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AHRQ Study Examines Adverse Drug Events Caused by Medication Administration Errors

Electronic Newsletter, Issue 352

The AHRQ Electronic Newsletter is issued periodically and summarizes Agency research and programmatic activities.

August 17, 2012

AHRQ Stats

Between 1999 and 2009, the number of Americans prescribed anticonvulsant drugs almost doubled, rising from 8.6 million to 15.2 million, while spending increased from $3.3 billion to $10.6 billion. [Source: Agency for Healthcare Research and Quality, MEPS Statistical Brief #372: Trends in Anticonvulsants Utilization and Expenditures for the U.S. Civilian Noninstitutionalized Population, 1999 and 2009.]

Today's Headlines

  1. AHRQ study examines adverse drug events caused by medication administration errors.
  2. AHRQ's Health Care Innovations Exchange focuses on innovative payment policies.
  3. Collaborative care may help patients with depression and other illnesses.
  4. Research review compares first- and second-generation antipsychotics in adults.
  5. New Web page for evaluation of CHIPRA quality demonstration grant program .
  6. AHRQ launches its new Facebook page.
  7. Learn about HCUP via webinar series—registration to open soon.
  8. AHRQ in the professional literature.

1. AHRQ Study Examines Adverse Drug Events Caused by Medication Administration Errors

A new study funded by AHRQ found that additional interventions are needed to prevent adverse drug events (ADEs) caused by administration errors in a hospital setting. "Adverse Drug Events Caused by Serious Medication Administration Errors," was published online July 12 in the British Medical Journal of Quality & Safety. Of the estimated 6 million doses administered at hospitals each year, about 4,000 preventable ADEs could be attributed to medication administration errors. The high incidence and cost implications for ADEs due to medication administration errors justify the need to target interventions to prevent these errors in a hospital setting. Select to access the abstract on PubMed.®

2. AHRQ's Health Care Innovations Exchange Focuses on Innovative Payment Policies

Three examples of innovative payment policies are featured in the August 15 issue of AHRQ's Health Care Innovations Exchange. They include an insurer's contracting program in Massachusetts; a New York medical center's accountable care organization that works to reduce health care costs and improve quality; and a multispecialty center in Maine that uses innovative payment policies to enhance access to care among low-income patients. True North Health Center, a standalone, practitioner-run, multispecialty center in Maine, enhanced access to conventional and alternative health care services, particularly for low-income individuals. The program has generated high satisfaction and retention among practitioners and staff. The Innovations Exchange Web site, which contains more than 700 searchable innovations and 1,525 QualityTools, now includes health care policy innovations in addition to health care service delivery innovations. Select to access the new inclusion criteria.

3. Collaborative Care May Help Patients with Depression and Other Illnesses

Collaborative care interventions may improve outcomes for depression symptoms, remission, depression-free days, and quality of life in primary care patients experiencing both depression and other chronic medical conditions, according to a new research review from AHRQ's Effective Health Care Program. Little evidence was available on the effect of collaborative care treatment on medical outcomes for arthritis, cancer, diabetes, heart disease, and HIV, except for HbA1c (a measurement of blood sugar) in diabetes, which showed no difference between collaborative care treatment and usual care. The review, Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting, recommends that future studies examine a broader range of medical conditions and compare variations of practice-based interventions.

4. Research Review Compares First- and Second-Generation Antipsychotics in Adults

Few differences of clinical importance for outcomes related to effectiveness were found in a new review of first-generation and second-generation antipsychotics for adults with schizophrenia, schizophrenia-related psychoses, or bipolar disorder. The review, from AHRQ's Effective Health Care Program, also found that outcomes such as death and quality of life were rarely assessed, and that data comparing side effects were sparse. Inconsistency in treatment comparisons, outcomes, outcome measurements, and patient populations across studies made drawing firm conclusions difficult. However, the research review provides extensive details of characteristics and methodological features of the studies that may help inform individual treatment decisions. Select to access Antipsychotics in Adults: Comparative Effectiveness of First-Generation versus Second-Generation Medications.

