National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Events (4)
- Ambulatory Care and Surgery (1)
- Clinician-Patient Communication (1)
- Communication (3)
- Education: Continuing Medical Education (1)
- Hospitals (1)
- Labor and Delivery (2)
- Medical Errors (4)
- (-) Medical Liability (9)
- Patient and Family Engagement (1)
- Patient Safety (7)
- Policy (3)
- Pregnancy (1)
- Provider (1)
- Quality of Care (1)
- Risk (1)
- Surgery (1)
- Women (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
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 DisplayedSage WM, Jablonski JS, Thomas EJ
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
The researchers sought to determine the frequency of nondisclosure agreements in medical malpractice settlements and the extent to which the restrictions in these agreements seem incompatible with good patient care. They found that an academic health system with a declared commitment to patient safety and transparency used nondisclosure clauses in most malpractice settlement agreements but with little standardization or consistency.
AHRQ-funded; HS019561.
Citation: Sage WM, Jablonski JS, Thomas EJ .
Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.
JAMA Intern Med 2015 Jul;175(7):1130-5. doi: 10.1001/jamainternmed.2015.1035..
Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety
Pradarelli JC, Campbell DA, Dimick JB
Hospital credentialing and privileging of surgeons: a potential safety blind spot.
Taylor v Intuitive, the first of at least 26 lawsuits against Intuitive, went to trial alleging injuries or death tied to the da Vinci Surgical System, a new robotic surgical system. This discussion of the events surrounding the case of Taylor v Intuitive highlights the importance of hospitals’ credentialing and privileging mechanisms for maintaining the quality and safety of surgical care, especially regarding new technologies for which practicing surgeons may not have formal training.
AHRQ-funded; HS017765.
Citation: Pradarelli JC, Campbell DA, Dimick JB .
Hospital credentialing and privileging of surgeons: a potential safety blind spot.
JAMA 2015 Apr 7;313(13):1313-4. doi: 10.1001/jama.2015.1943..
Keywords: Patient Safety, Surgery, Education: Continuing Medical Education, Medical Liability, Hospitals
Singer SJ, Reyes Nieva H, Brede N
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
This study reports findings from the baseline practice staff and administrator surveys designed as part of the PROMISES Project to assess safety and malpractice risks in the ambulatory setting. It found that administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems were related to staff perceptions of their quality.
AHRQ-funded; HS019508.
Citation: Singer SJ, Reyes Nieva H, Brede N .
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
Med Care 2015 Feb;53(2):141-52. doi: 10.1097/mlr.0000000000000269..
Keywords: Ambulatory Care and Surgery, Patient Safety, Medical Liability, Provider
Santos P, Ritter GA, Hefele JL
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
The researchers conducted a case study of a risk reduction labor and delivery model at 5 demonstration sites. After 27 months post implementation, reporting of unintended events increased significantly (43 vs 84 per 1000 births), while high-risk malpractice events decreased significantly (14 vs 7 per 1000 births).
AHRQ-funded; HS019608.
Citation: Santos P, Ritter GA, Hefele JL .
Decreasing intrapartum malpractice: targeting the most injurious neonatal adverse events.
J Healthc Risk Manag 2015;34(4):20-7. doi: 10.1002/jhrm.21168..
Keywords: Labor and Delivery, Patient Safety, Risk, Medical Liability, Medical Errors
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
Kachalia A, Little A, Isavoran M
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
The Oregon Health Authority analyzed the potential for safe harbors to improve patient safety and the performance of the medical liability system, as well as legal challenges and stakeholder concerns that might arise with legislation enacting safe harbors. They found that such legislation would have changed the liability outcome in favor of the physician defendant in only 1 percent of 266 claims from the period 2002–09 that were reviewed.
AHRQ-funded; HS019535.
Citation: Kachalia A, Little A, Isavoran M .
Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.
Health Aff 2014 Jan;33(1):59-66. doi: 10.1377/hlthaff.2013.0834..
Keywords: Patient Safety, Medical Liability, Medical Errors, Quality of Care, Policy
Sage WM, Gallagher TH, Armstrong S
How policy makers can smooth the way for communication-and- resolution programs.
The authors argue that State and federal policy makers should try to allay potential defendants’ fears of litigation (e.g., by protecting apologies from use in court), facilitate patient participation (e.g., by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (e.g., by clarifying practices governing National Practitioner Data Bank reporting and payers’ financial recourse following medical error).
AHRQ-funded; HS019505; HS019531; HS019561; HS019565; HSO19608; HS19537.
Citation: Sage WM, Gallagher TH, Armstrong S .
How policy makers can smooth the way for communication-and- resolution programs.
Health Aff 2014 Jan;33(1):11-9. doi: 10.1377/hlthaff.2013.0930..
Keywords: Communication, Policy, Medical Liability, Policy
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