National Healthcare Quality and Disparities Report
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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
726 to 743 of 743 Research Studies DisplayedChopra V, Ratz D, Kuhn L
Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.
This study was designed to determine patient, provider, and device outcome of deep vein thrombosis (DVT) associated with peripherally inserted central catheters (PICCs). Larger PICC gauge, especially in the use of recently diagnosed cancer patients, increases the likelihood of DVT.
AHRQ-funded; HS022835
Citation: Chopra V, Ratz D, Kuhn L .
Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.
J Thromb Haemost 2014 Jun;12(6):847-54. doi: 10.1111/jth.12549..
Keywords: Adverse Events, Blood Clots, Patient Safety, Risk
Boehme AK, Kapoor N, Albright KC
Predictors of systemic inflammatory response syndrome in ischemic stroke undergoing systemic thrombolysis with intravenous tissue plasminogen activator.
This study investigated predictors of systemic inflammatory response syndrome (SIRS) in acute ischemic stroke (AIS) patients treated with intravenous (IV) tissue plasminogen activator (tPA). The investigators indicated that in their sample of IV tPA-treated AIS patients, clinical and laboratory characteristics available on presentation were able to identify patients likely to develop SIRS during their acute hospitalization.
AHRQ-funded; HS013852.
Citation: Boehme AK, Kapoor N, Albright KC .
Predictors of systemic inflammatory response syndrome in ischemic stroke undergoing systemic thrombolysis with intravenous tissue plasminogen activator.
J Stroke Cerebrovasc Dis 2014 Apr;23(4):e271-6. doi: 10.1016/j.jstrokecerebrovasdis.2013.11.022..
Keywords: Adverse Events, Stroke
Nett S, Emeriaud G, Jarvis JD
Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children*.
This observational study of 15 pediatric intensive care units (PICUs) found that substantial site-level variance exists in tracheal intubation practice, adverse tracheal intubation associated-events and severe tracheal intubation associated-events. After adjusting for patient and provider characteristics, neither PICU size nor presence of fellowship training program explained site-level variance.
AHRQ-funded; HS021583
Citation: Nett S, Emeriaud G, Jarvis JD .
Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children*.
Pediatr Crit Care Med. 2014 May;15(4):306-13. doi: 10.1097/pcc.0000000000000120..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Registries, Adverse Events
Weissman JS, López L, Schneider EC
The association of hospital quality ratings with adverse events.
The researchers used a survey of 2,582 patients hospitalized at 16 acute care Massachusetts hospitals to understand how patient-reported quality is related to adverse events (AEs). Although patients with AEs rated hospital quality lower than others, patients with AEs who experienced ‘service recovery’ rated their quality of care at levels similar to those not experiencing AEs.
AHRQ-funded
Citation: Weissman JS, López L, Schneider EC .
The association of hospital quality ratings with adverse events.
Int J Qual Health Care. 2014 Apr;26(2):129-35. doi: 10.1093/intqhc/mzt092..
Keywords: Adverse Events, Quality of Care, Hospitals, Patient Experience, Patient Safety, Quality Indicators (QIs), Quality Measures
Chopra V, McMahon LF
Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.
In this paper, the authors discuss redesigning hospital alarms for patient safety. They note the benefits and dangers of patient safety alarms and outline potential solutions to make patient safety alarms more effective. The investigators suggest that the scope and design of alarm systems must shift from the status quo to a biologically valid, clinically relevant, patient-centered model. They assert that existing technology allows integration and intelligent assessment of patient data to create advanced alarm systems.
AHRQ-funded; HS022835.
Citation: Chopra V, McMahon LF .
Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.
JAMA 2014 Mar 26;311(12):1199-200. doi: 10.1001/jama.2014.710..
Keywords: Adverse Events, Hospitals, Patient Safety
Arkin N, Lee PH, McDonald K
Association of Nurse-to-Patient Ratio with mortality and preventable complications following aortic valve replacement.
The purpose of this study was to examine hospital resources associated with patient outcomes for aortic valve replacement (AVR), including inpatient adverse events and mortality. The investigators found that the hospital volume-outcomes relationship was associated with mortality outcomes but not postoperative complications. They identified structural differences in hospital size, nurses-to-patient ratio, and nursing skill level indicative of high quality outcomes.
AHRQ-funded; HS018558.
Citation: Arkin N, Lee PH, McDonald K .
Association of Nurse-to-Patient Ratio with mortality and preventable complications following aortic valve replacement.
J Card Surg 2014 Mar;29(2):141-8. doi: 10.1111/jocs.12284..
