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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
51 to 75 of 1293 Research Studies DisplayedTemkin-Greener H, Mao Y, McGarry B
Patient safety culture in assisted living: staff perceptions and association with state regulations.
The purpose this study was to evaluate views on patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their relationships with state regulations. The researchers utilized the PSC instrument developed by the Agency for Healthcare Research & Quality to conduct a survey of administrators and DCWs working in assisted living communities serving Medicare beneficiary residents. Secondary data on ALs and residents were obtained from the Medicare Master Beneficiary Summary Files. Other data sources included: the Area Health Resource Files, a previous national AL directory, the US census, and a prior study citing AL regulations. 714 administrators and DCWs in 257 The study found that administrators' and DCWs' perspectives on PSC differed significantly across almost all domains. The researchers concluded that PSC is a relevant metric for evaluating organizational performance.
AHRQ-funded; HS026893.
Citation: Temkin-Greener H, Mao Y, McGarry B .
Patient safety culture in assisted living: staff perceptions and association with state regulations.
J Am Med Dir Assoc 2022 Dec;23(12):1997-2022.e3. doi: 10.1016/j.jamda.2022.09.007..
Keywords: Patient Safety, Elderly, Long-Term Care, Policy
White A, Fulda KG, Blythe R
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
The purpose of this narrative review was to further define the nature of collaboration between pharmacists and primary care providers in improving medication safety in community settings, and to describe related barriers and strategies. The researchers searched PubMed studies published between January 2000 and December 2020 using search terms including: "collaboration," "community pharmacy," "patient safety," "medication safety," and "primary care physician." The identified articles were placed into 3 categories: 1) defining collaboration, 2) types of collaboration, and 3) barriers and solutions to collaboration. The authors concluded that medication review and other strategies are a common form of collaboration between pharmacists and primary care providers, and that barriers to that collaboration can include erroneous beliefs regarding roles, variation in access to clinical information, and differences in community pharmacy practice.
AHRQ-funded; HS027277.
Citation: White A, Fulda KG, Blythe R .
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
Expert Opin Drug Saf 2022 Nov;21(11):1357-64. doi: 10.1080/14740338.2022.2147923..
Keywords: Provider: Pharmacist, Primary Care, Medication, Patient Safety, Community-Based Practice
Chui MA, Berbakov ME, Gilson AM
Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: a randomized controlled trial.
This paper is a protocol of a pilot study to address a gap in medication safety and decrease misuse of over-the-counter (OTC) medications by older adults aged 65 years or older by creating a pharmacy “Senior Section”. The study will occur in three phases: adaptation, effectiveness using a randomized controlled trial, and sustainment. The study will take place within a regional Midwest integrated health system in conjunction with administration leadership and pharmacy sites. The authors hope this project will provide a road map for pharmacy organizations to tailor and adopt the Senior Section.
AHRQ-funded; HS027737.
Citation: Chui MA, Berbakov ME, Gilson AM .
Effectiveness and sustainment of a tailored over-the-counter medication safety intervention in community pharmacies: a randomized controlled trial.
Res Social Adm Pharm 2022 Nov;18(11):3953-63. doi: 10.1016/j.sapharm.2022.06.008..
Keywords: Medication, Medication: Safety, Patient Safety, Provider: Pharmacist
Ostrovsky D, Novack V, Smulowitz PB
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
This cross-sectional study examined survey responses about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians regarding what might be considered excessive testing. The authors surveyed 1222 clinicians and the mean score was greater for fear of harm to patients than fear of a malpractice suit. This finding was true regardless of clinician subtype, experience, or sex.
AHRQ-funded; HS026730.
Citation: Ostrovsky D, Novack V, Smulowitz PB .
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
JAMA Netw Open 2022 Nov;5(11):e2241461. doi: 10.1001/jamanetworkopen.2022.41461..
Keywords: Emergency Department, Medical Errors, Adverse Events, Patient Safety
Gomez Lumbreras A, Reese TJ, Del Fiol G
Shared decision-making for drug-drug interactions: formative evaluation of an anticoagulant drug interaction.
This study evaluated a tool called DDInteract that was developed to enhance and support shared decision-making (SDM) between patients and physicians when both warfarin and NSAIDs are used concurrently. The study used case vignettes with physicians and patients on warfarin to conduct simulated virtual clinical encounters where they discussed the use of taking ibuprofen and warfarin concurrently and determined an appropriate therapeutic plan based on the patient’s individualized risk. Participants completed a postsession interview and SDM process survey, including the 9-item Shared Decision-Making Questionnaire (SDM-Q-9), tool usability and workload National Aeronautics and Space Administration (NASA) Task Load Index, Unified Theory of Acceptance and Use of Technology (UTAUT), Perceived Behavioral Control (PBC) scale, System Usability Scale (SUS), and Decision Conflict Scale (DCS). A total of 12 physician-patient dyads were used, with over 91% of the patients over 50 and 75% had been taking warfarin for over 2 years. Most participants rated DDInteract higher than usual care (UC) and would be willing to use the tool for an interaction involving warfarin and NSAIDs.
