Patient Safety Learning Labs Advance Research and Practice

Today’s Headlines:

• Patient Safety Learning Labs Advance Research and Practice.
• Now Available: Updates to AHRQ’s Compendium of U.S. Health Systems.
• New Report Details Trends in Adverse Events Among Medicare Patients.
• New Insights on Pediatric Mental Health in Emergency Departments.
• Catch Up on Recent AHRQ Webinars.
• Register for Upcoming Webinars.
• AHRQ Stats: Prevalence of Chronic Conditions or Obesity Among U.S. Adults by Sex.  
• AHRQ in the Professional Literature.

Patient Safety Learning Labs Advance Research and Practice

AHRQ’s Patient Safety Learning Lab (PSLL) program has been advancing patient safety research and practice since 2014. In a new Journal of Patient Safety supplement, AHRQ authors present the value and impact of PSLLs and introduce a dozen publications generated by these innovative projects. These papers showcase how diverse teams—clinicians, engineers, data scientists, and other experts—work together to develop and test system- and policy-level solutions to serious safety challenges. This special journal supplement includes studies on the following topics, among others: 

• Emergency department medication reconciliation and mental/behavioral health.
• Interruptions during trauma care.
• Clinical decision support failures.
• Telehealth and readmission safety.
• Clinician communication.
• Interfacility neonatal transportation.

 Access the journal supplement to learn more about PSLLs and their unique contributions to patient safety research and improvement.

Now Available: Updates to AHRQ’s Compendium of U.S. Health Systems

AHRQ’s Compendium of U.S. Health Systems, the first publicly available database to track trends in health system affiliation and consolidation over time, has been updated with three new files: 

• Two new 2023 Compendium files for nursing homes and home healthcare organizations that provide information on location, system affiliation, and ownership for nearly 15,000 nursing homes and 13,000 home healthcare organizations.
• An updated version of the 2023 System file with new variables that provide information on system ownership of Medicare Advantage plans. 

Access the new 2023 Compendium data and Compendium data from previous years.

New Report Details Trends in Adverse Events Among Medicare Patients

A new AHRQ report, Adverse Events Among Medicare Hospitalizations in 2021–2023, presents national findings from the Quality and Safety Review System. The analysis captures more than 40 types of adverse events through systematic review of inpatient Medicare records from rural, targeted urban, critical access, and other acute care hospitals. Key findings of the report include the following: 

•  Between 2021 and 2023, the share of Medicare patients with at least one adverse event per hospital stay declined from 7.1 percent to 5.2 percent, while the overall rate of adverse events dropped from 83.1 to 59.4 per 1,000 discharges.
• Across all 3 years, medication events, pressure injuries/ulcers, and hospital-acquired infections represented about 80 percent of adverse events.
• Critical access hospitals consistently showed the lowest occurrence of adverse events compared with other hospital types. 

Read the full report for detailed data on adverse event trends across hospital types.

New Insights on Pediatric Mental Health in Emergency Departments

AHRQ-Funded Studies Examine Emergency Department Visits for Children With Mental and Behavioral Conditions 

Two AHRQ-funded studies offer insight into the experience of children with mental and behavioral health (MBH) conditions in the emergency department (ED). One article, published in the Journal of Patient Safety, found based on interviews with 55 staff members from 4 ED departments that self-harm, harm to others, and elopement were critical safety concerns for pediatric MBH patients. The ED environment was seen as a trigger for patient agitation, exacerbating MBH conditions. A second study, published in BMC Health Services Research, explored how often children at risk for MBH conditions visit hospital EDs. The study analyzed data from the 2019 National Health Interview Survey and found that children at higher risk for MBH conditions were more likely to visit the ED. 

Study Identifies Suggestions To Improve Care for Children in Mental Health Emergencies 

Constant observation of children admitted to the ED with serious mental health issues is a critical but challenging component to ensuring safer care, according to an AHRQ-funded study. While continuous observation helps prevent harm, such as self-injury, some patients feel anxious or angry about being watched all the time. In addition, staff conducting constant observation can be exposed to aggressive or unpredictable behavior. Through interviews with 55 members of ED teams, including patient observers, researchers examined how constant observation affects care, staff, and workflow. The study includes recommendations, including better ED design, de-escalation training, and therapeutic engagement to improve safety and care for children experiencing mental health emergencies. Access the abstract in Evidence-Based Practice in Child and Adolescent Mental Health.

