National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
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Search All Research Studies
Topics
- Adverse Events (5)
- Care Management (1)
- Children/Adolescents (3)
- Clinical Decision Support (CDS) (2)
- Clinician-Patient Communication (1)
- Communication (3)
- Decision Making (3)
- Education: Continuing Medical Education (1)
- Evidence-Based Practice (4)
- Falls (3)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Costs (1)
- Hospitals (3)
- Imaging (1)
- Implementation (2)
- Injuries and Wounds (2)
- Inpatient Care (1)
- Labor and Delivery (1)
- Medical Errors (3)
- Medication (4)
- Medication: Safety (3)
- Newborns/Infants (1)
- Nursing (1)
- Opioids (1)
- Patient-Centered Healthcare (2)
- (-) Patient Safety (19)
- Practice Patterns (1)
- Pregnancy (1)
- Prevention (4)
- Primary Care (1)
- Provider (1)
- Provider: Pharmacist (1)
- Quality Improvement (2)
- Quality Indicators (QIs) (1)
- Quality Measures (1)
- Quality of Care (3)
- Risk (1)
- Substance Abuse (1)
- Surgery (2)
- Teams (1)
- TeamSTEPPS (1)
- (-) Tools & Toolkits (19)
- Training (2)
- Web-Based (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 19 of 19 Research Studies DisplayedSchnipper JL, Reyes Nieva H, Mallouk M
Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.
This study was a follow-up of the first Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS1) that demonstrated mentored implementation of a medication reconciliation best practices toolkit. The toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The toolkit has been refined with lessons learned and retooled as MARQUIS2. The tool was implemented at 18 North American hospitals or hospital systems from 2016 to 2018, offering 17 system-level and 6-patient-level interventions. One of eight physicians coached each site remotely via monthly calls and one or two site visits. A total of 4947 patients were sampled, with 1229 preimplementation and 3718 postimplementation. A steady decline in medication discrepancy rates were experienced from 2.85 discrepancies per patient down to 0.98 discrepancies. An interrupted time series analysis of the 17 sites showed the intervention was associated with a 5% relative decrease in discrepancies per month.
AHRQ-funded; HS025486; HS023757.
Citation: Schnipper JL, Reyes Nieva H, Mallouk M .
Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.
BMJ Qual Saf 2022 Apr;31(4):278-86. doi: 10.1136/bmjqs-2020-012709..
Keywords: Medication, Evidence-Based Practice, Tools & Toolkits, Implementation, Quality Improvement, Quality of Care, Medication: Safety, Patient Safety
Alley L, Novak K, Havlin T
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
The authors developed the Resources Encouraging Safe Prescription Opioid and Naloxone Dispensing (RESPOND) Toolkit to enhance community pharmacists' understanding of their role in addressing opioid safety; to improve integration of prescription drug monitoring program (PDMP) into daily workflow; and to enhance communication between pharmacists, prescribers, and patients. In this paper, they described the development of the RESPOND Toolkit and summarized their findings from initial pilot testing. They concluded that the RESPOND Toolkit has promise as an effective and scalable approach to providing community pharmacist-tailored training to promote behavioral shifts supporting opioid safety for patients.
AHRQ-funded; HS024227.
Citation: Alley L, Novak K, Havlin T .
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
Res Social Adm Pharm 2020 Oct;16(10):1422-30. doi: 10.1016/j.sapharm.2019.12.023..
Keywords: Opioids, Substance Abuse, Medication, Medication: Safety, Patient Safety, Tools & Toolkits, Communication, Provider: Pharmacist, Provider, Training
Stolldorf DP, Mixon AS, Auerbach AD
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.
MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here the investigators described hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Mixon AS, Auerbach AD .
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.
Am J Health Syst Pharm 2020 Jul 7;77(14):1135-43. doi: 10.1093/ajhp/zxaa136..
Keywords: Medication, Medication: Safety, Patient Safety, Hospitals, Tools & Toolkits
Ray-Barruel G, Cooke M, Chopra V
The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation.
