Errors associated with the use of
smart infusion pumps. Medication
errors and adverse drug events are
common among critically ill cardiac
surgery patients who receive
medications through intravenous
infusion pumps. AHRQ researchers
studied smart infusion pump data for
735 cardiac surgery patients and found
180 serious medication errors. They
concluded that although smart pumps
have great promise, technological and
nursing behavioral factors must be
addressed if these pumps are to achieve
their potential for improving medication
safety.
Project Title: Improving Medication
Safety Across Clinical Settings
Research Area: COE
AHRQ Grant: HS11534
Principal Investigator: David Bates,
M.D.
Reference: Rothschild JM, Keohane
CA, Cook EF, Orav EJ, Burdick E,
Thompson S, Hayes J, Bates DW. A
controlled trial of smart infusion pumps
to improve medication safety in
critically ill patients. Crit Care Med 2005 Mar;33(3):533-40.
Dosing errors in children are
associated with inadequate
national standards for medication
dosing based on patient weight
and age. Although medications are
prescribed to millions of children each
year in the United States, little is known
about medication errors in ambulatory
pediatrics. In the process of completing
a study to determine the prevalence of
outpatient dosing errors, AHRQ
researchers identified a number of issues
with respect to medication errors in
children. These include prescribing
medication not labeled for use in children, discrepancies in published
dosing recommendations for many
medications, unclear guidelines on use
of adult dosing recommendations for
children of different ages and weights,
and the lack of readily available,
documented weights to determine
appropriate weight-based doses for
children. The authors suggest we need
better national standards of medication-dosing
that are appropriate for children
and an improved ability to determine
errors through databases that include
children's weights as well as prescription
information.
Project Title: Pediatric EBM-Getting
Evidence Used at the Point of Care
AHRQ Grant: HS10516
Principal Investigator: Robert Davis,
M.D., M.P.H.
Reference: McPhillips H, Stille C,
Smith D, Pearson J, Stull J, Hecht J,
Andrade S, Miller M, Davis R.
Methodological challenges in describing
medication dosing errors in children. In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to Implementation.
Vol. 2, Concepts and Methodology.
AHRQ Publication No. 05-0021-2.
Rockville, MD: Agency for Healthcare
Research and Quality; Feb 2005. pp. 213-23.
High rates of adverse events in
long-term care facilities found
during the ordering and
monitoring stages of care. There
were over 800 adverse drug events, of
which more than 40 percent were
judged preventable, in two large long-term
care facilities during a 9-month
period in 2000-2001, according to an
AHRQ-funded study. Of the 225
adverse drug events considered to be
serious, life-threatening, or fatal, over 60
percent were preventable. The study
found that preventable adverse drug
events occurred most often during the
ordering and monitoring stages of care
and that the two drugs most commonly
involved were warfarin and atypical
antipsychotic agents (olanzapine,
risperidone, quetiapine, and clozapine).
Project Title: Reducing Adverse Drug
Events in the Nursing Home
Research Area: TRIP
AHRQ Grant: HS10481
Principal Investigator: Jerry Gurwitz,
M.D.
Reference: Gurwitz JH, Field TS, Judge
J, Rochon P, Harrold LR, Cadoret C,
Lee M, White K, LaPrino J, Erramuspe-Mainard J, DeFlorio M, Gavendo L,
Auger J, Bates DW. The incidence of
adverse drug events in two large
academic long-term care facilities. Am J
Med 2005 Mar;118(3):251-8.
PDA-based drug information
sources improve medication safety.
Having drug information sources readily
available at the point of care is one
practice-improvement intervention that
may reduce medication errors. PDAs
offer great potential for improving
quality in health care and several PDA-based
drug information sources are
available. AHRQ researchers developed
a quality and safety framework and used
it to evaluate 11 drug information
sources. Three of those sources met the
criteria of the framework: Eprocrates Rx
Pro, Lexi-Drugs, and
mobileMICROMEDEX. Lexi-Drugs
was found to be the most specific and
complete PDA resource to optimize
medication safety by reducing potential
errors associated with insufficient or
incomplete drug information. However,
the researchers found that no resource
sufficiently addressed all patient safety
information needs for all cases, and it is
often necessary to use more than one
resource to reduce medication errors and
improve patient safety.
