National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (5)
- Ambulatory Care and Surgery (1)
- Antibiotics (1)
- Antimicrobial Stewardship (1)
- Care Coordination (1)
- Caregiving (2)
- Clinician-Patient Communication (4)
- Communication (4)
- Critical Care (1)
- Education: Continuing Medical Education (1)
- Education: Patient and Caregiver (1)
- Elderly (1)
- Electronic Health Records (EHRs) (2)
- Falls (1)
- Health Information Technology (HIT) (5)
- Health Promotion (1)
- Hospitalization (2)
- Hospitals (3)
- Inpatient Care (2)
- Long-Term Care (1)
- Medical Errors (2)
- Medical Liability (1)
- Medication (3)
- Medication: Safety (3)
- Patient-Centered Healthcare (1)
- (-) Patient and Family Engagement (19)
- Patient Experience (1)
- (-) Patient Safety (19)
- Prevention (3)
- Provider Performance (1)
- Public Health (1)
- Quality of Care (3)
- Teams (1)
- Training (2)
- Transitions of Care (2)
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 DisplayedBeeber AS, Hoben M, Leeman J
Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.
This paper describes an AHRQ-funded study protocol (Engage) to develop a toolkit for increasing resident and family engagement in assisted living (AL) safety. The study goals are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. Methods, including qualitative interviews, a scoping review of persona and family engagement (PFE) interventions, and stakeholder panel meetings are discussed. The authors also detail how the protocol was modified to address the unique challenges of the COVID-19 pandemic.
AHRQ-funded; HS026473.
Citation: Beeber AS, Hoben M, Leeman J .
Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.
Res Nurs Health 2022 Aug;45(4):413-23. doi: 10.1002/nur.22232..
Keywords: Patient and Family Engagement, Patient Safety, Caregiving, Public Health, Long-Term Care
Bardach NS, Stotts JR, Fiore DM
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.
This study’s goal was to test a real-time mobile-responsive website called Family Input for Quality and Safety (FIQS) for inpatient reporting from families and patients. The tool was piloted from June 2017 to April 2018 on the medical-surgical unit of a children’s hospital. The authors enrolled 253 patients aged 13 and older and patient family members. This resulted in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one reports met incident reporting (IR) criteria with only 1 having been reported via the IR system. White participants submitted more observations than Latinx participants.
AHRQ-funded; HS028477; HS024553.
Citation: Bardach NS, Stotts JR, Fiore DM .
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.
J Hosp Med 2022 Jun;17(6):456-65. doi: 10.1002/jhm.2777..
Keywords: Quality of Care, Patient Safety, Health Information Technology (HIT), Patient and Family Engagement
Schnock KO, Snyder JE, Gershanik E
Unique patient-reported hospital safety concerns with online tool: MySafeCare.
This study evaluated the MySafeCare (MSC) application at six acute care units for 18 months as part of a patient-centered health information technology intervention to promote engagement and safety in the acute care setting. This web-based application allowed hospitalized patients to submit safety concerns anonymously and in real time. The authors evaluated rates of submissions to MSC and compared them to the hospital’s submissions to the Patient Family Relations Department. They received 46 submissions to MSC, and 33% of them were received anonymously. The overall rate of submissions was 0.6 submissions per 1000 patient-days, which was considerably lower than the rate of submissions to the Patient Family Relations Department during the same time period (4.1 per 1000 patient-days). MSC did capture important content concerning unmet care needs and preferences, inadequate communication, and concerns about safety of care.
AHRQ-funded; HS023535.
Citation: Schnock KO, Snyder JE, Gershanik E .
Unique patient-reported hospital safety concerns with online tool: MySafeCare.
J Patient Saf 2022 Jan;18(1):e33-e39. doi: 10.1097/pts.0000000000000697..
