National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (19)
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- Simulation (2)
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- Social Determinants of Health (1)
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- Surgery (31)
- Surveys on Patient Safety Culture (5)
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- TeamSTEPPS (2)
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- Transitions of Care (9)
- Trauma (2)
- Treatments (1)
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- Urinary Tract Infection (UTI) (4)
- Vaccination (1)
- Women (5)
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- Workforce (2)
- Young Adults (1)
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
51 to 75 of 176 Research Studies DisplayedJones KJ, Crowe J, Allen JA
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
The purpose of this study was to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture. The investigators concluded that post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles were likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Crowe J, Allen JA .
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
BMC Health Serv Res 2019 Sep 9;19(1):650. doi: 10.1186/s12913-019-4453-y..
Keywords: TeamSTEPPS, Falls, Adverse Events, Surveys on Patient Safety Culture, Patient Safety, Hospitals, Teams
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
AHRQ-funded; HS024596.
Citation: Kapoor A, Field T, Handler S .
Adverse events in long-term care residents transitioning from hospital back to nursing home.
JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Zhang AD, Schwartz JL, Ross JS
Association between Food and Drug Administration Advisory Committee recommendations and agency actions, 2008-2015.
In this paper, the authors examined the association between Food and Drug Administration Advisory Committee Recommendations and agency actions for a time period of 2008-2015. The investigators concluded that the FDA disagrees with the recommendations of its advisory committees a minority of the time, and in these cases it tends to be less likely to approve new products or supplemental indications and take safety actions.
AHRQ-funded; HS022882.
Citation: Zhang AD, Schwartz JL, Ross JS .
Association between Food and Drug Administration Advisory Committee recommendations and agency actions, 2008-2015.
Milbank Q 2019 Sep;97(3):796-819. doi: 10.1111/1468-0009.12403..
Keywords: Medical Devices, Policy, Patient Safety
McCarthy DM, Russell AM , Effler MR
Implementation fidelity of patient-centered prescription label to promote opioid safe use.
The authors assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording. They found that exact intervention adherence was not achieved in the majority of cases, limiting impact, but that community pharmacies were responsive to new instructions, with higher implementation reliability requiring additional supports.
AHRQ-funded; HS023459.
Citation: McCarthy DM, Russell AM , Effler MR .
Implementation fidelity of patient-centered prescription label to promote opioid safe use.
Pharmacoepidemiol Drug Saf 2019 Sep;28(9):1251-57. doi: 10.1002/pds.4795..
Keywords: Opioids, Patient Safety, Health Literacy, Medication, Provider: Pharmacist, Provider
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Knox CA, Hampp C, Palmsten K
Validation of mother-infant linkage using Medicaid Case ID variable within the Medicaid Analytic eXtract (MAX) database.
The authors established and validated an algorithm within the Medicaid Analytic eXtract (MAX) that links mothers to infants and to identify factors influencing successful mother-infant linkage. They found that their algorithm can correctly link liveborn infants to their mothers, with linkage performance being associated with certain characteristics that may affect representativeness of successfully linked pairs.
AHRQ-funded; HS022384.
Citation: Knox CA, Hampp C, Palmsten K .
Validation of mother-infant linkage using Medicaid Case ID variable within the Medicaid Analytic eXtract (MAX) database.
Pharmacoepidemiol Drug Saf 2019 Sep;28(9):1222-30. doi: 10.1002/pds.4843..
Keywords: Caregiving, Medicaid, Newborns/Infants, Patient Safety, Pregnancy
Chopra V, Kaatz S, Swaminathan L
Variation in use and outcomes related to midline catheters: results from a multicentre pilot study.
This study examined complication rates from placement of midline vascular catheters. They have become more common in use recently. Complications were analyzed using medical records from hospitalized patients in 12 hospitals from January 2017 to February 2018. Most midline catheters were placed in general ward settings for difficult intravenous access. About half were removed within 5 days of insertion. Major or minor complications occurred in 10.3% of midlines with minor complications accounting for 71% of all adverse events. These minor complications included dislodgement, leaking, and infiltration. Major complications included occlusion, upper-extremity DVT and BSI. Use of midlines and outcomes varied widely across hospitals.
AHRQ-funded; HS025891.
Citation: Chopra V, Kaatz S, Swaminathan L .
Variation in use and outcomes related to midline catheters: results from a multicentre pilot study.
BMJ Qual Saf 2019 Sep;28(9):714-20. doi: 10.1136/bmjqs-2018-008554..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Infectious Diseases, Adverse Events, Practice Patterns, Outcomes, Hospitals
Wang E, Kang H, Gong Y
Generating a health information technology event database from FDA MAUDE reports.
