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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
126 to 150 of 176 Research Studies DisplayedP Dellsperger, KC Fallaw, D
AHRQ Author: Rangachari
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
This study sought to identify issues related to electronic health record (EHR) medication reconciliation (MedRec) from the perspective of practitioners directly involved in the EHR MedRec process, with the goal of reducing medication discrepancies during transitions of care and improving the accuracy of patient medication lists. The study was conducted in two rounds: individual interviews, then a survey of physicians, nurses, and pharmacists based in the outpatient and inpatient medicine service at AU Health. The survey elicited practitioner ratings of the importance of issues identified during the interviews. Issues that were rated as important by more than 70 percent of respondents include care coordination, patient education, ownership and accountability, processes-of-care, IT-related issues, and workforce training. From these issues, the authors conclude that there is an absence of shared understanding among practitioners regarding the value of EHR MedRec in promoting patient safety, which contributes to work-arounds and the suboptimal use of the EHR MedRec system, and there is also a sociotechnical dimension to many of these issues which creates an additional layer of complexity.
AHRQ-funded; HS024335.
Citation: P Dellsperger, KC Fallaw, D .
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
Qual Manag Health Care 2019 Apr/Jun;28(2):84-95. doi: 10.1097/qmh.0000000000000208..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety, Provider, Provider: Clinician
Wong A, Seger DL, Lai KH
Drug hypersensitivity reactions documented in electronic health records within a large health system.
The goal of this study was to examine the epidemiology of hypersensitivity reactions (HSRs) using EHR data from the Partners Enterprise-wide Allergy Repository for two large tertiary care hospitals. HSRs were categorized as immediate or delayed and the causative drugs and drug groups assessed. Prevalence of HSRs was determined, and the sex and race of patients analyzed. Penicillins were associated with the most immediate and delayed reactions. Nearly half of the reported immediate HSRs manifested as hives. HSRs were more prevalent in females and white patients, but differences were identified for specific, rare HSRs.
AHRQ-funded; HS022728; HS025375.
Citation: Wong A, Seger DL, Lai KH .
Drug hypersensitivity reactions documented in electronic health records within a large health system.
J Allergy Clin Immunol Pract 2019 Apr;7(4):1253-60.e3. doi: 10.1016/j.jaip.2018.11.023..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety
Keller SC, Cosgrove SE, Kohut M
Hazards from physical attributes of the home environment among patients on outpatient parenteral antimicrobial therapy.
This study looked at hazards that patients undergoing outpatient parenteral antimicrobial therapy (OPAT) have to avoid while undergoing the treatment at home with a venous catheter. A qualitative study was conducted with patients discharged from 2 academic medical centers in Baltimore, Maryland. Hazards identified included bathing, pets, temperature extremes, household clutter, food and soil exposures and travel. Patients that were interviewed developed strategies to avoid these hazards.
AHRQ-funded; HS025782.
Citation: Keller SC, Cosgrove SE, Kohut M .
Hazards from physical attributes of the home environment among patients on outpatient parenteral antimicrobial therapy.
Am J Infect Control 2019 Apr;47(4):425-30. doi: 10.1016/j.ajic.2018.09.020..
Keywords: Home Healthcare, Infectious Diseases, Patient Safety, Prevention
Kahwati LC, Sorensen AV, Teixeira-Poit S
AHRQ Author: Mistry KB
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
The purpose of this study was to describe the Safety Program for Perinatal Care (SPPC) implementation experience and evaluate the short-term impact on labor and delivery (L&D) unit patient safety culture, processes, and adverse events. SPPC implementation by L&D units were supported sing a program toolkit, trainings, and technical assistance. Researchers then evaluated the program using a pre-post, mixed-methods design. Changes in safety and quality were measured using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators. Findings showed that SPPC had a favorable impact on unit patient safety culture and processes, but mixed short-term impact on maternal and neonatal adverse events.
AHRQ-authored; AHRQ-funded; 2902010000241.
Citation: Kahwati LC, Sorensen AV, Teixeira-Poit S .
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Jt Comm J Qual Patient Saf 2019 Apr;45(4):231-40. doi: 10.1016/j.jcjq.2018.11.002..
Keywords: Adverse Events, Communication, Comprehensive Unit-based Safety Program (CUSP), Labor and Delivery, Maternal Care, Newborns/Infants, Outcomes, Patient Safety, Pregnancy, Simulation, Surveys on Patient Safety Culture, Teams, TeamSTEPPS, Training, Women
Berry JG, Johnson C, Crofton C
Predicting postoperative physiologic decline after surgery.
