National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (13)
- Ambulatory Care and Surgery (1)
- Behavioral Health (1)
- Clinician-Patient Communication (4)
- Communication (11)
- Education: Continuing Medical Education (1)
- Emergency Department (1)
- Healthcare Costs (1)
- Health Insurance (1)
- Hospital Discharge (1)
- Hospitals (2)
- Labor and Delivery (2)
- Medical Errors (15)
- (-) Medical Liability (26)
- Patient-Centered Healthcare (1)
- Patient and Family Engagement (1)
- Patient Safety (17)
- Policy (4)
- Practice Patterns (1)
- Pregnancy (1)
- Prevention (1)
- Primary Care (2)
- Provider (1)
- Provider Performance (1)
- Quality of Care (3)
- Risk (3)
- Surgery (2)
- Transitions of Care (1)
- Women (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
1 to 25 of 26 Research Studies DisplayedShapiro J, Robins L, Galowitz P
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
The authors developed an "Ask-Tell-Ask" model and materials to guide the disclosure coaching process. In this paper, they described a comprehensive approach to coaching developed over years of coaching experience that incorporates their model, its rationale, step-by-step coaching strategies and guidance, and organizational considerations regarding implementation of a coaching program to support patient-centered transparent communication after harmful events.
AHRQ-funded; HS019531.
Citation: Shapiro J, Robins L, Galowitz P .
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
J Patient Saf 2021 Dec 1;17(8):e1364-e70. doi: 10.1097/pts.0000000000000491..
Keywords: Clinician-Patient Communication, Communication, Medical Liability, Patient Safety
Antunez AG, Saari A, Miller J
Patient preferences in cases of inter-system medical error discovery (IMED).
This study looked at patients’ preferences in reporting by physicians when there are medical errors, both self-discovered by the physician, and for inter-system medical error discoveries (IMEDs). Telephone interviews were conducted with 30 patient volunteers from Michigan from January to March 2018. Two medical vignettes were presented, one involving a single physician discovering their own error and the other involving an IMED scenario. Analysis showed that patients considered IMED essentially equivalent to self-discovered errors, and strongly preferred disclosure for both scenarios. Patients said they would likely take certain actions following disclosure of another physician’s error, ranging from confronting the physician to changing providers to taking legal action.
AHRQ-funded; HS026030.
Citation: Antunez AG, Saari A, Miller J .
Patient preferences in cases of inter-system medical error discovery (IMED).
Ann Surg 2021 Mar;273(3):516-22. doi: 10.1097/sla.0000000000003507..
Keywords: Medical Errors, Adverse Events, Medical Liability, Clinician-Patient Communication, Communication
Arbaje AI, Werner NE, Kasda EM
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
This study used malpractice claims data to evaluate safety risks during care transitions from hospital to home and to help develop care transitions planning tools and pilot test them. The authors analyzed closed malpractice claims for 230 adult patients discharged from 4 hospital sites. Two structured focus groups were also conducted for stakeholders to review concerns. This led to the development of two care transitions planning tools – one for patients/caregivers and one for healthcare providers. Feasibility on 53 patient discharges were tested for both tools. A total of 33 risk factors corresponding to hospital work system elements, care transitions processes, and care outcomes were found using qualitative analysis. Providers found the tool easy to use and patients felt the length and response of the tool was acceptable.
AHRQ-funded; HS022916; HS019519.
Citation: Arbaje AI, Werner NE, Kasda EM .
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
J Patient Saf 2020 Mar;16(1):52-57. doi: 10.1097/pts.0000000000000238.
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Keywords: Medical Liability, Transitions of Care, Risk, Hospital Discharge, Hospitals, Patient Safety
Terp S, Wang B, Burner E
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
This study analyzed civil monetary penalties resulting from Emergency Medical and Treatment Act (EMTALA) violations involving psychiatric emergencies from 2002 to 2018. Psychiatric treatment settlements are larger with the average settlement being $85,488 compared to $32,004 for non-psychiatric-related cases. Five of six of the largest settlements during the study period were psychiatric-related. The penalties were for failure to provide appropriate medical screening examinations, receive stabilizing treatment, or arrange appropriate transfer. Almost half (41%) occurred in the Southeast Region and 20% in the Central region.
AHRQ-funded; HS022402; HS025281.
Citation: Terp S, Wang B, Burner E .
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
Acad Emerg Med 2019 May;26(5):470-78. doi: 10.1111/acem.13710..
