National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (6)
- Caregiving (1)
- Care Management (2)
- Communication (2)
- Comprehensive Unit-based Safety Program (CUSP) (1)
- Education: Continuing Medical Education (1)
- Electronic Health Records (EHRs) (1)
- Evidence-Based Practice (1)
- Guidelines (2)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Health Information Technology (HIT) (1)
- Injuries and Wounds (2)
- Labor and Delivery (8)
- Maternal Care (8)
- Medicaid (1)
- Medical Errors (1)
- Medication (1)
- Medication: Safety (1)
- Newborns/Infants (5)
- Nursing (2)
- Outcomes (3)
- Patient-Centered Outcomes Research (1)
- Patient Experience (1)
- (-) Patient Safety (13)
- (-) Pregnancy (13)
- Provider (1)
- Provider: Nurse (2)
- Quality Improvement (1)
- Quality of Care (2)
- Simulation (1)
- Surgery (2)
- Surveys on Patient Safety Culture (1)
- Teams (2)
- TeamSTEPPS (2)
- Tools & Toolkits (1)
- Training (2)
- Women (6)
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 13 of 13 Research Studies DisplayedZhong J, Simpson KR, Spetz J
Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs Survey.
The objective of this study was to explore the association of nurses' perceptions of patient safety climate with missed nursing care in labor and delivery (L&D) units. Nurse respondents were recruited via email distribution of an electronic survey; hospitals with L&D units were recruited from states with projected availability of 2018 state inpatient data. Measures included the Safety Attitudes Questionnaire Safety Climate Subscale and the Perinatal Missed Care Survey. The results suggested that improving safety climate through means such as better teamwork and communication may improve nursing care quality during labor and birth through decreasing missed nursing care. Strategies to reduce missed care may also conversely improve the safety climate.
AHRQ-funded; HS025715.
Citation: Zhong J, Simpson KR, Spetz J .
Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs Survey.
J Patient Saf 2023 Apr 1;19(3):166-72. doi: 10.1097/pts.0000000000001106.
Keywords: Maternal Care, Pregnancy, Labor and Delivery, Nursing, Patient Safety, Provider: Nurse
Ernest EC, Hellar A, Varallo J
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
This study evaluated the impact of a multicomponent safe surgery intervention in Tanzania to reduce surgical site infection (SSI) rates and mortality after caesarean sections (CS). The authors used the WHO Surgical Safety Checklist (SSC) to measure WHO SSC utilization, SSI rates, and CS-related perioperative mortality rates (POMRs) before and 18 months after implementation. The SSC utilization rate for CS increased from 3.7% to 95.1%, which decreased the proportion of women with SSI after CS from 14% during baseline to 1%. CS-related POMR decreased by 38.5% after implementation of safe surgery interventions as well.
AHRQ-funded; HS024235.
Citation: Ernest EC, Hellar A, Varallo J .
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
BMJ Glob Health 2021 Dec;6(12). doi: 10.1136/bmjgh-2021-006788..
Keywords: Maternal Care, Pregnancy, Healthcare-Associated Infections (HAIs), Surgery, Injuries and Wounds, Adverse Events, Patient Safety
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y
Wrong-patient orders in obstetrics.
The objective of this observational study was to compare rates of wrong-patient orders among patients on obstetric units compared with reproductive-aged women admitted to medical-surgical units. The investigators concluded that order errors occurred more frequently on obstetric units compared with medical-surgical units.
AHRQ-funded; HS024538; HS026121.
Citation: Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y .
Wrong-patient orders in obstetrics.
Obstet Gynecol 2021 Aug 1;138(2):229-35. doi: 10.1097/aog.0000000000004474..
Keywords: Medical Errors, Maternal Care, Pregnancy, Women, Adverse Events, Patient Safety
Sherman JP, Hedli LC, Kristensen-Cabrera AI
Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. In this study, the investigators employed design thinking methodology to understand how the design of labor and delivery units impacted safety and identified spaces and systems where improvements are needed.
AHRQ-funded; HS023506.
Citation: Sherman JP, Hedli LC, Kristensen-Cabrera AI .
Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
Am J Perinatol 2020 May;37(6):638-46. doi: 10.1055/s-0039-1685494..
Keywords: Labor and Delivery, Pregnancy, Patient Safety, Maternal Care, Women, Newborns/Infants
Knox CA, Hampp C, Palmsten K
Validation of mother-infant linkage using Medicaid Case ID variable within the Medicaid Analytic eXtract (MAX) database.
The authors established and validated an algorithm within the Medicaid Analytic eXtract (MAX) that links mothers to infants and to identify factors influencing successful mother-infant linkage. They found that their algorithm can correctly link liveborn infants to their mothers, with linkage performance being associated with certain characteristics that may affect representativeness of successfully linked pairs.
AHRQ-funded; HS022384.
Citation: Knox CA, Hampp C, Palmsten K .
Validation of mother-infant linkage using Medicaid Case ID variable within the Medicaid Analytic eXtract (MAX) database.
