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Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (12)
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- Cardiovascular Conditions (1)
- Children/Adolescents (1)
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- Data (1)
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- Healthcare-Associated Infections (HAIs) (9)
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- (-) Patient Safety (21)
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- Quality Indicators (QIs) (1)
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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 21 of 21 Research Studies DisplayedChen VW, Chidi AP, Dong Y
Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality.
This study’s goal was to compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. The study cohort included 697,566 patients treated at 104 Veterans’ Affairs hospitals across 24 quarters with a mean age of 60.9 years and 91.4% male. These patients underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters). Outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]. Of 274 hospital quarters detected with observed to expected ratios, 72.6% were concurrently detected by at least 1 CUSUM signal vs 42.7% by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49).
AHRQ-funded; HS013853.
Citation: Chen VW, Chidi AP, Dong Y .
Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality.
JAMA Surg 2023 Nov; 158(11):1176-83. doi: 10.1001/jamasurg.2023.3673..
Keywords: Quality Improvement, Surgery, Hospitals, Patient Safety, Mortality, Quality of Care
Herzig SJ, Anderson TS, Urman RD
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
The purpose of this retrospective cohort study was to identify risk factors for opioid-related adverse drug events (ORADEs) after hospital discharge following orthopedic procedures. The participants of this study included a national sample of Medicare beneficiaries who underwent major orthopedic surgery during hospitalization in 2016 and had an opioid prescription filled within 2 days of discharge. The study found that among 30,514 hospitalizations with a major orthopedic procedure and an opioid claim, a potential ORADE requiring hospital revisit occurred in 2.5%. After adjustment for patient characteristics, prior opioid use, co-prescribed sedating medications, and opioid prescription characteristics were not related with ORADEs. Independent risk factors did include age of 80 years or older, female sex, and clinical conditions, including heart failure, respiratory illness, kidney disease, dementia/delirium, anxiety disorder, and musculoskeletal/nervous system injuries.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Urman RD .
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
J Patient Saf 2023 Oct 1; 19(6):379-85. doi: 10.1097/pts.0000000000001144..
Keywords: Elderly, Opioids, Adverse Drug Events (ADE), Adverse Events, Hospitalization, Orthopedics, Surgery, Medication, Risk, Medication: Safety, Patient Safety
Langlieb ME, Sharma P, Hocevar M
The additional cost of perioperative medication errors.
The aim of this study was to calculate the additional annual cost to the U.S. healthcare system attributable to preventable medication errors (MEs) in the operating room. The ME types were grouped into 13 categories by their related harm (or potential harm), and researchers calculated the incidence of operations involving each ME category: 1) delayed or missed required perioperative antibiotic; 2) prolonged hemodynamic swings; 3) untreated postoperative pain; 4) residual neuromuscular blockade; 5) oxygen saturation <90% due to ME; 6) delayed emergence; 7) untreated new onset intraoperative cardiac arrhythmia; 8) medication documentation errors; 9) syringe swaps; 10) presumed hypotension with inability to obtain a blood pressure reading; 11) potential for bacterial contamination due to expired medication syringes; 12) untreated bradycardia <40 beats/min; and 13) other. Through a PubMed search, the researchers established the possibility that the ME category would cause downstream patient harm such as surgical site infection or acute kidney injury, and the additional fully allocated cost of care for each potential downstream patient harm event. The cost of the MEs across the U.S. healthcare system was then calculated by scaling the number of MEs to the total number of annual operations in the United States. The total additional fully allocated annual cost of care due to perioperative MEs was estimated to be $5.33 billion U.S. dollars.
AHRQ-funded; HS024764.
Citation: Langlieb ME, Sharma P, Hocevar M .
The additional cost of perioperative medication errors.
J Patient Saf 2023 Oct 1; 19(6):375-78. doi: 10.1097/pts.0000000000001136..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Surgery, Patient Safety
Silber JH, Rosenbaum PR, Reiter JG
The safety of performing surgery at ambulatory surgery centers versus hospital outpatient departments in older patients with or without multimorbidity.
The objective of this matched cohort study was to determine if there are differential outcomes in older patients undergoing surgical procedures at ambulatory surgery centers (ASCs) versus hospital outpatient departments (HOPDs). The results indicated that revisits and complication rates for ASC patients were lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was higher than the baseline risk for the same procedures performed at the ASC, which suggested that surgeons are selecting their riskier patients to be treated at the HOPD rather than the ASC.
AHRQ-funded; HS026897.
Citation: Silber JH, Rosenbaum PR, Reiter JG .
