National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (11)
- Blood Pressure (1)
- Cardiovascular Conditions (1)
- Care Coordination (1)
- Care Management (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (6)
- Communication (3)
- Critical Care (7)
- Diagnostic Safety and Quality (1)
- Education: Continuing Medical Education (2)
- Elderly (1)
- Electronic Health Records (EHRs) (4)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (2)
- Evidence-Based Practice (1)
- Healthcare-Associated Infections (HAIs) (5)
- Healthcare Costs (1)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (4)
- Health Services Research (HSR) (1)
- Heart Disease and Health (1)
- Hospitalization (1)
- Hospital Readmissions (2)
- (-) Intensive Care Unit (ICU) (27)
- Kidney Disease and Health (1)
- Medical Errors (1)
- Medication (4)
- Medication: Safety (3)
- Methicillin-Resistant Staphylococcus aureus (MRSA) (1)
- Mortality (1)
- Neurological Disorders (1)
- Newborns/Infants (4)
- Organizational Change (1)
- Outcomes (4)
- (-) Patient Safety (27)
- Prevention (3)
- Provider (1)
- Provider: Clinician (1)
- Quality Improvement (2)
- Quality Indicators (QIs) (1)
- Quality of Care (7)
- Registries (2)
- Respiratory Conditions (3)
- Risk (1)
- Shared Decision Making (1)
- Surgery (3)
- Training (2)
- Transitions of Care (1)
- Trauma (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 25 of 27 Research Studies DisplayedNapolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
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.
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
Kizzier-Carnahan V, Artis KA, Mohan V
Frequency of passive EHR alerts in the ICU: another form of alert fatigue?
The authors researched the impact of passive data alerts in the intensive care unit (ICU) on patient safety. They found that the average ICU patient generates a large number of passive alerts daily, many of which may be clinically irrelevant. Issues with Electronic Health Record design and use likely further magnified this problem. They concluded that their results established the need for additional studies to understand how a high burden of passive alerts impact clinical decision making and how to design passive alerts to optimize their clinical utility.
AHRQ-funded; HS023793; HS021637.
Citation: Kizzier-Carnahan V, Artis KA, Mohan V .
Frequency of passive EHR alerts in the ICU: another form of alert fatigue?
J Patient Saf 2019 Sep;15(3):246-50. doi: 10.1097/pts.0000000000000270..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Intensive Care Unit (ICU), Patient Safety
Carayon P, Wetterneck TB, Cartmill R
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
This study examined the impact of electronic health record (EHR) implementation in two intensive care units (ICUs). The authors assessed 1254 consecutive admissions before and after an EHR implementation. They identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). The overall potential for harm due to medication errors decreased post-implementation, but only 2 of the 3 error rates were significantly lower post-implementation. They observed reductions in rates of medication errors per admission at the stages of transcription, dispensing, and administration. In the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information).
AHRQ-funded; HS015274; HS000083.
Citation: Carayon P, Wetterneck TB, Cartmill R .
Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations.
J Patient Saf 2021 Aug 1;17(5):e429-e39. doi: 10.1097/pts.0000000000000358.
AHRQ-funded; HS015274; HS000083..
AHRQ-funded; HS015274; HS000083..
Keywords: Medication: Safety, Medication, Intensive Care Unit (ICU), Critical Care, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
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)
Hoonakker PLT, Wooldridge AR, Hose BZ
Information flow during pediatric trauma care transitions: things falling through the cracks.
In order to investigate information flow during pediatric trauma care transitions, researchers interviewed 18 clinicians about communication and coordination between the emergency department, operating room, and pediatric intensive care unit, then surveyed the clinicians about patient safety during these transitions. They found that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To manage the transition of this fragile and complex population better, they recommend finding ways to manage the information flow during these transitions better by, for instance, providing technological support to ensure shared mental models.
AHRQ-funded; HS023837.
Citation: Hoonakker PLT, Wooldridge AR, Hose BZ .
Information flow during pediatric trauma care transitions: things falling through the cracks.
Intern Emerg Med 2019 Aug;14(5):797-805. doi: 10.1007/s11739-019-02110-7..
Keywords: Children/Adolescents, Communication, Emergency Department, Healthcare Delivery, Intensive Care Unit (ICU), Patient Safety, Provider, Provider: Clinician, Surgery, Transitions of Care, Trauma
Sanders R, Edwards L, Nishisaki A
Tracheal intubations for critically Ill children outside specialized centers in the United Kingdom-patient, provider, practice factors, and adverse events.