Pharmacoepidemiol Drug Saf 2019 Sep;28(9):1222-30. doi: 10.1002/pds.4843..
Keywords: Caregiving, Medicaid, Newborns/Infants, Patient Safety, Pregnancy
Guglielminotti J, Landau R, Li. G
Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries.
Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with increased risk of maternal adverse events. Reducing avoidable general anesthetics for cesarean delivery may improve safety of obstetric anesthesia care. This study examined adverse events, trends, and factors associated with potentially avoidable general anesthetics for cesarean delivery. The investigators concluded that compared with neuraxial anesthesia, avoidable general anesthetics are associated with increased risk of adverse maternal outcomes.
AHRQ-funded; HS025787.
Citation: Guglielminotti J, Landau R, Li. G .
Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries.
Anesthesiology 2019 Jun;130(6):912-22. doi: 10.1097/aln.0000000000002629..
Keywords: Healthcare Cost and Utilization Project (HCUP), Labor and Delivery, Surgery, Pregnancy, Adverse Drug Events (ADE), Adverse Events, Women, Medication, Medication: Safety, Patient Safety, Maternal Care
Simpson KR, Lyndon A, Spetz J
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Labor and delivery nurses were surveyed to determine if their units adhere to Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines. Labor nurses in selected hospitals in California, Michigan and New Jersey were invited via email to participate in the study. Their nurse leaders facilitated the invitations. A total of 615 labor nurses from 67 hospitals participated. Most nurses did report that staffing guidelines were adhered to. The hospitals with smaller annual birth volumes (500-999 range) were significantly more like to be perceived as compliant than hospitals with 2,500 or more annual births.
AHRQ-funded; HS025715.
Citation: Simpson KR, Lyndon A, Spetz J .
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Nurs Womens Health 2019 Jun;23(3):217-23. doi: 10.1016/j.nwh.2019.03.003..
Keywords: Care Management, Guidelines, Labor and Delivery, Maternal Care, Patient Safety, Pregnancy, Provider, Provider: Nurse, Women
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
Lyndon A, Malana J, Hedi LC
Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth.
This study used an interdisciplinary team of five investigators to examine women’s birth experiences in the perspective of patient safety. Five investigators in the fields of nursing, medicine, product design, and journalism analyzed transcripts to see how women felt about their physical or emotional safety during birth, and to identify opportunities for improvement in care. Teams that were well-organized promoted feelings of safety as well as human connection.
AHRQ-funded; HS023506.
Citation: Lyndon A, Malana J, Hedi LC .
Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth.
J Obstet Gynecol Neonatal Nurs 2018 May;47(3):324-32. doi: 10.1016/j.jogn.2018.02.008..
Keywords: Labor and Delivery, Pregnancy, Women, Patient Safety, Patient Experience
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
Webb J, Sorensen A, Sommerness S
AHRQ Author: Mistry K
Advancing perinatal patient safety through application of safety science principles using health IT.
Researchers used semi-structured interviews with Labor and Delivery (L&D) units participating in AHRQ's Safety Program for Perinatal Care (SPPC) to assess units' experience with program implementation. Seventy percent of the units reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects.
AHRQ-authored; AHRQ-funded; 2902010000241.
Citation: Webb J, Sorensen A, Sommerness S .
Advancing perinatal patient safety through application of safety science principles using health IT.
BMC Med Inform Decis Mak 2017 Dec 19;17(1):176. doi: 10.1186/s12911-017-0572-8.
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Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Pregnancy, Maternal Care
Burstein PD, Zalenski DM, Edwards JL
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
The researchers established a multifactorial shoulder dystocia response and management protocol to promote sustainable practice change. In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.
AHRQ-funded; HS019608.
Citation: Burstein PD, Zalenski DM, Edwards JL .
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2472-86. doi: 10.1111/1475-6773.12589.
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Keywords: Labor and Delivery, Newborns/Infants, Adverse Events, Quality Improvement, Quality of Care, Patient Safety, Patient-Centered Outcomes Research, Outcomes, Guidelines, Evidence-Based Practice, Pregnancy, Teams
Yaghjyan L, Ghita GL, Dumont-Driscoll M
Maternal exposure to di-2-ethylhexylphthalate and adverse delivery outcomes: a systematic review.
This systematic review summarizes published studies that investigated the association of DEHP with preterm delivery, gestational age, and birthweight. identified important methodological concerns which could have resulted in selection bias and exposure misclassification and contributed to null findings and biased associations. Given limitations of the previous studies discussed in this review, more thorough investigation of these associations is warranted to advance scientific knowledge.
AHRQ-funded; HS022330.
Citation: Yaghjyan L, Ghita GL, Dumont-Driscoll M .
Maternal exposure to di-2-ethylhexylphthalate and adverse delivery outcomes: a systematic review.
Reprod Toxicol 2016 Oct;65:76-86. doi: 10.1016/j.reprotox.2016.07.002.
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Keywords: Outcomes, Patient Safety, Pregnancy