The safety of performing surgery at ambulatory surgery centers versus hospital outpatient departments in older patients with or without multimorbidity.
Med Care 2023 May; 61(5):328-37. doi: 10.1097/mlr.0000000000001836..
Keywords: Elderly, Surgery, Patient Safety, Ambulatory Care and Surgery
Ervin JN, Vitous CA, Wells EE
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
The objective of this study was to understand the effectiveness of the Rescue Improvement Conference, a forum that addresses failure to rescue (FTR). FTR is the phenomenon where delayed recognition or response to surgical complications leads to a progressive cascade of adverse events culminating in patient death. The authors used 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and opportunities for improvement and conducted semi-structured interviews. The results showed that conference felt that the Rescue Improvement Conference was effective in all five indicators. The authors concluded that the conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications that contribute to FTR.
AHRQ-funded; HS024403; HS023621.
Citation: Ervin JN, Vitous CA, Wells EE .
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
Ann Surg 2023 Feb; 277(2):233-37. doi: 10.1097/sla.0000000000004832..
Keywords: Surgery, Adverse Events, Patient Safety, Quality of Care, Quality Improvement
Aterburn D, Powers JD, Toh S
Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass.
A retrospective study of 7,457 patients undergoing laparoscopic bariatric surgery found that patients receiving gastric bypass experienced much greater weight loss than those receiving gastric banding but they had a higher risk of short-term complications and long-term subsequent hospitalizations. However, gastric bypass patients had a lower risk of long-term subsequent intervention procedures than did gastric banding patients.
AHRQ-funded; HS019912
Citation: Aterburn D, Powers JD, Toh S .
Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass.
JAMA Surg. 2014 Dec;149(12):1279-87. doi: 10.1001/jamasurg.2014.1674..
Keywords: Obesity, Surgery, Adverse Events, Patient Safety, Hospitalization
Segal CG, Waller DK, Tilley B
An evaluation of differences in risk factors for individual types of surgical site infections after colon surgery.
The authors developed four independent, multivariate, predictive models to assess the unique associations between risk factors and each surgical site infection (SSI) group: superficial, deep, organ space, and an aggregate of all 3 types of SSIs. They found that unique risks for superficial SSIs include diabetes, chronic obstructive pulmonary disease, and dyspnea; deep SSIs had the greatest magnitude of association with BMI and the greatest incidence of wound disruption; and organ space SSIs were often owing to anastomotic leaks and were uniquely associated with disseminated cancer, preoperative dialysis, preoperative radiation treatment, and a bleeding disorder. They concluded that more effective prevention strategies may be developed by reporting and examining each type of SSI separately.
AHRQ-funded; HS021857.
Citation: Segal CG, Waller DK, Tilley B .
An evaluation of differences in risk factors for individual types of surgical site infections after colon surgery.
Surgery 2014 Nov;156(5):1253-60. doi: 10.1016/j.surg.2014.05.010.
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Keywords: Risk, Healthcare-Associated Infections (HAIs), Adverse Events, Surgery, Patient Safety
Bish EK, El-Amine H, Steighner LA
A socio-technical, probabilistic risk assessment model for surgical site infections in ambulatory surgery centers.
The researchers sought to identify the risk factors associated with surgical site infections (SSIs) resulting from procedures performed at ambulatory surgery centers (ASCs) and to design an intervention to mitigate the likelihood of SSIs for the most common risk factors that were identified by the socio-technical probabilistic risk assessment (ST-PRA) tool for a particular surgical procedure. They found that failure to protect the patient effectively accounted for 51.9% of SSIs in the ambulatory care setting. Critical components of this event included skin preparation, antibiotic administration, staff training, proper response to glove punctures during surgery, and adherence to surgical preparation rules related to the wearing of jewelry, watches, and artificial nails. They determined that, assuming a 75% reduction in noncompliance on any combination of 2 of these 5 components, the risk for an SSI decreased.
AHRQ-funded; 290200600019I.
Citation: Bish EK, El-Amine H, Steighner LA .
A socio-technical, probabilistic risk assessment model for surgical site infections in ambulatory surgery centers.
Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S133-41. doi: 10.1086/677824.
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Keywords: Ambulatory Care and Surgery, Risk, Surgery, Healthcare-Associated Infections (HAIs), Patient Safety, Injuries and Wounds, Adverse Events
Warren DK, Nickel KB, Wallace AE
Can additional information be obtained from claims data to support surgical site infection diagnosis codes?
