National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (7)
- Children/Adolescents (4)
- Chronic Conditions (2)
- Critical Care (1)
- Diagnostic Safety and Quality (5)
- Disparities (1)
- Electronic Health Records (EHRs) (2)
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- Family Health and History (2)
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- Intensive Care Unit (ICU) (1)
- Kidney Disease and Health (1)
- (-) Medical Errors (11)
- Medication (2)
- Medication: Safety (2)
- Newborns/Infants (1)
- Patient Safety (9)
- Provider: Pharmacist (1)
- Provider: Physician (1)
- Quality of Care (1)
- Risk (1)
- Transplantation (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 DisplayedGiardina TD, Hunte H, Hill MA
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
This study looked at peer-reviewed published literature to explore how researchers operationalize the National Academies of Science, Engineering, and Medicine’s (NASEM) definition of diagnostic error that was defined in their 2015 publication “Improving Diagnosis in Health Care”. Published literature was identified from October 2015 to February 2021. The authors also conducted subject matter expert interviews. Of the 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by four themes: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies identified used the NASM definition. Five of those studies also operationalized with existing definitions proposed before the NASEM report, four operationalized the components of the NASEM definition, and three studies operationalized error using existing definitions only. Subject matter experts concluded that the NASEM definition functions as a foundation for researchers to conceptualize diagnostic error.
AHRQ-funded; 233201500022I; HS027280; HS025474; HS027363.
Citation: Giardina TD, Hunte H, Hill MA .
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
J Patient Saf 2022 Dec 1;18(8):770-78. doi: 10.1097/pts.0000000000000999..
Keywords: Diagnostic Safety and Quality, Quality of Care, Medical Errors, Adverse Events, Healthcare Delivery
Malik MA, Motta-Calderon D, Piniella N
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
The purpose of this study was to examine a structured electronic health record (EHR) case review process to identify diagnostic errors (DE) and diagnostic process failures (DPFs) in acute care. The researchers created two test cohorts of all preventable cases (n=28) and an equal number of randomly sampled non-preventable cases (n=28) from 365 adult general medicine patients who expired and were part of the mortality case review process at the research institution. Twenty-seven preventable and 24 non-preventable cases were included in the review process. The study found that the frequency of DE contributing to death was significantly higher for the preventable cohort compared to the non-preventable cohort. The researchers concluded that substantial agreement was observed among final consensus and expert panel reviews using their structured EHR case review process, and DEs contributing to death associated with DPFs were identified in institutionally designated preventable and non-preventable cases.
AHRQ-funded; HS026613.
Citation: Malik MA, Motta-Calderon D, Piniella N .
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Diagnosis 2022 Nov;9(4):446-57. doi: 10.1515/dx-2022-0032..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Medical Errors
Ostrovsky D, Novack V, Smulowitz PB
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
This cross-sectional study examined survey responses about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians regarding what might be considered excessive testing. The authors surveyed 1222 clinicians and the mean score was greater for fear of harm to patients than fear of a malpractice suit. This finding was true regardless of clinician subtype, experience, or sex.
AHRQ-funded; HS026730.
Citation: Ostrovsky D, Novack V, Smulowitz PB .
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
JAMA Netw Open 2022 Nov;5(11):e2241461. doi: 10.1001/jamanetworkopen.2022.41461..
Keywords: Emergency Department, Medical Errors, Adverse Events, Patient Safety
Luximon DC, Ritter T, Fields E
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
The purpose of this study was to develop an automatic error detection algorithm that uses a three-branch convolutional neural network error detection model (EDM) to detect off-by-one vertebral-body misalignments using planning computed tomography (CT) images and setup CBCT images. The researchers collected algorithm training and test data from 480 patients undergoing radiotherapy treatment at two radiotherapy clinics. One model (EDM(1) ) was trained solely on data from institution 1. EDM(1) was further trained on a dataset from institution 2 to produce a fine-tuned model, EDM(2) . Another model, EDM(3), was trained using a training dataset composed of data from both institutions. The study found that when applied to the combined test set, EDM(1) , EDM(2) , and EDM(3) resulted in an area under curve of 99.5%, 99.4%, and 99.5%, respectively. EDM(1) achieved a sensitivity of 96% and 88% on Institution 1 and Institution 2 test set, respectively. EDM(2) obtained a sensitivity of 95% on each institution's test set. EDM(3) achieved a sensitivity of 95% and 88% on Institution 1 and Institution 2 test set, respectively. The researchers concluded that in CBCT-guided radiotherapy, the proposed algorithm demonstrated accuracy in identifying off-by-one vertebral-body misalignments that was sufficiently high enough to justify implementation in practice.
AHRQ-funded; HS026486.
Citation: Luximon DC, Ritter T, Fields E .
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
Med Phys 2022 Oct;49(10):6410-23. doi: 10.1002/mp.15927..
Keywords: Imaging, Diagnostic Safety and Quality, Medical Errors, Patient Safety
Shafer GJ, Singh H, Thomas EJ
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
The objective of this study was to determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients. The "Safer Dx NICU Instrument" was used to review electronic health records. The reviewers discovered that the frequency of diagnostic error in inborn NICU patients during the first 7 days of admission was 6.2%.
AHRQ-funded; HS027363.
Citation: Shafer GJ, Singh H, Thomas EJ .