This study examined using a health information technology (HIT) event database to identify patient safety events (PSEs) or medical errors. The study used the FDA Manufacturer and User Facility Device Experience (MAUDE) database to extract HIT events. Classic and CNN models were utilized on a test set. The model was capable of identifying HIT event with about a 90% accuracy.
AHRQ-funded; HS022895.
Citation: Wang E, Kang H, Gong Y .
Generating a health information technology event database from FDA MAUDE reports.
Stud Health Technol Inform 2019 Aug 21;264:883-87. doi: 10.3233/shti190350..
Keywords: Health Information Technology (HIT), Medical Devices, Adverse Events, Data, Medical Errors, Patient Safety
Nguyen BP, Reese T, Decker S
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
The authors report on the implementation and evaluation of CDS Services which represent potential drug-drug interactions knowledge with Clinical Quality Language (CQL). Their suggested solution is based on emerging standards including CDS Hooks, FHIR, and CQL. They selected two use cases, implemented them with CQL rules, and tested them.
AHRQ-funded; HS023826; HS025984.
Citation: Nguyen BP, Reese T, Decker S .
Implementation of clinical decision support services to detect potential drug-drug interaction using clinical quality language.
Stud Health Technol Inform 2019 Aug 21;264:724-28. doi: 10.3233/shti190318..
Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Medication, Adverse Events, Patient Safety, Health Information Technology (HIT)
Liang C, Miao Q, Kang H
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
The present study sought to explore the associations between federal incentives of patient safety research and the outcomes from 1995 to 2014, in which two historical events - the release of To Err Is Human and the American Recovery and Reinvestment Act - were considered in the analysis. They concluded that their findings suggested a positive outcome in patient safety research.
AHRQ-funded; HS022895.
Citation: Liang C, Miao Q, Kang H .
Leveraging patient safety research: efforts made fifteen years since To Err Is Human.
Stud Health Technol Inform 2019 Aug 21;264:983-87. doi: 10.3233/shti190371..
Keywords: Patient Safety, Medical Errors, Adverse Events, Clinical Decision Support (CDS), Health Information Technology (HIT)
Klock M, Kang H, Gon Y
Scoring patient fall reports using quality rubric and machine learning.
Employing AHRQ’s rubric for assessing the quality of fall reports, the authors compared three different machine-learning models and identified the most effective method for scoring fall reports. They intend that their study results will be applicable in healthcare facilities to score reports during reporting for reporters to improve report quality. Their ultimate goal is to increase learning from fall reports for better prevention of patient falls.
AHRQ-funded; HS022895.
Citation: Klock M, Kang H, Gon Y .
Scoring patient fall reports using quality rubric and machine learning.
Stud Health Technol Inform 2019 Aug 21;264:639-43. doi: 10.3233/shti190301..
Keywords: Falls, Patient Safety, Prevention, Quality of Care, Quality Improvement
Henderson WG, Bronsert MR, Hammermeister KE
Refining the predictive variables in the "Surgical Risk Preoperative Assessment System" (SURPAS): a descriptive analysis.
The authors systematically evaluated eight issues to improve the Surgical Risk Preoperative Assessment System (SURPAS). They found that refinements to SURPAS were successful in improving accuracy. They developed graphical displays of risk for providers and patients, including a take-home handout and automated documentation of risk in the electronic health record in order to facilitate easier implementation of SURPAS.
AHRQ-funded; HS024124.
Citation: Henderson WG, Bronsert MR, Hammermeister KE .
Refining the predictive variables in the "Surgical Risk Preoperative Assessment System" (SURPAS): a descriptive analysis.
Patient Saf Surg 2019 Aug 20;13:28. doi: 10.1186/s13037-019-0208-2..
Keywords: Patient Safety, Risk, Surgery
Yao B, Kang H, Gong Y
Data quality assessment of narrative medication error reports.
This study examined the data quality of patient safety event (PSE) reports that are used to analyze the root causes of PSE. If the data quality is poor then the reporting and root cause analysis (RCA) will also be poor. Incomplete or missing data is the most prevalent problem in these reports. The researchers used an adapted taxonomy to assess the data quality of PSE reports, and extracted sample reports based on eight error types. The extracts were scored by experts. They found that most structured fields were ignored by reporters, but the narrative parts of the reports contained rich and valuable information. The results show that the adapted taxonomy could be a promising tool for report quality assessment and improvement.
AHRQ-funded; HS022895.
Citation: Yao B, Kang H, Gong Y .
Data quality assessment of narrative medication error reports.
Stud Health Technol Inform 2019 Aug 9;265:101-06. doi: 10.3233/shti190146..
Keywords: Adverse Drug Events (ADE), Medication, Medical Errors, Adverse Events, Data, Patient Safety
Anderson DJ, Watson S, Moehring RW
Feasibility of core antimicrobial stewardship interventions in community hospitals.
