National Healthcare Quality and Disparities Report
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Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (7)
- Behavioral Health (1)
- Burnout (3)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Children/Adolescents (2)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (1)
- Communication (3)
- Depression (1)
- Education: Continuing Medical Education (6)
- Electronic Health Records (EHRs) (1)
- Emergency Department (2)
- Evidence-Based Practice (2)
- Family Health and History (1)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (1)
- Health Services Research (HSR) (1)
- Hospitals (3)
- Inpatient Care (1)
- Medical Errors (5)
- Medication (1)
- Medication: Safety (1)
- Obesity (2)
- Outcomes (3)
- Patient-Centered Outcomes Research (1)
- (-) Patient Safety (27)
- Practice Patterns (1)
- Provider (20)
- Provider: Clinician (1)
- Provider: Nurse (4)
- (-) Provider: Physician (27)
- Provider Performance (2)
- Quality Improvement (1)
- Quality Indicators (QIs) (1)
- Quality of Care (4)
- Shared Decision Making (1)
- Simulation (2)
- Sleep Problems (1)
- Surgery (12)
- Teams (2)
- Training (3)
- Transitions of Care (1)
- Urinary Tract Infection (UTI) (1)
- Workflow (2)
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 27 Research Studies DisplayedBarger LK, Weaver MD, Sullivan JP
Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.
The purpose of this study was to determine if long weekly work hours and shifts of extended duration are associated with adverse patient and physician safety outcomes. The criteria included work hours and shifts (≥24 hours) and for senior resident physicians (postgraduate year 2 and above; PGY2+). This study was conducted in the U.S. and spanned eight academic years. The analysis concluded that working 48 hours per week or longer, and extended shifts endanger even experienced (ie, PGY2+) resident physicians and their patients. It recommends lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.
AHRQ-funded; HS012032.
Citation: Barger LK, Weaver MD, Sullivan JP .
Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.
BMJ Med 2023; 2(1):e000320. doi: 10.1136/bmjmed-2022-000320..
Keywords: Provider: Physician, Burnout, Patient Safety
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
Metersky ML, Eldridge N, Wang Y
AHRQ Author: Eldridge N
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
This retrospective analysis aimed to determine whether patients in teaching hospitals are at greater risk of suffering from an adverse event during the July/August summer trainee changeover period. The Medicare Patient Safety Monitoring System was used to extract data on hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure. Adverse event rates in July and August were compared with the rest of the year. Hospitals were classified into major teaching, minor teaching, or nonteaching. The authors included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event was not significantly different at any of the hospital types.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation: Metersky ML, Eldridge N, Wang Y .
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
J Patient Saf 2022 Apr 1;18(3):253-59. doi: 10.1097/pts.0000000000000887..
Keywords: Adverse Events, Patient Safety, Provider: Physician
Vu K, Zhou J, Everhart A
Uptake of evidence by physicians: de-adoption of erythropoiesis-stimulating agents after the TREAT trial.
Variation in de-adoption of ineffective or unsafe treatments is not well-understood. In this study the investigators examined de-adoption of erythropoiesis-stimulating agents (ESA) in anemia treatment among patients with chronic kidney disease (CKD) following new clinical evidence of harm and ineffectiveness (the TREAT trial) and the FDA's revision of its safety warning. The investigators found that physician specialty had a dominant role in prescribing decision, and specializations with higher use of treatment (nephrologists) were more responsive to new evidence of unsafety and ineffectiveness.
AHRQ-funded; HS025164.
Citation: Vu K, Zhou J, Everhart A .
Uptake of evidence by physicians: de-adoption of erythropoiesis-stimulating agents after the TREAT trial.
BMC Nephrol 2021 Aug 21;22(1):284. doi: 10.1186/s12882-021-02491-y..
Keywords: Evidence-Based Practice, Medication: Safety, Medication, Patient Safety, Practice Patterns, Provider: Physician
O'Leary KJ, Manojlovich M, Johnson JK
A multisite study of interprofessional teamwork and collaboration on general medical services.