This prospective study looked at postoperative physiologic decline (PoPD) in pediatric surgical patients at a freestanding children’s hospital. Median age of the child at surgery was 8 years, 70.9% had a complex chronic condition (CCC), and 7.3% used 11 or more home medications. The odds of a patient experiencing PoPD increases if the child has an active health problem, takes 11 or more home medications and has 3 or more CCCs. More than 25% of pediatric patients undergoing elective surgery experienced PoPD.
AHRQ-funded; HS024453.
Citation: Berry JG, Johnson C, Crofton C .
Predicting postoperative physiologic decline after surgery.
Pediatrics 2019 Apr;143(4). doi: 10.1542/peds.2018-2042..
Keywords: Adverse Events, Children/Adolescents, Patient Safety, Surgery
Blay E, Huang R, Chung JW
Evaluating the impact of the venous thromboembolism outcome measure on the PSI 90 composite quality metric.
Patient Safety Indicator (PSI) 90 is a composite measure widely used in federal pay-for-performance and public reporting programs. A component metric of PSI 90, venous thromboembolism (VTE) rate, has been shown to be subject to surveillance bias and not a valid measure for hospital quality comparisons. A study was conducted to examine how hospital PSI 90 scores would change if the VTE measure were removed from calculation of this composite measure.
AHRQ-funded; HS021857.
Citation: Blay E, Huang R, Chung JW .
Evaluating the impact of the venous thromboembolism outcome measure on the PSI 90 composite quality metric.
Jt Comm J Qual Patient Saf 2019 Mar;45(3):148-55. doi: 10.1016/j.jcjq.2018.08.009..
Keywords: Blood Clots, Patient Safety, Quality Measures, Quality Indicators (QIs), Quality of Care
Soffin EM, Gibbons MM, Ko CY
Evidence review conducted for the Agency for Healthcare Research and Quality Safety program for improving surgical care and recovery: focus on anesthesiology for total hip arthroplasty.
Successes using enhanced recovery after surgery (ERAS) protocols for total hip arthroplasty (THA) are increasingly being reported. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. In this study, the investigators conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after total hip arthroplasty (THA).
AHRQ-funded; 233201500020I.
Citation: Soffin EM, Gibbons MM, Ko CY .
Evidence review conducted for the Agency for Healthcare Research and Quality Safety program for improving surgical care and recovery: focus on anesthesiology for total hip arthroplasty.
Anesth Analg 2019 Mar;128(3):454-65. doi: 10.1213/ane.0000000000003663..
Keywords: Evidence-Based Practice, Patient-Centered Outcomes Research, Surgery, Patient Safety, Quality Improvement, Quality of Care
Frasier LL, Pavuluri Quamme SR, Ma Y
Familiarity and communication in the operating room.
Researchers sought to evaluate the relationship between familiarity, communication rates, and communication ineffectiveness of health care providers in the operating room. They found that team members do not compensate for unfamiliarity by increasing their verbal communication, and dyad familiarity is not protective against ineffective communication. Cross-disciplinary communication remains vulnerable in the operating room, suggesting poor crosstalk across disciplines in the operative setting. They recommended further investigation to explore these relationships and identify effective interventions, ensuring that all team members have the necessary information to optimize their performance.
AHRQ-funded; HS022403.
Citation: Frasier LL, Pavuluri Quamme SR, Ma Y .
Familiarity and communication in the operating room.
J Surg Res 2019 Mar;235:395-403. doi: 10.1016/j.jss.2018.09.079..
Keywords: Communication, Patient Safety, Surgery, Teams, Provider: Physician, Provider
Dworsky JQ, Castle SC, Lee CC
Gerofit prehabilitation pilot program: preparing frail older veterans for surgery.
Older Veterans are increasingly undergoing surgery and are at particularly high risk of postoperative morbidity and mortality. Prehabilitation has emerged as a method to improve postoperative outcomes by enhancing the patient's preoperative condition. IN this paper, the authors present data from their prehabilitation pilot project and plans for expansion and dissemination of a nationwide quality improvement effort.
Citation: Dworsky JQ, Castle SC, Lee CC .
Gerofit prehabilitation pilot program: preparing frail older veterans for surgery.
J Healthc Qual 2019 Mar/Apr;41(2):91-98. doi: 10.1097/jhq.0000000000000185..
Keywords: Elderly, Patient Safety, Quality of Care, Quality Improvement, Surgery
Santosa KB, Keller M, Olsen MA
Negative-pressure wound therapy in infants and children: a population-based study.
Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. In this study, the investigators performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT.
AHRQ-funded; HS019455.
Citation: Santosa KB, Keller M, Olsen MA .
Negative-pressure wound therapy in infants and children: a population-based study.