This study assessed the I-DECIDED clinical decision-making tool for peripheral intravenous catheter (PIVC) assessment and safe removal. A clinimetric validation process was designed and conducted in three distinct phases. Content validity testing was conducted via online survey with vascular access experts and clinicians from Australia, the UK, Canada, and the US. Then inter-rater reliability was conducted between 34 pairs of assessors for a total of 68 PIVC assessments. The tool demonstrated strong content validity among international vascular access experts and clinicians and high inter-rater reliability in seven adult medical-surgical wards of three Australian hospitals. Overall, inter-rater reliability was 87.13%. Time to complete assessments averaged 2 minutes, and nurse-reported acceptability was also high.
AHRQ-funded; HS025891.
Citation: Ray-Barruel G, Cooke M, Chopra V .
The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation.
BMJ Open 2020 Jan 21;10(1):e035239. doi: 10.1136/bmjopen-2019-035239..
Keywords: Decision Making, Patient Safety, Tools & Toolkits, Implementation
Mixon AS, Smith GR, Mallouk M
Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.
The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. In this study, the investigators sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.
AHRQ-funded; HS023757; HS025486.
Citation: Mixon AS, Smith GR, Mallouk M .
Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.
BMC Health Serv Res 2019 Sep 11;19(1):659. doi: 10.1186/s12913-019-4491-5.
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Keywords: Evidence-Based Practice, Medication, Patient Safety, Quality of Care, Quality Improvement, Quality Indicators (QIs), Quality Measures, Tools & Toolkits
Dossett L, Miller J, Jagsi R
A modified communication and optimal resolution program for intersystem medical error discovery: protocol for an implementation study.
AHRQ’s Communication and Optimal Resolution (CANDOR) Toolkit facilitates transparent communication, error prevention, and achieving optimal resolution with patients and families; how medical errors should be addressed when they are discovered between systems-intersystem medical error discovery (IMED)-remains unclear. This study aims to develop and test implementation of a modified CANDOR process for application to IMED scenarios. Step 1 of aim 1 is currently underway. This work is expected to provide important insights into the potential utility of an implementation toolkit to improve transparent communication and optimal resolution of IMED scenarios.
AHRQ-funded; HS026030.
Citation: Dossett L, Miller J, Jagsi R .
A modified communication and optimal resolution program for intersystem medical error discovery: protocol for an implementation study.
JMIR Res Protoc 2019 Jul 2;8(7):e13396. doi: 10.2196/13396..
Keywords: Adverse Events, Communication, Clinician-Patient Communication, Medical Errors, Patient Safety, Tools & Toolkits
Eriksson CO, Ovregaard N, Hansen M
Reliability and usability of a 7-minute chart review tool to identify pediatric prehospital adverse safety events.
As part of a multiphase study, the authors developed and evaluated the reliability and usability of the pediatric prehospital safety event detection system (PEDS), a tool used to identify safety events in prehospital care. They concluded that the PEDS tool is the first chart review tool designed to identify safety events for children receiving prehospital care, and it displayed good usability and reliability in their study.
AHRQ-funded; HS022981.
Citation: Eriksson CO, Ovregaard N, Hansen M .
Reliability and usability of a 7-minute chart review tool to identify pediatric prehospital adverse safety events.
Hosp Pediatr 2018 Aug;8(8):494-98. doi: 10.1542/hpeds.2017-0155..
Keywords: Adverse Events, Children/Adolescents, Patient-Centered Healthcare, Patient Safety, Tools & Toolkits
Ray-Barruel G, Cooke M, Mitchell M
Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study.
This study aims to validate an evidence-based peripheral intravenous catheter (PIVC) assessment and decision-making tool called I-DECIDED and evaluate the effect of implementing this tool into acute hospital clinical practice.
AHRQ-funded; HS022835.
Citation: Ray-Barruel G, Cooke M, Mitchell M .
Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study.
BMJ Open 2018 Jun 4;8(6):e021290. doi: 10.1136/bmjopen-2017-021290..
Keywords: Clinical Decision Support (CDS), Decision Making, Patient Safety, Tools & Toolkits
Sun B, Lam D, Yang D
A machine learning approach to the accurate prediction of monitor units for a compact proton machine.
Physical phantom measurements are commonly employed to determine field-specific output factors (OFs) but are often subject to limited machine time, measurement uncertainties and intensive labor. The goal of this study was to develop a secondary check tool for output factors (OF) measurements and eventually eliminate patient-specific OF measurements. The study concluded that machine learning methods can be used to predict OF for double-scatter proton machines with greater prediction accuracy than the most popular semi-empirical prediction model.