Project Title: Training Clinicians to Use
a Handheld Device for Electronic
Prescribing
Research Area: CLIPS
AHRQ Grant: HS11808
Principal Investigator: Kimberly Galt,
Pharm.D., FASHP
Reference: Galt KA, Rule AM,
Houghton B, Young DO, Remington
G. Personal digital assistant-based drug
information sources: potential to
improve medication safety. J Med Libr
Assoc 2005 Apr;93(2):229-36.
Medication safety guide for
evaluating best practices in
ambulatory care is available.
AHRQ researchers have developed a
quality and safety framework for health
providers to evaluate medication safety
in their practice. The tool helps
providers identify areas for improvement
and establish an action plan for various
levels of implementation. A key aspect
of the tool is its identification of
methods to improve the environment
for medication safety through individual
behavior and policy or system changes.
It also identifies implementation plans
that need additional financial or expert
resources beyond ambulatory care. The
tool requires providers to think about
safe practices pertaining to medication
use, office environment, error
management, workplace conditions,
safety education, safety perceptions, and
most importantly, the patient. The tool
can be downloaded and distributed
without permission.
Project Title: Impact of Personal
Digital Assistant Devices on Medication
Errors in Primary Care
Research Area: CLIPS
AHRQ Grant: HS11808
Principal Investigator: Kimberly Galt,
Pharm.D., FASHP
Reference:
http://chrp.creighton.edu/documents/BestPractices.pdf
*Potential medication dosing
errors among children are
common in outpatient pediatrics
using both hand-written and
electronic prescriptions. AHRQ
researchers have found that prescriptions
for 22 common medications dispensed
to children often contain potential
dosing errors. Using automated
pharmacy data from 3 HMOs—two
using hand-written prescriptions and
one using CPOE—researchers
examined the prevalence of under- and
overdosed medications prescribed to
1,933 children. About 15 percent of
children were prescribed a potentially
wrong dose for a medication: eight
percent were potentially overdosed and
seven percent were potentially
underdosed. Only 67 percent of
children weighing less than 35 kg (77
lbs.) received medication doses within
recommended ranges, and children
prescribed medication outside of a clinic
visit were at a 50 percent greater risk for
an overdose. Potential error rates were
not lower at the site using CPOE.
Project Title: The CERTs Prescribing
Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11843
Principal Investigator: Richard Platt,
M.D., M.Sc.
Reference: McPhillips HA, Stille CJ,
Smith D, Hecht J, Pearson J, Stull J,
Debellis K, Andrade S, Miller M,
Kaushal R, Gurwitz J, Davis RL.
Potential medication dosing errors in
outpatient pediatrics. J Pediatr 2005
Dec;147(6):761-7.
*Toolkit can help hospitals
identify and implement successful
techniques for reconciling
medications at admission. The
Massachusetts Coalition for the
Prevention of Medical Errors and the
Massachusetts Hospital Association
recruited 50 hospitals to participate in a
statewide patient safety initiative. The
goal of the program was to reduce
medication errors by implementing a set
of safe practice recommendations for
reconciling medications at admission.
By the end of the 18-month adoption
period, 20 percent of the hospitals had
diffused the practices throughout their
organization and 64 percent reported
using a standardized medication
reconciliation form. Active clinician and
senior administrator involvement,
multidisciplinary implementation
teams, and small pilot tests of change
were key factors in successful
implementation of the program. A
medication reconciliation toolkit based
on the hospitals' experiences is available
online (http://www.macoalition.org/Initiatives/RMToolkit.shtml).
Project Title: Evaluate the Effects of
Massachusetts Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11928
Principal Investigator: Nancy Ridley,
M.S.