This editorial discusses a research study on outcomes of performing pediatric trachael intubations (TIs) and how the results can be applied to performing intubations on critically ill children in the United Kingdom outside of specialized centers. One of the authors is from a U.S. site that submits its airway management data to the National Emergency Airway Registry for Children (NEAR4KIDS). The results from the registry were compared to the results from the study. A total of 1,051 patients out of 1,237 eligible patients were analyzed. The results came from 47 nonspecialized local hospitals in the North Thames and East Anglia region of the UK. Adverse TI-associated events (TIAEs) occurred in 22.7% of the patients, which is higher than those in PICUs and cardiac ICUs. The majority of intubations were performed by the anesthesiologist in the team. The results were similar to those in the NEAR4KIDS registry. There were more complications with children with a higher grade of airway difficulties and comorbidities. The authors believe that pediatric airway management for acutely ill children would benefit from new strategies. They recommend a system change using Plan, Do, Study, Act (PDSA) cycles.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Sanders R, Edwards L, Nishisaki A .
Tracheal intubations for critically Ill children outside specialized centers in the United Kingdom-patient, provider, practice factors, and adverse events.
Pediatr Crit Care Med 2019 Jun;20(6):572-73. doi: 10.1097/pcc.0000000000001946..
Keywords: Adverse Events, Children/Adolescents, Critical Care, Intensive Care Unit (ICU), Outcomes, Patient Safety, Registries, Respiratory Conditions
Artis KA, Bordley J, Mohan V
Data omission by physician trainees on ICU rounds.
This observational study measured how frequently physician trainees omitted data from prerounding notes ("artifacts") and verbal presentations during daily rounds. The authors concluded that in an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. They assert that additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.
AHRQ-funded; HS023793.
Citation: Artis KA, Bordley J, Mohan V .
Data omission by physician trainees on ICU rounds.
Crit Care Med 2019 Mar;47(3):403-09. doi: 10.1097/ccm.0000000000003557..
Keywords: Education: Continuing Medical Education, Intensive Care Unit (ICU), Medical Errors, Patient Safety, Quality of Care
Foglia EE, Ades A, Sawyer T
Neonatal intubation practice and outcomes: an international registry study.
Neonatal tracheal intubation is a critical but potentially dangerous procedure. In this study, the investigators sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. They developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. They suggest that their results will inform future interventional studies to improve neonatal intubation safety.
AHRQ-funded; HS024511.
Citation: Foglia EE, Ades A, Sawyer T .
Neonatal intubation practice and outcomes: an international registry study.
Pediatrics 2019 Jan;143(1). doi: 10.1542/peds.2018-0902..
Keywords: Emergency Department, Health Services Research (HSR), Intensive Care Unit (ICU), Newborns/Infants, Outcomes, Patient Safety, Registries
Mokhateb-Rafii T, Bakar A, Gangadharan S
Hemodynamic impact of oxygen desaturation during tracheal intubation among critically ill children with cyanotic and noncyanotic heart disease.
The objective of this study was to determine a level of oxygen desaturation associated with increased risk of tracheal intubation events in children in a pediatric or cardiac ICU with cyanotic and noncyanotic heart disease. Oxygen desaturation was measured by a fall in pulse oximetry from baseline after pre-oxygenation. The primary outcome was occurrence of hemodynamic tracheal intubation associated events defined as cardiac arrest, hypotension, or dysrhythmia. Results indicate that oxygen desaturation by 30% or more is associated with increased odds for adverse hemodynamic events, after adjusting for confounders. Oxygen desaturation was observed more often in children with cyanotic than those with noncyanotic heart disease, but hemodynamic tracheal intubation associated event rates were similar.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Mokhateb-Rafii T, Bakar A, Gangadharan S .
Hemodynamic impact of oxygen desaturation during tracheal intubation among critically ill children with cyanotic and noncyanotic heart disease.
Pediatr Crit Care Med 2019 Jan;20(1):19-26. doi: 10.1097/pcc.0000000000001766..