The purpose of this study was to determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals. The two antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy.
AHRQ-funded; HS023866.
Citation: Anderson DJ, Watson S, Moehring RW .
Feasibility of core antimicrobial stewardship interventions in community hospitals.
The purpose of this study was to determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals. The two antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy..
Keywords: Antibiotics, Antimicrobial Stewardship, Healthcare-Associated Infections (HAIs), Hospitals, Infectious Diseases, Medication, Patient Safety
Sobieraj DM, Martinez BK, Hernandez AV
Adverse effects of pharmacologic treatments of major depression in older adults.
The objective of this study was to assess adverse effects of pharmacologic antidepressants for treatment of major depressive disorder (MDD) in adults 65 years of age or older. The investigators found, among other conclusions, that in patients 65 years of age or older with MDD, treatment of the acute phase of MDD with serotonin norepinephrine reuptake inhibitors (SNRIs), but not selective serotonin reuptake inhibitors (SSRIs), was associated with a statistically greater number of overall adverse events vs placebo.
AHRQ-funded; 290201500012I.
Citation: Sobieraj DM, Martinez BK, Hernandez AV .
Adverse effects of pharmacologic treatments of major depression in older adults.
J Am Geriatr Soc 2019 Aug;67(8):1571-81. doi: 10.1111/jgs.15966..
Keywords: Depression, Behavioral Health, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Elderly
Balk EM, Adam GP, Corsi K
Adverse events associated with nonsurgical treatments for urinary incontinence in women: a systematic review.
Investigators systematically reviewed nonsurgical interventions for urgency, stress, or mixed urinary incontinence (UI) in women, focusing on adverse events (AEs). They found that behavioral therapies and neuromodulation have a low risk of adverse events, while anticholinergics and alpha agonists have high rates of dry mouth and constitutional effects. Further, onabotulinum toxin A (BTX) is associated with UTIs and voiding dysfunction, and periurethral bulking agents are associated with erosion and voiding dysfunction. They concluded that these AEs should be considered when selecting appropriate UI treatment options, noting that AE reporting is inconsistent and that AE rates across studies tended to vary widely.
AHRQ-funded; 290201500002.
Citation: Balk EM, Adam GP, Corsi K .
Adverse events associated with nonsurgical treatments for urinary incontinence in women: a systematic review.
J Gen Intern Med 2019 Aug;34(8):1615-25. doi: 10.1007/s11606-019-05028-0.
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Keywords: Adverse Events, Patient Safety, Women, Evidence-Based Practice, Patient-Centered Outcomes Research
Odell DD, Quinn CM, Matulewicz RS
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.
The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. In this study, the investigators examined the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes. The authors found, among other results that operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive).
AHRQ-funded; HS024516.
Citation: Odell DD, Quinn CM, Matulewicz RS .
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.
J Am Coll Surg 2019 Aug;229(2):175-83. doi: 10.1016/j.jamcollsurg.2019.02.046..
Keywords: Hospitals, Patient Safety, Quality of Care, Quality Improvement, Outcomes, Surgery, Surveys on Patient Safety Culture
Brunsberg KA, Landrigan CP, Garcia BM
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
The objective of this paper was to determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. Results of this prospective cohort study showed that resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors, indicating the importance of determining what interventions might mitigate the patient safety risk.
AHRQ-funded; HS019456.
Citation: Brunsberg KA, Landrigan CP, Garcia BM .
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
Acad Med 2019 Aug;94(8):1150-56. doi: 10.1097/acm.0000000000002778..
Keywords: Children/Adolescents, Provider: Physician, Provider, Medical Errors, Adverse Events, Burnout, Patient Safety, Depression, Behavioral Health
Libertucci J, Bassis CM, Cassone M
Bacteria detected in both urine and open wounds in nursing home residents: a pilot study.
Researchers sought to determine if bacterial species colonizing open wounds are also found in the urine. Their pilot study of nursing home residents provided evidence that bacterial species identified within the urine can also be identified in open wounds in the same patient at one point in time. They recommended further studies to investigate if these species are of the same lineage and if the urinary microbiota are able to seed colonization of open wounds below the umbilicus.
AHRQ-funded; HS019767.
Citation: Libertucci J, Bassis CM, Cassone M .
Bacteria detected in both urine and open wounds in nursing home residents: a pilot study.
mSphere 2019 Aug 28;4(4). doi: 10.1128/mSphere.00463-19..
Keywords: Elderly, Nursing Homes, Long-Term Care, Healthcare-Associated Infections (HAIs), Injuries and Wounds, Patient Safety
Hefner JL, Fareed N, Walker DM
Central line infections in United States hospitals: an exploration of variation in central line device days and infection rates across hospitals that serve highly complex patient populations.
