National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (4)
- Ambulatory Care and Surgery (1)
- Decision Making (1)
- (-) Diagnostic Safety and Quality (11)
- Electronic Health Records (EHRs) (2)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (3)
- Imaging (5)
- Intensive Care Unit (ICU) (1)
- Medical Errors (3)
- Medication (1)
- Medication: Safety (1)
- Neonatal Intensive Care Unit (NICU) (1)
- Neurological Disorders (1)
- Newborns/Infants (1)
- (-) Patient Safety (11)
- Quality Improvement (2)
- Quality of Care (2)
- Surveys on Patient Safety Culture (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 11 of 11 Research Studies DisplayedShafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Campione JR, Mardon RE, McDonald KM
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
Researchers investigated the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting. Using survey data from the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database, they found that the most frequent problem was "results from a lab or imaging test were not available when needed," with 15% of respondents reporting that it happened daily or weekly. Higher overall culture scores were significantly associated with fewer occurrences of each problem assessed, and offices in the process of health IT implementation had higher frequency of problems.
AHRQ-funded; 290201200003I.
Citation: Campione JR, Mardon RE, McDonald KM .
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
J Patient Saf 2019 Dec;15(4):267-73. doi: 10.1097/pts.0000000000000531..
Keywords: Surveys on Patient Safety Culture, Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety, Ambulatory Care and Surgery
Lacson R, Gujrathi I, Healey M
Closing the loop on unscheduled diagnostic imaging orders: a systems-based approach.
This study looked at the impact of implementing a tool called SCORE (System for Coordinating Orders for Radiology Exams), whose objective is to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry. The rate of unscheduled imaging orders was compared before SCORE (October 2017 to September 2018) and after (October 2018 to June 2019). There was a 49% reduction in unscheduled orders after SCORE implementation at a large academic institution.
AHRQ-funded; HS024722.
Citation: Lacson R, Gujrathi I, Healey M .
Closing the loop on unscheduled diagnostic imaging orders: a systems-based approach.
J Am Coll Radiol 2021 Jan;18(1 Pt A):60-67. doi: 10.1016/j.jacr.2020.09.031..
Keywords: Imaging, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Cochon LR, Kapoor N, Carrodeguas E
Variation in follow-up imaging recommendations in radiology reports: patient, modality, and radiologist predictors.
The purpose of this study was to determine the incidence and to identify factors associated with follow-up recommendations in radiology reports from multiple modalities, patient care settings, and imaging divisions. A trained algorithm classified 318,366 report; the findings indicate that substantial interradiologist variation exists in the probability of recommending a follow-up examination in a radiology report.
AHRQ-funded; HS024722.
Citation: Cochon LR, Kapoor N, Carrodeguas E .
Variation in follow-up imaging recommendations in radiology reports: patient, modality, and radiologist predictors.
Radiology 2019 Jun;291(3):700-07. doi: 10.1148/radiol.2019182826..
Keywords: Decision Making, Diagnostic Safety and Quality, Imaging, Patient Safety, Quality of Care, Quality Improvement
Ablordeppey EA, Drewry AM, Theodoro DL
Current practices in central venous catheter position confirmation by point of care ultrasound: a survey of early adopters.
Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. In this study, they aimed to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography.
AHRQ-funded; R18 HS025052.
Citation: Ablordeppey EA, Drewry AM, Theodoro DL .
Current practices in central venous catheter position confirmation by point of care ultrasound: a survey of early adopters.
Shock 2019 May;51(5):613-18. doi: 10.1097/shk.0000000000001218..
Keywords: Imaging, Diagnostic Safety and Quality, Patient Safety
Lacson R, Cochon L, Ip I
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
This study measured the prevalence of safety events related to diagnostic imaging reported to an electronic safety reporting system. The authors evaluated reports all system reports from 2015 at an academic medical center. Out of 11,570 safety reports submitted, only 7% were related to diagnostic imaging. The adverse event was reported as either result communication or harm during the imaging procedure itself. The harms were rates from 0 to 4 by the reporter. Harms from 2-4 were considered as “potential harm."
