National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (3)
- Blood Thinners (1)
- Burnout (2)
- Cardiovascular Conditions (1)
- Children/Adolescents (1)
- (-) COVID-19 (9)
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- Intensive Care Unit (ICU) (1)
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- Medication: Safety (2)
- (-) Patient Safety (9)
- Provider: Clinician (1)
- Provider: Health Personnel (1)
- Provider: Nurse (1)
- Public Health (2)
- Respiratory Conditions (1)
- Sepsis (1)
- Simulation (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 9 of 9 Research Studies DisplayedCohen TN, Berdahl CT, Coleman BL
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
This study’s objective was to understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. The authors randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. Results showed that among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Seven of these events were linked to COVID-19.
AHRQ-funded; HS027455.
Citation: Cohen TN, Berdahl CT, Coleman BL .
Medication safety event reporting: Factors that contribute to safety events during times of organizational stress.
J Nurs Care Qual 2024 Jan-Mar; 39(1):51-57. doi: 10.1097/ncq.0000000000000720..
Keywords: Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors
Kravchenko OV, Boyce RD, Gomez-Lumbreras A
Drug-drug interaction between dexamethasone and direct-acting oral anticoagulants: a nested case-control study in the national COVID cohort collaborative (N3C).
This study examined whether there is an association between thromboembolotic events (TEEs) and concomitant use of dexamethasone with either apixaban or rivaroxaban (both direct oral anticoagulants or DOACs) during treatment for COVID-19. The authors used data from the National COVID Cohort Collaborative (N3C) to conduct a nested case-control study. Eligible participants were adults over 18 years who were exposed to a DOAC for 10 or more consecutive days and exposure to dexamethasone at least 5 or more consecutive days. The study did not find a discernible association of TEE in patients concomitantly exposed to dexamethasone and a DOAC.
AHRQ-funded; HS025984.
Citation: Kravchenko OV, Boyce RD, Gomez-Lumbreras A .
Drug-drug interaction between dexamethasone and direct-acting oral anticoagulants: a nested case-control study in the national COVID cohort collaborative (N3C).
BMJ Open 2022 Dec 29; 12(12):e066846. doi: 10.1136/bmjopen-2022-066846..
Keywords: COVID-19, Blood Thinners, Medication, Adverse Drug Events (ADE), Adverse Events, Cardiovascular Conditions, Medication: Safety, Patient Safety
Rosen A, Carter D, Applebaum JR
Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.
The purpose of this mixed methods, multi-institutional study was to explore how the COVID-19 pandemic worsened preexisting issues of patient safety and created new challenges for patient safety within United States intensive care units (ICU.) The researchers conducted a national survey of critical care clinicians to assess their experiences related to patient safety during the pandemic. The survey instrument was distributed via email through the Society of Critical Care Medicine listserv, with results reported as percentages while free-text responses were analyzed and coded for themes. The study found that of the 355 survey responses received, 61% believed that conditions during the pandemic were more hazardous when compared with the period prior to the pandemic. When compared with providers who cared for mostly non-COVID-19 or no COVID-19 patients, the professionals who cared for primarily COVID-19 patients had an increased likelihood of perceiving that care was more hazardous. In the coded free-text responses, providers identified themes in patient safety risks including ventilator-related lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls. The study concluded that higher levels of COVID-19 case burden were significantly related with perceptions of a less safe patient care environment by frontline ICU clinicians, and further identified specific hazards in intensive care units.
AHRQ-funded; HS026121.
Citation: Rosen A, Carter D, Applebaum JR .
Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.
J Patient Saf 2022 Dec 1;18(8):e1219-e25. doi: 10.1097/pts.0000000000001060..
Keywords: COVID-19, Patient Safety, Critical Care, Intensive Care Unit (ICU)
Evans LV, Ray JM, Bonz JW
Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.
The purpose of this study will be to simultaneously assess the challenges and facilitators of COVID-19 preparedness in the emergency department (ED) and the mitigation of emergency physician stress, test the effectiveness of a simulation preparedness intervention on physician physiological stress, and improve physician preparedness while decreasing physician stress and anxiety.
AHRQ-funded; HS028340.
Citation: Evans LV, Ray JM, Bonz JW .
Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.
BMJ Open 2022 May 19;12(5):e058980. doi: 10.1136/bmjopen-2021-058980..
Keywords: COVID-19, Patient Safety, Simulation, Burnout, Provider: Clinician
Parmasad V, Keating JA, Carayon P
Physical distancing for care delivery in health care settings: considerations and consequences.
Physical distancing in high complexity systems such as health care is particularly challenging and may benefit from a human factors and systems engineering perspective. In this paper the investigators discussed challenges to implementing and maintaining physical distancing in health care settings and presented possible solutions from a human factors and systems engineering perspective.
AHRQ-funded; HS026226.
Citation: Parmasad V, Keating JA, Carayon P .
Physical distancing for care delivery in health care settings: considerations and consequences.
Am J Infect Control 2021 Aug;49(8):1085-88. doi: 10.1016/j.ajic.2020.12.014..
Keywords: COVID-19, Healthcare Delivery, 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
Haidari E, Main EK, Cui X
Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic.
The purpose of this study was to assess the perspectives of maternal and neonatal healthcare workers (HCWs) on well-being and patient safety amid the COVID-19 pandemic. Using HCW surveys, findings showed that 66% of respondents reported symptoms of burnout and 73% felt that burnout among their co-workers had significantly increased. Compared to physicians, nurses reported higher rates of unprofessional behavior and difficulty focusing on work. The authors concluded that three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.
AHRQ-funded; HS027837.
Citation: Haidari E, Main EK, Cui X .
Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic.
J Perinatol 2021 May;41(5):961-69. doi: 10.1038/s41372-021-01014-9..
Keywords: COVID-19, Burnout, Patient Safety, Provider: Nurse, Provider: Health Personnel, Maternal Care
Soares WE, Schoenfeld EM, Visintainer P
Safety assessment of a noninvasive respiratory protocol for adults with COVID-19.
As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)-related respiratory distress, the investigators implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, the investigators conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020).
AHRQ-funded; HS025701.
Citation: Soares WE, Schoenfeld EM, Visintainer P .
Safety assessment of a noninvasive respiratory protocol for adults with COVID-19.
J Hosp Med 2020 Dec;15(12):734-38. doi: 10.12788/jhm.3548..
Keywords: Patient Safety, COVID-19, Respiratory Conditions, Inpatient Care, Infectious Diseases
Steuart R, Huang FS, Schaffzin JK
Finding the value in personal protective equipment for hospitalized patients during a pandemic and beyond.
Innovative protocols have been conceptualized and used to conserve PPE in hospitals. Conservation protocols often fail to identify missed opportunities to improve the value of personal protective equipment (PPE) that already exist in hospital care. By defining the value of inpatient PPE, hospitals can identify opportunities for value improvement. Changes implemented now will maximize PPE value and preserve supply during this pandemic and beyond. In this article, the authors discuss the value in PPE for hospitalized patients during a pandemic and beyond.
AHRQ-funded; HS025138.
Citation: Steuart R, Huang FS, Schaffzin JK .
Finding the value in personal protective equipment for hospitalized patients during a pandemic and beyond.
J Hosp Med 2020 May;15(5):295-98. doi: 10.12788/jhm.3429..
Keywords: COVID-19, Emergency Preparedness, Public Health, Hospitals, Patient Safety