Keywords: Adverse Events, Cardiovascular Conditions, Quality of Care, Mortality, Risk
Owens PL, Barrett ML, Raetzman S
AHRQ Author: Owens PL, Steiner CA
Surgical site infections following ambulatory surgery procedures.
The authors determined the incidence of clinically significant surgical site infections (CS-SSIs) following low- to moderate-risk ambulatory surgery in patients with low risk for surgical complications. They found that among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes but may represent a substantial number of adverse outcomes in aggregate, thus meriting quality improvement efforts to minimize their occurrence.
AHRQ-authored; AHRQ-funded; 290201300002C.
Citation: Owens PL, Barrett ML, Raetzman S .
Surgical site infections following ambulatory surgery procedures.
JAMA 2014 Feb 19;311(7):709-16. doi: 10.1001/jama.2014.4.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Healthcare-Associated Infections (HAIs), Injuries and Wounds, Ambulatory Care and Surgery, Surgery, Hospitalization, Patient Safety, Adverse Events
Hendrich A, McCoy CK, Gale J
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
This article presents a case study concerning challenges, including physician resistance, to the establishment of a common full disclosure protocol at five labor and delivery demonstration sites. Twenty-seven months after implementation, the rate of full disclosure had increased by 221 percent. Practitioners saw a number of factors as key catalysts for change including consistent and ongoing leadership by local practitioners and hospitals.
AHRQ-funded; HS019608.
Citation: Hendrich A, McCoy CK, Gale J .
Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
Health Aff 2014 Jan;33(1):39-45. doi: 10.1377/hlthaff.2013.1009..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Labor and Delivery, Medical Errors, Medical Liability, Policy, Pregnancy, Women
Dimick JB, Birkmeyer NJ, Finks JF
Composite measures for profiling hospitals on bariatric surgery performance.
The study objective was to develop a novel composite measure for profiling hospital performance with bariatric surgery. Composite measures are much better at explaining hospital-level variation in serious complications and predicting future performance than other approaches. This study provides preliminary data that empirically weighted composite outcomes measures may be better than existing alternatives for selective referral and outcomes feedback programs.
AHRQ-funded; HS017765.
Citation: Dimick JB, Birkmeyer NJ, Finks JF .
Composite measures for profiling hospitals on bariatric surgery performance.
JAMA Surg 2014 Jan;149(1):10-6. doi: 10.1001/jamasurg.2013.4109..
Keywords: Adverse Events, Quality of Care, Hospitals
Mello MM, Senecal SK, Kuznetsov Y
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
The researchers report on the experiences of five hospitals with implementing the communications-and-resolution program (CRP) in general surgery over a twenty-two-month period. They found that all of the hospitals improved disclosure and surveillance of adverse events but were not able to fully implement the program’s compensation component. These experiences suggest that strong support from top leadership at the hospital and insurer levels, and adequate staff resources, are critical for the success of CRPs.
AHRQ-funded; HS019505.
Citation: Mello MM, Senecal SK, Kuznetsov Y .
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
Health Aff 2014 Jan;33(1):30-8. doi: 10.1377/hlthaff.2013.0849..
Keywords: Adverse Events, Communication, Medical Liability, Patient Safety
Etchegaray JM, Ottosen MJ, Burress L
Structuring patient and family involvement in medical error event disclosure and analysis.
The researchers conducted a two-phase study to understand whether patients and families who have experienced an adverse event should be involved in the postevent analysis following the disclosure of a medical error. After evaluating the findings, participants concluded that increasing the involvement of patients and their families in the event analysis process was desirable but needed to be structured in a patient-centered way to be successful.
AHRQ-funded; HS019561.
Citation: Etchegaray JM, Ottosen MJ, Burress L .
Structuring patient and family involvement in medical error event disclosure and analysis.
Health Aff 2014 Jan;33(1):46-52. doi: 10.1377/hlthaff.2013.0831..
Keywords: Adverse Events, Medical Liability, Patient and Family Engagement, Patient Safety
Starmer AJ, Sectish TC, Simon DW
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
The researchers sought to determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. They found that implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children.
AHRQ-funded; HS019456.
Citation: Starmer AJ, Sectish TC, Simon DW .
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
JAMA 2013 Dec 4;310(21):2262-70. doi: 10.1001/jama.2013.281961..
Keywords: Medical Errors, Adverse Events, Children/Adolescents, Hospitalization, Patient Safety
Letourneau AR, Calderwood MS, Huang SS
Harnessing claims to improve detection of surgical site infections following hysterectomy and colorectal surgery.
