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Search All Research Studies
Topics
- (-) Adverse Events (9)
- (-) Children/Adolescents (9)
- Critical Care (1)
- Diagnostic Safety and Quality (3)
- Healthcare-Associated Infections (HAIs) (1)
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- Intensive Care Unit (ICU) (3)
- Medical Errors (3)
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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 9 of 9 Research Studies DisplayedMarshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
Dadlez NM, Adelman J, Bundy DG
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
This study examined root causes of three common pediatric diagnostic errors by having 31 practices enrolled in a national QI collaborative perform monthly “mini-RCAs” (mini root cause analyses). The diagnoses errors studied were missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. Twenty-eight practices submitted 184 mini-RCAs with the most common causes being patient volume (adolescent depression and elevated BP), inadequate staffing (adolescent depression), clinic milieu (elevated BP), written communication and provider knowledge (actionable laboratory values), and electronic health records (EHRs) – (elevated BP and actionable laboratory values). The median number of mini-RCAs submitted was 6.
AHRQ-funded; HS024538; HS024713; HS026121.
Citation: Dadlez NM, Adelman J, Bundy DG .
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Pediatr Qual Saf 2020 May-Jun;5(3):e299. doi: 10.1097/pq9.0000000000000299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety
Napolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Bundy DG, Singh H, Stein RE
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
This paper discusses the results of Project RedDE, which was a virtual collaborative quality improvement study to reduce diagnostic errors in pediatric primary care practices. Forty-three practices were initially recruited, with a total of 31 practices left at the end due to practice dropout and two participating practices merging. This study was a randomized controlled trial targeting three common diagnostic errors (missed diagnoses of adolescent depression, abnormal blood pressure, and lack of followup for abnormal laboratory results). Contamination across study groups was a recurring problem, but risk mitigations were used. Electronic health records contributed to teams’ success.
AHRQ-funded; HS203608.
Citation: Bundy DG, Singh H, Stein RE .
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
Clin Trials 2019 Apr;16(2):154-64. doi: 10.1177/1740774518820522..
Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention, Primary Care, Quality of Care, Quality Improvement
Roxbury CR, Li L, Rhee D
Safety and perioperative adverse events in pediatric endoscopic sinus surgery: an ACS-NSQIP-P analysis.
This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. It concluded that urgent/emergent procedures carry the greatest risk of postoperative adverse events, and black children are significantly more likely to undergo higher acuity surgery than white children.
AHRQ-funded; HS022932.
Citation: Roxbury CR, Li L, Rhee D .
Safety and perioperative adverse events in pediatric endoscopic sinus surgery: an ACS-NSQIP-P analysis.
Int Forum Allergy Rhinol 2017 Aug;7(8):827-36. doi: 10.1002/alr.21954.
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Keywords: Adverse Events, Children/Adolescents, Quality Improvement, Risk, Surgery
Cocoros NM, Priebe GP, Logan LK
A pediatric approach to ventilator-associated events surveillance.
The authors propose pediatric ventilator-associated conditions (VAC) for surveillance related to antimicrobial use, with pediatric possible ventilator-associated pneumonia (PVAP) as a subset of adult ventilator-associated conditions (AVAC). Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric ventilator-associated event (VAE) rates are associated with improvements in other outcomes.
AHRQ-funded; HS021636.
Citation: Cocoros NM, Priebe GP, Logan LK .
A pediatric approach to ventilator-associated events surveillance.
Infect Control Hosp Epidemiol 2017 Mar;38(3):327-33. doi: 10.1017/ice.2016.277.
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Keywords: Adverse Events, Children/Adolescents, Healthcare-Associated Infections (HAIs), Intensive Care Unit (ICU), Quality Improvement
Li S, Rehder KJ, Giuliano JS, Jr.
Development of a quality improvement bundle to reduce tracheal intubation-associated events in pediatric ICUs.
This paper described a methodology to develop a bundle to improve quality and safety of tracheal intubations in the pediatric intensive care unit. The Airway Bundle Checklist consists of four parts: a risk factor assessment, a plan generation, a preprocedure time-out, and a postprocedure huddle to identify improvement opportunities.
AHRQ-funded; HS021583.
Citation: Li S, Rehder KJ, Giuliano JS, Jr. .
Development of a quality improvement bundle to reduce tracheal intubation-associated events in pediatric ICUs.
Am J Med Qual 2016 Jan-Feb;31(1):47-55. doi: 10.1177/1062860614547259.
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Keywords: Adverse Events, Intensive Care Unit (ICU), Quality Improvement, Patient Safety, Children/Adolescents
McNamara ER, Kurtz MP, Schaeffer AJ
30-day morbidity after augmentation enterocystoplasty and appendicovesicostomy: a NSQIP pediatric analysis.
The researchers report 30-day outcomes from the first nationally based, prospectively assembled cohort of pediatric patients undergoing these complex pediatric urologic procedures. There were a total of 110 National Surgical Quality Improvement Program (NSQIP) complications seen in 87 patients. The most common complication was urinary tract infection. The composite measure of any 30- day event was seen in 27.8 percent of the cohort.
AHRQ-funded; HS000063.
Citation: McNamara ER, Kurtz MP, Schaeffer AJ .
30-day morbidity after augmentation enterocystoplasty and appendicovesicostomy: a NSQIP pediatric analysis.
J Pediatr Urol 2015 Aug;11(4):209.e1-6. doi: 10.1016/j.jpurol.2015.04.016..
Keywords: Children/Adolescents, Outcomes, Surgery, Adverse Events, Quality Improvement
Roxbury CR, Yang J, Salazar J
Safety and postoperative adverse events in pediatric otologic surgery: analysis of American College of Surgeons NSQIP-P 30-day outcomes.
This study described safety and postoperative sequelae of pediatric otologic surgery and identify predictive factors for postoperative events. It found that pediatric otologic procedures are common and have low rates of global 30-day postoperative events. Tympanomastoidectomy and cochlear implantation have the highest risk of 30-day readmission.
AHRQ-funded; HS022932.
Citation: Roxbury CR, Yang J, Salazar J .
Safety and postoperative adverse events in pediatric otologic surgery: analysis of American College of Surgeons NSQIP-P 30-day outcomes.
Otolaryngol Head Neck Surg 2015 May;152(5):790-5. doi: 10.1177/0194599815575711..
Keywords: Adverse Events, Children/Adolescents, Surgery, Patient Safety, Children/Adolescents, Quality Improvement