Keywords: Emergency Department, Medical Errors, Medical Liability, Behavioral Health, Quality of Care
Gallagher TH, Mello MM, Sage WM
Can communication-and-resolution programs achieve their potential? Five key questions.
Communication-and-resolution programs (CRPs) are intended to promote accountability, transparency, and learning after adverse events. In this article the authors address five key challenges to the programs' future success: implementation fidelity, the evidence base for CRPs and their link to patient safety, fair compensation of harmed patients, alignment of CRP design with participants' needs, and public policy on CRPs.
AHRQ-funded; HS024504.
Citation: Gallagher TH, Mello MM, Sage WM .
Can communication-and-resolution programs achieve their potential? Five key questions.
Health Aff 2018 Nov;37(11):1845-52. doi: 10.1377/hlthaff.2018.0727..
Keywords: Adverse Events, Communication, Medical Liability
Yu H, Greenberg M, Haviland A
The impact of state medical malpractice reform on individual-level health care expenditures.
This study aims to fill the evidence gap concerning the effect of different types of malpractice reform by examining the general population, not a subgroup or a specific health condition, and controlling for individual-level sociodemographic and health status. It found that only two of the 10 major state-level malpractice reforms had significant impacts on the growth of individual-level health expenditures.
AHRQ-funded; HS023336.
Citation: Yu H, Greenberg M, Haviland A .
The impact of state medical malpractice reform on individual-level health care expenditures.
Health Serv Res 2017 Dec;52(6):2018-37. doi: 10.1111/1475-6773.12789.
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Keywords: Healthcare Costs, Policy, Medical Liability, Policy
Schiff GD, Reyes Nieva H, Griswold P
Addressing ambulatory safety and malpractice: the Massachusetts PROMISES Project.
The researchers assembled a coalition of safety, regulatory, malpractice, and academic groups and recruited 25 primary care practices of which 16 were selected to receive a multifaceted improvement intervention. They describe how they developed and fielded the intervention, delineating some of the lessons learned in the course of the project and implications for future efforts in this field.
AHRQ-funded; HS019508.
Citation: Schiff GD, Reyes Nieva H, Griswold P .
Addressing ambulatory safety and malpractice: the Massachusetts PROMISES Project.
Health Serv Res 2016 Dec;51 Suppl 3:2634-41. doi: 10.1111/1475-6773.12621.
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Keywords: Patient Safety, Medical Liability, Primary Care
Mello MM, Greenberg Y, Senecal SK
Case outcomes in a communication-and-resolution program in New York hospitals.
The researchers sought to determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery. They concluded that the bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.
AHRQ-funded; R18 HS019505.
Citation: Mello MM, Greenberg Y, Senecal SK .
Case outcomes in a communication-and-resolution program in New York hospitals.
Health Serv Res 2016 Dec;51 Suppl 3:2583-99. doi: 10.1111/1475-6773.12594.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Surgery
Mello MM, Armstrong SJ, Greenberg Y
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
The researchers sought to implement a communication-and-resolution program (CRP) in a setting in which liability insurers and health care facilities must collaborate to resolve incidents involving a facility and separately insured clinicians. They found that sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP.
AHRQ-funded; HS019531.
Citation: Mello MM, Armstrong SJ, Greenberg Y .
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
Health Serv Res 2016 Dec;51 Suppl 3:2550-68. doi: 10.1111/1475-6773.12580.
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Keywords: Communication, Medical Errors, Medical Liability, Patient Safety
Helmchen LA, Lambert BL, McDonald TB
Changes in physician practice patterns after implementation of a communication-and-resolution program.
The researchers tested if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories. They found that the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.
AHRQ-funded; HS019565.
Citation: Helmchen LA, Lambert BL, McDonald TB .
Changes in physician practice patterns after implementation of a communication-and-resolution program.
Health Serv Res 2016 Dec;51 Suppl 3:2516-36. doi: 10.1111/1475-6773.12610.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Practice Patterns
Gallagher TH, Farrell ML, Karson H
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
The Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. After describing the process, the authors concluded that the CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Farrell ML, Karson H .
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
Health Serv Res 2016 Dec;51 Suppl 3:2569-82. doi: 10.1111/1475-6773.12557.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Patient Safety, Quality of Care
Gallagher TH, Etchegaray JM, Bergstedt B
Improving communication and resolution following adverse events using a patient-created simulation exercise.