The authors sought to confirm a claims algorithm to identify surgical site infections (SSIs) by examining the presence of clinically expected SSI treatment. They found that over 94% of patients identified by their claims algorithm as having an SSI received clinically expected treatment for infection, including antibiotics, surgical treatment, and culture, suggesting that this algorithm has very good positive predictive value. They concluded that their method may facilitate retrospective SSI surveillance and comparison of SSI rates across facilities and providers.
AHRQ-funded; HS019713.
Citation: Warren DK, Nickel KB, Wallace AE .
Can additional information be obtained from claims data to support surgical site infection diagnosis codes?
Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S124-32. doi: 10.1086/677830.
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Keywords: Data, Healthcare-Associated Infections (HAIs), Patient Safety, Surgery, Injuries and Wounds, Adverse Events
Calderwood MS, Kleinman K, Bratzler DW
Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.
This study found that among Medicare patients who underwent vascular surgery at 2,512 U.S. hospitals, a patient undergoing surgery in a hospital ranked in the worst-performing decile based on claims had a 2.5 times greater likelihood of developing a chart-confirmed surgical site infection relative to a patient characteristics in a hospital in the best-performing decile.
AHRQ-funded; HS018878
Citation: Calderwood MS, Kleinman K, Bratzler DW .
Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.
Med Care. 2014 Oct;52(10):918-25. doi: 10.1097/MLR.0000000000000212..
Keywords: Medicare, Surgery, Healthcare-Associated Infections (HAIs), Patient Safety, Hospitals, Adverse Events
Goode AP, Richardson WJ, Schectman RM
Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions.
The authors sought to determine the 1-year risk of complications, cervical revision fusions, hospital readmissions, and health care services utilization after bone morphogenetic protein (BMP) use with cervical spine fusions. They found that patients receiving BMP were 29% more likely to have a complication and a nervous system complication; cervical revision fusions were more likely among patients receiving BMP; the risk of 30-day readmission was greater with BMP use; and readmission occurred 27.4% sooner on an average. Additionally, patients receiving BMP were more likely to receive computed tomography scans and epidurals with anterior surgical approaches.
AHRQ-funded; HS019479.
Citation: Goode AP, Richardson WJ, Schectman RM .
Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions.
Spine J 2014 Sep;14(9):2051-9. doi: 10.1016/j.spinee.2013.11.042.
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Keywords: Adverse Events, Hospital Readmissions, Patient Safety, Outcomes, Patient-Centered Outcomes Research, Surgery, Treatments
Agos F, Shoda C, Bransford D
Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries.
Perioperative hyperglycemia management is an important factor in reducing the risk of surgical site infections (SSIs) in all patients whether they have diabetes or not. This article describes the impact of an evidence-based practice standard for perioperative hyperglycemia management in the reduction of SSIs in patients having total hip and knee replacement surgery.
AHRQ-funded; HS017892
Citation: Agos F, Shoda C, Bransford D .
Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries.
Nurs Clin North Am. 2014 Sep;49(3):299-308. doi: 10.1016/j.cnur.2014.05.004..
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Patient Safety, Orthopedics, Injuries and Wounds
Huang LC, Conley D, Lipsitz S
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
The authors assessed the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork. They found that both the Checklist Coaching Tool and the Surgical Teamwork Tool demonstrated substantial IRR and required limited training to use, indicating that both instruments may be used to observe checklist performance and teamwork in the operating room. They recommended that further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.
AHRQ-funded; HS019631.
Citation: Huang LC, Conley D, Lipsitz S .
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
BMJ Qual Saf 2014 Aug;23(8):639-50. doi: 10.1136/bmjqs-2013-002446.
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Keywords: Patient Safety, Surgery, Tools & Toolkits, Teams, Adverse Events, Medical Errors, Prevention
Drake FT, Mottey NE, Farrokhi ET
Time to appendectomy and risk of perforation in acute appendicitis.
This study sought to determine whether there is an association between time and perforation after acute appendicitis patients arrive at the hospital. Using data on 7,505 patients treated at 52 hospitals, they found that there was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy.
AHRQ-funded; SCOAP-CERTAIN
Citation: Drake FT, Mottey NE, Farrokhi ET .
Time to appendectomy and risk of perforation in acute appendicitis.
JAMA Surg. 2014 Aug;149(8):837-44. doi: 10.1001/jamasurg.2014.77..
Keywords: Surgery, Quality of Care, Patient Safety, Critical Care
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
Shih T, Zhang M, Kommareddi M
Center-level variation in infection rates after coronary artery bypass grafting.
