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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
1 to 25 of 187 Research Studies DisplayedParikh K, Hall M, Tieder JS
Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals.
A retrospective cohort study using the 2019 Kids' Inpatient Database found disparities in pediatric safety events. Black and Hispanic children had significantly higher odds in 5 of 7 safety indicators compared to white children, especially in postoperative sepsis and respiratory failure. Medicaid-covered children also showed higher odds in 4 of 7 indicators compared to privately insured children, highlighting the need for targeted interventions to enhance hospital patient safety, particularly among minority and Medicaid-covered populations.
AHRQ-funded; HS028484.
Citation: Parikh K, Hall M, Tieder JS .
Disparities in racial, ethnic, and payer groups for pediatric safety events in US hospitals.
Pediatrics 2024 Mar; 153(3):e2023063714. doi: 10.1542/peds.2023-063714.
Keywords: Healthcare Cost and Utilization Project (HCUP), Disparities, Racial and Ethnic Minorities, Children/Adolescents, Patient Safety, Hospitals
Auerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Loi MV, Lee JH, Huh JW
Ketamine use in the intubation of critically ill children with neurological indications: a multicenter retrospective analysis.
This study examined use of ketamine in children undergoing tubal intubation (TI) for a primary neurological indication. The authors conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. They screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Of 21,562 TIs, 2,073 were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020. Criteria for ketamine use includes a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) TIs and were more common in the ketamine group (17.0% vs. 13.0%). After adjusting for location, patient age and co-diagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes. This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%).
AHRQ-funded; HS022464, HS024511.
Citation: Loi MV, Lee JH, Huh JW .
Ketamine use in the intubation of critically ill children with neurological indications: a multicenter retrospective analysis.
Neurocrit Care 2024 Feb; 40(1):205-14. doi: 10.1007/s12028-023-01734-0.
Keywords: Children/Adolescents, Critical Care, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Ali KJ, Goeschel CA, DeLia DM
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
The authors conducted a literature review and interviewed subject matter experts to develop a multi-component Payer Relationships for Improving Diagnoses (PRIDx) framework. The PRIDx framework can be used to encourage public and private payers to take specific actions to improve diagnostic safety. The authors noted that implementation of the PRIDx framework will require new types of partnerships, including external support from public and private payer organizations, and also require the creation of strong provider incentives.
AHRQ-funded; 2332015000221.
Citation: Ali KJ, Goeschel CA, DeLia DM .
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
https://www.pubmed.ncbi.nlm.nih.gov/37795579.
Keywords: Diagnostic Safety and Quality, Quality of Care, Patient Safety
Hendren S, Ameling J, Rocker C
Validation of measures for perioperative urinary catheter use, urinary retention, and urinary catheter-related trauma in surgical patients.
This article described a retrospective cohort study to analyze the effects of non-infectious urinary catheter-related complications, such as measurements of indwelling urinary catheter overuse, catheter-related trauma, and urinary retention. Participants were 200 patients who were undergoing general surgery operations; 65% had an indwelling urinary catheter placed at the time of surgery, 16% had urinary retention, and 6% had urinary trauma. The authors concluded that this study suggests a persistent high rate of catheter use, significant rates of urinary retention and trauma, and variation in the management of retention.
AHRQ-funded; HS026912.
Citation: Hendren S, Ameling J, Rocker C .
Validation of measures for perioperative urinary catheter use, urinary retention, and urinary catheter-related trauma in surgical patients.
Am J Surg 2024 Feb; 228:199-205. doi: 10.1016/j.amjsurg.2023.09.027.
Keywords: Surgery, Adverse Events, Patient Safety
Newman-Toker DE, Nassery N, Schaffer AC
Burden of serious harms from diagnostic error in the USA.
Americans who experience serious harm from misdiagnosis annually. Serious harm is defined as permanent morbidity or morality. This cross-sectional analysis used nationally representative observational data. The authors estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). US-based cancer registries were used to find annual new cancers. They derived diagnostic errors and serious harms by multiplying by literature-based rates for disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories). Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), they estimated total serious harms annually in the USA to be 795,000 (plausible range 598,000-1,023,000). Using more conservative assumptions they estimated 549,000 serious harms. These results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. Fifteen dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.
