National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (1)
- Burnout (1)
- Cardiovascular Conditions (1)
- Children/Adolescents (2)
- Clinical Decision Support (CDS) (1)
- Communication (1)
- Critical Care (1)
- Electronic Health Records (EHRs) (3)
- Emergency Department (1)
- Emergency Medical Services (EMS) (1)
- Evidence-Based Practice (1)
- (-) Health Information Technology (HIT) (8)
- Hospitals (4)
- Implementation (1)
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- Medication: Safety (1)
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- Patient and Family Engagement (1)
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- (-) Patient Safety (8)
- Quality Improvement (4)
- (-) Quality of Care (8)
- Shared Decision Making (1)
- Simulation (1)
- Telehealth (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 8 of 8 Research Studies DisplayedGriffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: validation and testing to optimize yield.
Researchers validated the emergency department trigger tool (EDTT) in an independent sample and compared record selection approaches to optimize yield for quality improvement. In this single-site study of the EDTT, they observed high levels of validity in trigger selection, yield, and representativeness of adverse events, with yields that are superior to estimates for traditional approaches to adverse event detection. Record selection using weighted triggers outperformed a trigger count threshold approach and far outperformed random sampling from records with at least one trigger. They concluded that the EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the emergency department.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: validation and testing to optimize yield.
Acad Emerg Med 2020 Dec;27(12):1279-90. doi: 10.1111/acem.14101..
Keywords: Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Events, Patient Safety, Quality Improvement, Quality of Care
Luo B, McLoone M, Rasooly IR
Analysis: protocol for a new method to measure physiologic monitor alarm responsiveness.
A team of researchers including biomedical engineers, human factors engineers, information technology specialists, nurses, physicians, facilitators from a hospital’s simulation center, clinical informaticians, and hospital administrative leadership worked with three units at a pediatric hospital to design and conduct simulations on newly implemented monitoring technology that will be used for patient critical alarms. The system was tested using a simulation with existing hospital technology to transmit an unambiguously critical alarm that appeared to originate from an actual patient to the nurse’s mobile device, with discreet observers measuring responses.
AHRQ-funded; HS026620.
Citation: Luo B, McLoone M, Rasooly IR .
Analysis: protocol for a new method to measure physiologic monitor alarm responsiveness.
Biomed Instrum Technol 2020 Nov/Dec;54(6):389-96. doi: 10.2345/0899-8205-54.6.389..
Keywords: Children/Adolescents, Hospitals, Simulation, Quality Improvement, Quality of Care, Patient Safety, Health Information Technology (HIT)
Co Z, Holmgren AJ, Classen DC
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
This study evaluated the overall performance of hospitals that used the Computerized Physician Order Entry Evaluation Tool in 2017 and 2018 and compared performances for fatal orders and nuisance orders each year. The authors evaluated 1599 hospitals that took the test by using their overall percentage scores along with the percentage of fatal orders appropriately alerted on and the percentage of nuisance orders incorrectly alerted on. Overall hospital scores improved from 58.1% in 2017 to 66.2% in 2018. Fatal order performance improved slightly from 78.8% to 83.0%, but there no very little change in nuisance order performance (89.0% to 89.7%). Conclusions were that perhaps hospitals are not targeting the deadliest orders first and some hospitals may be achieving higher scores by over-alerting. This has the potential to cause clinician burnout and even worsen patient safety.
AHRQ-funded; HS023696.
Citation: Co Z, Holmgren AJ, Classen DC .
The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.
J Am Med Inform Assoc 2020 Aug;27(8):1252-58. doi: 10.1093/jamia/ocaa098..
Keywords: Medication: Safety, Medication, Patient Safety, Clinical Decision Support (CDS), Shared Decision Making, Burnout, Hospitals, Health Information Technology (HIT), Quality of Care
Stangenes SR, Painter IS, Rea TD
Delays in recognition of the need for telephone-assisted CPR due to caller descriptions of chief complaint.
The objective of this study was to test if caller descriptions of chief complaint delays emergency medical dispatchers' (EMDs) recognition of the need for telephone-assisted CPR (T-CPR). The investigators conducted an analysis of N = 433 cardiac arrest calls from six large call centers in the United States. They concluded that caller chief complaint description affected the time to recognition of the need for T-CPR.
