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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 39 Research Studies DisplayedSchnipper JL, Raffel KE, Keniston A
Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: a multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.
This paper describes the protocol for a study that will build surveillance for hospital diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates. The authors will test achieving diagnostic excellence through prevention and teamwork (ADEPT), a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. They will use a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. There will be surveillance for diagnostic errors on 10 events per month per site using a previously established two-person adjudication process. With guidance from national experts in quality and safety, study sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. The primary outcome sought after will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program.
AHRQ-funded; HS029366.
Citation: Schnipper JL, Raffel KE, Keniston A .
Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: a multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.
J Hosp Med 2023 Dec; 18(12):1072-81. doi: 10.1002/jhm.13230..
Keywords: Diagnostic Safety and Quality, Patient Safety, Quality of Care, Hospitals, Inpatient Care
Kaufman BG, Holland DE, Vanderboom CE
Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.
The aim of this randomized controlled trial study was to evaluate the effectiveness of a multicomponent intervention for decreasing clinically important medication errors (CIMEs). The researchers included ambulatory patients beginning a DOAC or resuming one after a complication. The intervention included pharmacist evaluation and monitoring based on the implementation of a recently published checklist. The primary measure was anticoagulant-related CIMEs and non-anticoagulant-related CIMEs over 90 days from DOAC initiation. Primary variables included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. A total of 561 patients contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs. The most common anticoagulant-related CIMEs were failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients or non-anticoagulant-related CIMEs.
AHRQ-funded; HS02592401.
Citation: Kaufman BG, Holland DE, Vanderboom CE .
Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.
J Gen Intern Med 2023 Dec; 38(16):3526-34. doi: 10.1007/s11606-023-08315-z..
Keywords: Provider: Pharmacist, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Blood Thinners, Medication: Safety, Patient Safety
Cifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
McLoone M, McNamara M, Jennings MA
Observing sources of system resilience using in situ alarm simulations.
The authors conducted in situ simulations of a hypoxemic-event alarm in medical/surgical and intensive care units at a tertiary care pediatric hospital to identify sources of resilience in alarm systems. They collected data on response timing, made observations of the environment, and conducted postsimulation debrief interviews. Four primary means of successful alarm responses were mapped to domains of the Systems Engineering Initiative for Patient Safety framework to guide future alarm system design and improvement.
AHRQ-funded; HS026620; HS028682.
Citation: McLoone M, McNamara M, Jennings MA .
Observing sources of system resilience using in situ alarm simulations.
J Hosp Med 2023 Nov; 18(11):994-98. doi: 10.1002/jhm.13217..
Keywords: Patient Safety, Hospitals
Kieren MQ, Kelly MM, Garcia MA
Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.
The objective of this study was to describe the process of identifying and reporting inpatient safety concerns from the perspective of parents of children with medical complexity (CMC). Researchers conducted a secondary analysis of qualitative data from semi-structured interviews with English and Spanish-speaking parents of CMC at two tertiary children's hospitals. The parents described a multi-step process of reporting their safety concerns and a spectrum of staff response and validation. The researchers concluded that their findings could inform family-centered interventions that support safety concern reporting in the inpatient setting.
AHRQ-funded; HS025781.
Citation: Kieren MQ, Kelly MM, Garcia MA .
Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.
Acad Pediatr 2023 Nov-Dec; 23(8):1535-41. doi: 10.1016/j.acap.2023.06.008..
Keywords: Children/Adolescents, Patient Safety, Inpatient Care, Chronic Conditions
Chen VW, Chidi AP, Dong Y
Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality.
