National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Events (3)
- Care Management (1)
- Clinician-Patient Communication (1)
- Communication (3)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Disparities (1)
- Education: Continuing Medical Education (1)
- Evidence-Based Practice (1)
- Falls (1)
- Hospitals (3)
- Implementation (1)
- Injuries and Wounds (1)
- Labor and Delivery (2)
- Maternal Care (1)
- Newborns/Infants (2)
- Nursing (1)
- Organizational Change (1)
- Outcomes (1)
- Patient-Centered Healthcare (1)
- (-) Patient Safety (8)
- Pregnancy (2)
- Quality Improvement (1)
- Quality of Care (2)
- Rural Health (1)
- Simulation (1)
- Surveys on Patient Safety Culture (2)
- Teams (4)
- (-) TeamSTEPPS (8)
- Tools & Toolkits (1)
- Training (3)
- 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 8 of 8 Research Studies DisplayedBaloh J, Zhu X, Ward MM
What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS.
This study looked at the influences on sustainment of internal facilitation activities. For two years the authors followed 10 small rural hospitals implementing TeamSTEPPS, a patient safety program. Factors the authors examined were the influence of senior management support (SMS), middle management support (MMS), facilitator team time availability (TIME), and team continuity (CONTINUITY). Five hospitals sustained facilitation activities and they found that the combination of SMS, MMS, and CONTINUITY was a sufficient condition for sustainment. The five other hospitals that did not sustain facilitation activities either lacked MMS or lacked both TIME and CONTINUITY. They also discussed the implications for research and practice.
AHRQ-funded; HS024112; HS018396.
Citation: Baloh J, Zhu X, Ward MM .
What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS.
Med Care Res Rev 2021 Apr;78(2):146-56. doi: 10.1177/1077558719848267..
Keywords: TeamSTEPPS, Teams, Implementation, Hospitals, Patient Safety, Rural Health, Organizational Change
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.
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
Kahwati LC, Sorensen AV, Teixeira-Poit S
AHRQ Author: Mistry KB
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
The purpose of this study was to describe the Safety Program for Perinatal Care (SPPC) implementation experience and evaluate the short-term impact on labor and delivery (L&D) unit patient safety culture, processes, and adverse events. SPPC implementation by L&D units were supported sing a program toolkit, trainings, and technical assistance. Researchers then evaluated the program using a pre-post, mixed-methods design. Changes in safety and quality were measured using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators. Findings showed that SPPC had a favorable impact on unit patient safety culture and processes, but mixed short-term impact on maternal and neonatal adverse events.
AHRQ-authored; AHRQ-funded; 2902010000241.
Citation: Kahwati LC, Sorensen AV, Teixeira-Poit S .
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Jt Comm J Qual Patient Saf 2019 Apr;45(4):231-40. doi: 10.1016/j.jcjq.2018.11.002..
Keywords: Adverse Events, Communication, Comprehensive Unit-based Safety Program (CUSP), Labor and Delivery, Maternal Care, Newborns/Infants, Outcomes, Patient Safety, Pregnancy, Simulation, Surveys on Patient Safety Culture, Teams, TeamSTEPPS, Training, Women
McArdle J, Sorensen A, Fowler CI
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
The purpose of this study using TeamSTEPPS was to assess the implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Results suggested that successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The Safety Program for Perinatal Care strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.
AHRQ-funded; 2902010000241.
Citation: McArdle J, Sorensen A, Fowler CI .
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
J Obstet Gynecol Neonatal Nurs 2018 Mar;47(2):191-201. doi: 10.1016/j.jogn.2017.11.014.
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Keywords: Labor and Delivery, Newborns/Infants, Pregnancy, Adverse Events, TeamSTEPPS, Injuries and Wounds, Care Management, Education: Continuing Medical Education, Training, Tools & Toolkits, Patient Safety, Nursing, Communication, Quality of Care
Natafgi N, Zhu X, Baloh J
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did.
AHRQ-funded; HS018396.
Citation: Natafgi N, Zhu X, Baloh J .
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
J Nurs Care Qual 2017 Jan/Mar;32(1):77-86. doi: 10.1097/ncq.0000000000000203.
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Keywords: Communication, Patient Safety, Quality Improvement, TeamSTEPPS, Transitions of Care
Stewart GL, Manges KA, Ward MM
Empowering sustained patient safety: the benefits of combining top-down and bottom-up approaches.
Implementation of TeamSTEPPS for improving patient safety is examined via descriptive qualitative analysis of semistructured interviews with 21 informants at 12 hospitals. Implementation approaches fit 3 strategies: top-down, bottom-up, and combination. The top-down approach failed to develop enough commitment to spread implementation. The bottom-up approach was unable to marshal the resources necessary to spread implementation. Combining top-down and bottom-up, processes best facilitated the implementation and spread of the TeamSTEPPS safety initiative.
AHRQ-funded; HS018396.
Citation: Stewart GL, Manges KA, Ward MM .
Empowering sustained patient safety: the benefits of combining top-down and bottom-up approaches.
J Nurs Care Qual 2015 Jul-Sep;30(3):240-6. doi: 10.1097/ncq.000000000000103.
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Keywords: Patient Safety, TeamSTEPPS, Hospitals, Training
Brady PJ, Battles JB, Ricciardi R
AHRQ Author: Brady PJ, Battles JB, Ricciardi R
Teamwork: what health care has learned from the military.
Health care depends on clear instructions and relies not just on individuals but also on strong teams. The authors point out that well-functioning teams make fewer mistakes than do individuals. They describe how military principles can be applied to healthcare, including the elements of structure, accountability, and patient-centeredness.
AHRQ-authored.
Citation: Brady PJ, Battles JB, Ricciardi R .
Teamwork: what health care has learned from the military.
J Nurs Care Qual 2015 Jan-Mar;30(1):3-6. doi: 10.1097/ncq.0000000000000094.
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Keywords: TeamSTEPPS, Teams, Patient-Centered Healthcare, Patient Safety, Quality of Care
Wasserman M, Renfrew MR, Green AR
AHRQ Author: Brach C
Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.
This article describes the development, content, and testing of two new evidence-based AHRQ tools for limited English proficiency (LEP) patient safety in the hospital setting. These tools contain recommendations to improve detection and prevention of medical errors across diverse populations and to improve team communication through incorporating interpreters in the care process.
AHRQ-authored
Citation: Wasserman M, Renfrew MR, Green AR .
Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.
J Healthc Qual. 2014 May-Jun;36(3):5-16. doi: 10.1111/jhq.12065..
Keywords: Disparities, Evidence-Based Practice, Patient Safety, Clinician-Patient Communication, TeamSTEPPS