National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (4)
- Adverse Events (7)
- Ambulatory Care and Surgery (1)
- Clinical Decision Support (CDS) (2)
- Clinician-Patient Communication (1)
- Communication (1)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (4)
- Labor and Delivery (1)
- (-) Medical Errors (11)
- Medical Liability (2)
- Medication (5)
- Medication: Safety (1)
- Patient Safety (10)
- Policy (2)
- Pregnancy (1)
- Prevention (2)
- Quality Improvement (1)
- Quality of Care (3)
- Surgery (1)
- Teams (1)
- Tools & Toolkits (1)
- Women (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 DisplayedMeeks DW, Meyer AN, Rose B
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
The researchers described outcomes of peer review within the Department of Veterans Affairs (VA) healthcare system and identified opportunities to leverage peer review data for measurement and improvement of safety. Results showed that the most common process contributing to substandard care was 'timing and appropriateness of treatment'; approximately 16% had diagnosis-related performance concerns. The authors concluded that peer review may be a useful tool for healthcare organizations to assess their sharp end clinical performance, particularly safety events related to diagnostic and treatment errors.
AHRQ-funded; HS022087.
Citation: Meeks DW, Meyer AN, Rose B .
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
BMJ Qual Saf 2014 Dec;23(12):1023-30. doi: 10.1136/bmjqs-2014-003239.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Quality Improvement
Dollarhide AW, Rutledge T, Weinger MB
A real-time assessment of factors influencing medication events.
This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. It found that medication events were associated with 36.1 percent higher perceived workload, 8.6 percent higher inpatient caseloads and 55.9 percent higher emotional stress scores. Also, there was a trend for reported events to be associated with less sleep.
AHRQ-funded; HS014283.
Citation: Dollarhide AW, Rutledge T, Weinger MB .
A real-time assessment of factors influencing medication events.
J Healthc Qual 2014 Sep-Oct;36(5):5-12. doi: 10.1111/jhq.12012..
Keywords: Medication, Medical Errors, Patient Safety, Quality of Care
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
Pohl JM, Tanner C, Hamilton A
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
This study, conducted in five safety-net practices, examined the impact of implementing a commercial electronic health records system on medication safety. The authors found 130 "true" drug-drug interaction (DDI) pairs, representing 149,087 visits and 62 providers, with the largest DDI categories being related to antihypertensive medications, which are often prescribed together. They found no significant differences between physicians and nurse practitioners on the rate of DDI pairs.
AHRQ-funded; HS017191.
Citation: Pohl JM, Tanner C, Hamilton A .
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
J Am Assoc Nurse Pract 2014 Aug;26(8):438-44. doi: 10.1002/2327-6924.12089.
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Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety
Huang LC, Conley D, Lipsitz S
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
The authors assessed the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork. They found that both the Checklist Coaching Tool and the Surgical Teamwork Tool demonstrated substantial IRR and required limited training to use, indicating that both instruments may be used to observe checklist performance and teamwork in the operating room. They recommended that further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.
AHRQ-funded; HS019631.
Citation: Huang LC, Conley D, Lipsitz S .
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
BMJ Qual Saf 2014 Aug;23(8):639-50. doi: 10.1136/bmjqs-2013-002446.
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Keywords: Patient Safety, Surgery, Tools & Toolkits, Teams, Adverse Events, Medical Errors, Prevention
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
Cole B, Dickerson JA, Graber ML
AHRQ Author: Henriksen K
A prospective tool for risk assessment of sendout testing.
The authors developed a tool to assess risk of diagnostic errors involving laboratory sendout testing. The tool was determined, through testing at nine pilot sites, to be both useful and easy to use. It could be used by other laboratories to identify the areas of highest risk to patients, which in turn may guide them in focusing their quality improvement efforts and resources.
AHRQ-authored; AHRQ-funded; 29032001T.
Citation: Cole B, Dickerson JA, Graber ML .
A prospective tool for risk assessment of sendout testing.
Clin Chim Acta 2014 Jul 1;434:1-5. doi: 10.1016/j.cca.2014.03.028.
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Keywords: Diagnostic Safety and Quality, Quality of Care, Medical Errors, Patient Safety
Forrester SH, Hepp Z, Roth JA
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
The study objective was to estimate the cost-effectiveness of computerized provider order entry versus traditional paper-based prescribing in reducing medications errors and adverse drug events in the ambulatory setting of mid-sized medical group. Using a decision-analytic model, the researchers found that the adoption of CPOE in the ambulatory setting provides excellent value for the investment.
AHRQ-funded; HS014739
Citation: Forrester SH, Hepp Z, Roth JA .
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
Value Health. 2014 Jun;17(4):340-9. doi: 10.1016/j.jval.2014.01.009..
Keywords: Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Patient Safety, Healthcare Costs, Ambulatory Care and Surgery, Prevention
Newman-Toker DE
A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis.
Newman-Toker proposed a novel framework for considering diagnostic errors, offering a unified conceptual model for underdiagnosis, overdiagnosis, and misdiagnosis, concluding that the model should serve as a foundation for developing consensus terminology and operationalized definitions for relevant diagnostic-error categories.
AHRQ-funded; HS019252.
Citation: Newman-Toker DE .
A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis.
Diagnosis 2014 Jan;1(1):43-48. doi: 10.1515/dx-2013-0027.
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Keywords: Diagnostic Safety and Quality, Medical Errors, Patient Safety
Hendrich A, McCoy CK, Gale J
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
This article presents a case study concerning challenges, including physician resistance, to the establishment of a common full disclosure protocol at five labor and delivery demonstration sites. Twenty-seven months after implementation, the rate of full disclosure had increased by 221 percent. Practitioners saw a number of factors as key catalysts for change including consistent and ongoing leadership by local practitioners and hospitals.
AHRQ-funded; HS019608.
Citation: Hendrich A, McCoy CK, Gale J .
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
Health Aff 2014 Jan;33(1):39-45. doi: 10.1377/hlthaff.2013.1009..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Labor and Delivery, Medical Errors, Medical Liability, Policy, Pregnancy, Women
Kachalia A, Little A, Isavoran M
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
The Oregon Health Authority analyzed the potential for safe harbors to improve patient safety and the performance of the medical liability system, as well as legal challenges and stakeholder concerns that might arise with legislation enacting safe harbors. They found that such legislation would have changed the liability outcome in favor of the physician defendant in only 1 percent of 266 claims from the period 2002–09 that were reviewed.
AHRQ-funded; HS019535.
Citation: Kachalia A, Little A, Isavoran M .
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
Health Aff 2014 Jan;33(1):59-66. doi: 10.1377/hlthaff.2013.0834..
Keywords: Patient Safety, Medical Liability, Medical Errors, Quality of Care, Policy