National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (5)
- (-) Adverse Events (24)
- Ambulatory Care and Surgery (3)
- Blood Clots (1)
- Blood Thinners (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Children/Adolescents (1)
- Clinical Decision Support (CDS) (2)
- Communication (2)
- Data (1)
- Education: Continuing Medical Education (1)
- Electronic Health Records (EHRs) (1)
- Healthcare-Associated Infections (HAIs) (6)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Healthcare Costs (1)
- Health Information Technology (HIT) (4)
- Health Promotion (1)
- Hospitalization (2)
- Hospital Readmissions (1)
- Hospitals (3)
- Injuries and Wounds (3)
- Medical Errors (6)
- Medical Liability (2)
- Medicare (1)
- Medication (5)
- Medication: Safety (2)
- Obesity (1)
- Outcomes (1)
- Patient-Centered Outcomes Research (1)
- Patient and Family Engagement (2)
- Patient Experience (1)
- (-) Patient Safety (24)
- Practice Patterns (1)
- Prevention (4)
- Provider (1)
- Quality Improvement (2)
- Quality Indicators (QIs) (2)
- Quality Measures (1)
- Quality of Care (1)
- Risk (3)
- Surgery (9)
- Teams (1)
- Tools & Toolkits (1)
- Treatments (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 24 of 24 Research Studies DisplayedVaughan Sarrazin MS, Jones M, Mazur A
Bleeding rates in Veterans Affairs patients with atrial fibrillation who switch from warfarin to dabigatran.
This study evaluated the relative risks of any, gastrointestinal, intracranial, and other bleeding for Veterans Affairs patients who switched to dabigatran after at least 6 months on warfarin. It found that among veterans with atrial fibrillation who switched to dabigatran, dabigatran increased the risk of gastrointestinal hemorrhage by 54% and was not associated with rates of other bleeding or death.
AHRQ-funded; HS021992
Citation: Vaughan Sarrazin MS, Jones M, Mazur A .
Bleeding rates in Veterans Affairs patients with atrial fibrillation who switch from warfarin to dabigatran.
Am J Med. 2014 Dec;127(12):1179-85. doi: 10.1016/j.amjmed.2014.07.024..
Keywords: Blood Thinners, Adverse Events, Patient Safety
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
Meeks DW, Meyer AN, Rose B
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
The researchers described outcomes of peer review within the Department of Veterans Affairs (VA) healthcare system and identified opportunities to leverage peer review data for measurement and improvement of safety. Results showed that the most common process contributing to substandard care was 'timing and appropriateness of treatment'; approximately 16% had diagnosis-related performance concerns. The authors concluded that peer review may be a useful tool for healthcare organizations to assess their sharp end clinical performance, particularly safety events related to diagnostic and treatment errors.
AHRQ-funded; HS022087.
Citation: Meeks DW, Meyer AN, Rose B .
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
BMJ Qual Saf 2014 Dec;23(12):1023-30. doi: 10.1136/bmjqs-2014-003239.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Quality Improvement
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
Fakih MG, Krein SL, Edson B
AHRQ Author: Battles JB
Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm.
This article discusses catheter-associated urinary tract infection (CAUTI) prevention efforts, describes the national collaboration between different organizations, briefly reviews the technical and socio-adaptive components of the program, and specifically describes an approach to engaging health care workers as an essential part of CAUTI prevention and averting patient harm.
AHRQ-authored; AHRQ-funded; 290201000025I; 29032001T
Citation: Fakih MG, Krein SL, Edson B .
Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm.
Am J Infect Control. 2014 Oct;42(10 Suppl):S223-9. doi: 10.1016/j.ajic.2014.03.355..
Keywords: Adverse Events, Catheter-Associated Urinary Tract Infection (CAUTI), Healthcare-Associated Infections (HAIs), Patient Safety, Prevention, Practice Patterns, Quality Improvement
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
Hennessy S, Strom BL
Improving postapproval drug safety surveillance: getting better information sooner.
There are often long delays between when a drug is approved and when serious adverse drug events are identified. This article discusses ways to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
AHRQ-funded; HS018372.
Citation: Hennessy S, Strom BL .
Improving postapproval drug safety surveillance: getting better information sooner.
Annu Rev Pharmacol Toxicol 2015;55:75-87. doi: 10.1146/annurev-pharmtox-011613-135955.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Communication, Medication, Medication: Safety, Patient Safety
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
Ranji SR, Rennke S, Wachter RM
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
The authors searched AHRQ's Patient Safety Net to identify reviews of the effect of computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) on adverse drug event (ADE) rates in inpatient and outpatient settings. They found that CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, often leading to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects.
AHRQ-funded; 2902007100621.
Citation: Ranji SR, Rennke S, Wachter RM .
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
BMJ Qual Saf 2014 Sep;23(9):773-80. doi: 10.1136/bmjqs-2013-002165.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinical Decision Support (CDS), Health Information Technology (HIT), Medication, Patient Safety
Pohl JM, Tanner C, Hamilton A
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
This study, conducted in five safety-net practices, examined the impact of implementing a commercial electronic health records system on medication safety. The authors found 130 "true" drug-drug interaction (DDI) pairs, representing 149,087 visits and 62 providers, with the largest DDI categories being related to antihypertensive medications, which are often prescribed together. They found no significant differences between physicians and nurse practitioners on the rate of DDI pairs.
