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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
26 to 50 of 1300 Research Studies DisplayedBourgeois FC, Hart NJ, Dong Z
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
This study’s objective was to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage pediatric patients and their families in the diagnostic process (DxP). This cross-sectional study included 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, which was codeveloped and tested with patients and families. Patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns prior to each visit. The authors conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70) or "other" race (OR: 1.48) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53). No significant differences were found in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference.
AHRQ-funded; HS027367.
Citation: Bourgeois FC, Hart NJ, Dong Z .
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
Appl Clin Inform 2023 Oct; 14(5):903-12. doi: 10.1055/s-0043-1776055..
Keywords: Diagnostic Safety and Quality, Patient Safety, Racial and Ethnic Minorities
Herzig SJ, Anderson TS, Urman RD
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
The purpose of this retrospective cohort study was to identify risk factors for opioid-related adverse drug events (ORADEs) after hospital discharge following orthopedic procedures. The participants of this study included a national sample of Medicare beneficiaries who underwent major orthopedic surgery during hospitalization in 2016 and had an opioid prescription filled within 2 days of discharge. The study found that among 30,514 hospitalizations with a major orthopedic procedure and an opioid claim, a potential ORADE requiring hospital revisit occurred in 2.5%. After adjustment for patient characteristics, prior opioid use, co-prescribed sedating medications, and opioid prescription characteristics were not related with ORADEs. Independent risk factors did include age of 80 years or older, female sex, and clinical conditions, including heart failure, respiratory illness, kidney disease, dementia/delirium, anxiety disorder, and musculoskeletal/nervous system injuries.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Urman RD .
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
J Patient Saf 2023 Oct 1; 19(6):379-85. doi: 10.1097/pts.0000000000001144..
Keywords: Elderly, Opioids, Adverse Drug Events (ADE), Adverse Events, Hospitalization, Orthopedics, Surgery, Medication, Risk, Medication: Safety, Patient Safety
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
Mauskar S, Ngo T, Haskell H
In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.
The purpose of this study was to address the gap of research on inpatient safety/quality experience of Children with medical complexity (CMC) and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of children with medical complexity (CMC). Out of 208 families surveyed, 237 (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. The study found that themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency.
AHRQ-funded; HS025781.
Citation: Mauskar S, Ngo T, Haskell H .
In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.
J Hosp Med 2023 Sep; 18(9):777-86. doi: 10.1002/jhm.13178..
Keywords: Children/Adolescents, Patient Safety, Quality of Care, Chronic Conditions
Zhu Y, Wang Z, Newman-Toker D
Misdiagnosis-related harm quantification through mixture models and harm measures.
Investigating and monitoring misdiagnosis-related harm utilizing the traditional chart review process is labor intensive, potentially unstable, and not conducive to scaling. Researchers propose to leverage the association between symptoms and diseases based on electronic health records or claim data. Specifically, the increased risk of disease after a false-negative diagnosis can be utilized as an indicator of potential harm. The researcher report that the problem with off-the-shelf statistical methods to assess these dynamics is that they do not fully accommodate the data structure of a well-hypothesized risk pattern and thus fail to sufficiently address the unique challenges. The purpose of this study was to explore a mixture regression model and its associated goodness-of-fit testing to address the existing gaps seen in usual statistical analysis methods. The researchers additionally proposed harm measures and profiling analysis procedures to quantify, assess, and compare misdiagnosis-related harm across institutes with potentially differing patient population compositions. Simulation studies were utilized to study the performance of the proposed methods. Researchers then applied and demonstrated the methods through data analyses on stroke occurrence data from the Taiwan Longitudinal Health Insurance Database. From those analyses risk factors for being harmed due to misdiagnosis were assessed, which revealed insights for health care quality research. Finally, researchers compared general and special care hospitals in Taiwan and observed better diagnostic performance in special care hospitals utilizing a variety of new assessment measures.
AHRQ-funded; HS027614.
Citation: Zhu Y, Wang Z, Newman-Toker D .
Misdiagnosis-related harm quantification through mixture models and harm measures.
Biometrics 2023 Sep; 79(3):2633-48. doi: 10.1111/biom.13759..
Keywords: Diagnostic Safety and Quality, Patient Safety, Hospitals
Young RA, Gurses AP, Fulda KG
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
The purpose of this qualitative study was to examine actions by primary care teams to improve medication safety. During 2019-2020, the researchers utilized one-on-one, semi-structured interviews with 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in the Southwest United States. The study found that primary care teams described their actions in medication safety primarily in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. The majority of the actions required individual-level customization, such as restricting the supply of specific medications prescribed and simplifying the medication regimens of specific patients. Primary care teams engaged high reliability organization principles taking steps to improve resilience in patient work systems and by anticipating and moderating risks. The actions of the primary care teams demonstrated their safety organizing efforts as responses to many other agents in multiple settings that they could neither control nor coordinate easily.
