National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (2)
- Case Study (1)
- Genetics (1)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Delivery (1)
- Infectious Diseases (1)
- Intensive Care Unit (ICU) (2)
- Labor and Delivery (2)
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- Medication: Safety (1)
- Neonatal Intensive Care Unit (NICU) (1)
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- (-) Newborns/Infants (6)
- (-) Patient Safety (6)
- Pregnancy (1)
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- Quality Improvement (1)
- Quality of Care (1)
- Simulation (1)
- Treatments (1)
- Women (1)
- Workflow (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 DisplayedFeldman AG, Parsons JA, Dutmer CM
Subacute liver failure following gene replacement therapy for spinal muscular atrophy type 1.
This paper reports on two cases of transient, drug-induced liver failure after gene replacement therapy using an adeno-associated virus vector containing the survival motor neuron 1 gene.
AHRQ-funded; HS026510.
Citation: Feldman AG, Parsons JA, Dutmer CM .
Subacute liver failure following gene replacement therapy for spinal muscular atrophy type 1.
J Pediatr 2020 Oct;225:252-58.e1. doi: 10.1016/j.jpeds.2020.05.044..
Keywords: Newborns/Infants, Neurological Disorders, Genetics, Treatments, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Case Study
Dadiz R, Riccio J, Brown K
Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit.
This study’s objective was to identify 1) latent safety threats (LSTs) in a new neonatal intensive care unit (NICU) through simulation-based pre-occupancy operations testing, and 2) LSTs that remained unresolved 1-year post-occupancy. This qualitative study included 111 healthcare professionals who participated in patient care simulations and debriefings in a new NICU. Debriefing transcripts were analyzed to characterize LSTs. Three-hundred threats with four major themes affecting staff function and patient safety emerged: relay of information, workplace design, patient care processes, and patient family and staff focus. One-year post occupancy 29 (9%) LSTs were still unresolved.
AHRQ-funded; R18 HS023460.
Citation: Dadiz R, Riccio J, Brown K .
Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit.
J Perinatol 2020 Sep;40(Suppl 1):29-35. doi: 10.1038/s41372-020-0749-3..
Keywords: Newborns/Infants, Neonatal Intensive Care Unit (NICU), Intensive Care Unit (ICU), Patient Safety, Simulation
Herrick HM, Lorch S, Hsu JY
Impact of flow disruptions in the delivery room.
The goal of this study was to identify the impact of flow disruptions during neonatal resuscitation and to determine their association with key process and outcome measures. Delivery-room resuscitations of neonates less 32 weeks gestational age were video recorded for observation. Results showed that flow disruptions occurred frequently during neonatal resuscitation and recommendations included measuring flow disruptions as a feasible method to assess the impact of human factors in the delivery room and to identify modifiable factors and practices to improve patient care.
AHRQ-funded; HS023538; HS026491; HS026625; HS023806.
Citation: Herrick HM, Lorch S, Hsu JY .
Impact of flow disruptions in the delivery room.
Resuscitation 2020 May;150:29-35. doi: 10.1016/j.resuscitation.2020.02.037.
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Keywords: Workflow, Labor and Delivery, Newborns/Infants, Patient Safety, Healthcare Delivery, Quality Improvement, Quality of Care
Sherman JP, Hedli LC, Kristensen-Cabrera AI
Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. In this study, the investigators employed design thinking methodology to understand how the design of labor and delivery units impacted safety and identified spaces and systems where improvements are needed.
AHRQ-funded; HS023506.
Citation: Sherman JP, Hedli LC, Kristensen-Cabrera AI .
Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
Am J Perinatol 2020 May;37(6):638-46. doi: 10.1055/s-0039-1685494..
Keywords: Labor and Delivery, Pregnancy, Patient Safety, Maternal Care, Women, Newborns/Infants
Pfeifer E, Lozovatsky M, Abraham J
Effect of an alternative newborn naming strategy on wrong-patient errors: a quasi-experimental study.
Newborns are often assigned temporary names at birth. Temporary newborn names-often a combination of the mother's last name and the newborn's gender-are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. In this study, the investigators developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy.
AHRQ-funded; HS025443.
Citation: Pfeifer E, Lozovatsky M, Abraham J .
Effect of an alternative newborn naming strategy on wrong-patient errors: a quasi-experimental study.
Appl Clin Inform 2020 Mar;11(2):235-41. doi: 10.1055/s-0040-1705175..
Keywords: Newborns/Infants, Medical Errors, Adverse Events, Patient Safety
Milstone AM, Voskertchian A, Koontz DW
Effect of treating parents colonized with Staphylococcus aureus on transmission to neonates in the intensive care unit: a randomized clinical trial.
This study examined the effect of treating parents of neonates in the intensive care unit (NICUs) with intranasal mupirocin and topical chlorhexidine compared with a placebo treatment and whether it reduces transmission of Staphlyococcus aureus to their babies. A double-blind randomized trial was conducted at 2 tertiary NICUs in Baltimore, MD from November 2014 to December 2018. Parents were given intranasal treatments for 5 days. Of the intervention group 13 of 89 neonates acquired S aureus, and in the control group 29 of 101 neonates acquired S aureus with the same strain as their parents. The results showed a significant reduction in transmission.
AHRQ-funded; HS022872.
Citation: Milstone AM, Voskertchian A, Koontz DW .
Effect of treating parents colonized with Staphylococcus aureus on transmission to neonates in the intensive care unit: a randomized clinical trial.
JAMA 2020 Jan;323(4):295-386. doi: 10.1001/jama.2019.20785..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Healthcare-Associated Infections (HAIs), Infectious Diseases, Patient Safety, Prevention