This multisite study of four mid-sized hospitals measured teamwork climate of nurses, nurse assistants, and physicians working on general medical services. Teamwork climate scores for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurses) were measured using the Safety Attitudes Questionnaire. Hospitalists had the highest median teamwork climate score and nurses had the lowest, but it was not a statistically significant difference. A higher percentage of hospitalists (63.3%) rated the quality of collaboration with nurses as high or very high, but only 48.7% of nurses rated the collaboration with hospitalists as high or very high. There were significant differences in perceptions of teamwork climate across sites and across professional categories.
AHRQ-funded; HS025649.
Citation: O'Leary KJ, Manojlovich M, Johnson JK .
A multisite study of interprofessional teamwork and collaboration on general medical services.
Jt Comm J Qual Patient Saf 2020 Dec;46(12):667-72. doi: 10.1016/j.jcjq.2020.09.009..
Keywords: Teams, Hospitals, Patient Safety, Provider: Clinician, Provider: Physician, Provider: Nurse, Provider
Isbell LM, Boudreaux ED, Chimowitz H
What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.
Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks.
AHRQ-funded; HS025752.
Citation: Isbell LM, Boudreaux ED, Chimowitz H .
What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.
BMJ Qual Saf 2020 Oct;29(10):1-2. doi: 10.1136/bmjqs-2019-010179..
Keywords: Emergency Department, Provider: Nurse, Provider: Physician, Patient Safety
Khorfan R, Yuce TK, Love R
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.
The authors investigated the long-term effect of flexible duty-hour policies on resident outcomes. They found that cumulative time under flexible duty-hour policies had no detrimental effects on duty-hour violations or resident well-being. After multiple years of flexibility, residents continue to report a high rate of satisfaction and positive effects on continuity of care.
Citation: Khorfan R, Yuce TK, Love R .
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.
Ann Surg 2020 May;271(5):791-98. doi: 10.1097/sla.0000000000003802..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider: Physician, Provider, Surgery
Sheetz KH, Nuliyalu U, Nathan H
Association of surgeon case numbers of pancreaticoduodenectomies vs related procedures with patient outcomes to inform volume-based credentialing.
The purpose of this study was to evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The investigators indicated that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
AHRQ-funded; HS000053; HS024763.
Citation: Sheetz KH, Nuliyalu U, Nathan H .
Association of surgeon case numbers of pancreaticoduodenectomies vs related procedures with patient outcomes to inform volume-based credentialing.
JAMA Netw Open 2020 Apr;3(4):e203850. doi: 10.1001/jamanetworkopen.2020.3850..
Keywords: Surgery, Provider: Physician, Provider, Outcomes, Patient Safety
Banerjee A, Burden A, Slagle JM
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
This study analyzed performance gaps of practicing anesthesiologists, and used 4 different scenarios that illustrate those gaps and how they contribute to hazards in anesthesiology and proposals for addressing them. The authors used 4 standardized simulated scenarios of common events that anesthesiologists would expect to see in their practice. The 4 perioperative crisis events are: (1) local anesthetic systemic toxicity (LAST) leading to hemodynamic collapse; (2) retroperitoneal bleeding from insertion of a laparoscopic surgery trocar leading to hemorrhagic shock; (3) malignant hyperthermia (MH) presenting in the postanesthesia care unit; and (4) acute atrial fibrillation with hemodynamic instability, followed by signs of a ST-elevation myocardial infarction (AFib-MI). These scenarios came from a 2017 paper by Weinger, et al. A group of subject matter experts defined a set of clinical performance elements (CPEs) that they would expect to be performed in the scenarios. Only 4% of encounters in these scenarios had perfect performance by anesthesiologists where all prescribed CPEs were performed. Recommendations for improvement included providing high-fidelity simulation training, incorporating clinical lessons about gaps, fostering regular use by anesthesiologists and OR teams of clinical guidance, modifying organizational arrangements at clinical sites to ensure backup help is readily available, and implementing periodic formative performance assessments.
AHRQ-funded; HS020415.
Citation: Banerjee A, Burden A, Slagle JM .
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
Int Anesthesiol Clin 2020 Winter;58(1):13-20. doi: 10.1097/aia.0000000000000262..
Keywords: Medical Errors, Adverse Events, Adverse Drug Events (ADE), Patient Safety, Provider Performance, Provider: Physician, Provider, Surgery
Manojlovich M, Ameling JM, Forman J
Contextual barriers to communication between physicians and nurses about appropriate catheter use.
