National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
Topics
- Adverse Events (8)
- Care Coordination (1)
- Caregiving (1)
- (-) Children/Adolescents (13)
- Chronic Conditions (3)
- Clinician-Patient Communication (1)
- Communication (1)
- COVID-19 (1)
- Critical Care (1)
- Cultural Competence (1)
- Disparities (1)
- Evidence-Based Practice (1)
- Family Health and History (2)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Healthcare Delivery (1)
- Health Literacy (1)
- Health Services Research (HSR) (1)
- Hospital Discharge (1)
- Hospitalization (4)
- Hospitals (5)
- Infectious Diseases (1)
- (-) Inpatient Care (13)
- Medical Errors (5)
- Nursing (1)
- Patient-Centered Outcomes Research (1)
- (-) Patient Safety (13)
- Provider: Physician (1)
- Public Health (1)
- Quality of Care (1)
- Sepsis (1)
- Teams (1)
- Trauma (1)
- Young Adults (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 13 of 13 Research Studies DisplayedKieren MQ, Kelly MM, Garcia MA
Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.
The objective of this study was to describe the process of identifying and reporting inpatient safety concerns from the perspective of parents of children with medical complexity (CMC). Researchers conducted a secondary analysis of qualitative data from semi-structured interviews with English and Spanish-speaking parents of CMC at two tertiary children's hospitals. The parents described a multi-step process of reporting their safety concerns and a spectrum of staff response and validation. The researchers concluded that their findings could inform family-centered interventions that support safety concern reporting in the inpatient setting.
AHRQ-funded; HS025781.
Citation: Kieren MQ, Kelly MM, Garcia MA .
Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.
Acad Pediatr 2023 Nov-Dec; 23(8):1535-41. doi: 10.1016/j.acap.2023.06.008..
Keywords: Children/Adolescents, Patient Safety, Inpatient Care, Chronic Conditions
Halvorson EE, Thurtle DP, Easter A
Disparities in adverse event reporting for hospitalized children.
The authors compared the adverse event (AE) rate identified by voluntary event reporting (VER) with that identified using the Global Assessment of Pediatric Patient Safety (GAPPS) between hospitalized children by weight category, race, and English proficiency. In the population studied, they identified 288 total AEs, 270 by the GAPPS and 18 by VER. They found a disparity in AE reporting for children with limited English proficiency, with fewer AEs by VER compared with no difference in AEs by GAPPS. They identified no disparities by weight category or race. They concluded that voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.
AHRQ-funded; HS026038.
Citation: Halvorson EE, Thurtle DP, Easter A .
Disparities in adverse event reporting for hospitalized children.
J Patient Saf 2022 Sep 1;18(6):e928-e33. doi: 10.1097/pts.0000000000001049..
Keywords: Children/Adolescents, Disparities, Adverse Events, Medical Errors, Patient Safety, Hospitals, Hospitalization, Inpatient Care
Mercer AN, Mauskar S, Baird J
Family safety reporting in hospitalized children with medical complexity.
This prospective cohort study was conducted to evaluate safety concerns from families of hospitalized children with medical complexity (CMC) who are at high risk of medical errors. This survey was done predischarge with English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. A total of 155 parents and 214 staff completed surveys, with 43% (n = 66) having ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). A physician review found that 69% of concerns were medical errors, and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses, but only 32% of parents recalled being told how to report safety concerns. Higher education and longer length of stay were associated with family safety concerns.
AHRQ-funded; HS025781.
Citation: Mercer AN, Mauskar S, Baird J .
Family safety reporting in hospitalized children with medical complexity.
Pediatrics 2022 Aug 1; 150(2):e2021055098. doi: 10.1542/peds.2021-055098..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
Khan A, Baird J, Kelly MM
Family safety reporting in medically complex children: parent, staff, and leader perspectives.
This qualitative study examined parent, staff, and hospital leader perspectives about family safety reporting in children with medical complexity (CMC) to inform future interventions. The study was conducted at 2 tertiary care children’s hospitals with dedicated inpatient complex care services. Hour-long semi-structured, individual interviews were conducted with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. A total of 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders) were interviewed. Four themes related to family safety reporting emerged: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. The authors also identified potential strategies for engaging families and staff in family reporting.
AHRQ-funded; HS025781.
Citation: Khan A, Baird J, Kelly MM .
Family safety reporting in medically complex children: parent, staff, and leader perspectives.
