A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Project Final Report (PDF, 724.69 KB) Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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Project Details -
Completed
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Grant NumberR18 HS017020
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AHRQ Funded Amount$1,193,376
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Principal Investigator(s)
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Organization
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LocationBuffaloNew York
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Project Dates09/07/2007 - 11/30/2010
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Technology
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Care Setting
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Population
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Type of Care
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Health Care Theme
Medication safety is known to be a major problem in ambulatory primary care and existing methodologies to address this issue have had limited success. This project used an analysis based on failure modes and effects in a primary care setting to address this issue. Practices, including safety net practices, with pre-existing electronic medical records (EMRs) were recruited from within a local practice-based research network. The primary outcome measures were adverse drug events (ADEs) in adults 65 and older, ascertained using a trigger tool chart review methodology at two 12-month periods, pre and post intervention. The project also developed and pilot-tested a Web-based implementation of a Team Resource Management (TRM) intervention aimed at improving medication safety in primary care.
The objectives of this study were to:
- Examine the impact of an information technology (IT)-based TRM intervention on reducing selected ADEs among geriatric patients in primary care.
- Examine the impact of an IT-based TRM intervention on improving monitoring for geriatric patients taking selected chronic medications in primary care.
- Evaluate office staff use and application of the IT-based TRM Tool for improving geriatric medication safety in primary care settings.
The study achieved its main aims of developing and implementing a Web-based TRM in a variety of ambulatory settings. The main outcome was a trend toward a decrease in the rate of ADEs in the intervention group over time, in contrast to the control group which showed no such trend. This pilot study was limited by small size and short followup period, and by weaknesses of the trigger tool methodology for measuring ADEs. Nevertheless, it achieved its aim of demonstrating successful implementation of a Web-based TRM in busy primary care practices. The team hopes that future studies will test the intervention on a larger scale over a longer period of time, and will explore methods for overcoming common barriers faced.
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Citation:
Singh R, Anderson D, McLean-Plunkett E, et al. Effects of self-empowered teams on rates of adverse drug events in primary care. Int J Family Med 2012; 2012:374639. Epub 2012 Feb 16.
Principal Investigator:
Singh, Gurdev
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Journal Publication
Research Method:
Randomized Controlled Trial (RCT)
Technology:
Bar Coding, Registry
Citation:
Singh R, Anderson D, McLean-Plunkett E, et al. IT-enabled systems engineering approach to monitoring and reducing ADEs. Am J Manag Care 2012 Mar;18(3):169-75.
Principal Investigator:
Singh, Gurdev
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Journal Publication
Research Method:
Randomized Controlled Trial (RCT)
Technology:
Bar Coding, Registry
Citation:
Singh G. A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT - Final Report. (Prepared by State University of New York at Buffalo under Grant No. R18 HS017020). Rockville, MD: Agency for Healthcare Research and Quality, 2011.
Link:
PDF (724.69 KB)
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator:
Singh, Gurdev
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Report
Technology:
Bar Coding, Registry
Population:
Elderly, Minority Populations
Citation:
Singh R, Singh A, Anumba C, et al. Enhancing and measuring patient safety with an innovative web-based systems approach. Intl Jnl Adv Int Paradigms 2011; 3(2):164-77.
Principal Investigator:
Singh, Gurdev
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Journal Publication
Research Method:
Descriptive
Technology:
Bar Coding, Registry
Disclaimer
Disclaimer details
Description:
The Adverse Drug Events Trigger Tool standardizes the chart review process for ADEs.
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Logging Tool
Description:
The Primary Care Visual Medication Error Reporting Tool is a tool using pictures/diagrams to be used in the reporting of errors.
Project Name:
A Systems Engineering Approach: Improving Medication Safety with Clinician Use of Health IT
Document Type:
Logging Tool
Disclaimer
Disclaimer details