AHRQ-funded; HS027277.
Citation: Young RA, Gurses AP, Fulda KG .
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
BMJ Open Qual 2023 Sep; 12(3). doi: 10.1136/bmjoq-2023-002350..
Keywords: Medication: Safety, Medication, Primary Care, 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
Schnipper JL, Reyes Nieva H, Yoon C
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
The objective of this study was to assess the association of patient exposure to system-level intervention and receipt based on the results of the second Multicenter Medication Reconciliation Quality Improvement Study, which demonstrated a marked reduction in medication discrepancies per patient. Researchers conducted an on-treatment analysis of system-level interventions at 17 North American hospitals. The patient-level interventions most associated with discrepancy reductions were receipt of a best-possible medication history of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were also associated with a minor reduction in discrepancies for the average patient. The researchers concluded that these findings might be used to help hospitals and health systems prioritize interventions to improve medication safety during care transitions.
AHRQ-funded; HS023757.
Citation: Schnipper JL, Reyes Nieva H, Yoon C .
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
BMJ Qual Saf 2023 Aug; 32(8):457-69. doi: 10.1136/bmjqs-2022-014806..
Keywords: Medication, Medication: Safety, Quality Improvement, Quality of Care, Patient Safety, Hospital Discharge
Garber A, Garabedian P, Wu L
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
This study’s objective was to describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. The interventions to be developed were a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. After initial refinement from an analysis, final requirements were created for 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses including the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. An analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers identified included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).
AHRQ-funded; HS026613.
Citation: Garber A, Garabedian P, Wu L .
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
JAMIA Open 2023 Jul; 6(2):ooad031. doi: 10.1093/jamiaopen/ooad031..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety
Bradford A, Goeschel C, Shofer M
AHRQ Author: Shofer M
Five new ways to advance diagnostic safety in your clinical practice.
This AHRQ-authored article describes new resources that clinicians can use to advance diagnostic safety and prevent errors. The new AHRQ-funded resources include Calibrate Dx, Measure Dx, Safer Dx Checklist, TeamSTEPPS for Diagnostic Improvements, and the Toolkit for Engaging Patients to Improve Diagnostic Safety. A table is provided which describes the resource, gives an example or strategy or practice change, and describes the audience for the resource. Recommendations are also given to help clinicians reduce barriers to diagnostic safety including: 1) Start small and focused; 2) Align with other high-priority initiatives; 3) Start with the resources you have; and 4) Consider how diagnostic safety work can enhance missions other than clinical care.
AHRQ-authored.
Citation: Bradford A, Goeschel C, Shofer M .
Five new ways to advance diagnostic safety in your clinical practice.
Am Fam Physician 2023 Jul; 108(1):14-16..
Keywords: Diagnostic Safety and Quality, Patient Safety
Giuliano J, Krishna A, Napolitano N
Implementation of video laryngoscope-assisted coaching reduces adverse tracheal intubation-associated events in the PICU.
The purpose of this study was to assess the implementation of a video laryngoscope (VL) as a coaching device to decrease adverse tracheal intubation associated events (TIAEs). Between 2016 and 2020 the researchers implemented VLs as coaching devices with standardized coaching language. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. The study found that a VL was used in 71% of 5,060 tracheal intubations. VL utilization increased from a baseline of 29.7% to an implementation phase level of 89.4%. VL utilization was related with lower TIAEs compared with standard laryngoscope (SL). VL utilization was related with lower severe TIAE rate, but not related with a reduction in severe hypoxemia. VL utilization was related with greater first attempt success. In the primary analysis after adjusting for site clustering, VL utilization was related with lower adverse TIAEs. In secondary analyses, VL utilization was not significantly related with severe TIAEs, severe hypoxemia, or first attempt success. After additional controlling for patient and provider characteristics, VL utilization was independently related with a lower TIAE rate.
AHRQ-funded; HS024511.
Citation: Giuliano J, Krishna A, Napolitano N .
Implementation of video laryngoscope-assisted coaching reduces adverse tracheal intubation-associated events in the PICU.
Crit Care Med 2023 Jul; 51(7):936-47. doi: 10.1097/ccm.0000000000005847..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Adverse Events, Patient Safety
Shannon EM, Mueller SK, Schnipper JL
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
The purpose of this study was to explore whether medication safety could be improved by the use of a technologically-enabled pillbox prescribed to patients at hospital discharge. The study included semi-structured telephone interviews with patients, patient caregivers, and inpatient and outpatient clinicians who participated in the Smart Pillbox Transition Study. The researchers utilized the Systems Engineering Initiative for Patient Safety (SEIPS) framework to develop an interview guide, which included the a priori domains of 1) barriers to implementation, 2) facilitators of the intervention, and 3) general feedback regarding experience with the intervention. The study found patient-endorsed barriers in the theme of technology and tools included signal issues, inappropriate alarms, and portability. Barriers in the theme of logistics and tasks included coordination with pharmacists in the event of a prescription change. Barriers mentioned by clinicians included patients who were poor fits for the intervention and competing demands at discharge (under the themes of personnel and patients, and logistics and tasks, respectively). Facilitators that were reported often by patients and caregivers in the theme of technology and tools included useful alarms and ease of use. Clinicians reported that communication with pharmacy and study staff facilitated the intervention.