Pediatrics 2022 Jun; 149(6). doi: 10.1542/peds.2021-053913..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Provider: Physician, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
Rasooly IR, Kern-Goldberger AS, Xiao Rasooly IR, Kern-Goldberger AS, Xiao R
Physiologic monitor alarm burden and nurses' subjective workload in a children's hospital.
Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. The objective of this study was to measure the relationship between alarm count and nurse workload by using the NASA-TLX.
AHRQ-funded; R18 HS026620.
Citation: Rasooly IR, Kern-Goldberger AS, Xiao Rasooly IR, Kern-Goldberger AS, Xiao R .
Physiologic monitor alarm burden and nurses' subjective workload in a children's hospital.
Hosp Pediatr 2021 Jul;11(7):703-10. doi: 10.1542/hpeds.2020-003509..
Keywords: Children/Adolescents, Nursing, Inpatient Care, Patient Safety
Masonbrink AR, Harris M, Hall M
Safety events in children's hospitals during the COVID-19 pandemic.
The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. The objective of this study was to compare pediatric hospitalization safety events during the pandemic versus previous years. The investigators concluded that postoperative sepsis rates increased among children hospitalized during COVID-19. They suggest that efforts are needed to improve safety of postoperative care for hospitalized children.
AHRQ-funded; HS024554; HS024592.
Citation: Masonbrink AR, Harris M, Hall M .
Safety events in children's hospitals during the COVID-19 pandemic.
Hosp Pediatr 2021 Jun;11(6):e95-e100. doi: 10.1542/hpeds.2020-004937..
Keywords: Children/Adolescents, COVID-19, Patient Safety, Sepsis, Adverse Events, Hospitalization, Hospitals, Inpatient Care, Infectious Diseases, Public Health
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
Leary JC, Walsh KE, Morin RA
Quality and safety of pediatric inpatient care in community hospitals: a scoping review.
This study’s aim was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in nonpediatric hospitals in the United States. A systematic literature review was performed in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set. A total of 44 articles were included using inclusion criteria. There was a moderate or high risk of bias for 72% of the studies. This study shows there is very limited research currently and would benefit from more multicenter collaborations.
AHRQ-funded; HS024133.
Citation: Leary JC, Walsh KE, Morin RA .
Quality and safety of pediatric inpatient care in community hospitals: a scoping review.
J Hosp Med 2019 Nov 1;14(10):694-703. doi: 10.12788/jhm.3268..
Keywords: Patient-Centered Outcomes Research, Evidence-Based Practice, Children/Adolescents, Inpatient Care, Hospitals, Patient Safety, Quality of Care
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
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
Stockwell DC, Landrigan CP, Toomey SL
Adverse events in hospitalized pediatric patients.
Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). This study used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. The study concluded that AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.
AHRQ-funded; HS020513
Citation: Stockwell DC, Landrigan CP, Toomey SL .
Adverse events in hospitalized pediatric patients.
Pediatrics 2018 Aug;142(2). doi: 10.1542/peds.2017-3360..
Keywords: Children/Adolescents, Adverse Events, Patient Safety, Inpatient Care, Medical Errors
Dynan L, Goudie A, Brady PW
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
In this article, the investigators hypothesize that adverse event rates increase with the availability of more complex services and technologies (transplantation and pediatric open-heart surgery); increase as experience of providers decreases (July effect); and increase with residents per bed, a measure of both average provider inexperience and congestion. Using multilevel analysis, they found empirical evidence in support of their three hypotheses.
AHRQ-funded; HS023827.
Citation: Dynan L, Goudie A, Brady PW .
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
J Healthc Qual 2018 Mar/Apr;40(2):69-78. doi: 10.1097/jhq.0000000000000121..
Keywords: Children/Adolescents, Healthcare Cost and Utilization Project (HCUP), Adverse Events, Hospitals, Inpatient Care, Medical Errors, Patient Safety
Stockwell DC, Bisarya H, Classen DC
A trigger tool to detect harm in pediatric inpatient settings.
The researchers developed and pilot tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments. After reviewing review 100 randomly selected inpatient records from each of 6 academic children’s hospitals, they found that the most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications.
AHRQ-funded; HS020513.
Citation: Stockwell DC, Bisarya H, Classen DC .
A trigger tool to detect harm in pediatric inpatient settings.
Pediatrics 2015 Jun;135(6):1036-42. doi: 10.1542/peds.2014-2152..
Keywords: Children/Adolescents, Patient Safety, Inpatient Care, Children/Adolescents, Adverse Events