AHRQ-funded; HS017191.
Citation: Pohl JM, Tanner C, Hamilton A .
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
J Am Assoc Nurse Pract 2014 Aug;26(8):438-44. doi: 10.1002/2327-6924.12089.
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Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety
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
Galanter WL, Bryson ML, Falck S
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
The authors measured whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. They found that indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts and recommended that institutions with CPOE consider using indication prompts to intercept drug name confusion errors.
AHRQ-funded; HS021093.
Citation: Galanter WL, Bryson ML, Falck S .
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
PLoS One 2014 Jul 15;9(7):e101977. doi: 10.1371/journal.pone.0101977.
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Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Health Information Technology (HIT), Medication, 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
Shelton J, Kummerow K, Phillips S
Patient safety in the era of the 80-hour workweek.
The purpose of this paper was to evaluate the effect of duty-hour regulations (DHR) on patient safety. The researchers found no differences in the patient safety indicator (PSI) rates over time for hemorrhage or hematoma, physiologic or metabolic derangement, accidental puncture or laceration, or wound dehiscence. Teaching hospitals had higher rates than non-teaching hospitals both preintervention and postintervention for all the PSIs except wound dehiscence.
AHRQ-funded; HS013833.
Citation: Shelton J, Kummerow K, Phillips S .
Patient safety in the era of the 80-hour workweek.
J Surg Educ 2014 Jul-Aug;71(4):551-9. doi: 10.1016/j.jsurg.2013.12.011.
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Keywords: Adverse Events, Education: Continuing Medical Education, Patient Safety, Quality Indicators (QIs), Provider
Berger Z, Flickinger TE, Pfoh E
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
This review examined how interventions encouraging patient and family engagement have been implemented in controlled trials. Among 12 identified studies, the authors noted that definitions of patient and family engagement were lacking. They found insufficient high-quality evidence to inform real-world implementation and provided recommendations for further study.
AHRQ-funded; 290200710062I.
Citation: Berger Z, Flickinger TE, Pfoh E .
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
BMJ Qual Saf 2014 Jul;23(7):548-55. doi: 10.1136/bmjqs-2012-001769.
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Keywords: Adverse Events, Health Promotion, Patient and Family Engagement, Patient Safety, Prevention
Forrester SH, Hepp Z, Roth JA
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
The study objective was to estimate the cost-effectiveness of computerized provider order entry versus traditional paper-based prescribing in reducing medications errors and adverse drug events in the ambulatory setting of mid-sized medical group. Using a decision-analytic model, the researchers found that the adoption of CPOE in the ambulatory setting provides excellent value for the investment.
AHRQ-funded; HS014739
Citation: Forrester SH, Hepp Z, Roth JA .
Cost-effectiveness of a computerized provider order entry system in improving medication safety ambulatory care.
Value Health. 2014 Jun;17(4):340-9. doi: 10.1016/j.jval.2014.01.009..
Keywords: Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Medication, Patient Safety, Healthcare Costs, Ambulatory Care and Surgery, Prevention
Chopra V, Ratz D, Kuhn L
Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.
This study was designed to determine patient, provider, and device outcome of deep vein thrombosis (DVT) associated with peripherally inserted central catheters (PICCs). Larger PICC gauge, especially in the use of recently diagnosed cancer patients, increases the likelihood of DVT.
AHRQ-funded; HS022835
Citation: Chopra V, Ratz D, Kuhn L .
Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.
J Thromb Haemost 2014 Jun;12(6):847-54. doi: 10.1111/jth.12549..
Keywords: Adverse Events, Blood Clots, Patient Safety, Risk
Weissman JS, López L, Schneider EC
The association of hospital quality ratings with adverse events.
The researchers used a survey of 2,582 patients hospitalized at 16 acute care Massachusetts hospitals to understand how patient-reported quality is related to adverse events (AEs). Although patients with AEs rated hospital quality lower than others, patients with AEs who experienced ‘service recovery’ rated their quality of care at levels similar to those not experiencing AEs.
AHRQ-funded
Citation: Weissman JS, López L, Schneider EC .
The association of hospital quality ratings with adverse events.
Int J Qual Health Care. 2014 Apr;26(2):129-35. doi: 10.1093/intqhc/mzt092..
Keywords: Adverse Events, Quality of Care, Hospitals, Patient Experience, Patient Safety, Quality Indicators (QIs), Quality Measures
Chopra V, McMahon LF
Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.
In this paper, the authors discuss redesigning hospital alarms for patient safety. They note the benefits and dangers of patient safety alarms and outline potential solutions to make patient safety alarms more effective. The investigators suggest that the scope and design of alarm systems must shift from the status quo to a biologically valid, clinically relevant, patient-centered model. They assert that existing technology allows integration and intelligent assessment of patient data to create advanced alarm systems.
AHRQ-funded; HS022835.
Citation: Chopra V, McMahon LF .
Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.
JAMA 2014 Mar 26;311(12):1199-200. doi: 10.1001/jama.2014.710..
Keywords: Adverse Events, Hospitals, Patient Safety
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
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