AHRQ-funded; HS022888.
Citation: Sun B, Lam D, Yang D .
A machine learning approach to the accurate prediction of monitor units for a compact proton machine.
Med Phys 2018 May;45(5):2243-51. doi: 10.1002/mp.12842..
Keywords: Imaging, Patient Safety, Tools & Toolkits
Bartsch SM, Huang SS, McKinnell JA
The economic value of the Centers for Disease Control and Prevention carbapenem-resistant Enterobacteriaceae Toolkit.
The authors investigated whether and when economic benefits occur with the toolkit for carbapenem-resistant Enterobacteriaceae. Using their Regional Healthcare Ecosystem Analyst-generated agent-based model of all inpatient healthcare facilities, they identified cost savings in year 1 of implementation when hospitals acted independently and by year 3 if all hospitals collectively implemented the toolkit in a coordinated manner.
AHRQ-funded; HS023317.
Citation: Bartsch SM, Huang SS, McKinnell JA .
The economic value of the Centers for Disease Control and Prevention carbapenem-resistant Enterobacteriaceae Toolkit.
Infect Control Hosp Epidemiol 2018 May;39(5):516-24. doi: 10.1017/ice.2018.49.
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Keywords: Healthcare Costs, Patient Safety, Tools & Toolkits
Stockwell DC, Landrigan CP, Schuster MA
Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent.
The Centers for Medicare & Medicaid Services Partnership for Patients program identified 9 hospital-acquired conditions (HACs) for reduction, to make care safer, more reliable, and less costly. However, the proportion of inpatient pediatric harm represented by these HACs is unknown. The investigators conducted a retrospective review of 240 harms previously identified using the Pediatric All-Cause Harm Measurement Tool, a trigger tool that is applied to medical records to comprehensively identify harms.
AHRQ-funded; HS020513.
Citation: Stockwell DC, Landrigan CP, Schuster MA .
Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent.
Pediatr Qual Saf 2018 May-Jun;3(3):e081. doi: 10.1097/pq9.0000000000000081..
Keywords: Children/Adolescents, Healthcare-Associated Infections (HAIs), Patient Safety, Children/Adolescents, Tools & Toolkits
McArdle J, Sorensen A, Fowler CI
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
The purpose of this study using TeamSTEPPS was to assess the implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Results suggested that successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The Safety Program for Perinatal Care strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.
AHRQ-funded; 2902010000241.
Citation: McArdle J, Sorensen A, Fowler CI .
Strategies to improve management of shoulder dystocia under the AHRQ Safety Program for Perinatal Care.
J Obstet Gynecol Neonatal Nurs 2018 Mar;47(2):191-201. doi: 10.1016/j.jogn.2017.11.014.
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Keywords: Labor and Delivery, Newborns/Infants, Pregnancy, Adverse Events, TeamSTEPPS, Injuries and Wounds, Care Management, Education: Continuing Medical Education, Training, Tools & Toolkits, Patient Safety, Nursing, Communication, Quality of Care
Dykes PC, Duckworth M, Cunningham S
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. The investigators examined strategies to integrate this evidence into clinical practice. They concluded that engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice. They address and detail barriers to adoption of the protocol to provide guidance for spread to other institutions.
AHRQ-funded; HS025128.
Citation: Dykes PC, Duckworth M, Cunningham S .
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Jt Comm J Qual Patient Saf 2017 Aug;43(8):403-13. doi: 10.1016/j.jcjq.2017.05.002..
Keywords: Clinical Decision Support (CDS), Decision Making, Evidence-Based Practice, Falls, Hospitals, Injuries and Wounds, Inpatient Care, Patient Safety, Prevention, Risk, Tools & Toolkits
Mueller SK, Yoon C, Schnipper JL
Association of a web-based handoff tool with rates of medical errors.
The researchers implemented a web-based handoff tool and training for health care professionals and evaluated the association of the tool with rates of medical errors in adult medical and surgical patients. They found that implementation of this tool was associated with a significant reduction in rates of medical errors, driven largely by a reduction in errors attributable to communication failure and errors that occurred during end-of-shift handoffs.