AHRQ-funded.
Citation: Shannon EM, Mueller SK, Schnipper JL .
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
ACI Open 2023 Jul; 7(2):e61-e70..
Keywords: Medication, Health Information Technology (HIT), Patient Self-Management, Hospital Discharge, Medication: Safety, Patient Safety
Petragallo R, Bertram P, Halvorsen P
Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images.
In image-guided radiotherapy (IGRT), lack of correct alignment to the vertebral body continues to be a rare but serious risk to patient safety. The researchers propose that an automated image-review algorithm be included in the IGRT process as an interlock to detect off-by-one vertebral body errors. The purpose of this study was to describe the development and validation of a convolutional neural network (CNN)-based approach for an automated image-review algorithm using patient image data from a planar stereoscopic x-ray IGRT system. The researchers collected X-rays and digitally reconstructed radiographs (DRRs) from 429 spine radiotherapy patients treated using a stereoscopic x-ray image guidance system. True-negative, "no-error" cases were established using clinically-applied, physician approved alignments. "Off-by-one vertebral body" errors were simulated by translating DRRs along the spinal column using a semi-automated method. A leave-one-institution-out method was utilized to estimate the accuracy of the model on data from unseen institutions as follows: every image from five of the institutions was used to train a CNN model from scratch. The size of the resulting training set ranged from 5700 to 9372 images, and was dependent on which five institutions had contributed data. The training set was randomized and split using a 75/25 split into the final training/ validation sets. X-ray/ DRR image pairs and the related labels of "no-error" or "shift" were used as the model input. Accuracy of the model was assessed utilizing images from the sixth institution, which was omitted from the training phase. This test set ranged from 180 to 3852 images, again depending on which institution had been left out of the training phase. The trained model was utilized to categorize the images from the test set as either "no-error" or "shifted", and the model predictions were compared to the ground truth labels to evaluate model accuracy. This process was repeated until the images of each institution had been utilized as the testing dataset. The study found that when the six models were utilized to categorize unseen image pairs from the institution omitted during training, the resulting receiver operating characteristic area under the curve values ranged from 0.976 to 0.998.
AHRQ-funded; HS026486.
Citation: Petragallo R, Bertram P, Halvorsen P .
Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images.
Med Phys 2023 May; 50(5):2662-71. doi: 10.1002/mp.16359..
Keywords: Imaging, Patient Safety, Diagnostic Safety and Quality
Marcaccio CL, Patel PB, Rastogi V
Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting.
This study’s objective was to examine the efficacy and safety of preoperative single antiplatelet therapy (AP) therapy vs double antiplatelet therapy (DAPT) in patients who had undergone transfemoral CAS (tfCAS) or transcarotid artery revascularization (TCAR). The authors identified all patients who had undergone tfCAS or TCAR in the Vascular Quality Initiative database from 2016 to 2021. A total of 18,570 tfCAS patients were included, of which 70% had received DAPT, 5.6% no AP therapy, 10% ASA only, 8.0% ASA + AP loading dose, 4.6% P2Y12 inhibitor (P2Yi) only, and 2.9% P2Yi + AP loading dose. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy, ASA only, and ASA + AP loading dose, but was similar with P2Yi only, and P2Yi + AP loading dose. No differences were found in the incidence of bleeding rates between the treatment groups after tfCAS or TCAR. These findings support the current guidelines recommending DAPT before CAS but also suggest that P2Yi monotherapy might confer thromboembolic benefits similar to those with DAPT.
AHRQ-funded; HS027285.
Citation: Marcaccio CL, Patel PB, Rastogi V .
Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting.
J Vasc Surg 2023 May; 77(5):1434-46.e11. doi: 10.1016/j.jvs.2022.12.034..
Keywords: Blood Thinners, Medication, Medication: Safety, Cardiovascular Conditions, Stroke, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Karlic KJ, Valley TS, Cagino LM
Identification of patient safety threats in a post-intensive care clinic.
This observational cohort study examined patient safety threats at a post-ICU clinic in an academic, tertiary care medical center and whether post-ICU clinics improve patient safety. The study identified 83 patients, of which 60 patients had 96 separate safety threats. The threats were categorized into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviors (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). They were also categorized as 41% preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable.
AHRQ-funded; HS028038.