AHRQ-funded; HS021658.
Citation: Stangenes SR, Painter IS, Rea TD .
Delays in recognition of the need for telephone-assisted CPR due to caller descriptions of chief complaint.
Resuscitation 2020 Apr;149:82-86. doi: 10.1016/j.resuscitation.2020.02.013..
Keywords: Emergency Medical Services (EMS), Cardiovascular Conditions, Patient Safety, Quality of Care, Telehealth, Health Information Technology (HIT), Communication
Haldar S, Mishra SR, Pollack AH
Informatics opportunities to involve patients in hospital safety: a conceptual model.
This study investigated how hospital inpatients experience undesirable events (UEs) and to see if those present opportunities for new informatics solutions. The authors surveyed 242 patients and caregivers during their hospital stay and asked them open-ended questions about their experiences with UEs. They then developed a 4-stage conceptual model which illustrates inpatient experiences: from when they first encounter UEs, and opportunities to promote inpatients’ participation and engagement in the quality and safety of their care, help healthcare systems learn from inpatient experience, and reduce those harmful events.
AHRQ-funded; HS022894.
Citation: Haldar S, Mishra SR, Pollack AH .
Informatics opportunities to involve patients in hospital safety: a conceptual model.
J Am Med Inform Assoc 2020 Feb;27(2):202-11. doi: 10.1093/jamia/ocz167.
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Keywords: Patient Safety, Hospitals, Health Information Technology (HIT), Patient and Family Engagement, Patient Experience, Quality of Care
Businger AC, Fuller TE, Schnipper JL
Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center.
This paper describes the challenges, recommendations and lessons learned while developing and implementing a Patient Safety Learning Laboratory (PSLL) project, which is comprised of a suite of HIT tools integrated with a newly implemented Electronic Health Record (EHR) vendor system in the acute care setting of a large academic medical center. The PSLL Administrative Core engaged stakeholders and study personnel throughout all phases of the project. Challenges to implementation included stakeholder engagement, project scope and complexity, technology and governance, and team structure. Some changes were implemented during the trial and others were labeled as lessons learned for future iterative interventions. A willingness to think outside of current workflows and processes to change health system culture around adverse event prevention was one of the keys to success.
AHRQ-funded; HS023535.
Citation: Businger AC, Fuller TE, Schnipper JL .
Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center.
J Am Med Inform Assoc 2020 Feb;27(2):301-07. doi: 10.1093/jamia/ocz193.
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Keywords: Patient Safety, Implementation, Health Information Technology (HIT), Quality Improvement, Quality of Care, Patient-Centered Healthcare, Electronic Health Records (EHRs), Evidence-Based Practice
Dalal AK, Fuller T, Garabedian P
Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital.
This study examined systems engineering and human factors support of a system of novel electronic health record (EHR)-integrated tools for patient safety in the hospital. The authors established a Patient Safety Learning Laboratory of 2 core and 3 individual project teams to introduce a suite of digital health tools integrated with their EHR to identify, assess, and mitigate threats to patient safety. They identified 7 themes regarding use of 12 systems engineering and human factors over the 4-year project.
AHRQ-funded; HS023535.
Citation: Dalal AK, Fuller T, Garabedian P .
Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital.
J Am Med Inform Assoc 2019 Jun;26(6):553-60. doi: 10.1093/jamia/ocz002..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Hospitals, Quality Improvement, Quality of Care
Berrens ZJ, Gosdin CH, Brady PW
Efficacy and safety of pediatric critical care physician telemedicine involvement in rapid response team and code response in a satellite facility.
This study compared response rates at satellite inpatient facilities of larger children’s hospitals using telemedicine to response rates at main campus. Through the use of telemedicine, there was no difference in critical care response and rate of transfer to intensive-care units.
AHRQ-funded; HS023827.
Citation: Berrens ZJ, Gosdin CH, Brady PW .
Efficacy and safety of pediatric critical care physician telemedicine involvement in rapid response team and code response in a satellite facility.
Pediatr Crit Care Med 2019 Feb;20(2):172-77. doi: 10.1097/pcc.0000000000001796.
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Keywords: Children/Adolescents, Critical Care, Quality of Care, Health Information Technology (HIT), Patient Safety