AHRQ turns quality focus to medication administrative systems

New research by the Agency for Healthcare Research and Quality is looking for ways to streamline health information technology systems to reduce medical errors.

To further this AHRQ project, Raj Ratwani, an associate professor at the Georgetown University School of Medicine in Washington, is investigating ways to develop health IT tools and processes that help doctors keep patients safe while maximizing quality and efficiency.


AHRQ is part of the Department of Health and Human Services and has the mission of making healthcare safer, of higher quality, more accessible, equitable and affordable.

The goal is to work with clinicians to reduce the risk of medical errors by improving how health IT systems operate. “We have been able to develop machine learning algorithms to identify health IT-related usability and safety issues from patient safety event reports,” Ratwani explains.

“Safety analysts are using the algorithms to identify relevant usability and safety issues in their reporting systems so they will know where to focus improvement issues. The outputs from these algorithms are being used by other researchers as a foundation for their work to advance usability and safety methods and improve health IT more generally,” he adds.

Such work to improve has been ongoing for several years. Ratwani started his work at AHRQ investigating ways to reduce distractions to the flow of care delivered by emergency department personnel. Emergency physicians are frequently interrupted, which disrupts workflow and can increase patient safety risks—to mitigate this, Ratwani developed scenarios to help clinicians use specific cognitive strategies to mitigate disruptions.

Further work covered analyzing events associated with electronic health record usability and identifying design and implementation improvements to address the issues. Usability affects patient care, because studies show that EHR errors such as data entry and interoperability issues contribute to patient harm.

Now, Ratwani is assessing hazards with electronic medication administration records and the IT systems that are intended to support how medications are provided to patients. These systems can cause gaps in communication and information flow that could result in medication errors. Consequently, Ratwani and a group of colleagues are working now to better understand the role of these systems, and they’re building prototypes to address gaps inherent in current IT systems.