Am J Infect Control 2019 Aug;47(8):1032-34. doi: 10.1016/j.ajic.2018.12.001.
The authors’ descriptive analyses show a wide distribution in rates of central line device days and central line-associated bloodstream infections for a given standardized infection ratio among 215 US hospitals serving highly complex patient populations. They established that the standardized infection ratio masks hospital-level variation in device use and associated patient safety.
The authors’ descriptive analyses show a wide distribution in rates of central line device days and central line-associated bloodstream infections for a given standardized infection ratio among 215 US hospitals serving highly complex patient populations. They established that the standardized infection ratio masks hospital-level variation in device use and associated patient safety.
AHRQ-funded; HS024958.
Citation: Hefner JL, Fareed N, Walker DM .
Central line infections in United States hospitals: an exploration of variation in central line device days and infection rates across hospitals that serve highly complex patient populations.
Am J Infect Control 2019 Aug;47(8):1032-34. doi: 10.1016/j.ajic.2018.12.001..
Keywords: Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Patient Safety
Wooldridge A, Carayon P, Hoonakker P
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, the investigators combined interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity.
AHRQ-funded; HS023837.
Citation: Wooldridge A, Carayon P, Hoonakker P .
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Cogn Technol Work 2019 Aug;21(3):397-416. doi: 10.1007/s10111-018-0520-0..
Keywords: Care Coordination, Children/Adolescents, Critical Care, Health Services Research (HSR), Healthcare Delivery, Inpatient Care, Patient Safety, Teams, Trauma, Young Adults
Auger KA, Shah SS, Davis MM
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission. In this paper, the authors sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents.
AHRQ-funded; HS024735.
Citation: Auger KA, Shah SS, Davis MM .
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
J Hosp Med 2019 Aug;14(8):506-07. doi: 10.12788/jhm.3213..
Keywords: Children/Adolescents, Medication, Medication: Safety, Patient Safety, Hospital Discharge, Hospitals
Li Y, Cen X, Cai X
Perceived patient safety culture in nursing homes associated with "Nursing Home Compare" performance indicators.
This study examined the association between the use of “Nursing Home Compare” performance indicators and improved patient safety culture in nursing homes. A survey was conducted in 2017 using AHRQ’s Survey on Patient Safety Culture for Nursing Homes which collects data on 12 core domains of safety culture scores. Out of 2254 nursing homes sampled, there was a response rate of 36%. It was found that for every 10 percentage points increase in overall positive response rate for safety culture, there was an association with 0.56 fewer health care deficiencies, 0.74 fewer substantiated complaints, reduced fines by $2285.20, and 20% increased odds of being designed as 4-star or 5-star.
AHRQ-funded; HS024923.
Citation: Li Y, Cen X, Cai X .
Perceived patient safety culture in nursing homes associated with "Nursing Home Compare" performance indicators.
Med Care 2019 Aug;57(8):641-47. doi: 10.1097/mlr.0000000000001142..
Keywords: Surveys on Patient Safety Culture, Patient Safety, Nursing Homes, Quality Indicators (QIs), Quality Measures, Quality of Care, Provider Performance
Kates AE, Zimbric ML, Mitchell K
The impact of chlorhexidine gluconate on the skin microbiota of children and adults: a pilot study.
The authors examined the effect of chlorhexidine gluconate bathing on the skin microbiota of adult and pediatric patients. They observed no differences in pediatric patients, but multiple genera of bacteria were observed to be significantly less abundant in adults. They recommended further research to determine long-term impact.
AHRQ-funded; HS024039.
Citation: Kates AE, Zimbric ML, Mitchell K .
The impact of chlorhexidine gluconate on the skin microbiota of children and adults: a pilot study.
Am J Infect Control 2019 Aug;47(8):1014-16. doi: 10.1016/j.ajic.2019.01.024..
Keywords: Children/Adolescents, Skin Conditions, Healthcare-Associated Infections (HAIs), Prevention, Patient Safety
Glick AF, Brach C, Yin HS
AHRQ Author: Brach C
Health literacy in the inpatient setting: implications for patient care and patient safety.
This article considers how health literacy plays a part in events that lead up to children's hospitalizations both during hospital admission and after discharge. The authors discussed interventions that incorporate health-literacy-informed strategies and that target patients, families, and health care systems that should be implemented to improve patient outcomes and patient-centered and family-centered care.
AHRQ-authored.
Citation: Glick AF, Brach C, Yin HS .
Health literacy in the inpatient setting: implications for patient care and patient safety.
Pediatr Clin North Am 2019 Aug;66(4):805-26. doi: 10.1016/j.pcl.2019.03.007..
Keywords: Children/Adolescents, Health Literacy, Hospital Discharge, Hospitalization, Hospitals, Inpatient Care, Patient Safety