This study’s goal was to compare the risk-adjusted cumulative sum (CUSUM) with episodic evaluation for early detection of hospitals with excess perioperative mortality. The study cohort included 697,566 patients treated at 104 Veterans’ Affairs hospitals across 24 quarters with a mean age of 60.9 years and 91.4% male. These patients underwent a noncardiac operation at a Veterans Affairs hospital, had a record in the Veterans Affairs Surgical Quality Improvement Program (January 1, 2011, through December 31, 2016), and were aged 18 years or older. For each hospital, the median number of quarters detected with observed to expected ratios, at least 1 CUSUM signal, and more than 1 CUSUM signal was 2 quarters (IQR, 1-4 quarters), 8 quarters (IQR, 4-11 quarters), and 3 quarters (IQR, 1-4 quarters). Outlier hospitals were identified 33.3% of the time (830 quarters) with at least 1 CUSUM signal within a quarter, 12.5% (311 quarters) with more than 1 CUSUM signal, and 11.0% (274 quarters) with observed to expected ratios at the end of the quarter. The CUSUM detection occurred a median of 49 days (IQR, 25-63 days) before observed to expected ratio reporting (1 signal, 35 days [IQR, 17-54 days]; 2 signals, 49 days [IQR, 26-61 days]; 3 signals, 58 days [IQR, 44-69 days]; ≥4 signals, 49 days [IQR, 42-69 days]. Of 274 hospital quarters detected with observed to expected ratios, 72.6% were concurrently detected by at least 1 CUSUM signal vs 42.7% by more than 1 CUSUM signal. There was a dose-response relationship between the number of CUSUM signals in a quarter and the median observed to expected ratio (0 signals, 0.63; 1 signal, 1.28; 2 signals, 1.58; 3 signals, 2.08; ≥4 signals, 2.49).
AHRQ-funded; HS013853.
Citation: Chen VW, Chidi AP, Dong Y .
Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality.
JAMA Surg 2023 Nov; 158(11):1176-83. doi: 10.1001/jamasurg.2023.3673..
Keywords: Quality Improvement, Surgery, Hospitals, Patient Safety, Mortality, Quality of Care
Boxley C, Fujimoto M, Ratwani RM
A text mining approach to categorize patient safety event reports by medication error type.
This study examined whether natural language processing can be used to better categorize medication related patient safety event reports. A total of 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. The models were tested and performance was analyzed. The authors found the XGBoost model performed best across all medication error categories. 'Wrong Drug', 'Wrong Dosage Form or Technique or Route', and 'Improper Dose/Dose Omission' categories performed best across the three models. In addition, they identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur.
AHRQ-funded; HS026481.
Citation: Boxley C, Fujimoto M, Ratwani RM .
A text mining approach to categorize patient safety event reports by medication error type.
Sci Rep 2023 Oct 26; 13(1):18354. doi: 10.1038/s41598-023-45152-w..
Keywords: Health Information Technology (HIT), Patient Safety, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events
Thom KA, Rock C, Robinson GL
Direct gloving vs hand hygiene before donning gloves in adherence to hospital infection control practices: a cluster randomized clinical trial.
The purpose of this study was to assess the effectiveness of a direct-gloving policy on adherence to infection prevention control practices in a hospital setting. In this study, hospital units were randomly assigned to either the intervention (hand hygiene not required before putting on gloves) or to usual care (hand hygiene required prior to before putting on nonsterile gloves). The primary study outcome was adherence to the expected practice upon room entry and room exit. Thirteen hospital units participated in the trial, and 3,790 health care personnel (HCP) were observed. The study found that adherence to expected practice was higher in the 6 units with the direct-gloving intervention than in the 7 usual care units even when controlling for baseline hand hygiene rates, unit type, and universal gloving policies. The intervention had no effect on hand hygiene adherence measured at entry to non-contact precautions rooms or at room exit. The intervention was related with increased total bacteria colony counts and increased detection of pathogenic bacteria on gloves in the ED and reduced colony counts in pediatrics units, with no change in either total colony count for adult intensive care unit or presence of pathogenic bacteria for adult intensive care unit.
AHRQ-funded; HS024108.
Citation: Thom KA, Rock C, Robinson GL .
Direct gloving vs hand hygiene before donning gloves in adherence to hospital infection control practices: a cluster randomized clinical trial.
JAMA Netw Open 2023 Oct 2; 6(10):e2336758. doi: 10.1001/jamanetworkopen.2023.36758..
Keywords: Hospitals, Patient Safety, Guidelines, Healthcare-Associated Infections (HAIs)
Vear KR, Esbrook E, Padley E
"Time and money and support": adolescents and young adults' perceived social and logistical support needs for safe abortion care.
This study’s objective was to understand what support adolescents and young adults need to access abortion amidst the changing legal landscape. A diverse nationwide sample of individuals aged 14-24 responded to a text message survey in July 2022 about the social and logistical support they would need for safe abortion access. Out of the sample of 638, there was a 78% response rate. Primary sources of social support from parents and friends were named by the respondents for potential abortion decisions. The respondents frequently cited money and transportation as logistical support needs for out-of-state abortion care.
AHRQ-funded; HS026369.