Keywords: Adverse Events, Cardiovascular Conditions, Children/Adolescents, Heart Disease and Health, Respiratory Conditions, Intensive Care Unit (ICU), Patient Safety, Risk
Lee JH, Nuthall G, Ikeyama T
Tracheal intubation practice and safety across international PICUs: a report from national emergency airway registry for children.
Researchers hypothesized that there would be differences in the process of care and adverse outcomes for tracheal intubation across pediatric ICUs (PICUs) in six different geographical regions: Germany, Japan, Singapore, India, New Zealand, and North America. Adverse tracheal intubation-associated events and desaturation occurrences in PICUS in these regions were evaluated, and the international PICUs compared with those in North America. The proportion of tracheal intubations for endotracheal tube change was greater in international PICUs, and the median age for international tracheal intubations was younger when compared with North America PICUs. Occurrences of adverse tracheal intubation-associated events were slightly lower for international than for North American PICUs, except for Germany and Japan, which were slightly higher.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Lee JH, Nuthall G, Ikeyama T .
Tracheal intubation practice and safety across international PICUs: a report from national emergency airway registry for children.
Pediatr Crit Care Med 2019 Jan;20(1):1-8. doi: 10.1097/pcc.0000000000001782..
Keywords: Adverse Events, Care Management, Children/Adolescents, Intensive Care Unit (ICU), Respiratory Conditions, Outcomes, Patient Safety
Wang S, Allen D, Perkins A
Validation of a new clinical tool for post-intensive care syndrome.
The objective of this study was to validate the self-report version of the Healthy Aging Brain Care Monitor as a clinical tool for detecting post-intensive care syndrome. 142 patients who survived stays in intensive care units (ICUs) following a critical illness completed the self-report and standardized assessments of their cognition, their psychological symptoms, and physical functioning. Patients who had post-ICU syndrome were compared with a sample of primary care patients. Based on their findings, the researchers conclude that the self-report version is a valid clinical tool for the assessment of symptoms of post-ICU syndrome.
AHRQ-funded; HS024384.
Citation: Wang S, Allen D, Perkins A .
Validation of a new clinical tool for post-intensive care syndrome.
Am J Crit Care 2019 Jan;28(1):10-18. doi: 10.4037/ajcc2019639..
Keywords: Diagnostic Safety and Quality, Intensive Care Unit (ICU), Neurological Disorders, Patient Safety
Rehder KJ, Giuliano JS, Jr., Napolitano N
Increased occurrence of tracheal intubation-associated events during nights and weekends in the PICU.
Little is known about how the incidence of tracheal intubation-associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. After analyzing 5,096 tracheal intubation courses from the prospective multicenter National Emergency Airway Registry for Children, the researchers found that a higher occurrence of tracheal intubation-associated events was observed during nights and weekends, due primarily to emergent intubations.
AHRQ-funded; HS022464; HS021583.
Citation: Rehder KJ, Giuliano JS, Jr., Napolitano N .
Increased occurrence of tracheal intubation-associated events during nights and weekends in the PICU.
Crit Care Med 2015 Dec;43(12):2668-74. doi: 10.1097/ccm.0000000000001313.
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Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Events, Patient Safety, Critical Care
Wolfe H, Maltese MR, Niles DE
Blood pressure directed booster trainings improve intensive care unit provider retention of excellent cardiopulmonary resuscitation skills.
The authors incorporated arterial blood pressure (ABP) tracings into Booster Trainings, hypothesizing that ABP-directed CPR Booster Trainings would improve intensive care unit (ICU) provider 3-month retention of excellent CPR skills without need for interval retraining. They found that the ABP-directed CPR booster trainings improved ICU provider 3-month retention of excellent CPR skills without the need for interval retraining.
AHRQ-funded; HS022469; HS022464.
Citation: Wolfe H, Maltese MR, Niles DE .
Blood pressure directed booster trainings improve intensive care unit provider retention of excellent cardiopulmonary resuscitation skills.
Pediatr Emerg Care 2015 Nov;31(11):743-7. doi: 10.1097/pec.0000000000000394.
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Keywords: Blood Pressure, Education: Continuing Medical Education, Intensive Care Unit (ICU), Patient Safety, Training
McElroy LM, Macapagal KR, Collins KM
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
The goal of this study is to use qualitative research methods to describe clinician perceptions of OR-to-ICU handoffs, and to elucidate attributes of the handoff process associated with high quality, as well as those with poor quality that can lead to patient harm. The findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm.