AHRQ-funded; HS024722.
Citation: Lacson R, Cochon L, Ip I .
Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework.
J Am Coll Radiol 2019 Mar;16(3):282-88. doi: 10.1016/j.jacr.2018.10.015..
Keywords: Adverse Events, Diagnostic Safety and Quality, Imaging, Patient Safety, Medical Errors
Carrodeguas E, Lacson R, Swanson W
Use of machine learning to identify follow-up recommendations in radiology reports.
The aims of this study were to assess follow-up recommendations in radiology reports, develop and assess traditional machine learning (TML) and deep learning (DL) models in identifying follow-up, and benchmark them against a natural language processing (NLP) system. The investigators concluded that TML and DL were feasible methods to identify follow-up recommendations. They suggest that these methods have great potential for near real-time monitoring of follow-up recommendations in radiology reports.
AHRQ-funded; HS024722.
Citation: Carrodeguas E, Lacson R, Swanson W .
Use of machine learning to identify follow-up recommendations in radiology reports.
J Am Coll Radiol 2019 Mar;16(3):336-43. doi: 10.1016/j.jacr.2018.10.020..
Keywords: Diagnostic Safety and Quality, Imaging, Patient Safety
Murphy DR, Meyer AN, Sittig DF
Application of electronic trigger tools to identify targets for improving diagnostic safety.
This article discusses the use of electronic trigger tools to reduce diagnostic errors and improve patient safety. The authors present a framework called Safer Dx Trigger Tools Framework that will enable health systems to develop and implement e-trigger tools. It identifies and measures diagnostic errors using comprehensive electronic health record (EHR) data. The application of the algorithms used will require a diverse team of specialists to implement. Future research is also outlined.
AHRQ-funded; HS022901; HS022087; HS017820.
Citation: Murphy DR, Meyer AN, Sittig DF .
Application of electronic trigger tools to identify targets for improving diagnostic safety.
BMJ Qual Saf 2019 Feb;28(2):151-59. doi: 10.1136/bmjqs-2018-008086..
Keywords: Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Saff RR, Li Y, Santhanakrishnan N
Identification of inpatient allergic drug reactions using ICD-9-CM codes.
The study of allergic drug reactions has been limited because of challenges in identifying and confirming cases. The objective of this study was to determine the utility of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for identifying inpatient allergic drug reactions and to compare findings with previous data in the emergency department.
AHRQ-funded; HS022728; HS025375.
Citation: Saff RR, Li Y, Santhanakrishnan N .
Identification of inpatient allergic drug reactions using ICD-9-CM codes.
J Allergy Clin Immunol Pract 2019 Jan;7(1):259-64.e1. doi: 10.1016/j.jaip.2018.07.022..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Medication, Diagnostic Safety and Quality, Patient Safety
Wang S, Allen D, Perkins A
Validation of a new clinical tool for post-intensive care syndrome.
The objective of this study was to validate the self-report version of the Healthy Aging Brain Care Monitor as a clinical tool for detecting post-intensive care syndrome. 142 patients who survived stays in intensive care units (ICUs) following a critical illness completed the self-report and standardized assessments of their cognition, their psychological symptoms, and physical functioning. Patients who had post-ICU syndrome were compared with a sample of primary care patients. Based on their findings, the researchers conclude that the self-report version is a valid clinical tool for the assessment of symptoms of post-ICU syndrome.
AHRQ-funded; HS024384.
Citation: Wang S, Allen D, Perkins A .
Validation of a new clinical tool for post-intensive care syndrome.
Am J Crit Care 2019 Jan;28(1):10-18. doi: 10.4037/ajcc2019639..
Keywords: Diagnostic Safety and Quality, Intensive Care Unit (ICU), Neurological Disorders, Patient Safety