Catch Up on Recent AHRQ Webinars

Benefits of CAUTI Prevention Program: Recording Available 

The AHRQ Safety Program for Healthcare-Associated Infection (HAI) Prevention is recruiting adult intensive and nonintensive care units for its next cohort focused on preventing catheter-associated urinary tract infections (CAUTI). During informational webinars held October 3 and 28, lead subject matter expert Bradford Winters, Ph.D., M.D., presented program details and outlined how evidence-based practices can help hospitals reduce CAUTI rates. He highlighted key program benefits, including expert coaching, monthly educational webinars, implementation support, benchmarking reports, free CME/CEU credits, and a flexible data collection process. In response to attendee questions, Dr. Winters emphasized that involving a multidisciplinary team and an external expert familiar with the targeted adverse event—such as an infection preventionist—can strengthen a team’s success in preventing HAIs. Visit the website to register for upcoming webinars on December 2, December 11, January 13, and January 22, or download presentation materials to learn more about participation benefits. Apply for the program by January 30, 2026. 

Medical Expenditure Panel Survey Components 

AHRQ’s Medical Expenditure Panel Survey (MEPS) is the most complete source of data on the cost and use of healthcare and insurance coverage. An August webinar, “Overview of Two MEPS (IC and HC) Components,” discussed the two components of the MEPS data collection project. During this event, program leader Anita Soni, Ph.D., M.B.A., highlighted how the MEPS Insurance Component (IC) partners with the U.S. Census Bureau to collect information about Employer-Sponsored Insurance (ESI) from public and private entities about insurance offerings, eligibility, enrollments, premiums, and deductibles; and how the MEPS Household Component (HC) collects healthcare use and expenditures data from thousands of households across the United States. While it was not recorded, the webinar answered participant questions related to data variables, and access to data files, and questions related to data analyses. Compiled data from both components is available through a variety of publications and files, along with a series of tools that allow users to analyze and compare trends across high-priority topics.

Register for Upcoming Webinars

• AHRQ Safety Program for HAI Prevention: CAUTI Informational Webinar:
  • December 2, 10:30–11 a.m. ET.
  • December 11, 11:30 a.m.–12 p.m. ET.
  • January 13, 3–3:30 p.m. ET.
  • January 22, 2–2:30 p.m. ET.
• December 17, 1:30–3 p.m. ET: Prepping for the Future: Digital Solutions for Aging Populations.

AHRQ Stats: Prevalence of Chronic Conditions or Obesity Among U.S. Adults by Sex

Women aged 18–64 had the highest combined prevalence of obesity or any chronic condition in 2022, with 75.1 percent diagnosed with at least one overall. By comparison, 67.6 percent of men aged 18–64 were impacted by obesity or any chronic condition that year. (Source: AHRQ Medical Expenditure Panel Survey Research Findings #52, Combined Prevalence of Chronic Conditions or Obesity for Adults in 2022.)

AHRQ in the Professional Literature

Delabeling antibiotic allergy in the solid organ transplant population using a multiple antibiotic allergy evaluation strategy. Lee R, Koo G, Krantz MS, et al. Transpl Infect Dis 2025 Sep-Oct;27(5):e70099. Epub 2025 Sep 11. Access the abstract on PubMed®. 

Do not wait to challenge children: Results of a standard operating procedure for low-risk antibiotic challenges. Koo G, Sundar A, Woodward KB, et al. Ann Allergy Asthma Immunol 2025 Jun;134(6):736–8. Epub 2025 Mar 13. Access the abstract on PubMed®. 

ADHD medication and depressive symptoms in adolescents: a retrospective longitudinal study. Krantz LB, Froehlich TE, Beck AF, et al. Acad Pediatr 2025 Sep-Oct;25(7):102863. Epub 2025 Jun 6. Access the abstract on PubMed®. 

Development of the SMART Toolkit: an online collection of management resources for health care-associated infection prevention. Rush LJ, MacEwan SR, Hebert C, et al. Am J Infect Control 2025 Sep;53(9):997–1000. Epub 2025 Jun 5. Access the abstract on PubMed®. 

Pricing and insurance networks in outpatient surgery markets. Zhao X, Whaley CM, Munnich EL, et al. Am J Manag Care 2025 Oct;31(10):571–4. Access the abstract on PubMed®. 

Development of a patient-facing clinical decision support application for hypertension. Bobo M, Canfield SM, Shaffer V, et al. Appl Clin Inform 2025 Aug;16(4):1298–1309. Access the abstract on PubMed®. 

Does family-centered care coordination improve outcomes for children enrolled in early intervention services? An analysis of Colorado's GO4IT initiative. Lindrooth RC, Murphy NJ, Devoss R, et al. Health Serv Res 2025 Oct;60(5):e14634. Epub 2025 May 12. Access the abstract on PubMed®. 

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance. Hannum SM, Oladapo-Shittu O, Salinas AB, et al. Antimicrob Steward Healthc Epidemiol 2023 Apr 11;3(1):e69. Access the abstract on PubMed®.