National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (12)
- Adverse Events (28)
- Ambulatory Care and Surgery (2)
- Back Health and Pain (1)
- Caregiving (2)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (5)
- Clinical Decision Support (CDS) (3)
- Clinician-Patient Communication (4)
- Communication (8)
- Data (1)
- Decision Making (1)
- Diagnostic Safety and Quality (10)
- Elderly (1)
- Electronic Health Records (EHRs) (4)
- Electronic Prescribing (E-Prescribing) (1)
- Emergency Department (2)
- Evidence-Based Practice (2)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (14)
- Hospital Discharge (1)
- Hospitalization (3)
- Hospitals (2)
- Inpatient Care (1)
- Labor and Delivery (1)
- (-) Medical Errors (52)
- Medical Liability (10)
- Medication (12)
- Medication: Safety (5)
- Pain (1)
- Patient-Centered Healthcare (1)
- Patient and Family Engagement (1)
- Patient Experience (1)
- Patient Safety (42)
- Policy (2)
- Practice Patterns (3)
- Pregnancy (1)
- Prevention (3)
- Primary Care (3)
- Provider: Health Personnel (1)
- Provider: Pharmacist (1)
- Quality Improvement (4)
- Quality Measures (1)
- Quality of Care (8)
- Risk (1)
- Stress (1)
- Surgery (4)
- System Design (1)
- Teams (1)
- Tools & Toolkits (2)
- Transplantation (1)
- Web-Based (1)
- Women (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 52 Research Studies DisplayedCox 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
Kang H, Gong Y
Design of a user-centered voluntary reporting system for patient safety events.
A knowledge-based and user-centered patient safety events (PSE) reporting system is needed to organize scattered knowledge and improve user-friendliness. The researchers described the development of a knowledge base for patient falls, the most frequent PSE. Based on the knowledge base, user-centered design features were incorporated into the system to improve the reporting accuracy, completeness, and timeliness.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
Design of a user-centered voluntary reporting system for patient safety events.
Stud Health Technol Inform 2017;245:733-37.
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Keywords: Adverse Events, Medical Errors, Health Information Technology (HIT), Patient Safety
Kushniruk A, Senathirajah Y, Borycki E
Towards a usability and error "safety net": a multi-phased multi-method approach to ensuring system usability and safety.
The researchers describe a multi-phased multi-method approach to integrating usability engineering methods into system testing to ensure both usability and safety of healthcare IT upon widespread deployment. Their approach involves usability testing followed by clinical simulation (conducted in-situ) and "near-live" recording of user interactions with systems. At key stages in this process, usability problems are identified and rectified forming a usability and technology-induced error "safety net.”
AHRQ-funded; HS023708.
Citation: Kushniruk A, Senathirajah Y, Borycki E .
Towards a usability and error "safety net": a multi-phased multi-method approach to ensuring system usability and safety.
Stud Health Technol Inform 2017;245:763-67.
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Keywords: Health Information Technology (HIT), Medical Errors, 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
Gong Y, Kang H, Wu X
Enhancing patient safety event reporting. a systematic review of system design features.
Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. This paper aimed at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system. Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated. The authors concluded that the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.
AHRQ-funded; HS022895.
Citation: Gong Y, Kang H, Wu X .
Enhancing patient safety event reporting. a systematic review of system design features.
Appl Clin Inform 2017 Aug 30;8(3):893-909. doi: 10.4338/aci-2016-02-r-0023..
Keywords: Adverse Events, Medical Errors, Health Information Technology (HIT), Patient Safety, System Design
Miller GE, Sarpong EM, Davidoff AJ
AHRQ Author: Miller GE, Sarpong EM
Determinants of potentially inappropriate medication use among community-dwelling older adults.
The researchers examined the determinants of potentially inappropriate medication (PIM) use. The multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use
AHRQ-authored.
Citation: Miller GE, Sarpong EM, Davidoff AJ .
Determinants of potentially inappropriate medication use among community-dwelling older adults.
Health Serv Res 2017 Aug;52(4):1534-49. doi: 10.1111/1475-6773.12562.
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Keywords: Medication, Elderly, Medication: Safety, Adverse Drug Events (ADE), Medical Errors
Bhise V, Meyer AND, Singh H
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
With this study, the investigators set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement. The investigators found that despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses were common and involved inadequate history, physical examination, and test ordering. They suggested that solutions should include renewed attention to basic clinical skills.
AHRQ-funded; HS022087.
Citation: Bhise V, Meyer AND, Singh H .
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Am J Med 2017 Aug;130(8):975-81. doi: 10.1016/j.amjmed.2017.03.009..
Keywords: Adverse Events, Back Health and Pain, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Patient Safety
Fong A, Harriott N, Walters DM
Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.
Natural language processing (NLP) experts collaborated with clinical experts on a patient safety committee to assist in the identification and analysis of medication-related patient safety events. Four types of medication-related patient safety events were identified, and the models were compared. The authors demonstrated the capabilities of various NLP models and the use of two text inclusion strategies at categorizing medication-related patient safety events. They suggested that the NLP models and visualization could be used to improve the efficiency of patient safety event data review and analysis.