The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Etchegaray JM, Bergstedt B .
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Health Serv Res 2016 Dec;51 Suppl 3:2537-49. doi: 10.1111/1475-6773.12601.
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Keywords: Adverse Events, Clinician-Patient Communication, Medical Errors, Medical Liability, Patient-Centered Healthcare, Patient Safety
Battles JB, Reback KA, Azam I
AHRQ Author: Battles JB, Reback KA, Azam I
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
AHRQ launched the Patient Safety and Medical Liability (PSML) initiative in 2009. The papers in this issue cover a breadth of topics related to the PSML initiative. Members of the individual Demonstration project teams have authored the majority of the papers. Seven of these papers report outcomes associated with the individual Demonstrations and another four describe tools generated as a part of the interventions.
AHRQ-funded; 233201500029P.
Citation: Battles JB, Reback KA, Azam I .
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
Health Serv Res 2016 Dec;51 Suppl 3:2401-13. doi: 10.1111/1475-6773.12632.
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Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety, Prevention
Ridgely MS, Greenberg MD, Pillen MB
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
This article identifies lessons learned from the experience of AHRQ’s Patient Safety and Medical Liability (PSML) Demonstration Program. The demonstration lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm.
AHRQ-funded; 290200710073T.
Citation: Ridgely MS, Greenberg MD, Pillen MB .
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
Health Serv Res 2016 Dec;51 Suppl 3:2414-30. doi: 10.1111/1475-6773.12625.
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Keywords: Patient Safety, Medical Liability, Adverse Events, Medical Errors
Lambert BL, Centomani NM, Smith KM
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
This study's objective was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes. It found that the intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs. The study found that a communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.
AHRQ-funded; HS019565.
Citation: Lambert BL, Centomani NM, Smith KM .
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2491-515. doi: 10.1111/1475-6773.12548.
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Keywords: Adverse Events, Medical Liability, Medical Errors, Communication, Patient Safety
Sage WM, Jablonski JS, Thomas EJ
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
The researchers sought to determine the frequency of nondisclosure agreements in medical malpractice settlements and the extent to which the restrictions in these agreements seem incompatible with good patient care. They found that an academic health system with a declared commitment to patient safety and transparency used nondisclosure clauses in most malpractice settlement agreements but with little standardization or consistency.
AHRQ-funded; HS019561.
Citation: Sage WM, Jablonski JS, Thomas EJ .
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
JAMA Intern Med 2015 Jul;175(7):1130-5. doi: 10.1001/jamainternmed.2015.1035..
Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety
Pradarelli JC, Campbell DA, Dimick JB
Hospital credentialing and privileging of surgeons: a potential safety blind spot.
Taylor v Intuitive, the first of at least 26 lawsuits against Intuitive, went to trial alleging injuries or death tied to the da Vinci Surgical System, a new robotic surgical system. This discussion of the events surrounding the case of Taylor v Intuitive highlights the importance of hospitals’ credentialing and privileging mechanisms for maintaining the quality and safety of surgical care, especially regarding new technologies for which practicing surgeons may not have formal training.
AHRQ-funded; HS017765.
Citation: Pradarelli JC, Campbell DA, Dimick JB .
Hospital credentialing and privileging of surgeons: a potential safety blind spot.
JAMA 2015 Apr 7;313(13):1313-4. doi: 10.1001/jama.2015.1943..
Keywords: Patient Safety, Surgery, Education: Continuing Medical Education, Medical Liability, Hospitals
Singer SJ, Reyes Nieva H, Brede N
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
This study reports findings from the baseline practice staff and administrator surveys designed as part of the PROMISES Project to assess safety and malpractice risks in the ambulatory setting. It found that administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems were related to staff perceptions of their quality.
AHRQ-funded; HS019508.
Citation: Singer SJ, Reyes Nieva H, Brede N .
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
Med Care 2015 Feb;53(2):141-52. doi: 10.1097/mlr.0000000000000269..
Keywords: Ambulatory Care and Surgery, Patient Safety, Medical Liability, Provider
Santos P, Ritter GA, Hefele JL
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
The researchers conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births), while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births).
AHRQ-funded; HS019608.
Citation: Santos P, Ritter GA, Hefele JL .
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
J Healthc Risk Manag 2015;34(4):20-7. doi: 10.1002/jhrm.21168..