Reference: Rogers G, Alper E, Brunelle
D, Federico F, Fenn CA, Leape LL,
Kirle L, Ridley N, Clarridge BR, Bolcic-Jankovic D, Griswold P, Hanna D,
Annas CL. Reconciling Medications at
Admission: Safe Practice
Recommendations and Implementation
Strategies. Jt Comm J Qual Pat Saf
2006 Jan;32(1):37-50.
Online toolkit:
http://www.macoalition.org/Initiatives/RMToolkit.shtml
*Compliance with the Food and
Drug Administration's (FDA's)
black box warnings is highly
variable in ambulatory care. Black
box warnings (BBWs) are the FDA's
strongest labeling requirements for high-risk
medicines. However, it remains
unclear how effective they are at
communicating risk. AHRQ researchers
used data on 930,000 members in 10
health plans, nationwide to assess overall
BBW drug use and prescribing
compliance with BBW
recommendations in ambulatory care.
Among the 42 percent of health plan
members receiving at least one BBW
drug, use consistent with
recommendations varied by the drug.
Most noncompliance occurred with lab
monitoring—about half of all first-time
therapies that should have been
accompanied by baseline lab tests were
not, and 13 percent of ongoing
therapies were not monitored regularly.
There was almost no coprescribing of
the two contra-indicated QT-interval-prolonging
BBW drugs that, in some
patients, can lead to cardiac arrhythmia
and even sudden death. Pregnant
women were rarely prescribed BBW
drugs that are contra-indicated during
pregnancy. The researchers conclude
that, to minimize drug-associated risks,
BBWs must be clearly communicated to
both clinicians and patients.
Project Title: The CERTs Prescribing
Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11832
Principal Investigator: Richard Platt,
M.D., M.Sc.
Reference:Wagner AK, Chan KA,
Dashevsky I, Raebel MA, Andrade SE,
Lafata JE, Davis RL, Gurwitz JH,
Soumerai SB, Platt R. FDA drug
prescribing warnings: is the black box
half empty or half full?
Pharmacoepidemiol Drug Saf 2005
Nov 18 [In press, available in electronic
form].
Most people have difficulty
understanding pharmaceutical
label instructions, regardless of
their cultural background and
level of education. Pharmaceutical
labels that give dosage instructions can
be difficult to understand. AHRQ
researchers investigated the errors in
understanding instructions on
pharmaceutical labels by subjects of
different cultural and educational
backgrounds. Labels of three
medications of varying complexities
were used in the study: oral rehydration
therapy, cough medicine, and fever
medicine. The results indicated that all
subjects had considerable difficulty in
interpreting pharmaceutical labels,
independent of the cultural background
and level of education. The authors
suggest that the instructions be
presented in a simplified manner and in
multiple forms to meet the needs of
multiple groups and communities.
Project Title: Mining Complex Clinical
Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George
Hripcsak, M.D.
Reference: Patel VL, Branch T, Arocha
JF. Errors in interpreting quantities as
procedures: the case of pharmaceutical
labels. Int J Med Inform 2002 Nov
12;65(3):193-211.
Many chronically ill patients limit
use of prescription drugs because
of cost, but don't tell their
doctors. About two-thirds of
chronically ill adults who cut back on
their medications because of the cost
don't tell their doctors in advance.
AHRQ researchers surveyed 4,055
adults age 50 years and older taking
prescription medication for diabetes,
depression, heart problems, or high
cholesterol. Of these, 660 patients
reported forgoing some medication in
the prior year due to cost pressures, and
two-thirds of this group reported they
did not tell their clinicians in advance.
However, less than one-third of the
patients who spoke to their clinicians
about the cost of prescription drugs
reported being given information about
programs to assist patients with
medication costs or sources of lower-cost
refills.
Project Title: Automated Assessments
and the Quality of Diabetes Care
AHRQ Grant: HS10281
Principal Investigator: John Piette,
M.D.
Reference: Piette JD, Heisler M,
Wagner TH. Cost-related medication
underuse: Do patients with chronic
illnesses tell their doctors? Arch Intern
Med 2004 Sept. 13;164(16):1749-55.