This study identified contextual barriers to communication between physicians and nurses that contribute to inappropriate use of catheters and increased risk of health care-associated infections. The researchers conducted individual and small-group semistructured interviewed with physicians and nurses in a progressive care unit of an academic hospital. Common barriers included workflow misalignment between clinicians, issues with electronic medical records and pagers, and strained relationships between clinicians.
AHRQ-funded; HS024385.
Citation: Manojlovich M, Ameling JM, Forman J .
Contextual barriers to communication between physicians and nurses about appropriate catheter use.
Am J Crit Care 2019 Jul;28(4):290-98. doi: 10.4037/ajcc2019372..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Communication, Healthcare-Associated Infections (HAIs), Patient Safety, Provider, Provider: Nurse, Provider: Physician, Urinary Tract Infection (UTI), Workflow
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
Gupta K, Lisker S, Rivadeneira NA
Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM).
Researchers characterized events contributing to the second-victim effect among a diverse sample of physician mothers, described the impact on both provider and patient, and sought to determine the association between experiencing a mistake and burnout. They found that physician mothers involved in errors experience negative outcomes and may be at increased risk for burnout. They recommended additional research focusing on strategies to mitigate burnout associated with the second victim effect, particularly among women physicians and those with family responsibilities.
AHRQ-funded; HS023558.
Citation: Gupta K, Lisker S, Rivadeneira NA .
Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM).
BMJ Qual Saf 2019 Jul;28(7):564-73. doi: 10.1136/bmjqs-2018-008372..
Keywords: Adverse Events, Burnout, Medical Errors, Patient Safety, Provider: Physician
Mueller SK, Schnipper JL
Physician perspectives on interhospital transfers.
This study examined physician perspectives of the common problems that occur during acute care hospital interhospital transfers. The process tends to be nonstandardized which creates a number of issues. These issues include: patients sometimes, frequently, or always arriving without required specialized care (56% of the time), arriving with unrealistic expectations of care (77.2% of responses), arrived more than 24 hours after accepted transfer in 80.1% of responses, and arrived without necessary transfer records 86.9% of the time. The last issue and also time of day of arrival many physicians felt posed a risk to the transferred patients.
AHRQ-funded; HS023331.
Citation: Mueller SK, Schnipper JL .
Physician perspectives on interhospital transfers.
J Patient Saf 2019 Jun;15(2):86-89. doi: 10.1097/pts.0000000000000312..
Keywords: Healthcare Delivery, Hospitals, Patient Safety, Provider, Provider: Physician, Transitions of Care
St Hilaire MA, Anderson C, Anwar J
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
This study examines the impact of reinstating extended duration (24-28) work shifts (EDWS) for postgraduate year 1 resident physicians. The performance of residents was studied for 23 male residents between 2002-2004 during a three-week on-call rotation schedule at the Medical and Intensive Care Units at Brigham and Women’s Hospital in Boston. If the sleep episodes were four hours or less then the odds of >1 attentional failure was 2.72 times higher during post-call compared to matched sessions during non-EDWS.
AHRQ-funded; HS012032.
Citation: St Hilaire MA, Anderson C, Anwar J .
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
Sleep 2019 May;42(5):pii: zsz041. doi: 10.1093/sleep/zsz041..
Keywords: Adverse Events, Education: Continuing Medical Education, Medical Errors, Patient Safety, Provider, Provider: Physician, Quality of Care, Sleep Problems, Training
Vergis A, Hardy K, Stogryn S
Fellow and attending surgeon operative notes are deficient in reporting established quality indicators for Roux-en-y gastric bypass: a preliminary retrospective analysis of operative dictation.
This retrospective analysis investigated the completeness of reporting documentation for Roux-en-Y Gastric Bypass (RYGB) surgery. A total of 40 bariatric fellow and 40 attending RYGB narrative reports were analyzed. Fellows had a mean completion rate of 66.4% compared to 61.5% for attendings. Fellows also did a better job of completing subsections, with the exception of closure details. This information is important to communicating operative events and can make an impact on patient safety and quality.
AHRQ-funded; HS018546.