AHRQ-funded; HS027614; HS029350.
Citation: Newman-Toker DE, Nassery N, Schaffer AC .
Burden of serious harms from diagnostic error in the USA.
BMJ Qual Saf 2024 Jan 19; 33(2):109-20. doi: 10.1136/bmjqs-2021-014130..
Keywords: Healthcare Cost and Utilization Project (HCUP), Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality of Care, Adverse Events
MohammadiGorji S, Joseph A, Mihandoust S
Anesthesia workspaces for safe medication practices: design guidelines.
The purpose of this study was to create a set of evidence-based design guidelines for the design of anesthesia workspaces to support safer anesthesia medication tasks in operating rooms (ORs). The researchers collected data through literature review, observation, and coding of prerecorded videos of outpatient surgical procedures to identify challenges encountered by anesthesia providers while performing medication tasks. The study findings were summarized into 7 design guidelines, including: 1) locate critical tasks within a primary field of vision, 2) eliminate other staff travel into and through the anesthesia zone, 3) identify and delineate a clear anesthesia zone with adequate space for the anesthesia provider, 4) maximize the ability to reconfigure the anesthesia workspace, 5) minimize workspace clutter from equipment, 6) provide adequate and appropriately positioned surfaces for medication preparation and administration, and 7) optimize lighting of tasks and surfaces.
AHRQ-funded.
Citation: MohammadiGorji S, Joseph A, Mihandoust S .
Anesthesia workspaces for safe medication practices: design guidelines.
HERD 2024 Jan; 17(1):64-83. doi: 10.1177/19375867231190646..
Keywords: Medication: Safety, Medication, Patient Safety
Cohen TN, Berdahl CT, Coleman BL
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
This study’s objective was to understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. The authors randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. Results showed that among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Seven of these events were linked to COVID-19.
AHRQ-funded; HS027455.
Citation: Cohen TN, Berdahl CT, Coleman BL .
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
J Nurs Care Qual 2024 Jan-Mar; 39(1):51-57. doi: 10.1097/ncq.0000000000000720..
Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors
Quinn M, Horowitz JK, Krein SL
The role of hospital-based vascular access teams and implications for patient safety: a multi-methods study.
The purpose of this study was to examine the roles, functions, and composition of vascular access teams (VATs) related to the use and management of PICC and midline catheters. The researchers administered an online survey of 62 hospitals participating in a quality improvement consortium and qualitative interviews with 74 hospital-based clinicians in 10 sites. The study found that more than 77% of hospitals had an on-site VAT. The average team size was seven nurses; their main function was device insertion. Findings from the interviews revealed variations in team characteristics and functions. Interviewees characterized the broad role that teams play in device insertion, care, and removal, and in educating/training hospital staff. The researchers found that teams' role in decision making, especially related to appropriate device selection, was limited an was met with physician resistance in some cases.
AHRQ-funded; HS025891.
Citation: Quinn M, Horowitz JK, Krein SL .
The role of hospital-based vascular access teams and implications for patient safety: a multi-methods study.
J Hosp Med 2024 Jan; 19(1):13-23. doi: 10.1002/jhm.13253..
Keywords: Patient Safety, Inpatient Care, Cardiovascular Conditions
Berbakov ME, Hoffins EL, Stone JA
AHRQ-funded; HS028475.
A study team collaborated with Aurora Pharmacy, Inc. to develop Senior Safe, a community pharmacy-based intervention designed to increase awareness of safe over-the-counter medication use for older adults. Senior Safe was adapted through pilot testing and a randomized control trial before a finalized version was provided to Aurora Pharmacy to integrate into all its pharmacy sites. The authors concluded that this multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.
AHRQ-funded; HS024490; HS027737.
Citation: Berbakov ME, Hoffins EL, Stone JA .
AHRQ-funded; HS028475.
J Am Pharm Assoc 2024 Jan-Feb; 64(1):159-68. doi: 10.1016/j.japh.2023.11.009.
