National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (3)
- Adverse Events (2)
- Burnout (1)
- Children/Adolescents (1)
- Clinical Decision Support (CDS) (1)
- Decision Making (1)
- Electronic Health Records (EHRs) (1)
- Health Information Technology (HIT) (2)
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- (-) Hospitals (7)
- Implementation (1)
- Long-Term Care (1)
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- Medication (7)
- (-) Medication: Safety (7)
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- Patient and Family Engagement (1)
- (-) Patient Safety (7)
- Prevention (1)
- Quality Improvement (2)
- Quality of Care (1)
- Tools & Toolkits (1)
- Transitions of Care (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 7 of 7 Research Studies DisplayedCo Z, Holmgren AJ, Classen DC
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
This study evaluated the overall performance of hospitals that used the Computerized Physician Order Entry Evaluation Tool in 2017 and 2018 and compared performances for fatal orders and nuisance orders each year. The authors evaluated 1599 hospitals that took the test by using their overall percentage scores along with the percentage of fatal orders appropriately alerted on and the percentage of nuisance orders incorrectly alerted on. Overall hospital scores improved from 58.1% in 2017 to 66.2% in 2018. Fatal order performance improved slightly from 78.8% to 83.0%, but there no very little change in nuisance order performance (89.0% to 89.7%). Conclusions were that perhaps hospitals are not targeting the deadliest orders first and some hospitals may be achieving higher scores by over-alerting. This has the potential to cause clinician burnout and even worsen patient safety.
AHRQ-funded; HS023696.
Citation: Co Z, Holmgren AJ, Classen DC .
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
J Am Med Inform Assoc 2020 Aug;27(8):1252-58. doi: 10.1093/jamia/ocaa098..
Keywords: Medication: Safety, Medication, Patient Safety, Clinical Decision Support (CDS), Decision Making, Burnout, Hospitals, Health Information Technology (HIT), Quality of Care
Stolldorf DP, Mixon AS, Auerbach AD
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.
MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here the investigators described hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Mixon AS, Auerbach AD .
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.
Am J Health Syst Pharm 2020 Jul 7;77(14):1135-43. doi: 10.1093/ajhp/zxaa136..
Keywords: Medication, Medication: Safety, Patient Safety, Hospitals, Tools & Toolkits
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
Auger KA, Shah SS, Davis MM
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission. In this paper, the authors sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents.
AHRQ-funded; HS024735.
Citation: Auger KA, Shah SS, Davis MM .
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
J Hosp Med 2019 Aug;14(8):506-07. doi: 10.12788/jhm.3213..
Keywords: Children/Adolescents, Medication, Medication: Safety, Patient Safety, Hospital Discharge, Hospitals
Schnipper JL, Mixon A, Stein J
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
The authors of this paper conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The investigators found that a mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. They suggest that the effect of EHR implementation on medication discrepancies warrants further study.
AHRQ-funded; HS019598.
Citation: Schnipper JL, Mixon A, Stein J .
Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.
BMJ Qual Saf 2018 Dec;27(12):954-64. doi: 10.1136/bmjqs-2018-008233..
Keywords: Hospitals, Medication, Medication: Safety, Patient Safety, Quality Improvement
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care