Citation: Vergis A, Hardy K, Stogryn S .
Fellow and attending surgeon operative notes are deficient in reporting established quality indicators for Roux-en-y gastric bypass: a preliminary retrospective analysis of operative dictation.
Cureus 2019 Apr 24;11(4):e4535. doi: 10.7759/cureus.4535..
Keywords: Obesity, Quality of Care, Quality Indicators (QIs), Patient Safety, Provider, Provider: Physician, Surgery
Frasier LL, Pavuluri Quamme SR, Ma Y
Familiarity and communication in the operating room.
Researchers sought to evaluate the relationship between familiarity, communication rates, and communication ineffectiveness of health care providers in the operating room. They found that team members do not compensate for unfamiliarity by increasing their verbal communication, and dyad familiarity is not protective against ineffective communication. Cross-disciplinary communication remains vulnerable in the operating room, suggesting poor crosstalk across disciplines in the operative setting. They recommended further investigation to explore these relationships and identify effective interventions, ensuring that all team members have the necessary information to optimize their performance.
AHRQ-funded; HS022403.
Citation: Frasier LL, Pavuluri Quamme SR, Ma Y .
Familiarity and communication in the operating room.
J Surg Res 2019 Mar;235:395-403. doi: 10.1016/j.jss.2018.09.079..
Keywords: Communication, Patient Safety, Surgery, Teams, Provider: Physician, Provider
Anton NE, Mizota T, Timsina LR
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
The objective of this study was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. The investigators concluded that promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. They indicated that mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal.
AHRQ-funded; HS022080.
Citation: Anton NE, Mizota T, Timsina LR .
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
Am J Surg 2019 Feb;217(2):266-71. doi: 10.1016/j.amjsurg.2018.11.028..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider, Provider: Physician, Simulation, Surgery, Training
Shubeck SP, Kanters AE, Dimick JB
Surgeon leadership style and risk-adjusted patient outcomes.
The goal of this study was to determine if individual surgeons' personality traits and related leadership behaviors – such as participation in continuing education, effective self-reflection, and openness to feedback – correlated with patient-level outcomes after bariatric surgery. Surgeons from the Michigan Bariatric Surgery Collaborative (MBSC) were administered the Life Styles Inventory (LSI) assessment, the results of which were then collapsed into three styles corresponding with particular patterns of individual thinking and behavior: constructive, passive/defensive, and aggressive/defensive. Patient-level risk-adjusted rates of complications after bariatric surgery were then used to quantify the impact surgeon style had on post-operative outcomes. The results of the study demonstrate that surgeons' leadership styles are correlated with surgical outcomes for their individual patients.
AHRQ-funded; HS023597.
Citation: Shubeck SP, Kanters AE, Dimick JB .
Surgeon leadership style and risk-adjusted patient outcomes.
Surg Endosc 2019 Feb;33(2):471-74. doi: 10.1007/s00464-018-6320-z.
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Keywords: Education: Continuing Medical Education, Patient Safety, Outcomes, Provider: Physician, Surgery
Fong A, Ratwani RM
Understanding emergency medicine physicians multitasking behaviors around interruptions.
Interruptions can adversely impact human performance, particularly in fast-paced and high-risk environments such as the emergency department (ED). In this paper, the investigators present a comprehensive framework for understanding interruptions that is composed of three phases, each with multiple levels: interruption start transition, interruption engagement, and interruption end transition. This three-phase framework is not constrained to discrete task transitions, providing a robust method to categorize multitasking behaviors around interruptions. They apply this framework in categorizing 457 interruption episodes.
AHRQ-funded; HS022362.
Citation: Fong A, Ratwani RM .
Understanding emergency medicine physicians multitasking behaviors around interruptions.
Acad Emerg Med 2018 Oct;25(10):1164-68. doi: 10.1111/acem.13496..
Keywords: Emergency Department, Workflow, Patient Safety, Provider: Physician, Provider
Jones LK, Jennings BM, Higgins MK
Ethological observations of social behavior in the operating room.
This study used ethological observation techniques, recording live all social behavior to document the full range of behavior of operating room teams. The study focused on examining the hierarchical, mixed-gender aspects of clinical teams.
AHRQ-funded; HS023403.