Patients develop more positive
attitudes toward electronic health
care records and Web-based
communication. AHRQ researchers
found patients are becoming
increasingly satisfied by Web-based
communication with their health care
providers while having online access to
their electronic health care records.
Researchers conducted an online survey
of 4,282 members of the Geisinger
Health System who were registered users
of an application that allows patients to
communicate electronically with their
providers and view selected portions of
their EHR. They also conducted focus
groups with 25 patients using the
system and conducted one-on-one
interviews with 10 primary care
clinicians.
Project Title: Impact of EpiCare on the
Management of Diabetes in the
Geisinger Health System
Research Area: IDSRN
AHRQ Grant: 290-00-0003 TO#2
Principal Investigator: Andrea Hassol,
M.S.P.H.
Reference: Hassol A, Walker JM,
Kidder D, Rokita K, Young D, Pierdon
S, Deitz D, Kuck S, Ortiz E. Patient
experiences and attitudes about access to
a patient electronic healthcare record
and linked Web messaging. J Am Med
Inform Assoc 2004 Nov-Dec;11(6):505-13.
Video available to help providers
disclose bad news. AHRQ researchers
offer an ethical argument as to why a
serious harm-causing medical error must
be disclosed. All the mechanics of
disclosure, including the initial contact,
the meeting setting, who should be
present, framing the disclosure, how to
talk, empathizing, and follow-up are laid
out as a guideline. A video tool to
educate physicians and other medical
personnel about these guidelines is
available free of charge at
http://www.gha.org/pha/video/index.asp.
Project Title: Accountability and
Health Safety, a Statewide Approach
Research Area: R-DEMO
AHRQ Grant: HS11918
Principal Investigator: Kenneth
Thorpe, Ph.D.
Reference: Banja J. Why, what and how
ought harmed parties be told? The art,
mechanics, and ambiguities of error
disclosure. In: Hatlie M and Youngberg
B, editors. The Patient Safety Handbook.
Sudbury, MA.: Jones and Bartlett
Publishers; 2003. pp. 531-48.
Patients and physicians view
disclosure of medical errors
differently. AHRQ researchers
undertook to determine patients' and
physicians' attitudes about error
disclosure. Thirteen focus groups were
organized, including six groups of adult
patients, four groups of academic and
community physicians, and three
groups of both physicians and patients. A total of 52 patients and 46 physicians
participated. Patients wanted disclosure
of all harmful errors. Physicians agreed
that harmful errors should be disclosed
but that they should "choose their
words carefully." Patients also desired
emotional support from physicians
following errors, including an apology.
However, physicians worried that an
apology might create legal liability.
Physicians may not be providing the
information or emotional support that
patients seek following harmful medical
errors.
Project Title: Surveillance, Analysis, and
Interventions to Improve Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11898
Principal Investigator: Victoria Fraser,
M.D.
Reference: Gallagher TH, Waterman
AD, Ebers AG, Fraser VJ, Levinson W.
Patients' and physicians' attitudes
regarding the disclosure of medical
errors. JAMA 2003 Feb
26;289(8):1001-7.
Visual aids may improve the
accuracy of medication assessment
and may be especially beneficial
for patients with communication
barriers. AHRQ researchers performed
a study among long-term warfarin users
in an anticoagulation clinic to assess
concordance between patient and
clinician reports of patient warfarin
regimens. Bilingual research assistants
asked patients to verbalize their
prescribed weekly warfarin regimen, and
identify this regimen from a digitized
color menu of warfarin pills. Fifty
percent of patients achieved verbal
concordance, and 66 percent achieved
visual concordance with clinicians
regarding the weekly warfarin regimen.
Clinician/patient discordance regarding
patients' warfarin regimen was
common, but occurred less frequently
when patients identified their regimen
with a visual aid. Visual aids may
improve the accuracy of medication
assessment and may be especially
beneficial for patients with
communication barriers.
Project Title: Promoting Effective
Communication and Decisionmaking
in Diverse Populations
AHRQ Grant: HS10856
Principal Investigator: Eugene
Washington, M.D., M.Sc.