5. New Web Page for Evaluation of CHIPRA Quality Demonstration Grant Program

A new AHRQ Web page offers information about the national evaluation of a Quality Demonstration Grant Program to identify effective strategies for enhancing quality and delivery of care for children. The grant program, which funds efforts in 18 states, was funded by the Children's Health Program Reauthorization Act of 2009 (CHIPRA), and AHRQ is overseeing its national evaluation. The new AHRQ Web page includes descriptions of the 51 projects being implemented, which fall into these categories:

  • Using quality measures to improve child health care.
  • Applying health information technology for quality improvement.
  • Implementing provider-based delivery models.
  • Investigating a model format for pediatric electronic health records (EHRs).
  • Assessing the utility of other innovative approaches to enhance quality.

Select to learn more as the projects progress and to sign up for ongoing Email updates.

6. AHRQ Launches Its New Facebook Page

AHRQ's new Facebook page  is now live. Like our page and be kept up-to-date about what is new from AHRQ. With links to the latest campaigns, publications, reports, and more, you'll be among the first to know what is new in health care quality and safety. We encourage everyone with a Facebook page to "like" us. Remember to share our posts with your friends too!

7. Learn About HCUP via Webinar Series—Registration To Open Soon

AHRQ will host a two-part webinar series on the Healthcare Cost and Utilization Project (HCUP) databases, product, and tools. Registration details will appear soon on the HCUP User Support Web site. Registration is limited and capacity is often reached quickly. The webinar covers:

  • Overview of the HCUP Databases, introducing health services and policy researchers to the HCUP databases and related resources that can enhance their research studies. The webinar provides a general overview of the HCUP databases. The webinar will be held on August 29 from 2:00 p.m. to 3:00 p.m. ET. Registration for this webinar will open on August 22 at 8:00 a.m. ET.
  • Overview of the HCUP Products and Tools will explain the HCUP products and tools that facilitate research, with a particular emphasis on HCUPnet, the free online data query system. The webinar will be held on September 12 from 2:00 p.m.—3:00 p.m. ET. Registration for this webinar will open on September 5 at 8:00 a.m. ET.

8. AHRQ in the Professional Literature

We are providing the following hyperlinks to journal abstracts through PubMed® for your convenience. Access to the abstracts may be blocked because of firewalls or specific settings on individual computer systems. If you experience problems in accessing articles, ask your technical support staff for possible remedies.

Wohlauer MV, Arora VM, Horwitz LI, et al. The patient handoff: a comprehensive curricular blueprint for resident education to improve continuity of care. Acad Med 2012 Apr; 87(4):411-18. Select to access the abstract on PubMed.®

Glance LG, Dick AW, Mukamel DB, et al. Association between trauma quality indicators and outcomes for injured patients. Arch Surg 2012 Apr; 147(4):308-15. Select to access the abstract on PubMed.®

Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. J Nurs Care Qual 2012 Apr-Jun; 27(2):99-108. Select to access the abstract on PubMed.®

Cooper PF, Manski RJ, Pepper JV. The effect of dental insurance on dental care use and selection bias. Med Care 2012 Apr 19 [Epub ahead of print.] Select to access the abstract on PubMed.®

Greiner MA, Hammill BG, Fonarow GC, et al. Predicting costs among Medicare beneficiaries with heart failure. Am J Cardiol 2012 Mar 1; 109(5):705-11. Select to access the abstract on PubMed.®

Profit J, Etchegaray J, Petersen LA, et al. Neonatal intensive care unit safety culture varies widely. Arch Dis Child Fetal Neonatal Ed 2012 Mar; 97(2):F120-F126. Select to access the abstract on PubMed.®

McCullough BJ, Johnson GR, Martin BI, et al. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology 2012 Mar; 262(3):941-6. Select to access the abstract on PubMed.®

Contact Information

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Page last reviewed August 2012
Internet Citation: AHRQ Study Examines Adverse Drug Events Caused by Medication Administration Errors: Electronic Newsletter, Issue 352. August 2012. Agency for Healthcare Research and Quality, Rockville, MD.


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