National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (1)
- Clinician-Patient Communication (1)
- Communication (1)
- Education: Continuing Medical Education (2)
- Emergency Department (1)
- Medical Errors (1)
- Outcomes (1)
- Patient-Centered Outcomes Research (1)
- Patient and Family Engagement (1)
- (-) Patient Safety (7)
- Provider (1)
- Provider: Physician (1)
- (-) Provider Performance (7)
- Quality Improvement (5)
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- Surgery (2)
- Teams (1)
- Training (2)
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 7 of 7 Research Studies DisplayedGriffey RT, Schneider RM, Sharp BR
Description and yield of current quality and safety review in selected US academic emergency departments.
This study examined the impact of current quality and safety reviews used in US academic emergency departments (EDs). The authors hypothesized that current protocols are decades old and inefficient with low yield for identifying patient harm. They conducted a prospective observational study at five academic EDs for a 12-month procedure. Sites used the Institute for Healthcare Improvement’s definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for severity grading of events. They reviewed a total of 4735 cases and identified 381 events, of which 287 were near-misses, and 94 had adverse events (AEs). The overall AE rate was 1.99% (1.24-3.47%) across all sites. Quality concern rate (events without harms) was 6.06% (5.42-6.78%). Forty-seven percent of cases used 72 hour returns as their referral source but with only a 0.81% yield in identifying harm. Other referral sources also had similar low yields. External referrals in the 94 AE cases accounted for 41.49% of cases. The authors concluded that new approaches to quality and safety review in the ED are needed to optimize yield and efficiency for identifying harms and areas for improvement.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Description and yield of current quality and safety review in selected US academic emergency departments.
J Patient Saf 2020 Dec;16(4):e245-e49. doi: 10.1097/pts.0000000000000379..
Keywords: Emergency Department, Patient Safety, Quality Improvement, Quality of Care, Provider Performance
Robbins j, McAlearney AS
Toward a high-performance management system in health care, part 5: how high-performance work practices facilitate speaking up in health care organizations.
Employees' reluctance to speak up about problems and/or make suggestions for improvement is a noted barrier to quality and patient safety improvement in health care organizations. High-performance work practices (HPWPs) offer a framework for considering how management practices can encourage speaking up in these organizations. In this study, the investigators aimed to explore how implementation of HPWPs in U.S. health care organizations could facilitate or remove barriers to speaking up.
AHRQ-funded; 290200600022.
Citation: Robbins j, McAlearney AS .
Toward a high-performance management system in health care, part 5: how high-performance work practices facilitate speaking up in health care organizations.
Health Care Manage Rev 2020 Oct/Dec;45(4):278-89. doi: 10.1097/hmr.0000000000000228..
Keywords: Quality Improvement, Quality of Care, Patient Safety, Provider Performance
Costar DM, Hall KK
Improving team performance and patient safety on the job through team training and performance support tools: a systematic review.
This systematic review’s objective was to identify recent studies that implemented practices to improve teamwork in health care and were associated with positive improvements on the job. Two databases were searched to identify relevant articles published between 2008 and 2018. Twenty articles were selected for inclusion. Across studies, measures assessing teamwork skills on the job were most often collected and sustained improvements were shown for up to 12 months. Evidence of improved clinical practices and increased patient safety was found in both studies team training interventions, as well as those that introduced performance support tools. All studies were conducted in hospitals with very few studies found in other health care settings such as office-based care.
AHRQ-funded; HHSP233201500013I.
Citation: Costar DM, Hall KK .
Improving team performance and patient safety on the job through team training and performance support tools: a systematic review.
J Patient Saf 2020 Sep;16(3S Suppl 1):S48-s56. doi: 10.1097/pts.0000000000000746..
Keywords: Teams, Patient Safety, Training, Patient Safety, Provider Performance, Quality Improvement, Quality of Care
Salzman DH, Rising KL, Cameron KA
Setting a minimum passing standard for the uncertainty communication checklist through patient and physician engagement.
