic health records contributed to teams’ success.
AHRQ-funded; HS203608.
Citation: Bundy DG, Singh H, Stein RE .
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
Clin Trials 2019 Apr;16(2):154-64. doi: 10.1177/1740774518820522..
Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention, Primary Care, Quality of Care, Quality Improvement
Lacson R, Cochon L, Ip I
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
This study measured the prevalence of safety events related to diagnostic imaging reported to an electronic safety reporting system. The authors evaluated reports all system reports from 2015 at an academic medical center. Out of 11,570 safety reports submitted, only 7% were related to diagnostic imaging. The adverse event was reported as either result communication or harm during the imaging procedure itself. The harms were rates from 0 to 4 by the reporter. Harms from 2-4 were considered as “potential harm."
AHRQ-funded; HS024722.
Citation: Lacson R, Cochon L, Ip I .
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
J Am Coll Radiol 2019 Mar;16(3):282-88. doi: 10.1016/j.jacr.2018.10.015..
Keywords: Adverse Events, Diagnostic Safety and Quality, Imaging, Patient Safety, Medical Errors
Artis KA, Bordley J, Mohan V
Data omission by physician trainees on ICU rounds.
This observational study measured how frequently physician trainees omitted data from prerounding notes ("artifacts") and verbal presentations during daily rounds. The authors concluded that in an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. They assert that additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.
AHRQ-funded; HS023793.
Citation: Artis KA, Bordley J, Mohan V .
Data omission by physician trainees on ICU rounds.
Crit Care Med 2019 Mar;47(3):403-09. doi: 10.1097/ccm.0000000000003557..
Keywords: Education: Continuing Medical Education, Intensive Care Unit (ICU), Medical Errors, Patient Safety, Quality of Care
Wang J, Liang H, Kang H
Understanding health information technology induced medication safety events by two conceptual frameworks.
While health information technology (health IT) is able to prevent medication errors in many ways, it may also potentially introduce new paths to errors. To understand the impact of health IT induced medication errors, this study aimed to conduct a retrospective analysis of medication safety reports. The investigators concluded that the two frameworks provided an opportunity to understand a comprehensive context of safety event and the impact of health IT induced errors on medication safety.
AHRQ-funded; HS022895.
Citation: Wang J, Liang H, Kang H .
Understanding health information technology induced medication safety events by two conceptual frameworks.
Appl Clin Inform 2019 Jan;10(1):158-67. doi: 10.1055/s-0039-1678693..
Keywords: Health Information Technology (HIT), Medication: Safety, Medication, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors
Mello MM, Greenberg Y, Senecal SK
Case outcomes in a communication-and-resolution program in New York hospitals.
The researchers sought to determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery. They concluded that the bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.
AHRQ-funded; R18 HS019505.
Citation: Mello MM, Greenberg Y, Senecal SK .
Case outcomes in a communication-and-resolution program in New York hospitals.
Health Serv Res 2016 Dec;51 Suppl 3:2583-99. doi: 10.1111/1475-6773.12594.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Surgery