Citation: Vear KR, Esbrook E, Padley E .
"Time and money and support": adolescents and young adults' perceived social and logistical support needs for safe abortion care.
Contraception 2023 Oct; 126:110128. doi: 10.1016/j.contraception.2023.110128..
Keywords: Children/Adolescents, Young Adults, Maternal Care, Patient Safety, Access to Care
Gupta AB, Greene MT, Fowler KE
Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.
Hospitalists are frequently attending to multiple tasks when overseeing patient care, and patients are at risk for diagnostic errors. The purpose of this single-center, prospective, pilot observational study was to measure hospitalist workload and examine its influences on diagnostic performance in a real-world clinical setting. The researchers had hospitalists admitting new patients to the hospital complete an abbreviated Mindful Attention Awareness Tool and a survey on diagnostic confidence upon shift completion. Complete data were available for 37 unique hospitalists who admitted 160 unique patients. The study found that increases in admissions and pages were related with higher odds of hospitalists reporting it was "difficult to focus on what is happening in the present." Increased pages was associated with a decrease in the number of differential diagnoses listed.
AHRQ-funded; HS024385; HS025891.
Citation: Gupta AB, Greene MT, Fowler KE .
Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.
J Patient Saf 2023 Oct 1; 19(7):447-52. doi: 10.1097/pts.0000000000001157..
Keywords: Hospitals, Diagnostic Safety and Quality, Patient Safety
Berdahl CT, Henreid AJ, Cohen TN
Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.
This paper describes the study protocol that will be used for a randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. There are six key attributes to the SAFE Loop: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will be conducted at 20 randomized nursing units at a large academic/community hospital in Los Angeles and will focus on medication errors. The investigators will look for the following outcomes: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. They will use quantitative analysis to compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses to explore nurses' experiences with implementation.
AHRQ-funded; HS027455.
Citation: Berdahl CT, Henreid AJ, Cohen TN .
Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.
Contemp Clin Trials Commun 2023 Oct; 35:101192. doi: 10.1016/j.conctc.2023.101192..
Keywords: Patient Safety, Adverse Events, Medical Errors
Gómez-Lumbreras A, Boyce RD, Villa-Zapata L
Drugs that interact with colchicine via inhibition of cytochrome P450 3A4 and P-glycoprotein: a signal detection analysis using a database of spontaneously reported adverse events (FAERS).
The objective of this study was to examine clinical outcomes associated with colchicine drug interactions. Researchers conducted a disproportionality analysis using the spontaneous reports of the FDA Adverse Event Reporting System (FAERS). The study’s results identified numerous safety signals for colchicine and CYP3A4/P-gp inhibitor drugs. The authors concluded that avoiding interactions or monitoring for toxicity in patients when co-prescribing colchicine and these agents is highly recommended.
AHRQ-funded; HS025984.
Citation: Gómez-Lumbreras A, Boyce RD, Villa-Zapata L .
Drugs that interact with colchicine via inhibition of cytochrome P450 3A4 and P-glycoprotein: a signal detection analysis using a database of spontaneously reported adverse events (FAERS).
Ann Pharmacother 2023 Oct; 57(10):1137-46. doi: 10.1177/10600280221148031..
Keywords: Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Bourgeois FC, Hart NJ, Dong Z
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
This study’s objective was to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage pediatric patients and their families in the diagnostic process (DxP). This cross-sectional study included 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, which was codeveloped and tested with patients and families. Patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns prior to each visit. The authors conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70) or "other" race (OR: 1.48) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53). No significant differences were found in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference.
AHRQ-funded; HS027367.
Citation: Bourgeois FC, Hart NJ, Dong Z .
Partnering with patients and families to improve diagnostic safety through the OurDX tool: effects of race, ethnicity, and language preference.
Appl Clin Inform 2023 Oct; 14(5):903-12. doi: 10.1055/s-0043-1776055..
