National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (2)
- (-) Adverse Events (6)
- Communication (1)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Critical Care (1)
- Diagnostic Safety and Quality (1)
- Electronic Prescribing (E-Prescribing) (1)
- Health Information Technology (HIT) (1)
- Intensive Care Unit (ICU) (2)
- Kidney Disease and Health (1)
- Labor and Delivery (2)
- Maternal Care (1)
- Medical Errors (1)
- Medication (3)
- Medication: Safety (2)
- Neonatal Intensive Care Unit (NICU) (1)
- (-) Newborns/Infants (6)
- Outcomes (2)
- Patient Safety (6)
- Pregnancy (1)
- Prevention (1)
- Quality Improvement (1)
- Quality of Care (1)
- Registries (1)
- Simulation (1)
- Surveys on Patient Safety Culture (1)
- Teams (1)
- TeamSTEPPS (1)
- Training (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 6 of 6 Research Studies DisplayedStoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Adelman JS, Applebaum JR, Southern WN
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Researchers assessed the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and examined the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). They found that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
AHRQ-funded; HS024538.
Citation: Adelman JS, Applebaum JR, Southern WN .
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
JAMA Pediatr 2019 Oct 10;173(10):979-85. doi: 10.1001/jamapediatrics.2019.2733..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Medication, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
Ozawa Y, Ades A, Foglia EE
Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events.
This study assessed the impact of using sedation with neuromuscular blockade in non-emergency tracheal intubation of neonates. The retrospective cohort was from infants in neonatal intensive care units (NICUs) participating the National Emergency Airway Registry for Neonates from 2014 to 2017. There was less adverse events associated with use of the neuromuscular blockade premedication.
AHRQ-funded; HS024511.
Citation: Ozawa Y, Ades A, Foglia EE .
Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events.
J Perinatol 2019 Jun;39(6):848-56. doi: 10.1038/s41372-019-0367-0..
Keywords: Adverse Events, Medication, Newborns/Infants, Outcomes, Patient Safety, Registries
Lapcharoensap W, Cong A, Sherman J
Safety and ergonomic challenges of ventilating a premature infant during delayed cord clamping.
This study discussed the reasons that delayed cord clamping (DCC) for term and preterm infants is endorsed by multiple medical organizations. It has been shown to reduce hemorrhage, lower incidence of necrotizing enterocolitis and the need for transfusions in preterm infants. The writers held a number of multidisciplinary simulation workshops of vaginal and Caesarean deliveries, with providers starting positive pressure ventilation and ending with CPAP on a preterm manikin. Videos were also reviewed and identified 5 themes of concern: sterility, equipment, mobility, space, and workflow.
AHRQ-funded; HS023506.
Citation: Lapcharoensap W, Cong A, Sherman J .
Safety and ergonomic challenges of ventilating a premature infant during delayed cord clamping.
Children 2019 Apr 13;6(4). doi: 10.3390/children6040059..
Keywords: Adverse Events, Labor and Delivery, Newborns/Infants, Patient Safety
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