Keywords: Medication, Medication: Safety, Provider: Pharmacist, Patient Safety, Community-Based Practice
Pacheco TB, Hettinger AZ, Ratwani RM
Identifying potential patient safety issues from the federal electronic health record surveillance program.
This research letter analyzed HHS’ Office of the National Coordinator (ONC) surveillance data on electronic health records (EHRs) to determine whether these vendor products may potentially create patient harm. The researchers analyzed records from 195 vendors and identified 3.7% total product IDs having a nonconformity issue that could be a contributing factor to a patient harm event. However, it is unknown whether these IDs might actually result in patient harm.
AHRQ-funded; HS025136; HS023701.
Citation: Pacheco TB, Hettinger AZ, Ratwani RM .
Identifying potential patient safety issues from the federal electronic health record surveillance program.
JAMA 2019 Dec 17;322(23):2339-40. doi: 10.1001/jama.2019.17242..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Venema DM, Skinner AM, Nailon R
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.
AHRQ-funded; HS021429.
Citation: Venema DM, Skinner AM, Nailon R .
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
BMC Geriatr 2019 Dec 11;19(1):348. doi: 10.1186/s12877-019-1368-8..
Keywords: Falls, Injuries and Wounds, Patient Safety, Elderly, Risk, Hospitals, Adverse Events
McCarthy DM, Curtis LM, Courtney DM
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Despite increased focus on opioid prescribing, little is known about the influence of prescription opioid medication information given to patients in the emergency department (ED). The objective of this study was to evaluate the effect of an Electronic Medication Complete Communication (EMC(2)) Opioid Strategy on patients' safe use of opioids and knowledge about opioids. The study found that the EMC(2) tools improved demonstrated safe dosing, but these benefits did not translate into actual use based on medication dairies. The text-messaging intervention did result in improved patient knowledge.
AHRQ-funded; HS023459.
Citation: McCarthy DM, Curtis LM, Courtney DM .
A multifaceted intervention to improve patient knowledge and safe use of opioids: results of the ED EMC(2) randomized controlled trial.
Acad Emerg Med 2019 Dec;26(12):1311-25. doi: 10.1111/acem.13860..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Health Literacy, Education: Patient and Caregiver, Clinician-Patient Communication, Communication, Health Information Technology (HIT)
Napolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Patel SA, Araujo T, Rodriguez LP
Long peripheral catheters: a retrospective review of major complications.
The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, the investigators did a retrospective review of major complications. Among other discoveries, they found LPCs were often placed for the indications of difficult access and long-term antibiotics.
AHRQ-funded; HS025891.
Citation: Patel SA, Araujo T, Rodriguez LP .
Long peripheral catheters: a retrospective review of major complications.
J Hosp Med 2019 Dec;14(12):758-60. doi: 10.12788/jhm.3313..
Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Patient Safety, Central Line-Associated Bloodstream Infections (CLABSI), Blood Clots, Infectious Diseases, Risk
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Ailabouni NJ, Marcum ZA, Schmader KE
Medication use quality and safety in older adults: 2018 update.
This study identified four key articles from 2018 that address medication use quality and safety for older adults. The first study highlighted a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and doctors to deprescribe four types of inappropriate medications. The second study from the UK examined the association between anticholinergic exposure, overall and by medication class, and dementia risk in 40,770 older adults. The third study was a Swedish longitudinal cohort study examining the association between antihypertensive medications and incident dementia. The fourth and last study was a randomized, double-blind, placebo-controlled trial and examined the effect of daily low-dose aspirin for primary prevention of cardiac events and hemorrhage in 19,144 community-dwelling older adults.
AHRQ-funded; HS022982.
Citation: Ailabouni NJ, Marcum ZA, Schmader KE .
Medication use quality and safety in older adults: 2018 update.
J Am Geriatr Soc 2019 Dec;67(12):2458-62. doi: 10.1111/jgs.16243..