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
J Perinatol 2022 Oct;42(10):1312-18. doi: 10.1038/s41372-022-01359-9..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Lusk C, Catchpole K, Neyens DM
Improving safety in the operating room: medication icon labels increase visibility and discrimination.
The purpose of this study was to assess whether the addition of icons to medication labels in an operating room setting would improve visibility and reduce medication administration errors. The multi-disciplinary team of researchers added icons to medication labels applied to vasoactive medication infusions, and the study found that participants were 1.12 times more likely to correctly identify medications with icons from farther away. In addition, when icons were present on the labels, participants were 2.16 times more likely to be more confident in their identifications.
AHRQ-funded; HS026625.
Citation: Lusk C, Catchpole K, Neyens DM .
Improving safety in the operating room: medication icon labels increase visibility and discrimination.
Appl Ergon 2022 Oct;104:103831. doi: 10.1016/j.apergo.2022.103831..
Keywords: Medication: Safety, Medication, Patient Safety, Medical Errors, Adverse Drug Events (ADE), Adverse Events
Halvorson EE, Thurtle DP, Easter A
Disparities in adverse event reporting for hospitalized children.
The authors compared the adverse event (AE) rate identified by voluntary event reporting (VER) with that identified using the Global Assessment of Pediatric Patient Safety (GAPPS) between hospitalized children by weight category, race, and English proficiency. In the population studied, they identified 288 total AEs, 270 by the GAPPS and 18 by VER. They found a disparity in AE reporting for children with limited English proficiency, with fewer AEs by VER compared with no difference in AEs by GAPPS. They identified no disparities by weight category or race. They concluded that voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.
AHRQ-funded; HS026038.
Citation: Halvorson EE, Thurtle DP, Easter A .
Disparities in adverse event reporting for hospitalized children.
J Patient Saf 2022 Sep 1;18(6):e928-e33. doi: 10.1097/pts.0000000000001049..
Keywords: Children/Adolescents, Disparities, Adverse Events, Medical Errors, Patient Safety, Hospitals, Hospitalization, Inpatient Care
Mercer AN, Mauskar S, Baird J
Family safety reporting in hospitalized children with medical complexity.
This prospective cohort study was conducted to evaluate safety concerns from families of hospitalized children with medical complexity (CMC) who are at high risk of medical errors. This survey was done predischarge with English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. A total of 155 parents and 214 staff completed surveys, with 43% (n = 66) having ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). A physician review found that 69% of concerns were medical errors, and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses, but only 32% of parents recalled being told how to report safety concerns. Higher education and longer length of stay were associated with family safety concerns.
AHRQ-funded; HS025781.
Citation: Mercer AN, Mauskar S, Baird J .
Family safety reporting in hospitalized children with medical complexity.
Pediatrics 2022 Aug 1; 150(2):e2021055098. doi: 10.1542/peds.2021-055098..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
Gonzales HM, Fleming JN, Gebregziabher M
A critical analysis of the specific pharmacist interventions and risk assessments during the 12-month TRANSAFE Rx randomized controlled trial.
The objective of this study was to describe frequency and types of interventions made during a pharmacist-led, mobile health-based intervention of high-risk kidney transplant (KTX) recipients and to assess impact on patient risk levels. Primary pharmacist intervention types were medication reconciliation, patient education, and medication changes. The authors concluded that pharmacist-led mHealth may enhance opportunities for interventions and mitigate risk levels in KTX recipients.
AHRQ-funded; HS023754.
Citation: Gonzales HM, Fleming JN, Gebregziabher M .
A critical analysis of the specific pharmacist interventions and risk assessments during the 12-month TRANSAFE Rx randomized controlled trial.
Ann Pharmacother 2022 Jun; 56(6):685-90. doi: 10.1177/10600280211044792..
Keywords: Provider: Pharmacist, Medication: Safety, Medication, Risk, Transplantation, Kidney Disease and Health, Adverse Drug Events (ADE), Medical Errors, Patient Safety
Khan A, Baird J, Kelly MM
Family safety reporting in medically complex children: parent, staff, and leader perspectives.
This qualitative study examined parent, staff, and hospital leader perspectives about family safety reporting in children with medical complexity (CMC) to inform future interventions. The study was conducted at 2 tertiary care children’s hospitals with dedicated inpatient complex care services. Hour-long semi-structured, individual interviews were conducted with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. A total of 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders) were interviewed. Four themes related to family safety reporting emerged: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. The authors also identified potential strategies for engaging families and staff in family reporting.
AHRQ-funded; HS025781.
Citation: Khan A, Baird J, Kelly MM .
Family safety reporting in medically complex children: parent, staff, and leader perspectives.
Pediatrics 2022 Jun; 149(6). doi: 10.1542/peds.2021-053913..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Provider: Physician, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
Marshall TL, Rinke ML, Olson APJ
Diagnostic error in pediatrics: a narrative review.
This narrative review focuses on the relative paucity of large, high-quality studies of diagnostic errors and what is known at present about the incident and epidemiology as well as the established research for identifying, evaluating, and reducing diagnostic errors. The authors propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature. The authors state that additional research is needed to better establish the epidemiology of diagnostic errors in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses.
AHRQ-funded; HS023827; HS026644.
Citation: Marshall TL, Rinke ML, Olson APJ .
Diagnostic error in pediatrics: a narrative review.
Pediatrics 2022 Mar;149(Suppl 3). doi: 10.1542/peds.2020-045948D..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Patient Safety, Medical Errors