National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (15)
- Ambulatory Care and Surgery (1)
- Behavioral Health (1)
- Burnout (1)
- Cancer (1)
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- (-) Children/Adolescents (19)
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- Diagnostic Safety and Quality (6)
- Disparities (1)
- Electronic Health Records (EHRs) (1)
- Family Health and History (2)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Health Information Technology (HIT) (1)
- Hospitalization (5)
- Hospitals (5)
- Inpatient Care (5)
- Intensive Care Unit (ICU) (3)
- (-) Medical Errors (19)
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- Medication: Safety (2)
- Patient Experience (1)
- (-) Patient Safety (19)
- Provider (1)
- Provider: Physician (2)
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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
1 to 19 of 19 Research Studies DisplayedCifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Wong CI, Vannatta K, Gilleland Marchak J
Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.
The goal of this longitudinal study was to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over seven months of treatment. The study included children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Ten percent experienced adverse drug events because of outpatient medication errors. Twenty-six percent of caregivers reported miscommunication leading to missed doses or overdoses. The authors concluded that improvements addressing communication with and among caregivers should be based on human-factors engineering and codeveloped with families.
AHRQ-funded; HS024390.
Citation: Wong CI, Vannatta K, Gilleland Marchak J .
Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.
Cancer 2023 Apr 1;129(7):1064-74. doi: 10.1002/cncr.34651.
Keywords: Children/Adolescents, Cancer, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Ambulatory Care and Surgery, Medication: Safety, Patient Safety
Halvorson EE, Thurtle DP, Easter A
Disparities in adverse event reporting for hospitalized children.
The authors compared the adverse event (AE) rate identified by voluntary event reporting (VER) with that identified using the Global Assessment of Pediatric Patient Safety (GAPPS) between hospitalized children by weight category, race, and English proficiency. In the population studied, they identified 288 total AEs, 270 by the GAPPS and 18 by VER. They found a disparity in AE reporting for children with limited English proficiency, with fewer AEs by VER compared with no difference in AEs by GAPPS. They identified no disparities by weight category or race. They concluded that voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.
AHRQ-funded; HS026038.
Citation: Halvorson EE, Thurtle DP, Easter A .
Disparities in adverse event reporting for hospitalized children.
J Patient Saf 2022 Sep 1;18(6):e928-e33. doi: 10.1097/pts.0000000000001049..
Keywords: Children/Adolescents, Disparities, Adverse Events, Medical Errors, Patient Safety, Hospitals, Hospitalization, Inpatient Care
Mercer AN, Mauskar S, Baird J
Family safety reporting in hospitalized children with medical complexity.
This prospective cohort study was conducted to evaluate safety concerns from families of hospitalized children with medical complexity (CMC) who are at high risk of medical errors. This survey was done predischarge with English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. A total of 155 parents and 214 staff completed surveys, with 43% (n = 66) having ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). A physician review found that 69% of concerns were medical errors, and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses, but only 32% of parents recalled being told how to report safety concerns. Higher education and longer length of stay were associated with family safety concerns.
AHRQ-funded; HS025781.
Citation: Mercer AN, Mauskar S, Baird J .
Family safety reporting in hospitalized children with medical complexity.
Pediatrics 2022 Aug 1; 150(2):e2021055098. doi: 10.1542/peds.2021-055098..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
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
Marshall TL, Rinke ML, Olson APJ
Diagnostic error in pediatrics: a narrative review.
This narrative review focuses on the relative paucity of large, high-quality studies of diagnostic errors and what is known at present about the incident and epidemiology as well as the established research for identifying, evaluating, and reducing diagnostic errors. The authors propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature. The authors state that additional research is needed to better establish the epidemiology of diagnostic errors in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses.
AHRQ-funded; HS023827; HS026644.
Citation: Marshall TL, Rinke ML, Olson APJ .
Diagnostic error in pediatrics: a narrative review.