AHRQ-funded; HS000078.
Citation: McElroy LM, Macapagal KR, Collins KM .
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
Am J Surg 2015 Oct;210(4):629-35. doi: 10.1016/j.amjsurg.2015.05.008..
Keywords: Patient Safety, Intensive Care Unit (ICU), Surgery, Adverse Events, Care Coordination
Valley TS, Sjoding MW, Ryan AM
Association of intensive care unit admission with mortality among older patients with pneumonia.
The purpose of this study was to estimate the relationship between ICU admission and outcomes for elderly patients with pneumonia. It concluded that among Medicare beneficiaries hospitalized with pneumonia, ICU admission of patients for whom the decision appeared to be discretionary was associated with improved survival and no significant difference in costs.
AHRQ-funded; HS020672.
Citation: Valley TS, Sjoding MW, Ryan AM .
Association of intensive care unit admission with mortality among older patients with pneumonia.
JAMA 2015 Sep 22-29;314(12):1272-9. doi: 10.1001/jama.2015.11068..
Keywords: Patient Safety, Intensive Care Unit (ICU), Elderly, Mortality, Hospitalization
McElroy LM, Collins KM, Koller FL
Operating room to intensive care unit handoffs and the risks of patient harm.
The goal of this study was to assess systems and processes involved in the operating room(OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality of specific steps of the handoff. In total, 81 process failures were identified, Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication, team member absence during handoff communication, and transport equipment malfunction.
AHRQ-funded; HS000078.
Citation: McElroy LM, Collins KM, Koller FL .
Operating room to intensive care unit handoffs and the risks of patient harm.
Surgery 2015 Sep;158(3):588-94. doi: 10.1016/j.surg.2015.03.061..
Keywords: Intensive Care Unit (ICU), Patient Safety, Surgery, Communication, Adverse Events
Croft LD, Harris AD, Pineles L
The effect of universal glove and gown use on adverse events in intensive care unit patients.
The researchers assessed if wearing gloves and gowns during all patient contact in the intensive care unit (ICU) changes adverse event rates. They found that in ICUs where healthcare workers donned gloves and gowns for all patient contact, patients were no more likely to experience adverse events than in control ICUs. Concerns of adverse events resulting from universal glove and gown use were not supported.
AHRQ-funded; 29020060001.
Citation: Croft LD, Harris AD, Pineles L .
The effect of universal glove and gown use on adverse events in intensive care unit patients.
Clin Infect Dis 2015 Aug 15;61(4):545-53. doi: 10.1093/cid/civ315..
Keywords: Patient Safety, Intensive Care Unit (ICU), Adverse Events, Healthcare-Associated Infections (HAIs), Critical Care
Rock C, Harris AD, Johnson JK
Infrequent air contamination with Acinetobacter baumannii of air surrounding known colonized or infected patients.
The researchers, by using a validated air sampling method, found Acinetobacter baumannii in the air surrounding only 1 of 12 patients known to be colonized or infected with A. baumannii. Patients’ closed-circuit ventilator status, frequent air exchanges in patient rooms, and short sampling time may have contributed to this low burden.
AHRQ-funded; HS022291.
Citation: Rock C, Harris AD, Johnson JK .
Infrequent air contamination with Acinetobacter baumannii of air surrounding known colonized or infected patients.
Infect Control Hosp Epidemiol 2015 Jul;36(7):830-2. doi: 10.1017/ice.2015.68..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Healthcare-Associated Infections (HAIs), Intensive Care Unit (ICU)
Morgan DJ, Pineles L, Shardell M
Effect of chlorhexidine bathing and other infection control practices on the Benefits of Universal Glove and Gown (BUGG) trial: a subgroup analysis.
The researchers report the results of a subgroup analysis of the Benefits of Universal Glove and Gown trial. In 20 intensive care units, the reduction in acquisition of methicillin-resistant Staphylococcus aureus observed in this trial was observed in units also using chlorhexidine bathing and in those that previously performed active surveillance.
AHRQ-funded; HS018111; 290200600015.
Citation: Morgan DJ, Pineles L, Shardell M .
Effect of chlorhexidine bathing and other infection control practices on the Benefits of Universal Glove and Gown (BUGG) trial: a subgroup analysis.