J Surg Res 2019 Mar;235:560-68. doi: 10.1016/j.jss.2018.10.043..
Keywords: Children/Adolescents, Newborns/Infants, Pressure Ulcers, Injuries and Wounds, Care Management, 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
Werzen A, Thom KA, Robinson GL
Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: a multicenter cohort study.
The purpose of this study was to examine and compare the effect of covert observers versus brief observation periods on hand hygiene compliance. The authors conclude that compliance rates were greater when reported by infection prevention programs than when reported by covert observers over brief observation periods.
AHRQ-funded; HS024108.
Citation: Werzen A, Thom KA, Robinson GL .
Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: a multicenter cohort study.
Am J Infect Control 2019 Mar;47(3):346-48. doi: 10.1016/j.ajic.2018.08.015..
Keywords: Patient Safety, Prevention, Provider
Artis KA, Bordley J, Mohan V
Data omission by physician trainees on ICU rounds.
This observational study measured how frequently physician trainees omitted data from prerounding notes ("artifacts") and verbal presentations during daily rounds. The authors concluded that in an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. They assert that additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.
AHRQ-funded; HS023793.
Citation: Artis KA, Bordley J, Mohan V .
Data omission by physician trainees on ICU rounds.
Crit Care Med 2019 Mar;47(3):403-09. doi: 10.1097/ccm.0000000000003557..
Keywords: Education: Continuing Medical Education, Intensive Care Unit (ICU), Medical Errors, Patient Safety, Quality of Care
McGrath SP, Perreard IM, Garland MD
Improving patient safety and clinician workflow in the general care setting with enhanced surveillance monitoring.
This researched analyzed the impact of implementing an improved clinical monitoring system with enhanced surveillance. This enhanced monitoring system was shown to improve patient safety and clinical workflow in inpatient hospital settings. After implementation higher staff satisfaction was shown and reduced average vital signs data collection time by 28%. It improved the availability and accuracy of patient information. However, there was little or no impact on clinical alarms.
AHRQ-funded; HS024403.
Citation: McGrath SP, Perreard IM, Garland MD .
Improving patient safety and clinician workflow in the general care setting with enhanced surveillance monitoring.
IEEE J Biomed Health Inform 2019 Mar;23(2):857-66. doi: 10.1109/jbhi.2018.2834863..
Keywords: Hospitals, Inpatient Care, Patient Safety, Provider: Clinician, Quality Improvement, Workflow
Gross AE, Hanna D, Rowan SA
Successful implementation of an antibiotic stewardship program in an academic dental practice.
Researchers created a comprehensive antibiotic stewardship program (ASP) for dental practices. A baseline needs assessment and literature evaluation was conducted by a team of dentists, pharmacists, and physician leaders. An academic dental center in Illinois that is the state’s largest oral health provider for Medicaid recipients was used. After intervention with the ASP, there was a 72.9% decrease in antibiotic prescribing for urgent care visits.
AHRQ-funded; HS025177.
Citation: Gross AE, Hanna D, Rowan SA .
Successful implementation of an antibiotic stewardship program in an academic dental practice.
Open Forum Infect Dis 2019 Mar;6(3):ofz067. doi: 10.1093/ofid/ofz067..
Keywords: Antibiotics, Antimicrobial Stewardship, Dental and Oral Health, Medication, Patient Safety
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
Hsu HE, Wang R, Jentzsch MS
Association between value-based incentive programs and catheter-associated urinary tract infection rates in the critical care setting.
This letter discussed a study which was done on value-based incentive programs to reduce the number of catheter-associated urinary tract infections (CAUTI) in intensive care units (ICUs). The study used data from 592 hospitals in the District of Columbia and 49 states. Researchers found these incentive programs did not significantly reduce CAUTI.
AHRQ-funded; HS000063; HS025008; HS018414.
Citation: Hsu HE, Wang R, Jentzsch MS .
Association between value-based incentive programs and catheter-associated urinary tract infection rates in the critical care setting.
JAMA 2019 Feb 5;321(5):509-11. doi: 10.1001/jama.2018.18997.
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Keywords: Adverse Events, Catheter-Associated Urinary Tract Infection (CAUTI), Critical Care, Healthcare-Associated Infections (HAIs), Inpatient Care, Patient Safety, Urinary Tract Infection (UTI)
Anton NE, Mizota T, Timsina LR
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
The objective of this study was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. The investigators concluded that promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. They indicated that mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal.
AHRQ-funded; HS022080.
Citation: Anton NE, Mizota T, Timsina LR .