Pediatrics 2022 Mar;149(Suppl 3). doi: 10.1542/peds.2020-045948D..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Patient Safety, Medical Errors
Cifra CL, Custer JW, Singh H
Diagnostic errors in pediatric critical care: a systematic review.
This study is a systematic review on the prevalence, impact, and contributing factors related to diagnostic errors in the PICU. A database search was done for literature up through December 2019. Using specific criteria, 396 abstracts were screened, and 17 studies were included. Fifteen of 17 studies had an observational research design. Autopsy studies showed a 10-23% rate of missed major diagnosis with 5-16% of the errors having a potential adverse impact on survival and would have changed care management. Retrospective record review studies reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions. About a quarter of those patients were discussed at PICU morbidity and mortality conferences. Most misdiagnosed conditions were cardiovascular, infectious, congenital, or neurologic. System, cognitive, and both system and cognitive factors were associated with diagnostic error but there is limited information on the impact of misdiagnosis.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Singh H .
Diagnostic errors in pediatric critical care: a systematic review.
Pediatr Crit Care Med 2021 Aug;22(8):701-12. doi: 10.1097/pcc.0000000000002735..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Intensive Care Unit (ICU), Critical Care
Marshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
Dadlez NM, Adelman J, Bundy DG
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
This study examined root causes of three common pediatric diagnostic errors by having 31 practices enrolled in a national QI collaborative perform monthly “mini-RCAs” (mini root cause analyses). The diagnoses errors studied were missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. Twenty-eight practices submitted 184 mini-RCAs with the most common causes being patient volume (adolescent depression and elevated BP), inadequate staffing (adolescent depression), clinic milieu (elevated BP), written communication and provider knowledge (actionable laboratory values), and electronic health records (EHRs) – (elevated BP and actionable laboratory values). The median number of mini-RCAs submitted was 6.
AHRQ-funded; HS024538; HS024713; HS026121.
Citation: Dadlez NM, Adelman J, Bundy DG .
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Pediatr Qual Saf 2020 May-Jun;5(3):e299. doi: 10.1097/pq9.0000000000000299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety
Cifra CL, Ten Eyck P, Dawson JD
Factors associated with diagnostic error on admission to a PICU: a pilot study.
This pilot retrospective cohort study examined errors in pediatric ICUs (PICUs) for children during the first 12 hours after PICU admission. A structured tool (Safer Dx) was used to identify diagnostic error in an academic tertiary institution. Out of 50 patients, 4 (8%) had diagnostic errors. The errors were in diagnoses of chronic ear infection, intracranial pressure (two cases), and Bartonella encephalitis. This pilot study will be expanded into a larger and more definitive multicenter study.
AHRQ-funded; HS022087.
Citation: Cifra CL, Ten Eyck P, Dawson JD .
Factors associated with diagnostic error on admission to a PICU: a pilot study.
Pediatr Crit Care Med 2020 May;21(5):e311-e15. doi: 10.1097/pcc.0000000000002257..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Critical Care, Intensive Care Unit (ICU), Hospitals
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
Ratwani RM, Savage E, Will A
Identifying electronic health record usability and safety challenges in pediatric settings.
To understand specific usability issues and medication errors in the care of children, the investigators analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. They found: the general pattern of usability challenges and medication errors were the same across the three sites; the most common usability challenges were associated with system feedback and the visual display; and the most common medication error was improper dosing.
AHRQ-funded; HS023701.
Citation: Ratwani RM, Savage E, Will A .
Identifying electronic health record usability and safety challenges in pediatric settings.
Health Aff 2018 Nov;37(11):1752-59. doi: 10.1377/hlthaff.2018.0699..
Keywords: Children/Adolescents, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Children/Adolescents
Stockwell DC, Landrigan CP, Toomey SL
Adverse events in hospitalized pediatric patients.
Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). This study used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. The study concluded that AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.
AHRQ-funded; HS020513
Citation: Stockwell DC, Landrigan CP, Toomey SL .