Infect Control Hosp Epidemiol 2015 Jun;36(6):734-7. doi: 10.1017/ice.2015.33..
Keywords: Patient Safety, Prevention, Intensive Care Unit (ICU), Methicillin-Resistant Staphylococcus aureus (MRSA), Healthcare-Associated Infections (HAIs)
Brown SE, Ratcliffe SJ, Halpern SD
Assessing the utility of ICU readmissions as a quality metric: an analysis of changes mediated by residency work-hour reforms.
This study sought to determine whether ICU readmission rates changed after the 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform and whether there were temporally corresponding changes in other ICU outcomes. The decrease in ICU readmission rates after reform, without corresponding changes in mortality, suggest that ICU readmissions are not causally related to other untoward patient outcomes.
AHRQ-funded; HS018406.
Citation: Brown SE, Ratcliffe SJ, Halpern SD .
Assessing the utility of ICU readmissions as a quality metric: an analysis of changes mediated by residency work-hour reforms.
Chest 2015 Mar;147(3):626-36. doi: 10.1378/chest.14-1060..
Keywords: Intensive Care Unit (ICU), Hospital Readmissions, Quality of Care, Patient Safety, Outcomes
Tarquinio KM, Howell JD, Montgomery V
Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study.
The objective of this study was to evaluate the association of medication selection on specific tracheal intubation–associated events across pediatric intensive care units. It found that fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.
AHRQ-funded; HS022464; HS021583.
Citation: Tarquinio KM, Howell JD, Montgomery V .
Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study.
Pediatr Crit Care Med 2015 Mar;16(3):210-8. doi: 10.1097/pcc.0000000000000319..
Keywords: Children/Adolescents, Patient Safety, Intensive Care Unit (ICU), Adverse Events, Medication
Gold JA, Tutsch AS, Gorsuch A
Integrating the electronic health record into high-fidelity interprofessional intensive care unit simulations.
The authors described the impact of integrating the electronic health record (EHR) into high-fidelity, interprofessional intensive care unit (ICU) simulations, and the errors induced. They found a number of safety issues directly related to the EHR, and they now have an infrastructure to focus educational initiative and deploy informatics solutions to mitigate these safety issues.
AHRQ-funded; HS021637.
Citation: Gold JA, Tutsch AS, Gorsuch A .
Integrating the electronic health record into high-fidelity interprofessional intensive care unit simulations.
J Interprof Care 2015;29(6):562-3. doi: 10.3109/13561820.2015.1063482.
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Keywords: Shared Decision Making, Electronic Health Records (EHRs), Intensive Care Unit (ICU), Patient Safety, Training
Rangachari P, Madaio M, Rethemeyer RK
The evolution of knowledge exchanges enabling successful practice change in two intensive care units.
There are gaps in understanding the mechanisms by which top-down communications enable practice change. The authors sought to address these gaps in order to help identify evidence-based management strategies for successful practice change at the unit level. They found that both intensive care units studied experienced substantially improved outcomes and indicated a statistically significant increase in proactive communications. Early in the study, champions emerged within each unit to initiate process improvements. The authors concluded that the study helped to identify evidence-based management strategies for successful practice change at the unit level.
AHRQ-funded; HS019785.
Citation: Rangachari P, Madaio M, Rethemeyer RK .
The evolution of knowledge exchanges enabling successful practice change in two intensive care units.
Health Care Manage Rev 2015 Jan-Mar;40(1):65-78. doi: 10.1097/hmr.0000000000000001.
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Keywords: Intensive Care Unit (ICU), Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Critical Care, Communication, Evidence-Based Practice, Organizational Change, Prevention, Patient Safety
Collinsworth AW, Masica AL, Priest EL
Modifying the electronic health record to facilitate the implementation and evaluation of a bundled care program for intensive care unit delirium.
This case study describes how an integrated health care delivery system modified its inpatient electronic health record to accelerate the implementation and evaluation of ABCDE bundle deployment as a safety and quality initiative for the prevention of delirium in intensive care unit patients.
AHRQ-funded; HS021459
Citation: Collinsworth AW, Masica AL, Priest EL .
Modifying the electronic health record to facilitate the implementation and evaluation of a bundled care program for intensive care unit delirium.
eGEMS. 2014;2(1):1121. doi: 10.13063/2327-9214.1121..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Intensive Care Unit (ICU), Patient Safety, Quality of Care