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AHRQ Research Studies Date
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- Adverse Events (5)
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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 5 of 5 Research Studies DisplayedDadlez NM, Adelman J, Bundy DG
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
This study examined root causes of three common pediatric diagnostic errors by having 31 practices enrolled in a national QI collaborative perform monthly “mini-RCAs” (mini root cause analyses). The diagnoses errors studied were missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. Twenty-eight practices submitted 184 mini-RCAs with the most common causes being patient volume (adolescent depression and elevated BP), inadequate staffing (adolescent depression), clinic milieu (elevated BP), written communication and provider knowledge (actionable laboratory values), and electronic health records (EHRs) – (elevated BP and actionable laboratory values). The median number of mini-RCAs submitted was 6.
AHRQ-funded; HS024538; HS024713; HS026121.
Citation: Dadlez NM, Adelman J, Bundy DG .
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Pediatr Qual Saf 2020 May-Jun;5(3):e299. doi: 10.1097/pq9.0000000000000299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety
Cifra CL, Ten Eyck P, Dawson JD
Factors associated with diagnostic error on admission to a PICU: a pilot study.
This pilot retrospective cohort study examined errors in pediatric ICUs (PICUs) for children during the first 12 hours after PICU admission. A structured tool (Safer Dx) was used to identify diagnostic error in an academic tertiary institution. Out of 50 patients, 4 (8%) had diagnostic errors. The errors were in diagnoses of chronic ear infection, intracranial pressure (two cases), and Bartonella encephalitis. This pilot study will be expanded into a larger and more definitive multicenter study.
AHRQ-funded; HS022087.
Citation: Cifra CL, Ten Eyck P, Dawson JD .
Factors associated with diagnostic error on admission to a PICU: a pilot study.
Pediatr Crit Care Med 2020 May;21(5):e311-e15. doi: 10.1097/pcc.0000000000002257..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Critical Care, Intensive Care Unit (ICU), Hospitals
Brunsberg KA, Landrigan CP, Garcia BM
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
The objective of this paper was to determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. Results of this prospective cohort study showed that resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors, indicating the importance of determining what interventions might mitigate the patient safety risk.
AHRQ-funded; HS019456.
Citation: Brunsberg KA, Landrigan CP, Garcia BM .
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
Acad Med 2019 Aug;94(8):1150-56. doi: 10.1097/acm.0000000000002778..
Keywords: Children/Adolescents, Provider: Physician, Provider, Medical Errors, Adverse Events, Burnout, Patient Safety, Depression, Behavioral Health
Bundy DG, Singh H, Stein RE
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
This paper discusses the results of Project RedDE, which was a virtual collaborative quality improvement study to reduce diagnostic errors in pediatric primary care practices. Forty-three practices were initially recruited, with a total of 31 practices left at the end due to practice dropout and two participating practices merging. This study was a randomized controlled trial targeting three common diagnostic errors (missed diagnoses of adolescent depression, abnormal blood pressure, and lack of followup for abnormal laboratory results). Contamination across study groups was a recurring problem, but risk mitigations were used. Electronic health records contributed to teams’ success.
AHRQ-funded; HS203608.
Citation: Bundy DG, Singh H, Stein RE .
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
Clin Trials 2019 Apr;16(2):154-64. doi: 10.1177/1740774518820522..
Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention, Primary Care, Quality of Care, Quality Improvement
Khan A, Furtak SL, Melvin P
Parent-reported errors and adverse events in hospitalized children.
The researchers sought to determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). They found that parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record.
AHRQ-funded; HS022986.
Citation: Khan A, Furtak SL, Melvin P .
Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr 2016 Apr 4;170(4):e154608. doi: 10.1001/jamapediatrics.2015.4608..
Keywords: Children/Adolescents, Hospitalization, Patient Safety, Adverse Events, Medical Errors