AHRQ-funded; HS023331.
Citation: Mueller SK, Yoon C, Schnipper JL .
Association of a web-based handoff tool with rates of medical errors.
JAMA Intern Med 2016 Sep;176(9):1400-2. doi: 10.1001/jamainternmed.2016.4258.
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Keywords: Medical Errors, Patient Safety, Surgery, Tools & Toolkits, Web-Based
Katsulis Z, Ergai A, Leung WY
Iterative user centered design for development of a patient-centered fall prevention toolkit.
The use of electronic decision support that tailors fall prevention strategy to patient-specific risk factors, known as Fall T.I.P.S (Tailoring Interventions for Patient Safety), has proven to be an effective approach for decreasing hospital falls. A paper version of the Fall T.I.P.S toolkit was developed primarily for hospitals that do not have the resources to implement the electronic solution; however, more work is needed to optimize the effectiveness of the paper version of this tool.
AHRQ-funded; HS023535.
Citation: Katsulis Z, Ergai A, Leung WY .
Iterative user centered design for development of a patient-centered fall prevention toolkit.
Appl Ergon 2016 Sep;56:117-26. doi: 10.1016/j.apergo.2016.03.011.
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Keywords: Falls, Tools & Toolkits, Prevention, Patient Safety, Hospitals
Landrigan CP, Stockwell D, Toomey SL
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool.
This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of adverse events (AEs) and preventable AEs. In total, 3,814 medical records were reviewed. It found that both primary and secondary reviewers agreed 92 percent of the time on presence or absence of a suspected AE.
AHRQ-funded; HS020513.
Citation: Landrigan CP, Stockwell D, Toomey SL .
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool.
Pediatrics 2016 Jun;137(6):pii: e20154076. doi: 10.1542/peds.2015-4076.
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Keywords: Patient Safety, Children/Adolescents, Tools & Toolkits, Adverse Events, Children/Adolescents
Huang LC, Conley D, Lipsitz S
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
The authors assessed the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork. They found that both the Checklist Coaching Tool and the Surgical Teamwork Tool demonstrated substantial IRR and required limited training to use, indicating that both instruments may be used to observe checklist performance and teamwork in the operating room. They recommended that further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.
AHRQ-funded; HS019631.
Citation: Huang LC, Conley D, Lipsitz S .
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
BMJ Qual Saf 2014 Aug;23(8):639-50. doi: 10.1136/bmjqs-2013-002446.
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Keywords: Patient Safety, Surgery, Tools & Toolkits, Teams, Adverse Events, Medical Errors, Prevention
Pohl JM, Nath R, Zheng K
Use of a comprehensive patient safety tool in primary care practices.
This article describes experiences with the use of the Physician Practice Patient Safety Assessment tool in six safety net practices—three of which were primary care nurse-managed health centers and three were physician-led federally qualified health centers. The authors concluded that this tool has enormous relevance for primary care settings, especially those preparing themselves for patient-centered medical home status and meaningful use.
AHRQ-funded; HS017191.
Citation: Pohl JM, Nath R, Zheng K .
Use of a comprehensive patient safety tool in primary care practices.
J Am Assoc Nurse Pract 2013 Aug;25(8):415-8. doi: 10.1111/1745-7599.12021..
Keywords: Patient Safety, Primary Care, Patient-Centered Healthcare, Practice Patterns, Tools & Toolkits
Clancy CM
AHRQ Author: Clancy CM
Evidence-based toolkit helps organizations reduce patient falls.
This article describes an evidence-based hospital fall-prevention toolkit developed by AHRQ that helps clinicians negotiate the change process at their organization. It was created by a team with expertise both in fall prevention and in organizational change, including staff from the RAND Corporation, ECRI Institute, and Boston University.
AHRQ-authored.
Citation: Clancy CM .
Evidence-based toolkit helps organizations reduce patient falls.
J Nurs Care Qual 2013 Jul-Sep;28(3):195-7. doi: 10.1097/NCQ.0b013e318294a9d1.
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Keywords: Evidence-Based Practice, Falls, Tools & Toolkits, Patient Safety, Prevention