This study was undertaken to compare observed and expected rates of healthcare-acquired infections (HAIs) across all 33 institutions performing isolated CABG surgery in the state of Michigan. Although predicted risk of HAI differed in absolute terms by 2.8 percent across centers, The study found that observed rates varied by 18.2 percent. Differences in observed rates of infections could not be fully explained by patient case mix.
AHRQ-funded; HS022535.
Citation: Shih T, Zhang M, Kommareddi M .
Center-level variation in infection rates after coronary artery bypass grafting.
Circ Cardiovasc Qual Outcomes 2014 Jul;7(4):567-73. doi: 10.1161/circoutcomes.113.000770..
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Cardiovascular Conditions, Patient Safety
Nguyen C, Hernandez-Boussard T, Davies SM
Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type.
The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. Results showed that pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS greater than 2 days, and median costs and charges increased by 41% with LOS greater than 2 days.
AHRQ-funded; HS018558.
Citation: Nguyen C, Hernandez-Boussard T, Davies SM .
Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type.
Cleft Palate Craniofac J 2014 Jul;51(4):412-9. doi: 10.1597/12-150.
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Keywords: Adverse Events, Children/Adolescents, Patient Safety, Children/Adolescents, Surgery
Schweizer ML, Cullen JJ, Perencevich EN
Costs associated with surgical site infections in Veterans Affairs hospitals.
This study evaluated surgical site infections(SSIs) in 1,756 Veterans Administration patients to determine the excess costs associated with total, deep, and superficial SSIs. It found that the highest risk-adjusted costs occurred with deep SSIs and SSIs associated with neurosurgery patients.
AHRQ-funded; HS021992
Citation: Schweizer ML, Cullen JJ, Perencevich EN .
Costs associated with surgical site infections in Veterans Affairs hospitals.
JAMA Surg. 2014 Jun;149(6):575-581. doi:10.1001/jamasurg.2013.4663..
Keywords: Surgery, Healthcare-Associated Infections (HAIs), Patient Safety, Healthcare Costs
Echenique IA, Cohen D, Rudow DL
Impact of repeat testing of living kidney donors within 14 days of the transplant procedure: a multicenter retrospective survey.
The researchers surveyed 15 living donor kidney and/or liver transplant programs in New York State to determine if the requirement for re-testing of the donor within 14 days of the transplant procedure would result in delays and cancelled transplants. They found that no cancellations occurred but 2 centers experienced delays.
AHRQ-funded; HS021060
Citation: Echenique IA, Cohen D, Rudow DL .
Impact of repeat testing of living kidney donors within 14 days of the transplant procedure: a multicenter retrospective survey.
Transpl Infect Dis. 2014 Jun;16(3):403-11. doi: 10.1111/tid.12219..
Keywords: Transplantation, Patient Safety, Surgery
Leotsakos A, Zheng H, Croteau R
Standardization in patient safety: the WHO High 5s project.
This paper reports on a global safety initiative of the World Health Organization to facilitate development, implementation, and evaluation of Standard Operating Protocols (SOPs) within a global learning community. Thus far, 3 SOPs—correct surgery, medication reconciliation, concentrated injectable medicines—have been developed, implemented and evaluated in hospitals in 7 participating countries.
AHRQ-funded; 290201200006C
Citation: Leotsakos A, Zheng H, Croteau R .
Standardization in patient safety: the WHO High 5s project.
Int J Qual Health Care. 2014 Apr;26(2):109-16. doi: 10.1093/intqhc/mzu010..
Keywords: Patient Safety, Quality of Care, Surgery, Medication: Safety, Healthcare-Associated Infections (HAIs)
Owens PL, Barrett ML, Raetzman S
AHRQ Author: Owens PL, Steiner CA
Surgical site infections following ambulatory surgery procedures.
The authors determined the incidence of clinically significant surgical site infections (CS-SSIs) following low- to moderate-risk ambulatory surgery in patients with low risk for surgical complications. They found that among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes but may represent a substantial number of adverse outcomes in aggregate, thus meriting quality improvement efforts to minimize their occurrence.
AHRQ-authored; AHRQ-funded; 290201300002C.
Citation: Owens PL, Barrett ML, Raetzman S .
Surgical site infections following ambulatory surgery procedures.
JAMA 2014 Feb 19;311(7):709-16. doi: 10.1001/jama.2014.4.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Healthcare-Associated Infections (HAIs), Injuries and Wounds, Ambulatory Care and Surgery, Surgery, Hospitalization, Patient Safety, Adverse Events