Keywords: Patient Safety, Health Information Technology (HIT), Hospitals, Patient-Centered Healthcare, Patient and Family Engagement
Holden RJ, Abebe E
Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
The authors present a novel view of transitions from the lens of patient ergonomics which posits that patients and other nonprofessionals experience many changes during patient work transitions toward health-related goals. Medication transitions are particularly vulnerable. Two cases of medication transitions; new and medication deprescribing are described in which the patient work lens reveals many accompanying changes, vulnerabilities, and opportunities for human factors and ergonomics.
AHRQ-funded; HS024384.
Citation: Holden RJ, Abebe E .
Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
Appl Ergon 2021 Jan;90:103279. doi: 10.1016/j.apergo.2020.103279..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Transitions of Care, Patient Safety
Yen PY, Lehmann LS, Snyder J
Development and validation of WeCares, a survey instrument to assess hospitalized patients' and family members' "Willingness to engage in your care and safety."
Patient engagement is recognized as a method to improve care quality and safety. A research team developed WeCares (Willingness to Engage in Your Care and Safety), a survey instrument assessing patients' and families' engagement in the safety of their care during their hospital stay. The objective of this study was to establish the preliminary construct validity and internal consistency of WeCares.
AHRQ-funded; HS0235335.
Citation: Yen PY, Lehmann LS, Snyder J .
Development and validation of WeCares, a survey instrument to assess hospitalized patients' and family members' "Willingness to engage in your care and safety."
Jt Comm J Qual Patient Saf 2020 Oct;46(10):565-72. doi: 10.1016/j.jcjq.2020.07.002..
Keywords: Patient and Family Engagement, Patient Safety, Inpatient Care, Hospitalization
Christiansen TL, Lipsitz S, Scanlan M
Patient activation related to fall prevention: a multisite study.
The purpose of this study was to examine the impact of the Fall TIPS (Tailoring Interventions for Patient Safety) program on patient activation related to fall prevention. Researchers used the short form Patient Activation Measure (PAM-13) adapted for fall prevention. Their findings showed that patient activation improved from preintervention to postintervention at all three studied sites. Patients with access to the Fall TIPS program are more activated and engaged in their fall prevention plan. Recommendations include engaging patients in the fall prevention plan to increase their knowledge, skill, and confidence.
AHRQ-funded; HS023535.
Citation: Christiansen TL, Lipsitz S, Scanlan M .
Patient activation related to fall prevention: a multisite study.
Jt Comm J Qual Patient Saf 2020 Mar;46(3):129-35. doi: 10.1016/j.jcjq.2019.11.010..
Keywords: Falls, Prevention, Patient Safety, Patient and Family Engagement, Education: Patient and Caregiver
Haldar S, Mishra SR, Pollack AH
Informatics opportunities to involve patients in hospital safety: a conceptual model.
This study investigated how hospital inpatients experience undesirable events (UEs) and to see if those present opportunities for new informatics solutions. The authors surveyed 242 patients and caregivers during their hospital stay and asked them open-ended questions about their experiences with UEs. They then developed a 4-stage conceptual model which illustrates inpatient experiences: from when they first encounter UEs, and opportunities to promote inpatients’ participation and engagement in the quality and safety of their care, help healthcare systems learn from inpatient experience, and reduce those harmful events.
AHRQ-funded; HS022894.
Citation: Haldar S, Mishra SR, Pollack AH .
Informatics opportunities to involve patients in hospital safety: a conceptual model.
J Am Med Inform Assoc 2020 Feb;27(2):202-11. doi: 10.1093/jamia/ocz167.
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Keywords: Patient Safety, Hospitals, Health Information Technology (HIT), Patient and Family Engagement, Patient Experience, Quality of Care
Salzman DH, Rising KL, Cameron KA
Setting a minimum passing standard for the uncertainty communication checklist through patient and physician engagement.