Citation: Jones LK, Jennings BM, Higgins MK .
Ethological observations of social behavior in the operating room.
Proc Natl Acad Sci U S A 2018 Jul 17;115(29):7575-80. doi: 10.1073/pnas.1716883115..
Keywords: Patient Safety, Surgery, Provider: Physician, Provider
Barsuk JH, Cohen ER, Williams MV
Simulation-based mastery learning for thoracentesis skills improves patient outcomes: a randomized trial.
Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax, hemothorax, and reexpansion pulmonary edema.
AHRQ-funded; HS021202.
Citation: Barsuk JH, Cohen ER, Williams MV .
Simulation-based mastery learning for thoracentesis skills improves patient outcomes: a randomized trial.
Acad Med 2018 May;93(5):729-35. doi: 10.1097/acm.0000000000001965..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider, Provider: Physician, Simulation, Training
Greenberg CC, Ghousseini HN, Pavuluri Quamme SR
A statewide surgical coaching program provides opportunity for continuous professional development.
Researchers sought to develop and evaluate a video-based coaching program for board-eligible/certified surgeons. They found that, overall, participants were satisfied with their experience and found the coaching program valuable. Future research to evaluate the impact of coaching on practice change and patient outcomes is recommended.
AHRQ-funded; HS022403.
Citation: Greenberg CC, Ghousseini HN, Pavuluri Quamme SR .
A statewide surgical coaching program provides opportunity for continuous professional development.
Ann Surg 2018 May;267(5):868-73. doi: 10.1097/sla.0000000000002341..
Keywords: Education: Continuing Medical Education, Health Services Research (HSR), Patient Safety, Provider, Provider: Physician, Quality of Care, Surgery
Stevens H, Carlin AM, Ross R
Effect of surgeon age on bariatric surgery outcomes.
This study examined the effect of surgeon age on complication rates for bariatric surgery. A retrospective study was done with 71 surgeons in Michigan who participated in a statewide collaborative improvement program. Older surgeons performed more Roux-en Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons. There was not found to be any statistically significant differences in patient outcome between the two age groups.
AHRQ-funded; HS024403.
Citation: Stevens H, Carlin AM, Ross R .
Effect of surgeon age on bariatric surgery outcomes.
Ann Surg 2018 May;267(5):905-09. doi: 10.1097/sla.0000000000002297..
Keywords: Adverse Events, Obesity, Outcomes, Patient Safety, Provider, Provider: Physician, Provider Performance
Varghese TK, Jr., Ghaferi AA
Cutting-edge efforts in surgical patient safety.
In October, 2015, the Surgical Outcomes Club convened a patient safety panel in Chicago, Illinois. The goal was to emphasize that patient safety efforts require a uniform, systematic, evidence-based approach. This article incorporates the major themes of the session—developing reliable measures of surgeon performance, real-world methods for continuous improvement and learning, and opportunities for incorporating the principles of implementation science into patient safety efforts.
AHRQ-funded; HS023621; HS024403.
Citation: Varghese TK, Jr., Ghaferi AA .
Cutting-edge efforts in surgical patient safety.
JAMA Surg 2017 Aug;152(8):719-20. doi: 10.1001/jamasurg.2017.0858.
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Keywords: Patient-Centered Outcomes Research, Surgery, Patient Safety, Evidence-Based Practice, Provider: Physician, Provider
Ancker JS, Edwards A, Nosal S
Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
In this study, the investigators tested hypotheses arising from two possible alert fatigue mechanisms: (A) cognitive overload associated with amount of work, complexity of work, and effort distinguishing informative from uninformative alerts, and (B) desensitization from repeated exposure to the same alert over time. The investigators found that clinicians became less likely to accept alerts as they received more of them, particularly more repeated alerts. There was no evidence of an effect of workload per se, or of desensitization over time for a newly deployed alert.
AHRQ-funded; HS021531.
Citation: Ancker JS, Edwards A, Nosal S .
Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
BMC Med Inform Decis Mak 2017 Apr 10;17(1):1-9. doi: 10.1186/s12911-017-0430-8..
Keywords: Clinical Decision Support (CDS), Shared Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Provider, Provider: Nurse, Provider: Physician