Adverse events in hospitalized pediatric patients.
Pediatrics 2018 Aug;142(2). doi: 10.1542/peds.2017-3360..
Keywords: Children/Adolescents, Adverse Events, Patient Safety, Inpatient Care, Medical Errors
Dynan L, Goudie A, Brady PW
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
In this article, the investigators hypothesize that adverse event rates increase with the availability of more complex services and technologies (transplantation and pediatric open-heart surgery); increase as experience of providers decreases (July effect); and increase with residents per bed, a measure of both average provider inexperience and congestion. Using multilevel analysis, they found empirical evidence in support of their three hypotheses.
AHRQ-funded; HS023827.
Citation: Dynan L, Goudie A, Brady PW .
Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.
J Healthc Qual 2018 Mar/Apr;40(2):69-78. doi: 10.1097/jhq.0000000000000121..
Keywords: Children/Adolescents, Healthcare Cost and Utilization Project (HCUP), Adverse Events, Hospitals, Inpatient Care, Medical Errors, Patient Safety
Cox ED, Hansen K, Rajamanickam VP
Are parents who feel the need to watch over their children's care better patient safety partners?
In this study, the investigators assessed whether needing to watch over care predicted parent performance of recommended safety behaviors to reduce medication errors and health care-associated infections. The researchers concluded that parents who reported the need to watch over care were more likely to perform behaviors specific to safe medication use (but not hand hygiene) compared with those not reporting this need.
AHRQ-funded; HS018680.
Citation: Cox ED, Hansen K, Rajamanickam VP .
Are parents who feel the need to watch over their children's care better patient safety partners?
Hosp Pediatr 2017 Dec;7(12):716-22. doi: 10.1542/hpeds.2017-0036..
Keywords: Adverse Drug Events (ADE), Adverse Events, Caregiving, Children/Adolescents, Healthcare-Associated Infections (HAIs), Medical Errors, Medication, Patient Safety
Khan A, Furtak SL, Melvin P
Parent-provider miscommunications in hospitalized children.
The objectives of this study were to: (1) examine characteristics of parent-provider miscommunications about hospitalized children; (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience; and (3) compare parent and attending physician reports of parent-provider miscommunications. The investigators found that parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.
AHRQ-funded; HS022986; HS000063.
Citation: Khan A, Furtak SL, Melvin P .
Parent-provider miscommunications in hospitalized children.
Hosp Pediatr 2017 Sep;7(9):505-15. doi: 10.1542/hpeds.2016-0190..
Keywords: Adverse Events, Caregiving, Children/Adolescents, Clinician-Patient Communication, Communication, Hospitalization, Hospitals, Medical Errors, Patient Safety
Haldar S, Filipkowski A, Mishra SR
"Scared to go to the hospital": inpatient experiences with undesirable events.
Researchers surveyed pediatric inpatients and caregivers to understand their perspectives on undesirable events. By giving them an opportunity to use their own words to describe their experiences, they found a diverse array of undesirable events. Their qualitative analysis revealed four major types of events that patients and caregivers experienced: mismanagement, communication, policy, and lack of care coordination.
AHRQ-funded; HS022894.
Citation: Haldar S, Filipkowski A, Mishra SR .
"Scared to go to the hospital": inpatient experiences with undesirable events.
AMIA Annu Symp Proc 2017 Feb 10;2016:609-17.
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Keywords: Patient Experience, Children/Adolescents, Hospitalization, Patient Safety, Medical Errors
Khan A, Furtak SL, Melvin P
Parent-reported errors and adverse events in hospitalized children.
The researchers sought to determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). They found that parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record.
AHRQ-funded; HS022986.
Citation: Khan A, Furtak SL, Melvin P .
Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr 2016 Apr 4;170(4):e154608. doi: 10.1001/jamapediatrics.2015.4608..
Keywords: Children/Adolescents, Hospitalization, Patient Safety, Adverse Events, Medical Errors
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