National Healthcare Quality and Disparities Report
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- Adverse Drug Events (ADE) (17)
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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 25 of 156 Research Studies DisplayedWebb J, Sorensen A, Sommerness S
AHRQ Author: Mistry K
Advancing perinatal patient safety through application of safety science principles using health IT.
Researchers used semi-structured interviews with Labor and Delivery (L&D) units participating in AHRQ's Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Seventy percent of the units reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects.
AHRQ-authored; AHRQ-funded; 2902010000241.
Citation: Webb J, Sorensen A, Sommerness S .
Advancing perinatal patient safety through application of safety science principles using health IT.
BMC Med Inform Decis Mak 2017 Dec 19;17(1):176. doi: 10.1186/s12911-017-0572-8.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Pregnancy, Maternal Care
Cox 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
Chang X, Mazur T, Li HH, Yang D. X, Mazur T, Li HH
A method to recognize anatomical site and image acquisition view in x-ray images.
A method was developed to recognize anatomical site and image acquisition view automatically in 2D X-ray images that are used in image-guided radiation therapy. The purpose was to enable site and view dependent automation and optimization in the image processing tasks including 2D-2D image registration, 2D image contrast enhancement, and independent treatment site confirmation.
AHRQ-funded; HS022888.
Citation: Chang X, Mazur T, Li HH, Yang D. X, Mazur T, Li HH .
A method to recognize anatomical site and image acquisition view in x-ray images.
J Digit Imaging 2017 Dec;30(6):751-60. doi: 10.1007/s10278-017-9981-6..
Keywords: Diagnostic Safety and Quality, Imaging, Patient Safety
Krein SL, Harrod M, Collier S
A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: a qualitative assessment.
AHRQ’s Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a catheter-associated urinary tract infections (CAUTI) prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. The observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support.
AHRQ-funded; 290201000025I; 29032008T.
Citation: Krein SL, Harrod M, Collier S .
A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: a qualitative assessment.
Am J Infect Control 2017 Dec;45(12):1342-48. doi: 10.1016/j.ajic.2017.07.006.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Long-Term Care, Nursing Homes, Quality Improvement, Patient Safety
Bowen ME, Rumana U, Kilgore EA
A user-centered glucose-insulin data display for the inpatient setting.
Researchers sought to develop a set of user-centered displays of capillary glucose data and insulin dose to improve inpatient management of insulin-dependent diabetes. Their proposed conceptual data display prototype is designed to simplify the presentation and visualization of key information needed for treatment decisions. The goal is also to enhance clinician's ability to identify opportunities to optimize insulin dosing and decrease end users' cognitive load and error rates.
AHRQ-funded; HS022895.
Citation: Bowen ME, Rumana U, Kilgore EA .
A user-centered glucose-insulin data display for the inpatient setting.
Stud Health Technol Inform 2017;245:684-88.
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Keywords: Care Management, Diabetes, Health Information Technology (HIT), Inpatient Care, Patient Safety
McElligott M, Welham G, Pop-Vicas A
Antibiotic stewardship in nursing facilities.
The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.
AHRQ-funded; HS022465.
Citation: McElligott M, Welham G, Pop-Vicas A .
Antibiotic stewardship in nursing facilities.
Antibiotics, Elderly, Nursing Homes, Patient Safety, Provider Practice Patterns.
Keywords: Antibiotics, Elderly, Nursing Homes, Patient Safety, Practice Patterns
Liang C, Gong Y
Automated classification of multi-labeled patient safety reports: a shift from quantity to quality measure.
The capacity for extracting useful information from patient safety reports remains limited. This study investigated the multi-labeled nature of patient safety reports as a key to disclose the complex relations between many components during the courses and development of medical errors. The authors developed automated multi-label text classifiers to process patient safety reports. The experiments demonstrated feasibility and efficiency of a combination of multi-label algorithms in the benchmark comparison.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
Automated classification of multi-labeled patient safety reports: a shift from quantity to quality measure.