AHRQ-funded; HS023701.
Citation: Fong A, Harriott N, Walters DM .
Integrating natural language processing expertise with patient safety event review committees to improve the analysis of medication events.
Int J Med Inform 2017 Aug;104:120-25. doi: 10.1016/j.ijmedinf.2017.05.005.
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Keywords: Adverse Drug Events (ADE), Medical Errors, Medication, Patient Safety
Kang H, Gong Y
Developing a similarity searching module for patient safety event reporting system using semantic similarity measures.
In this study, three prevailing algorithms of semantic similarity were implemented to measure the similarities of the 366 patient safety events (PSE) annotated by the taxonomy of AHRQ. The result shows that the similarity scores reflect a higher consistency with the experts' review than those randomly assigned. Moreover, incorporating the algorithms into the reporting system enables a mechanism to learn and update, based upon PSE similarity.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
Developing a similarity searching module for patient safety event reporting system using semantic similarity measures.
BMC Med Inform Decis Mak 2017 Jul 5;17(Suppl 2):75. doi: 10.1186/s12911-017-0467-8.
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Keywords: Patient Safety, Adverse Events, Medical Errors, Health Information Technology (HIT)
Arnold S
AHRQ Author: Arnold S
The imperative to address diagnostic safety.
Diagnostic errors are likely to impact most of us in our lifetime. The author discusses two studies pointing to the vastness of the challenge and the urgency to act now. He also discusses other aspects of this issue and highlights two current AHRQ dedicated research opportunities on diagnostic safety: one to look at the incidence and causes of diagnostic errors in ambulatory care, and the second to look at improvement strategies and interventions.
AHRQ-authored.
Citation: Arnold S .
The imperative to address diagnostic safety.
Diagnosis 2017 Jun 27;4(2):55-56. doi: 10.1515/dx-2017-0017.
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Keywords: Diagnostic Safety and Quality, Medical Errors, Ambulatory Care and Surgery, Patient Safety, Quality Improvement
Henriksen K, Dymek C, Harrison MI
AHRQ Author: Henriksen K, Dymek C, Harrison MI, Brady PJ, Arnold SB
Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.
AHRQ held a research summit in the fall of 2016, inviting members from a diverse collection of organizations, both inside and outside of government, to share their suggestions regarding what is known about diagnosis and the challenges that need to be addressed. Among the goals of the summit were to learn from the insights of participants and examine issues associated with definitions of diagnostic error and gaps in the evidence base.
AHRQ-authored.
Citation: Henriksen K, Dymek C, Harrison MI .
Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.
Diagnosis 2017 Jun;4(2):57-66.
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Keywords: Diagnostic Safety and Quality, Medical Errors, Evidence-Based Practice, Quality of Care
Singh H, Schiff GD, Graber ML
The global burden of diagnostic errors in primary care.
In this narrative review, the authors discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. They then synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. Finally, they summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors.
AHRQ-funded; HS022087; HS023602.
Citation: Singh H, Schiff GD, Graber ML .
The global burden of diagnostic errors in primary care.
BMJ Qual Saf 2017 Jun;26(6):484-94. doi: 10.1136/bmjqs-2016-005401.
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Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Medical Errors, Patient Safety, Primary Care
Schroeder SR, Salomon MM, Galanter WL
Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
The researchers conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. They found that across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception.
AHRQ-funded; HS021093.
Citation: Schroeder SR, Salomon MM, Galanter WL .
Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
BMJ Qual Saf 2017 May;26(5):395-407. doi: 10.1136/bmjqs-2015-005099.
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Keywords: Adverse Drug Events (ADE), Medical Errors, Medication: Safety, Medication, Provider: Pharmacist
Khan A, Coffey M, Litterer KP
Families as partners in hospital error and adverse event surveillance.
This study compared error and adverse event (AE) rates among hospitalized children : (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Among the findings: Family-reported error rates were 5.0-fold higher and AE rates 2.9-fold higher than hospital incident report rates.
AHRQ-funded; HS022986; HS000063.
Citation: Khan A, Coffey M, Litterer KP .
Families as partners in hospital error and adverse event surveillance.
JAMA Pediatr 2017 Apr;171(4):372-81. doi: 10.1001/jamapediatrics.2016.4812.
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Keywords: Adverse Events, Children/Adolescents, Hospitals, Medical Errors, Patient and Family Engagement
Walsh KE, Harik P, Mazor KM
Measuring harm in health care: optimizing adverse event review.
The objective of this study was to identify modifiable factors that improve the reliability of ratings of severity of health care-associated harm in clinical practice improvement and research. Using a generalizability theory framework to estimate the impact of number of raters, rater experience, and rater provider type on reliability, the researchers found that reliability was greatly improved with 2 reviewers.
AHRQ-funded; 290201000022I.
Citation: Walsh KE, Harik P, Mazor KM .