Historically, medically trained experts have served as judges to establish a minimum passing standard (MPS) for mastery learning. As mastery learning expands from procedure-based skills to patient-centered domains, such as communication, there is an opportunity to incorporate patients as judges in setting the MPS. In this study, the investigators described their process of incorporating patients as judges to set the minimum passing standard (MPS) and compared the MPS set by patients and emergency medicine residency program directors (PDs).
AHRQ-funded; HS025651.
Citation: Salzman DH, Rising KL, Cameron KA .
Setting a minimum passing standard for the uncertainty communication checklist through patient and physician engagement.
J Grad Med Educ 2020 Feb;12(1):58-65. doi: 10.4300/jgme-d-19-00483.1..
Keywords: Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety, Education: Continuing Medical Education, Training, Provider Performance
Gaufberg E, Olmsted MW, Bell SK
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
The authors discuss an AHRQ conference held to establish a research agenda on patient and family emotional harm after medical errors. Topics include implications for quality and safety, educational innovation, and qualitative research.
AHRQ-funded; HS024463.
Citation: Gaufberg E, Olmsted MW, Bell SK .
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
J Med Humanit 2019 Dec;40(4):489-504. doi: 10.1007/s10912-019-09563-z..
Keywords: Medical Errors, Adverse Events, Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety
Xiao Y, Abebe E, Gurses AP
Engineering a foundation for partnership to improve medication safety during care transitions.
Current approaches to safe, self-medication management for patients and caregivers after hospital discharge tend to focus on adding isolated strategies. Positing the concept that medication safety during care transition and at patient homes is the property of a "work system," in which the patient and caregivers are in collaboration with health professionals, this article argues that system thinking can enable a fundamental transformation that redesigns professionals' interactions with patients and caregivers, with the explicit goal of developing patients and caregivers into true partners with targeted roles. The authors describe a set of recommendations based on human factors principles that creates an engineering partnership with patients and their caregivers at different stages during a care episode, to enable productive interactions.
AHRQ-funded; HS024436.
Citation: Xiao Y, Abebe E, Gurses AP .
Engineering a foundation for partnership to improve medication safety during care transitions.
J Patient Saf Risk Manag 2019 Feb 1;24(1):30-36. doi: 10.1177/2516043518821497..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Transitions of Care
Khan A, Spector ND, Baird JD
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
The objective of this prospective, multicenter before and after intervention was to determine whether medical errors, family experience, and communication processes improved after implementation of the intervention to standardize the structure of healthcare provider-family communication on family centered rounds. The investigators concluded that although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved.
AHRQ-funded; HS00063.
Citation: Khan A, Spector ND, Baird JD .
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
BMJ 2018 Dec 5;363:k4764. doi: 10.1136/bmj.k4764..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Medical Errors, Patient and Family Engagement, Patient Safety
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Ricciardi R, Shofer M
AHRQ Author: Ricciardi R, Shofer M.
Moving patient safety into ambulatory settings and beyond.
This paper discusses patient safety across various clinical settings, the importance of patient and family engagement, and innovations in patient safety such as the Patient Safety Learning Laboratories.
AHRQ-authored.
Citation: Ricciardi R, Shofer M .
Moving patient safety into ambulatory settings and beyond.
J Nurs Care Qual 2018 Jul/Sep;33(3):195-99. doi: 10.1097/ncq.0000000000000329.
Keywords: Ambulatory Care and Surgery, Patient and Family Engagement, Patient Safety
Cox ED, Jacobsohn GC, Rajamanickam VP
A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.
The researchers examined the impact of the family-centered rounds (FCRs) checklist intervention, a checklist and associated provider training, on performance of FCR elements, family engagement, and patient safety. They found that the performance of FCR checklist elements was enhanced by checklist implementation and associated with changes in family engagement and more positive perceptions of safety climate.
AHRQ-funded; HS018680.
Citation: Cox ED, Jacobsohn GC, Rajamanickam VP .
A family-centered rounds checklist, family engagement, and patient safety: a randomized trial.
Pediatrics 2017 May;139(5). doi: 10.1542/peds.2016-1688.