Keywords: Labor and Delivery, Patient Safety, Risk, Medical Liability, Medical Errors
Hendrich A, McCoy CK, Gale J
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
This article presents a case study concerning challenges, including physician resistance, to the establishment of a common full disclosure protocol at five labor and delivery demonstration sites. Twenty-seven months after implementation, the rate of full disclosure had increased by 221 percent. Practitioners saw a number of factors as key catalysts for change including consistent and ongoing leadership by local practitioners and hospitals.
AHRQ-funded; HS019608.
Citation: Hendrich A, McCoy CK, Gale J .
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
Health Aff 2014 Jan;33(1):39-45. doi: 10.1377/hlthaff.2013.1009..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Labor and Delivery, Medical Errors, Medical Liability, Policy, Pregnancy, Women
Kachalia A, Little A, Isavoran M
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
The Oregon Health Authority analyzed the potential for safe harbors to improve patient safety and the performance of the medical liability system, as well as legal challenges and stakeholder concerns that might arise with legislation enacting safe harbors. They found that such legislation would have changed the liability outcome in favor of the physician defendant in only 1 percent of 266 claims from the period 2002–09 that were reviewed.
AHRQ-funded; HS019535.
Citation: Kachalia A, Little A, Isavoran M .
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
Health Aff 2014 Jan;33(1):59-66. doi: 10.1377/hlthaff.2013.0834..
Keywords: Patient Safety, Medical Liability, Medical Errors, Quality of Care, Policy
Sage WM, Gallagher TH, Armstrong S
How policy makers can smooth the way for communication-and- resolution programs.
The authors argue that State and federal policy makers should try to allay potential defendants’ fears of litigation (e.g., by protecting apologies from use in court), facilitate patient participation (e.g., by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (e.g., by clarifying practices governing National Practitioner Data Bank reporting and payers’ financial recourse following medical error).
AHRQ-funded; HS019505; HS019531; HS019561; HS019565; HSO19608; HS19537.
Citation: Sage WM, Gallagher TH, Armstrong S .
How policy makers can smooth the way for communication-and- resolution programs.
Health Aff 2014 Jan;33(1):11-9. doi: 10.1377/hlthaff.2013.0930..
Keywords: Communication, Policy, Medical Liability, Policy
Mello MM, Senecal SK, Kuznetsov Y
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
The researchers report on the experiences of five hospitals with implementing the communications-and-resolution program (CRP) in general surgery over a twenty-two-month period. They found that all of the hospitals improved disclosure and surveillance of adverse events but were not able to fully implement the program’s compensation component. These experiences suggest that strong support from top leadership at the hospital and insurer levels, and adequate staff resources, are critical for the success of CRPs.
AHRQ-funded; HS019505.
Citation: Mello MM, Senecal SK, Kuznetsov Y .
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
Health Aff 2014 Jan;33(1):30-8. doi: 10.1377/hlthaff.2013.0849..
Keywords: Adverse Events, Communication, Medical Liability, Patient Safety
Etchegaray JM, Ottosen MJ, Burress L
Structuring patient and family involvement in medical error event disclosure and analysis.
The researchers conducted a two-phase study to understand whether patients and families who have experienced an adverse event should be involved in the postevent analysis following the disclosure of a medical error. After evaluating the findings, participants concluded that increasing the involvement of patients and their families in the event analysis process was desirable but needed to be structured in a patient-centered way to be successful.
AHRQ-funded; HS019561.
Citation: Etchegaray JM, Ottosen MJ, Burress L .
Structuring patient and family involvement in medical error event disclosure and analysis.
Health Aff 2014 Jan;33(1):46-52. doi: 10.1377/hlthaff.2013.0831..
Keywords: Adverse Events, Medical Liability, Patient and Family Engagement, Patient Safety
Schiff GD, Puopolo AL, Huben-Kearney A
Primary care closed claims experience of Massachusetts malpractice insurers.
The researchers studied patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. In Massachusetts, most primary care claims filed were related to alleged misdiagnosis.
AHRQ-funded; HS019508.
Citation: Schiff GD, Puopolo AL, Huben-Kearney A .
Primary care closed claims experience of Massachusetts malpractice insurers.
JAMA Intern Med 2013 Dec 9-23;173(22):2063-8. doi: 10.1001/jamainternmed.2013.11070..
Keywords: Primary Care, Medical Errors, Health Insurance, Patient Safety, Medical Liability