Historically, medically trained experts have served as judges to establish a minimum passing standard (MPS) for mastery learning. As mastery learning expands from procedure-based skills to patient-centered domains, such as communication, there is an opportunity to incorporate patients as judges in setting the MPS. In this study, the investigators described their process of incorporating patients as judges to set the minimum passing standard (MPS) and compared the MPS set by patients and emergency medicine residency program directors (PDs).
AHRQ-funded; HS025651.
Citation: Salzman DH, Rising KL, Cameron KA .
Setting a minimum passing standard for the uncertainty communication checklist through patient and physician engagement.
J Grad Med Educ 2020 Feb;12(1):58-65. doi: 10.4300/jgme-d-19-00483.1..
Keywords: Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety, Education: Continuing Medical Education, Training, Provider Performance
Banerjee A, Burden A, Slagle JM
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
This study analyzed performance gaps of practicing anesthesiologists, and used 4 different scenarios that illustrate those gaps and how they contribute to hazards in anesthesiology and proposals for addressing them. The authors used 4 standardized simulated scenarios of common events that anesthesiologists would expect to see in their practice. The 4 perioperative crisis events are: (1) local anesthetic systemic toxicity (LAST) leading to hemodynamic collapse; (2) retroperitoneal bleeding from insertion of a laparoscopic surgery trocar leading to hemorrhagic shock; (3) malignant hyperthermia (MH) presenting in the postanesthesia care unit; and (4) acute atrial fibrillation with hemodynamic instability, followed by signs of a ST-elevation myocardial infarction (AFib-MI). These scenarios came from a 2017 paper by Weinger, et al. A group of subject matter experts defined a set of clinical performance elements (CPEs) that they would expect to be performed in the scenarios. Only 4% of encounters in these scenarios had perfect performance by anesthesiologists where all prescribed CPEs were performed. Recommendations for improvement included providing high-fidelity simulation training, incorporating clinical lessons about gaps, fostering regular use by anesthesiologists and OR teams of clinical guidance, modifying organizational arrangements at clinical sites to ensure backup help is readily available, and implementing periodic formative performance assessments.
AHRQ-funded; HS020415.
Citation: Banerjee A, Burden A, Slagle JM .
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
Int Anesthesiol Clin 2020 Winter;58(1):13-20. doi: 10.1097/aia.0000000000000262..
Keywords: Medical Errors, Adverse Events, Adverse Drug Events (ADE), Patient Safety, Provider Performance, Provider: Physician, Provider, Surgery
Maggard-Gibbons M
The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.
This review summarized the history of American College of Surgeons National Surgical Quality Improvement Project and its components, and described the evidence that feeding outcomes back to providers, along with real-time comparisons with other hospital rates, leads to quality improvement, better patient outcomes, cost savings and overall improved patient safety.
AHRQ-funded; 2902007100621.
Citation: Maggard-Gibbons M .
The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.
BMJ Qual Saf 2014 Jul;23(7):589-99. doi: 10.1136/bmjqs-2013-002223..
Keywords: Quality Improvement, Quality Indicators (QIs), Quality Measures, Quality of Care, Surgery, Patient Safety, Outcomes, Patient-Centered Outcomes Research, Provider Performance
Arora VM, Berhie S, Horwitz LI
Using standardized videos to validate a measure of handoff quality: the handoff mini-clinical examination exercise.
The researchers report the results of the development of a shorter Handoff Mini-Clinical Examination Exercise (CEX), along with the formal establishment of its construct validity, namely its ability to distinguish between levels of performance in 3 domains of handoff quality. They were able to demonstrate evidence that the Handoff Mini-CEX can draw reliable and valid conclusions regarding handoff performance by physicians in U.S. hospitals.
AHRQ-funded; HS018278
Citation: Arora VM, Berhie S, Horwitz LI .
Using standardized videos to validate a measure of handoff quality: the handoff mini-clinical examination exercise.
J Hospital Med. 2014 Jul;9(7):441-6. doi: 10.1002/jhm.2185.
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Keywords: Provider Performance, Quality Measures, Quality Improvement, Quality of Care, Education: Continuing Medical Education, Patient Safety