Stud Health Technol Inform 2017;245:1070-74..
Keywords: Adverse Events, Data, Patient Safety, Quality Measures
Skube SJ, Hu Z, Arsoniadis EG
Characterizing surgical site infection signals in clinical notes.
Building off of previous work for automated and semi-automated surgical site infections (SSIs) detection using expert-derived "strong features" from clinical notes, researchers hypothesized that additional SSI phrases may be contained in clinical notes. They systematically characterized phrases and expressions associated with SSIs. While 83 percent of expert-derived original terms overlapped with new terms and modifiers, an additional 362 modifiers associated with both positive and negative SSI signals were identified.
AHRQ-funded; HS024532.
Citation: Skube SJ, Hu Z, Arsoniadis EG .
Characterizing surgical site infection signals in clinical notes.
Stud Health Technol Inform 2017;245:955-59.
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Keywords: Healthcare-Associated Infections (HAIs), Surgery, Injuries and Wounds, Patient Safety, Adverse Events, Quality Improvement, Quality of Care
Zhou S, Kang H, Gong Y
Design a learning-oriented fall event reporting system based on Kirkpatrick model.
Patient fall has been a severe problem in healthcare facilities around the world due to its prevalence and cost. Routine fall prevention training programs are not as effective as expected. Using event reporting systems is the trend for reducing patient safety events such as falls, although some limitations of the systems exist at current stage. The authors of this paper summarized these limitations through literature review, and developed an improved web-based fall event reporting system.
AHRQ-funded; HS022895.
Citation: Zhou S, Kang H, Gong Y .
Design a learning-oriented fall event reporting system based on Kirkpatrick model.
Stud Health Technol Inform 2017;245:828-32..
Keywords: Falls, Health Information Technology (HIT), Patient Safety, Web-Based, Adverse Events
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
Effective usability engineering in healthcare: a vision of usable and safer healthcare IT.
This paper presents a vision for deploying usability engineering in healthcare in a more substantive way to improve the current situation.
AHRQ-funded; HS023708.
Citation: Kushniruk A, Senathirajah Y, Borycki E .
Effective usability engineering in healthcare: a vision of usable and safer healthcare IT.
Stud Health Technol Inform 2017;245:1066-69..
Keywords: Healthcare Delivery, Health Information Technology (HIT), Health Information Technology (HIT), Patient Safety, System Design
Catchpole K, Neyens DM, Abernathy J
Framework for direct observation of performance and safety in healthcare.
This viewpoint paper discusses non-participant direct observation of healthcare processes as a rich method for understanding safety and performance improvement. The authors suggest that as a prospective method for error prediction and modelling, observation can capture a broad range of performance issues that can be related to higher aspects of the system.
AHRQ-funded; HS024380.
Citation: Catchpole K, Neyens DM, Abernathy J .
Framework for direct observation of performance and safety in healthcare.
BMJ Qual Saf 2017 Dec;26(12):1015-21. doi: 10.1136/bmjqs-2016-006407..
Keywords: Healthcare Delivery, Patient Safety, Provider Performance, Quality Improvement
Asan O, Carayon P
Human factors of health information technology—challenges and opportunities.
This paper introduces a special issue presenting state-of -the-art research on human factors of health IT with eight articles that identify and address various human factor aspects of health IT. These eight articles examine multiple technologies and user groups and describe how health IT can support care that is highly distributed over time, space, and boundaries.
AHRQ-funded; HS023626.
Citation: Asan O, Carayon P .
Human factors of health information technology—challenges and opportunities.
Int J Hum Comput Interact 2017;33(4):255–57.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Hernandez-Boussard T, Davies S, McDonald K
Interhospital facility transfers in the United States: a nationwide outcomes study.
This study identified and compared characteristics and outcomes of transfer and nontransfer patients. In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients. Study results suggest that transfer patients have inferior outcomes compared with nontransfer patients.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard T, Davies S, McDonald K .