Keywords: Diagnostic Safety and Quality, Patient Safety, Racial and Ethnic Minorities
Herzig SJ, Anderson TS, Urman RD
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
The purpose of this retrospective cohort study was to identify risk factors for opioid-related adverse drug events (ORADEs) after hospital discharge following orthopedic procedures. The participants of this study included a national sample of Medicare beneficiaries who underwent major orthopedic surgery during hospitalization in 2016 and had an opioid prescription filled within 2 days of discharge. The study found that among 30,514 hospitalizations with a major orthopedic procedure and an opioid claim, a potential ORADE requiring hospital revisit occurred in 2.5%. After adjustment for patient characteristics, prior opioid use, co-prescribed sedating medications, and opioid prescription characteristics were not related with ORADEs. Independent risk factors did include age of 80 years or older, female sex, and clinical conditions, including heart failure, respiratory illness, kidney disease, dementia/delirium, anxiety disorder, and musculoskeletal/nervous system injuries.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Urman RD .
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
J Patient Saf 2023 Oct 1; 19(6):379-85. doi: 10.1097/pts.0000000000001144..
Keywords: Elderly, Opioids, Adverse Drug Events (ADE), Adverse Events, Hospitalization, Orthopedics, Surgery, Medication, Risk, Medication: Safety, Patient Safety
Langlieb ME, Sharma P, Hocevar M
The additional cost of perioperative medication errors.
The aim of this study was to calculate the additional annual cost to the U.S. healthcare system attributable to preventable medication errors (MEs) in the operating room. The ME types were grouped into 13 categories by their related harm (or potential harm), and researchers calculated the incidence of operations involving each ME category: 1) delayed or missed required perioperative antibiotic; 2) prolonged hemodynamic swings; 3) untreated postoperative pain; 4) residual neuromuscular blockade; 5) oxygen saturation <90% due to ME; 6) delayed emergence; 7) untreated new onset intraoperative cardiac arrhythmia; 8) medication documentation errors; 9) syringe swaps; 10) presumed hypotension with inability to obtain a blood pressure reading; 11) potential for bacterial contamination due to expired medication syringes; 12) untreated bradycardia <40 beats/min; and 13) other. Through a PubMed search, the researchers established the possibility that the ME category would cause downstream patient harm such as surgical site infection or acute kidney injury, and the additional fully allocated cost of care for each potential downstream patient harm event. The cost of the MEs across the U.S. healthcare system was then calculated by scaling the number of MEs to the total number of annual operations in the United States. The total additional fully allocated annual cost of care due to perioperative MEs was estimated to be $5.33 billion U.S. dollars.
AHRQ-funded; HS024764.
Citation: Langlieb ME, Sharma P, Hocevar M .
The additional cost of perioperative medication errors.
J Patient Saf 2023 Oct 1; 19(6):375-78. doi: 10.1097/pts.0000000000001136..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Surgery, Patient Safety
Mauskar S, Ngo T, Haskell H
In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.
The purpose of this study was to address the gap of research on inpatient safety/quality experience of Children with medical complexity (CMC) and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of children with medical complexity (CMC). Out of 208 families surveyed, 237 (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. The study found that themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency.
AHRQ-funded; HS025781.
Citation: Mauskar S, Ngo T, Haskell H .
In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.
J Hosp Med 2023 Sep; 18(9):777-86. doi: 10.1002/jhm.13178..
Keywords: Children/Adolescents, Patient Safety, Quality of Care, Chronic Conditions
Zhu Y, Wang Z, Newman-Toker D
Misdiagnosis-related harm quantification through mixture models and harm measures.
Investigating and monitoring misdiagnosis-related harm utilizing the traditional chart review process is labor intensive, potentially unstable, and not conducive to scaling. Researchers propose to leverage the association between symptoms and diseases based on electronic health records or claim data. Specifically, the increased risk of disease after a false-negative diagnosis can be utilized as an indicator of potential harm. The researcher report that the problem with off-the-shelf statistical methods to assess these dynamics is that they do not fully accommodate the data structure of a well-hypothesized risk pattern and thus fail to sufficiently address the unique challenges. The purpose of this study was to explore a mixture regression model and its associated goodness-of-fit testing to address the existing gaps seen in usual statistical analysis methods. The researchers additionally proposed harm measures and profiling analysis procedures to quantify, assess, and compare misdiagnosis-related harm across institutes with potentially differing patient population compositions. Simulation studies were utilized to study the performance of the proposed methods. Researchers then applied and demonstrated the methods through data analyses on stroke occurrence data from the Taiwan Longitudinal Health Insurance Database. From those analyses risk factors for being harmed due to misdiagnosis were assessed, which revealed insights for health care quality research. Finally, researchers compared general and special care hospitals in Taiwan and observed better diagnostic performance in special care hospitals utilizing a variety of new assessment measures.