Measuring harm in health care: optimizing adverse event review.
Med Care 2017 Apr;55(4):436-41. doi: 10.1097/mlr.0000000000000679.
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Keywords: Medical Errors, Adverse Events, Quality Improvement, Adverse Drug Events (ADE), 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
Kang H, Gong Y
A novel schema to enhance data quality of patient safety event reports.
In this study, the researchers designed a patient safety event (PSE) similarity searching model based on semantic similarity measures, and proposed a novel schema of PSE reporting system which can effectively learn from previous experiences and timely inform the subsequent actions. Their system will not only help promote the report qualities but also serve as a knowledge base and education tool to guide healthcare providers in terms of preventing the recurrence of PSEs.
AHRQ-funded; HS022895.
Citation: Kang H, Gong Y .
A novel schema to enhance data quality of patient safety event reports.
AMIA Annu Symp Proc 2017 Feb 10;2016:1840-49.
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Keywords: Quality of Care, Patient Safety, Data, Adverse Events, Medical Errors
Horsky J, Aarts J, Verheul L
Clinical reasoning in the context of active decision support during medication prescribing.
The purpose of this study was to describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. The investigators found that declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher.
AHRQ-funded; HS021094.
Citation: Horsky J, Aarts J, Verheul L .
Clinical reasoning in the context of active decision support during medication prescribing.
Int J Med Inform 2017 Jan;97:1-11. doi: 10.1016/j.ijmedinf.2016.09.004..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Mello MM, Greenberg Y, Senecal SK
Case outcomes in a communication-and-resolution program in New York hospitals.
The researchers sought to determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery. They concluded that the bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.
AHRQ-funded; R18 HS019505.
Citation: Mello MM, Greenberg Y, Senecal SK .
Case outcomes in a communication-and-resolution program in New York hospitals.
Health Serv Res 2016 Dec;51 Suppl 3:2583-99. doi: 10.1111/1475-6773.12594.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Surgery
Mello MM, Armstrong SJ, Greenberg Y
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
The researchers sought to implement a communication-and-resolution program (CRP) in a setting in which liability insurers and health care facilities must collaborate to resolve incidents involving a facility and separately insured clinicians. They found that sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP.
AHRQ-funded; HS019531.
Citation: Mello MM, Armstrong SJ, Greenberg Y .
Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.
Health Serv Res 2016 Dec;51 Suppl 3:2550-68. doi: 10.1111/1475-6773.12580.
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Keywords: Communication, Medical Errors, Medical Liability, Patient Safety
Helmchen LA, Lambert BL, McDonald TB
Changes in physician practice patterns after implementation of a communication-and-resolution program.
The researchers tested if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories. They found that the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.
AHRQ-funded; HS019565.
Citation: Helmchen LA, Lambert BL, McDonald TB .
Changes in physician practice patterns after implementation of a communication-and-resolution program.
Health Serv Res 2016 Dec;51 Suppl 3:2516-36. doi: 10.1111/1475-6773.12610.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Practice Patterns
Gallagher TH, Farrell ML, Karson H
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
The Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. After describing the process, the authors concluded that the CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Farrell ML, Karson H .
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
Health Serv Res 2016 Dec;51 Suppl 3:2569-82. doi: 10.1111/1475-6773.12557.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Patient Safety, Quality of Care
Gallagher TH, Etchegaray JM, Bergstedt B
Improving communication and resolution following adverse events using a patient-created simulation exercise.
The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Etchegaray JM, Bergstedt B .
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Health Serv Res 2016 Dec;51 Suppl 3:2537-49. doi: 10.1111/1475-6773.12601.
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Keywords: Adverse Events, Clinician-Patient Communication, Medical Errors, Medical Liability, Patient-Centered Healthcare, Patient Safety
Battles JB, Reback KA, Azam I
AHRQ Author: Battles JB, Reback KA, Azam I
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
AHRQ launched the Patient Safety and Medical Liability (PSML) initiative in 2009. The papers in this issue cover a breadth of topics related to the PSML initiative. Members of the individual Demonstration project teams have authored the majority of the papers. Seven of these papers report outcomes associated with the individual Demonstrations and another four describe tools generated as a part of the interventions.
AHRQ-funded; 233201500029P.
Citation: Battles JB, Reback KA, Azam I .
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
Health Serv Res 2016 Dec;51 Suppl 3:2401-13. doi: 10.1111/1475-6773.12632.
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Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety, Prevention
Ridgely MS, Greenberg MD, Pillen MB
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
This article identifies lessons learned from the experience of AHRQ’s Patient Safety and Medical Liability (PSML) Demonstration Program. The demonstration lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm.
AHRQ-funded; 290200710073T.
Citation: Ridgely MS, Greenberg MD, Pillen MB .
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
Health Serv Res 2016 Dec;51 Suppl 3:2414-30. doi: 10.1111/1475-6773.12625.
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Keywords: Patient Safety, Medical Liability, Adverse Events, Medical Errors