Interhospital facility transfers in the United States: a nationwide outcomes study.
J Patient Saf 2017 Dec;13(4):187-91. doi: 10.1097/pts.0000000000000148.
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Keywords: Adverse Events, Healthcare Cost and Utilization Project (HCUP), Hospitalization, Patient Safety, Transitions of Care
Yao B, Kang H, Miao Q
Leveraging event reporting through knowledge support: a knowledge-based approach to promoting patient fall prevention.
The authors constructed a knowledge base of fall events by combining expert-reviewed fall prevention solutions and then integrating them into a reporting system. The knowledge base enables timely and tailored knowledge support and thus will serve as a prevailing fall prevention tool. This effort holds promise in making knowledge acquisition and management a routine process for enhancing the reporting and understanding of patient safety events.
AHRQ-funded; HS022895.
Citation: Yao B, Kang H, Miao Q .
Leveraging event reporting through knowledge support: a knowledge-based approach to promoting patient fall prevention.
Stud Health Technol Inform 2017;245:973-77.
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Keywords: Adverse Events, Falls, Patient Safety, Prevention
Haynes AB, Edmondson LB, Lipsitz SR
Mortality trends after a voluntary checklist-based surgical safety collaborative.
This study sought to determine whether completion of a voluntary, checklist-based surgical quality improvement program is associated with reduced 30-day postoperative mortality. It It found that, despite similar pre-existing rates and trends of postoperative mortality, hospitals in South Carolina completing a voluntary checklist-based surgical quality improvement program had a reduction in deaths after inpatient surgery over the first 3 years of the collaborative compared with other hospitals in the state.
AHRQ-funded; HS019631.
Citation: Haynes AB, Edmondson LB, Lipsitz SR .
Mortality trends after a voluntary checklist-based surgical safety collaborative.
Annals of Surgery 2017 Dec;266(6):923-29. doi: 10.1097/SLA.0000000000002249.
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Keywords: Mortality, Patient Safety, Surgery, Quality Improvement, Quality of Care
Cai B, Li H, Yang D
Performance of a multi leaf collimator system for MR-guided radiation therapy.
The purpose of this study was to investigate and characterize the performance of a Multi Leaf Collimator (MLC) designed for Cobalt-60 based MR-guided radiation therapy system in a 0.35 T magnetic field. The authors concluded that the MRIdian MLC has a good RF noise shielding design, low radiation leakage, good positioning accuracy, comparable TG effect, and can be modeled by an independent Monte Carlo calculation platform.
AHRQ-funded; HS022888.
Citation: Cai B, Li H, Yang D .
Performance of a multi leaf collimator system for MR-guided radiation therapy.
Med Phys 2017 Dec;44(12):6504-14. doi: 10.1002/mp.12571..
Keywords: Imaging, Patient Safety, Treatments
George MD, Baker JF, Hsu JY
Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty.
The purpose of this retrospective cohort study was to evaluate the association between infliximab timing and serious infection after elective hip or knee arthroplasty. The investigators concluded that administering infliximab within 4 weeks of elective knee or hip arthroplasty was not associated with a higher risk of short- or long-term serious infection compared to withholding infliximab for longer time periods. They also concluded that glucocorticoid use, especially >10 mg/day, was associated with an increased infection risk.
AHRQ-funded; HS018517.
Citation: George MD, Baker JF, Hsu JY .
Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Orthopedics, Patient Safety, Surgery
Wang J, Gong Y
Potential of decision support in preventing pressure ulcers in hospitals.
The development of hospital-acquired pressure ulcers signals low quality of care. To meet the challenges of consistently translating best practices into effective clinical practices and promote effective teamwork communication and interprofessional collaboration, the authors consider the failure of consistent care delivery as loss of information and reveal the opportunities of informatics methods to reinforce information delivery, evidenced by typical cases. They then explain and summarize information-related issues existing at the initial assessment upon hospital admission, routine treatments, and team communication.