AHRQ-funded; HS027614.
Citation: Zhu Y, Wang Z, Newman-Toker D .
Misdiagnosis-related harm quantification through mixture models and harm measures.
Biometrics 2023 Sep; 79(3):2633-48. doi: 10.1111/biom.13759..
Keywords: Diagnostic Safety and Quality, Patient Safety, Hospitals
Young RA, Gurses AP, Fulda KG
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
The purpose of this qualitative study was to examine actions by primary care teams to improve medication safety. During 2019-2020, the researchers utilized one-on-one, semi-structured interviews with 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in the Southwest United States. The study found that primary care teams described their actions in medication safety primarily in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. The majority of the actions required individual-level customization, such as restricting the supply of specific medications prescribed and simplifying the medication regimens of specific patients. Primary care teams engaged high reliability organization principles taking steps to improve resilience in patient work systems and by anticipating and moderating risks. The actions of the primary care teams demonstrated their safety organizing efforts as responses to many other agents in multiple settings that they could neither control nor coordinate easily.
AHRQ-funded; HS027277.
Citation: Young RA, Gurses AP, Fulda KG .
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
BMJ Open Qual 2023 Sep; 12(3). doi: 10.1136/bmjoq-2023-002350..
Keywords: Medication: Safety, Medication, Primary Care, Patient Safety
Kalenderian E, Bangar S, Yansane A
Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.
This study’s objective was to analyze harmful dental adverse events (AEs) to assess potential contributing factors. Harmful AEs were defined as those that resulted in temporary moderate to severe harm, required hospitalization, or resulted in permanent moderate to severe harm. The authors classified potential contributing factors according to (1) who was involved (person), (2) what were they doing (tasks), (3) what tools/technologies were they using (tools/technologies), (4) where did the event take place (environment), (5) what organizational conditions contributed to the event? (organization), (6) patient (including parents), and (7) professional-professional collaboration. A second review was conducted by a blinded panel of dental experts to confirm the presence of an AE. A total of 59 cases at 2 dental institutions had 1 or more harmful AEs. The most common harmful AE was pain (27.1%) followed by nerve injury (16.9%), hard tissue injury (15.2%), and soft tissue injury (15.2%). The most common contribution factor was the care provider (training, supervision, and fatigue at 31.5%) followed by patient ((noncompliance, unsafe practices at home, low health literacy, 17.1%), and professional-professional collaboration (15.3%).
AHRQ-funded; HS027268.
Citation: Kalenderian E, Bangar S, Yansane A .
Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.
J Patient Saf 2023 Aug 1; 19(5):305-12. doi: 10.1097/pts.0000000000001122..
Keywords: Dental and Oral Health, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Patient Safety
Liberman AL, Wang Z, Zhu Y
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
The purpose of this paper was to clarify features of the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach to accurately measure diagnostic errors to assure that researchers utilize this method to yield valid results, as well as improve the validity of SPADE and related approaches to quantify diagnostic error in medicine. The researchers describe four types of comparators (intra-group and inter-group), detailing the reason for selecting one over the other and conclusions that can be drawn from these comparative analyses.
AHRQ-funded; HS027614.
Citation: Liberman AL, Wang Z, Zhu Y .
Optimizing measurement of misdiagnosis-related harms using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): comparison groups to maximize SPADE validity.
Diagnosis 2023 Aug 1; 10(3):225-34. doi: 10.1515/dx-2022-0130..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Schnipper JL, Reyes Nieva H, Yoon C
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
The objective of this study was to assess the association of patient exposure to system-level intervention and receipt based on the results of the second Multicenter Medication Reconciliation Quality Improvement Study, which demonstrated a marked reduction in medication discrepancies per patient. Researchers conducted an on-treatment analysis of system-level interventions at 17 North American hospitals. The patient-level interventions most associated with discrepancy reductions were receipt of a best-possible medication history of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were also associated with a minor reduction in discrepancies for the average patient. The researchers concluded that these findings might be used to help hospitals and health systems prioritize interventions to improve medication safety during care transitions.
AHRQ-funded; HS023757.
Citation: Schnipper JL, Reyes Nieva H, Yoon C .
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
BMJ Qual Saf 2023 Aug; 32(8):457-69. doi: 10.1136/bmjqs-2022-014806..