Citation: Karlic KJ, Valley TS, Cagino LM .
Identification of patient safety threats in a post-intensive care clinic.
Am J Med Qual 2023 May-Jun; 38(3):117-21. doi: 10.1097/jmq.0000000000000118..
Keywords: Patient Safety, Transitions of Care, Adverse Events
Silber JH, Rosenbaum PR, Reiter JG
The safety of performing surgery at ambulatory surgery centers versus hospital outpatient departments in older patients with or without multimorbidity.
The objective of this matched cohort study was to determine if there are differential outcomes in older patients undergoing surgical procedures at ambulatory surgery centers (ASCs) versus hospital outpatient departments (HOPDs). The results indicated that revisits and complication rates for ASC patients were lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was higher than the baseline risk for the same procedures performed at the ASC, which suggested that surgeons are selecting their riskier patients to be treated at the HOPD rather than the ASC.
AHRQ-funded; HS026897.
Citation: Silber JH, Rosenbaum PR, Reiter JG .
The safety of performing surgery at ambulatory surgery centers versus hospital outpatient departments in older patients with or without multimorbidity.
Med Care 2023 May; 61(5):328-37. doi: 10.1097/mlr.0000000000001836..
Keywords: Elderly, Surgery, Patient Safety, Ambulatory Care and Surgery
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
Barger LK, Weaver MD, Sullivan JP
Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.
The purpose of this study was to determine if long weekly work hours and shifts of extended duration are associated with adverse patient and physician safety outcomes. The criteria included work hours and shifts (≥24 hours) and for senior resident physicians (postgraduate year 2 and above; PGY2+). This study was conducted in the U.S. and spanned eight academic years. The analysis concluded that working 48 hours per week or longer, and extended shifts endanger even experienced (ie, PGY2+) resident physicians and their patients. It recommends lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.
AHRQ-funded; HS012032.
Citation: Barger LK, Weaver MD, Sullivan JP .
Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.
BMJ Med 2023; 2(1):e000320. doi: 10.1136/bmjmed-2022-000320..
Keywords: Provider: Physician, Burnout, Patient Safety
Zhong J, Simpson KR, Spetz J
Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs Survey.
The objective of this study was to explore the association of nurses' perceptions of patient safety climate with missed nursing care in labor and delivery (L&D) units. Nurse respondents were recruited via email distribution of an electronic survey; hospitals with L&D units were recruited from states with projected availability of 2018 state inpatient data. Measures included the Safety Attitudes Questionnaire Safety Climate Subscale and the Perinatal Missed Care Survey. The results suggested that improving safety climate through means such as better teamwork and communication may improve nursing care quality during labor and birth through decreasing missed nursing care. Strategies to reduce missed care may also conversely improve the safety climate.
AHRQ-funded; HS025715.
Citation: Zhong J, Simpson KR, Spetz J .
Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs Survey.
J Patient Saf 2023 Apr 1;19(3):166-72. doi: 10.1097/pts.0000000000001106.
Keywords: Maternal Care, Pregnancy, Labor and Delivery, Nursing, Patient Safety, Provider: Nurse
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
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
Jallow F, Stehling E, Sajwani-Merchant Z
A multisite qualitative analysis of perceived roles in medication safety: older adults' perspectives.
The objective of this study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Researchers conducted semi-structured qualitative interviews with community-dwelling adults over 65 years old who took five or more prescription medications daily. Their results suggested that older adults' perceptions of their role and the roles of primary care providers and pharmacists in medication safety varied widely. The researchers concluded that educating providers and pharmacists about the expectations of this population can ultimately improve medication safety.
AHRQ-funded; HS027277.
Citation: Jallow F, Stehling E, Sajwani-Merchant Z .
A multisite qualitative analysis of perceived roles in medication safety: older adults' perspectives.
J Patient Exp 2023 Jan-Dec; 10:23743735231158887. doi: 10.1177/23743735231158887..
Keywords: Elderly, Medication, Medication: Safety, Patient Safety, Patient Experience
Ervin JN, Vitous CA, Wells EE
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
The objective of this study was to understand the effectiveness of the Rescue Improvement Conference, a forum that addresses failure to rescue (FTR). FTR is the phenomenon where delayed recognition or response to surgical complications leads to a progressive cascade of adverse events culminating in patient death. The authors used 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and opportunities for improvement and conducted semi-structured interviews. The results showed that conference felt that the Rescue Improvement Conference was effective in all five indicators. The authors concluded that the conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications that contribute to FTR.
AHRQ-funded; HS024403; HS023621.
Citation: Ervin JN, Vitous CA, Wells EE .
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
Ann Surg 2023 Feb; 277(2):233-37. doi: 10.1097/sla.0000000000004832..
Keywords: Surgery, Adverse Events, Patient Safety, Quality of Care, Quality Improvement