AHRQ-funded; HS022895.
Citation: Wang J, Gong Y .
Potential of decision support in preventing pressure ulcers in hospitals.
Stud Health Technol Inform 2017;241:15-20.
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Keywords: Clinical Decision Support (CDS), Decision Making, Hospitals, Patient Safety, Pressure Ulcers, Prevention
Sarkar U, McDonald K, Motala A
Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.
In this article, the investigators (1) reviewed the methods and results for the key informant input process for a Technical Brief on ambulatory safety commissioned by the Agency for Healthcare Research and Quality (AHRQ), (2) summarized the key informant perspectives on ambulatory safety, (3) expanded on key informant input with specific recommendations for an ambulatory safety agenda, (4) reported on existing initiatives and progress related to key informant perspectives and our recommendations, and (5) proposed specific research and policy activities that would advance ambulatory safety.
AHRQ-funded; 290201500010I.
Citation: Sarkar U, McDonald K, Motala A .
Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.
Jt Comm J Qual Patient Saf 2017 Dec;43(12):661-70. doi: 10.1016/j.jcjq.2017.06.009..
Keywords: Ambulatory Care and Surgery, Patient Safety, Quality of Care
Liang C, Gong Y
Predicting harm scores from patient safety event reports.
The Harm Scale developed by the AHRQ is widely used in the US hospitals. However, recent studies have indicated a moderate to poor inter-rater reliability of the scale across a number of US hospitals. This study proposed that key information to identify and refine the severity of harm is contained in the narrative data in patient safety reports. The researchers found that using automated text classification to categorize harm score provided reduced subjective judgments and improved efficiency.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
Predicting harm scores from patient safety event reports.
Stud Health Technol Inform 2017;245:1075-79..
Keywords: Adverse Events, Data, Hospitals, Patient Safety
Acker WW, Plasek JM, Blumenthal KG
Prevalence of food allergies and intolerances documented in electronic health records.
The researchers sought to determine the prevalence of food allergy and intolerance documented in the EHR allergy module. Among 2.7 million patients, they identified 97,482 patients (3.6 percent) with 1 or more food allergies or intolerances. The prevalence of food allergy and intolerance was higher in females (4.2 percent vs 2.9 percent) and Asians (4.3 percent vs 3.6 percent).
AHRQ-funded; HS022728.
Citation: Acker WW, Plasek JM, Blumenthal KG .
Prevalence of food allergies and intolerances documented in electronic health records.
J Allergy Clin Immunol 2017 Dec;140(6):1587-91.e1. doi: 10.1016/j.jaci.2017.04.006.
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Keywords: Electronic Health Records (EHRs), Patient Safety, Racial and Ethnic Minorities, Sex Factors
Ratanawongsa N, Chan LL, Fouts MM
The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.
This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, it presents evidence for the adoption of RxNorm and standardized naming and picklist options for high alert medications such as insulin.
AHRQ-funded; HS022561; HS023558.
Citation: Ratanawongsa N, Chan LL, Fouts MM .
The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.
J Diabetes Res 2017;2017:8983237. doi: 10.1155/2017/8983237.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Vulnerable Populations, Diabetes, Patient Safety, Chronic Conditions
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
Yang D, Zhang M, Chang X
A method to detect landmark pairs accurately between intra-patient volumetric medical images.
An image processing procedure was developed in this study to detect large quantity of landmark pairs accurately in pairs of volumetric medical images. The procedure allows a semi-automatic way to generate the ground truth landmark datasets that allow quantitatively evaluation of deformable image registration algorithms for radiation therapy applications.
AHRQ-funded; HS022888.
Citation: Yang D, Zhang M, Chang X .
A method to detect landmark pairs accurately between intra-patient volumetric medical images.
Med Phys 2017 Nov;44(11):5859-72. doi: 10.1002/mp.12526..
Keywords: Imaging, Patient Safety, Diagnostic Safety and Quality