The researchers conducted retrospective cohort studies at 2 academic medical centers, extending analyses of patients undergoing hysterectomy or colorectal surgery. They concluded that claims-enhanced surveillance can help to identify surgical site infections (SSIs) missed by routine surveillance, identifying nearly twice as many SSIs following hysterectomy and 4 times more SSIs following colorectal surgery.
AHRQ-funded; HS021424.
Citation: Letourneau AR, Calderwood MS, Huang SS .
Harnessing claims to improve detection of surgical site infections following hysterectomy and colorectal surgery.
Infect Control Hosp Epidemiol 2013 Dec;34(12):1321-3. doi: 10.1086/673975..
Keywords: Healthcare-Associated Infections (HAIs), Injuries and Wounds, Surgery, Patient Safety, Adverse Events, Women, Digestive Disease and Health
Boothe DL, Coplowitz S, Greenwood E
Transforming growth factor beta-1 (TGF-beta1) is a serum biomarker of radiation induced fibrosis in patients treated with intracavitary accelerated partial breast irradiation: preliminary results of a prospective study.
This study examined a relationship between serum transforming growth factor b-1 (TGF-b1) values and radiation-induced fibrosis (RIF). The results suggest that serum TGF-b1 levels before surgery, and during radiation therapy, and after radiation therapy could signal whether a patient is at risk for the development of moderate to severe RIF.
AHRQ-funded; HS016075.
Citation: Boothe DL, Coplowitz S, Greenwood E .
Transforming growth factor beta-1 (TGF-beta1) is a serum biomarker of radiation induced fibrosis in patients treated with intracavitary accelerated partial breast irradiation: preliminary results of a prospective study.
Int J Radiat Oncol Biol Phys 2013 Dec 1;87(5):1030-6. doi: 10.1016/j.ijrobp.2013.08.045..
Keywords: Adverse Events, Cancer, Cancer: Breast Cancer, Risk
Waters TM, Chandler AM, Mion LC
Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.
The researchers compared falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge ICD-9-CM codes for the same set of inpatient episodes of care. They found that the CMS-targeted ICD-9-CM codes used to identify fall-related injuries in claims data do not always detect the most-serious falls.
AHRQ-funded; HS020627.
Citation: Waters TM, Chandler AM, Mion LC .
Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.
J Am Geriatr Soc 2013 Dec;61(12):2186-91. doi: 10.1111/jgs.12539..
Keywords: Falls, Elderly, Patient Safety, Inpatient Care, Adverse Events
Katz DF, Sun J, Khatri V
QTc interval screening in an opioid treatment program.
This pilot study supports the feasibility of implementing a population-based electrocardiographic monitoring program in order to decrease the QTc interval in high-risk patients undergoing methadone maintenance in an opioid treatment program. Clinical characteristics alone were inadequate to identify patients in need of electrocardiographic screening.
AHRQ-funded; HS021138
Citation: Katz DF, Sun J, Khatri V .
QTc interval screening in an opioid treatment program.
Am J Cardiol. 2013 Oct 1;112(7):1013-8. doi: 10.1016/j.amjcard.2013.05.037..
Keywords: Opioids, Medication, Substance Abuse, Screening, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Risk, Implementation
Hempel S, Newberry S, Wang Z
AHRQ Author: Spector WD
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
The authors sought to document systematically the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals. They found that most interventions included multiple components, and the pooled postintervention incidence rate ratio (IRR) was 0.77. They found no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR. They concluded that promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.
AHRQ-authored; AHRQ-funded; 290201000017I.
Citation: Hempel S, Newberry S, Wang Z .
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
J Am Geriatr Soc 2013 Apr;61(4):483-94. doi: 10.1111/jgs.12169.
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Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention
O'Leary KJ, Devisetty VK, Patel AR
Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.
This study compared a traditional trigger tool with an enterprise data warehouse (EDW) based screening method to detect hospital adverse events (AEs). The authors found relatively poor agreement between traditional trigger tool and EDW based screening with only approximately a third of all AEs detected by both methods. They recommended a combination of complementary methods as the optimal approach to detecting AEs among hospitalized patients.
AHRQ-funded; HS019630.
Citation: O'Leary KJ, Devisetty VK, Patel AR .
Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.
BMJ Qual Saf 2013 Feb;22(2):130-8. doi: 10.1136/bmjqs-2012-001102.
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Keywords: Adverse Events, Hospitals, Medical Errors, Patient Safety, Quality Indicators (QIs)