Reference: Schillinger D, Machtinger
EL, Wang F, Chen L-L, Win K, Palacios
J, Rodriguez M, Bindman A. Language,
literacy, and communication regarding
medication in an anticoagulation clinic:
are pictures better than words? In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to Implementation.
Vol. 2, Concepts and Methodology.
AHRQ Publication No. 05-0021-2.
Rockville, MD: Agency for Healthcare
Research and Quality; Feb 2005. pp.
191-212.
*Patient-provider communication
influences the resolution of adverse
medical events. Patient-provider
communication is essential to whether
patients and providers continue their
relationships, and it affects whether
patients perceive adverse events as
"mistakes" or "malpractice." AHRQ
researchers explored real-life patient-provider
communication after patients
experienced adverse medical events.
Prompt action and repeated reassurance
and support from providers helped
patients cope with the physical,
emotional, and financial trauma—and
the worries and frustration that follow
adverse events. All of the patients who
perceived providers as caring and
concerned reported positive post-incident
communication with providers. Health
organizations, providers, investigators,
and policymakers should consider the
patient experience when developing
training for providers or evaluating
adverse event resolution processes.
Project Title: Applied Strategies for
Improving Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11878
Principal Investigator: Wilson Pace,
M.D.
Reference: Duclos CW, Eichler M,
Taylor L, Quintela J, Main DS, Pace W, Staton EW. Patient perspectives of
patient-provider communication after
adverse events. Int J Qual Health Care 2005 Dec;17(6):479-86.
Techniques to reduce the incidence
of retained instruments and
sponges after surgery include
counting instruments and sponges
before and after the procedure,
and x-raying patients after surgery.
A surgical instrument or sponge is left
in more than 1,500 patients during
surgery each year. AHRQ researchers
studied 54 patients who had a total of
61 foreign bodies left inside them after
surgery. Of the 61 foreign bodies, 69
percent were sponges and 31 percent
were surgical instruments. They found
that patients who had emergency
surgery were nine times as likely to have
a sponge or surgical instrument left in
their body as patients undergoing the
same procedure on a nonemergency
basis. The risk increased by four times
for patients who had unplanned changes
in their procedure. The researchers note
that a number of techniques are
available to reduce these incidences,
including counting instruments and
sponges before and after the procedure,
and x-raying patients after surgery.
Project Title: Malpractice Insurers'
Medical Error Prevention Study
Research Area: R-DEMO
AHRQ Grant: HS11886
Principal Investigator: David M.
Studdert, M.D.
Reference: Gawande AA, Studdert
DM, Orav EJ, Brennan TA, Zinner MJ.
Risk factors for retained instruments
and sponges after surgery. N Engl J Med 2003 Jan 16;348(3):229-35.
Chlorhexidine gluconate reduces
the risk of catheter-related blood
stream infections by one-half
compared to povidone iodine and
can lead to reduced costs. More
than 150 million intravascular devices
are used annually in the United States,
including more than 5 million central
vascular catheter sites. However,
intravascular catheters can lead to
complications, such as catheter-related
bloodstream infection. AHRQ
researchers report that use of
chlorhexidine gluconate solution to
disinfect the central vascular catheter
insertion site reduces the risk of
catheter-related bloodstream infection
by one-half compared with povidone
iodine, and also leads to cost savings of
$113 per catheter used. They suggest
that the use of chlorhexidine in place of
povidone for vascular catheter site
disinfection is a simple and cost-effective
method of improving patient safety.
Project Title: Targeting Interventions to
Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Chaiyakunapruk N,
Veenstra DL, Lipsky BA, Sullivan SD,
Saint S. Vascular catheter site care: the
clinical and economic benefits of
chlorhexidine gluconate compared with
povidone iodine. Clin Infect Dis 2003
Sep 15;37(6):764-71.