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Keywords: Quality of Care, Patient Safety, Patient and Family Engagement, Clinician-Patient Communication, Training
Duckworth M, Leung E, Fuller T
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Differences emerged stemming from each group of end users' role on the care team.
AHRQ-funded; HS023535.
Citation: Duckworth M, Leung E, Fuller T .
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
J Gerontol Nurs 2017 Apr;43(4):15-22. doi: 10.3928/00989134-20170313-05.
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Keywords: Elderly, Electronic Health Records (EHRs), Health Information Technology (HIT), Caregiving, Patient Safety, Patient and Family Engagement, Care Coordination
Heid C, Knobloch MJ, Schulz LT
Use of the health belief model to study patient perceptions of antimicrobial stewardship in the acute care setting.
The authors identified themes associated with patient perceptions of antibiotic use and the role of patients in inpatient antimicrobial stewardship. They found that general medicine inpatients receiving at least one anti-infective medication recognized antibiotic resistance as a serious public health threat but expressed low perceived susceptibility to being personally affected by antibiotic resistance. Few participants reported being offered the opportunity to engage in shared decision making while hospitalized. The researchers concluded that the likelihood of patient engagement in stewardship practices is currently limited by low perceived susceptibility and lack of cues to act.
AHRQ-funded; HS023791.
Citation: Heid C, Knobloch MJ, Schulz LT .
Use of the health belief model to study patient perceptions of antimicrobial stewardship in the acute care setting.
Infect Control Hosp Epidemiol 2016 May;37(5):576-82. doi: 10.1017/ice.2015.342.
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Keywords: Critical Care, Antimicrobial Stewardship, Antibiotics, Patient and Family Engagement, Patient Safety
Dykes PC, Stade D, Dalal A
Strategies for managing mobile devices for use by hospitalized inpatients.
The authors implemented the PROSPECT (Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication and Technology) project at Brigham and Women's Hospital. The goal of PROSPECT is to transform the hospital environment by providing a suite of e-tools to facilitate teamwork. In this paper, the authors described decisions and challenges faced and related the strategies used and lessons learned.
AHRQ-funded; HS023535.
Citation: Dykes PC, Stade D, Dalal A .
Strategies for managing mobile devices for use by hospitalized inpatients.
AMIA Annu Symp Proc 2015 Nov 5;2015:522-31.
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Keywords: Communication, Inpatient Care, Patient and Family Engagement, Patient Safety, Teams
Berger Z, Flickinger TE, Pfoh E
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
This review examined how interventions encouraging patient and family engagement have been implemented in controlled trials. Among 12 identified studies, the authors noted that definitions of patient and family engagement were lacking. They found insufficient high-quality evidence to inform real-world implementation and provided recommendations for further study.
AHRQ-funded; 290200710062I.
Citation: Berger Z, Flickinger TE, Pfoh E .
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
BMJ Qual Saf 2014 Jul;23(7):548-55. doi: 10.1136/bmjqs-2012-001769.
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Keywords: Adverse Events, Health Promotion, Patient and Family Engagement, Patient Safety, Prevention
Etchegaray JM, Ottosen MJ, Burress L
Structuring patient and family involvement in medical error event disclosure and analysis.
The researchers conducted a two-phase study to understand whether patients and families who have experienced an adverse event should be involved in the postevent analysis following the disclosure of a medical error. After evaluating the findings, participants concluded that increasing the involvement of patients and their families in the event analysis process was desirable but needed to be structured in a patient-centered way to be successful.
AHRQ-funded; HS019561.
Citation: Etchegaray JM, Ottosen MJ, Burress L .
Structuring patient and family involvement in medical error event disclosure and analysis.
Health Aff 2014 Jan;33(1):46-52. doi: 10.1377/hlthaff.2013.0831..
Keywords: Adverse Events, Medical Liability, Patient and Family Engagement, Patient Safety