Keywords: Medication, Medication: Safety, Quality Improvement, Quality of Care, Patient Safety, Hospital Discharge
Garber A, Garabedian P, Wu L
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
This study’s objective was to describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients. The interventions to be developed were a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. After initial refinement from an analysis, final requirements were created for 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses including the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. An analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers identified included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).
AHRQ-funded; HS026613.
Citation: Garber A, Garabedian P, Wu L .
Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach.
JAMIA Open 2023 Jul; 6(2):ooad031. doi: 10.1093/jamiaopen/ooad031..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety
Bradford A, Goeschel C, Shofer M
AHRQ Author: Shofer M
Five new ways to advance diagnostic safety in your clinical practice.
This AHRQ-authored article describes new resources that clinicians can use to advance diagnostic safety and prevent errors. The new AHRQ-funded resources include Calibrate Dx, Measure Dx, Safer Dx Checklist, TeamSTEPPS for Diagnostic Improvements, and the Toolkit for Engaging Patients to Improve Diagnostic Safety. A table is provided which describes the resource, gives an example or strategy or practice change, and describes the audience for the resource. Recommendations are also given to help clinicians reduce barriers to diagnostic safety including: 1) Start small and focused; 2) Align with other high-priority initiatives; 3) Start with the resources you have; and 4) Consider how diagnostic safety work can enhance missions other than clinical care.
AHRQ-authored.
Citation: Bradford A, Goeschel C, Shofer M .
Five new ways to advance diagnostic safety in your clinical practice.
Am Fam Physician 2023 Jul; 108(1):14-16..
Keywords: Diagnostic Safety and Quality, Patient Safety
Giuliano J, Krishna A, Napolitano N
Implementation of video laryngoscope-assisted coaching reduces adverse tracheal intubation-associated events in the PICU.
The purpose of this study was to assess the implementation of a video laryngoscope (VL) as a coaching device to decrease adverse tracheal intubation associated events (TIAEs). Between 2016 and 2020 the researchers implemented VLs as coaching devices with standardized coaching language. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. The study found that a VL was used in 71% of 5,060 tracheal intubations. VL utilization increased from a baseline of 29.7% to an implementation phase level of 89.4%. VL utilization was related with lower TIAEs compared with standard laryngoscope (SL). VL utilization was related with lower severe TIAE rate, but not related with a reduction in severe hypoxemia. VL utilization was related with greater first attempt success. In the primary analysis after adjusting for site clustering, VL utilization was related with lower adverse TIAEs. In secondary analyses, VL utilization was not significantly related with severe TIAEs, severe hypoxemia, or first attempt success. After additional controlling for patient and provider characteristics, VL utilization was independently related with a lower TIAE rate.
AHRQ-funded; HS024511.
Citation: Giuliano J, Krishna A, Napolitano N .
Implementation of video laryngoscope-assisted coaching reduces adverse tracheal intubation-associated events in the PICU.
Crit Care Med 2023 Jul; 51(7):936-47. doi: 10.1097/ccm.0000000000005847..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Adverse Events, Patient Safety
Shannon EM, Mueller SK, Schnipper JL
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
The purpose of this study was to explore whether medication safety could be improved by the use of a technologically-enabled pillbox prescribed to patients at hospital discharge. The study included semi-structured telephone interviews with patients, patient caregivers, and inpatient and outpatient clinicians who participated in the Smart Pillbox Transition Study. The researchers utilized the Systems Engineering Initiative for Patient Safety (SEIPS) framework to develop an interview guide, which included the a priori domains of 1) barriers to implementation, 2) facilitators of the intervention, and 3) general feedback regarding experience with the intervention. The study found patient-endorsed barriers in the theme of technology and tools included signal issues, inappropriate alarms, and portability. Barriers in the theme of logistics and tasks included coordination with pharmacists in the event of a prescription change. Barriers mentioned by clinicians included patients who were poor fits for the intervention and competing demands at discharge (under the themes of personnel and patients, and logistics and tasks, respectively). Facilitators that were reported often by patients and caregivers in the theme of technology and tools included useful alarms and ease of use. Clinicians reported that communication with pharmacy and study staff facilitated the intervention.
AHRQ-funded.
Citation: Shannon EM, Mueller SK, Schnipper JL .
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
ACI Open 2023 Jul; 7(2):e61-e70..
Keywords: Medication, Health Information Technology (HIT), Patient Self-Management, Hospital Discharge, Medication: Safety, Patient Safety