For impregnated catheters,
minocycline/rifampin is more
effective and economical for
longer-term catheterization. Central
venous catheters impregnated with
minocycline/rifampin are known to be
clinically superior to chlorhexidine/silver
sulfadiazine impregnated catheters but
are more expensive. AHRQ researchers
reported that central venous catheters
coated with minocycline/rifampin are
cost-effective, compared with
chlorhexidine/silver sulfadiazine
impregnated catheters, for patients
catheterized for at least 1 week. They
also lead to overall cost savings when
patients are catheterized for 2 weeks or
longer. The expected duration of
catheterization should serve as a guiding
tool for the use of antimicrobial
catheters in high-risk patients.
Project Title: Targeting Interventions to
Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Marciante KD, Veenstra
DL, Lipsky BA, Saint S. Which
antimicrobial impregnated central
venous catheter should we use?
Modeling the costs and outcomes of
antimicrobial catheter use. Am J Infect
Control 2003 Feb;31(1):1-8.
Various methods can reduce
ventilator-associated pneumonia in
selected patients. Pneumonia severe
enough to require mechanical
ventilation is a common and highly
morbid condition occurring in about 10
to 25 percent of critically ill patients.
AHRQ researchers have done a
systematic review and synthesis of the
studies to prevent ventilator-associated
pneumonia. After evaluation of
potential benefits and risks, the authors
recommend several specific
interventions to reduce the incidence of
this condition: putting patients in a
semi-recumbent position, using
sucralfate rather than H2-antagonists to
prevent stress ulcers, aspirating
subglottic secretions, and using
oscillating beds to increase mobility of
lung secretions in selected patients.
Project Title: Targeting Interventions to
Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Collard HR, Saint S,
Matthay MA. Prevention of ventilator-associated
pneumonia: an evidence-based
systematic review. Ann Intern
Med 2003 Mar 18;138(6): 494-501.
Understanding barriers to clinician
use of PDAs is vital in evaluating
ways to overcoming those barriers.
PDAs can be a valuable resource for
ambulatory care, but many physicians
avoid using them at the point of care
due to their fear of patients' perceptions.
Although many physicians perceive that
patients disapprove of physicians' use of
PDAs, AHRQ researchers found that most patients are not averse to doctors
using handheld devices. Rather, patients
hold favorable attitudes toward
physicians' use of PDAs, even among
patients who are not computer literate.
However, AHRQ researchers found that
providing these survey data to
physicians did not lead to significant
increases in physicians' use of handhelds
in the presence of patients.
Project Title: Improving Primary Care
Patient Safety with Handheld Decision
Support Systems
Research Area: CLIPS
AHRQ Grant: HS11820
Principal Investigator: Eta Berner,
Ed.D.
Reference: Berner ES, Savage GT,
Houston TK, Williams ES, Crawford
MA, Ray MN. Impact of patient
feedback on residents' handheld
computer use: a multi-site study.
Medinfo 2004;11(Pt 1):582-6.
*Missing clinical information may
lead to adverse events and delays
in services in outpatient primary
care. AHRQ researchers collected
point-of-care data during patient visits
from 253 clinicians across 32 primary
care practices on the type, frequency,
and consequences of missing clinical
information. Among 1,614 clinical
visits, clinicians reported that important
information was missing in 13.6 percent
of cases (220 visits). Among these visits,
the most common types of missing
information were lab and radiology
results (45% and 28.2%, respectively),
letters or dictation containing clinical
information (39.5%), and patient
history or physical exam findings
(26.8%). Clinicians reported that
potential adverse outcomes due to
missing clinical information were at
least somewhat likely in 44 percent of
these visits, and clinicians with
completely electronic medical records
("full EMRs") were significantly less
likely to report missing clinical
information than their peers with paper-based
or partially electronic records.
Project Title: Applied Strategies for
Improving Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11878
Principal Investigator: Wilson Pace,
M.D.
Reference: Smith PC, Araya-Guerra R,
Bublitz C, Parnes B, Van Vorst R,
Westfall JM, Pace WD. Missing clinical
information during primary care visits.
JAMA 2005 Feb 2;293(5):565-71.