Keywords: Elderly, Medication, Medication: Safety, Patient Safety, Quality of Care, Provider: Pharmacist, Provider
Campione JR, Mardon RE, McDonald KM
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
Researchers investigated the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting. Using survey data from the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database, they found that the most frequent problem was "results from a lab or imaging test were not available when needed," with 15% of respondents reporting that it happened daily or weekly. Higher overall culture scores were significantly associated with fewer occurrences of each problem assessed, and offices in the process of health IT implementation had higher frequency of problems.
AHRQ-funded; 290201200003I.
Citation: Campione JR, Mardon RE, McDonald KM .
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
J Patient Saf 2019 Dec;15(4):267-73. doi: 10.1097/pts.0000000000000531..
Keywords: Surveys on Patient Safety Culture, Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety, Ambulatory Care and Surgery
Bushnell GA, Crystal S, Olfson M
Prescription benzodiazepine use in privately insured U.S. children and adolescents.
The goal of this cohort study was to describe youth initiating prescription benzodiazepine treatment, identify potential indications and prescribing concerns, estimate the duration of treatment by potential indication, and identify factors that predict long-term use. Investigators found that U.S. children and adolescents are prescribed benzodiazepines for various mental health and other medical conditions, many lacking evidence of pediatric efficacy. They concluded that long-term benzodiazepine treatment, concurrent opioid prescriptions, psychotropic use, and prior substance use disorder diagnoses suggest safety risks among some youth prescribed benzodiazepines.
AHRQ-funded; HS026001; HS021112; HS023258.
Citation: Bushnell GA, Crystal S, Olfson M .
Prescription benzodiazepine use in privately insured U.S. children and adolescents.
Am J Prev Med 2019 Dec;57(6):775-85. doi: 10.1016/j.amepre.2019.07.006..
Keywords: Children/Adolescents, Medication, Medication: Safety, Patient Safety
Gaufberg E, Olmsted MW, Bell SK
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
The authors discuss an AHRQ conference held to establish a research agenda on patient and family emotional harm after medical errors. Topics include implications for quality and safety, educational innovation, and qualitative research.
AHRQ-funded; HS024463.
Citation: Gaufberg E, Olmsted MW, Bell SK .
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
J Med Humanit 2019 Dec;40(4):489-504. doi: 10.1007/s10912-019-09563-z..
Keywords: Medical Errors, Adverse Events, Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety
Krein SL, Kuhn L, Ratz D
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
The authors identified the prevalence of and factors associated with having a designated nurse peripherally inserted central catheter (PICC) team among U.S. acute care hospitals. They found that nurse PICC teams inserted PICCs in more than 60% of U.S. hospitals during the study period. Moreover, certain practices to prevent central line-associated bloodstream infection, including maximum sterile barrier precautions, chlorhexidine gluconate for insertion site antisepsis, and facility-wide insertion checklists were regularly used by a higher percentage of hospitals with nurse PICC teams compared with those without. They concluded that nurse PICC teams play an integral role in PICC use at many hospitals and that use of such teams may promote key practices to prevent complications.
AHRQ-funded; HS022835.
Citation: Krein SL, Kuhn L, Ratz D .
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
J Patient Saf 2019 Dec;15(4):293-95. doi: 10.1097/pts.0000000000000246..
Keywords: Nursing, Teams, Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Inpatient Care, Hospitals, Patient Safety, Prevention, Provider: Nurse, Provider
Khan A, Yin HS, Brach C
AHRQ Author: Brach C
Association between parent comfort with English and adverse events among hospitalized children.
The purpose of this study was to examine the association between parents’ limited comfort with English (LCE) and adverse events in a cohort of hospitalized children. Participants included Arabic-, Chinese-, English-, and Spanish-speaking parents of patients 17 years and younger in the pediatric units of seven North American hospitals. Findings showed that hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.
AHRQ-authored; AHRQ-funded; HS022986.
Citation: Khan A, Yin HS, Brach C .
Association between parent comfort with English and adverse events among hospitalized children.
JAMA Pediatr 2020 Dec;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215..
Keywords: Children/Adolescents, Caregiving, Cultural Competence, Clinician-Patient Communication, Communication, Adverse Events, Patient Safety, Inpatient Care, Hospitalization