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
Am J Surg 2019 Feb;217(2):266-71. doi: 10.1016/j.amjsurg.2018.11.028..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider, Provider: Physician, Simulation, Surgery, Training
Wolfson AR, Zhou L, Li Y
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome identified in the electronic health record allergy module.
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but severe hypersensitivity reaction that remains poorly characterized in the United States. The objective of this study was to identify and describe DRESS syndrome cases in an integrated health care system using electronic health record (EHR) allergy module free-text searches.
AHRQ-funded; HS022728; HS025375.
Citation: Wolfson AR, Zhou L, Li Y .
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome identified in the electronic health record allergy module.
J Allergy Clin Immunol Pract 2019 Feb;7(2):633-40. doi: 10.1016/j.jaip.2018.08.013..
Keywords: Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Mistry RD, May LS, Pulia MS
Improving antimicrobial stewardship in pediatric emergency care: a pathway forward.
In this commentary, the authors discuss a study in this same issue. Recent multidisciplinary teams have used novel methods to successfully engage with and intervene in urgent care, pediatric, and general–emergency department antibiotic prescribing. Antibiotic stewardship programs are recommended, as well as emergency department experts continuing to collaborate and formulate thoughtful solutions to this important patient-safety and public-health issue.
AHRQ-funded; HS024342.
Citation: Mistry RD, May LS, Pulia MS .
Improving antimicrobial stewardship in pediatric emergency care: a pathway forward.
Pediatrics 2019 Feb;143(2). doi: 10.1542/peds.2018-2972..
Keywords: Antimicrobial Stewardship, Antibiotics, Children/Adolescents, Emergency Department, Medication, Patient Safety
Schiff GD, Klinger E, Salazar A
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
In this study, the investigators evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist- to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, depression, and insomnia. Systematic automated telephone outreach monitoring coupled with real-time phone referral to a pharmacist identified a substantial number of previously unidentified potentially drug-related symptoms, many of which were validated as probably or possibly related to the drug by the pharmacist or their physicians.
AHRQ-funded; HS021094.
Citation: Schiff GD, Klinger E, Salazar A .
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
J Gen Intern Med 2019 Feb;34(2):285-92. doi: 10.1007/s11606-018-4672-7..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Health Information Technology (HIT), Provider: Pharmacist, Provider, 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
Cook BL, Wang Y, Sonik R
Assessing provider and racial/ethnic variation in response to the FDA antidepressant box warning.
This study analyzed the rate that providers discontinued antidepressants for youth after a 2004 FDA box warning. It was found that prescriptions decreased for White youth but even increased slightly for Black and Latino youth.
AHRQ-funded; HS021486.
Citation: Cook BL, Wang Y, Sonik R .
Assessing provider and racial/ethnic variation in response to the FDA antidepressant box warning.
Health Serv Res 2019 Feb; 54(Suppl 1):255-62. doi: 10.1111/1475-6773.13104..
Keywords: Adverse Drug Events (ADE), Medication, Children/Adolescents, Patient Safety, Racial and Ethnic Minorities, Medication: Safety
Rhee C, Wang Jentzsch, MS
Comparison of hospital surgical site infection rates and rankings using claims versus National Healthcare Safety Network surveillance data.
This article examines national policies that target healthcare-associated infections by use of medical claims and National Healthcare Safety Network surveillance data. The authors looked at rates and rankings for surgical site infection following colon surgery in 155 hospitals, and found low concordance between these two data sources; they conclude that this underscores the limitations of evaluating hospital quality by using claims data.
AHRQ-funded; HS025008; HS000063; HS018414.
Citation: Rhee C, Wang Jentzsch, MS .
Comparison of hospital surgical site infection rates and rankings using claims versus National Healthcare Safety Network surveillance data.
Infect Control Hosp Epidemiol 2019 Feb;40(2):208-10. doi: 10.1017/ice.2018.310..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Patient Safety, Surgery, Injuries and Wounds
Miller MR, Mistry KB
AHRQ Author: Mistry KB
Developing pediatric patient safety research priorities.
This article is a commentary on a newly published article by Hoffman et al entitled “Priorities for Pediatric Safety Research”. The authors agree with the discussion in the article and further elaborate on several ideas in the article. The four points discussed are: 1) broadening the stakeholders; 2) recognize the role of distinct data sources; 3) understand real-world barriers to uptake of evidence-based strategies; and 4) incorporate maternal health factors into the research.
AHRQ-authored.
Citation: Miller MR, Mistry KB .
Developing pediatric patient safety research priorities.
Pediatrics 2019 Feb;143(2):pii: e20182970. doi: 10.1542/peds.2018-2970..
Keywords: Children/Adolescents, Health Services Research (HSR), Patient Safety