AHRQ-funded; HS027099.
Citation: Gomez Lumbreras A, Reese TJ, Del Fiol G .
Shared decision-making for drug-drug interactions: formative evaluation of an anticoagulant drug interaction.
JMIR Form Res 2022 Oct 19;6(10):e40018. doi: 10.2196/40018..
Keywords: Decision Making, Medication, Blood Thinners, Clinical Decision Support (CDS), Health Information Technology (HIT), Medication: Safety, Patient Safety
Blike GT, Perreard IM, McGovern KM
A pragmatic method for measuring inpatient complications and complication-specific mortality.
This study’s objective was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement and to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.). The authors used AHRQ metrics as the basis for identifying specific complications related to major organ system morbidity associated with death. Using component ICD, 10th Revision codes, complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations. Statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions were shown with the complication-specific method. Use of a monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths.
AHRQ-funded; HS024403.
Citation: Blike GT, Perreard IM, McGovern KM .
A pragmatic method for measuring inpatient complications and complication-specific mortality.
J Patient Saf 2022 Oct 1;18(7):659-66. doi: 10.1097/pts.0000000000000984..
Keywords: Inpatient Care, Adverse Events, Patient Safety
Chen Z, Gleason LJ, Sanghavi P
Accuracy of pressure ulcer events in US nursing home ratings.
This study investigated the accuracy of the government website Nursing Home Compare (NHC) pressure ulcer measures, which are chief indicators of nursing home patient safety. The authors identified hospital admissions for pressure ulcers and linked them to the nursing home-reported data at the patient level using Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017. Percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race was calculated. Reporting rates were low for both short-stay (70.2%) and long-stay (59.7%) for stage 2-4 pressure ulcer hospitalizations. Black residents experienced more severe pressure ulcers than White residents. Correlations between claims-based measures and NHC ratings were found to be poor.
AHRQ-funded; HS026957.
Citation: Chen Z, Gleason LJ, Sanghavi P .
Accuracy of pressure ulcer events in US nursing home ratings.
Med Care 2022 Oct;60(10):775-83. doi: 10.1097/mlr.0000000000001763.
AHRQ-funded; HS026957..
AHRQ-funded; HS026957..
Keywords: Elderly, Nursing Homes, Long-Term Care, Pressure Ulcers, Quality Measures, Quality of Care, Patient Safety
Campbell NL, Pitts C, Corvari C
Deprescribing anticholinergics in primary care older adults: experience from two models and impact on a continuous measure of exposure.
The purpose of this study was to assess two pilot pharmacist-based advanced practice deprescribing intervention models and their impact on patients’ exposure to high-risk anticholinergics. The researchers conducted pilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention. Deprescribing was defined as a discontinuation or dose reduction. Patients participating in the clinic-based pharmacy model were aged 55 years and older and were referred for deprescribing at a specialty clinic. Patients participating in the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. The study found that among the 24 medications deemed eligible for deprescribing for the18 patients in the clinic-based model, 23 were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 17% of medications were represcribed within 6 months. Among the 24 medications deemed eligible for deprescribing for the 24 patients in the telephone-based pharmacy model, 50% were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months. The researchers concluded that pharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in the study population.
AHRQ-funded; HS24384.
Citation: Campbell NL, Pitts C, Corvari C .
Deprescribing anticholinergics in primary care older adults: experience from two models and impact on a continuous measure of exposure.
Journal of the American College of Pharmacy 2022 Oct;5(10):1039-47. doi: 10.1002/jac5.1682..
Keywords: Elderly, Primary Care, Medication, Provider: Pharmacist, Medication: Safety, Patient Safety
Luximon DC, Ritter T, Fields E
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
The purpose of this study was to develop an automatic error detection algorithm that uses a three-branch convolutional neural network error detection model (EDM) to detect off-by-one vertebral-body misalignments using planning computed tomography (CT) images and setup CBCT images. The researchers collected algorithm training and test data from 480 patients undergoing radiotherapy treatment at two radiotherapy clinics. One model (EDM(1) ) was trained solely on data from institution 1. EDM(1) was further trained on a dataset from institution 2 to produce a fine-tuned model, EDM(2) . Another model, EDM(3), was trained using a training dataset composed of data from both institutions. The study found that when applied to the combined test set, EDM(1) , EDM(2) , and EDM(3) resulted in an area under curve of 99.5%, 99.4%, and 99.5%, respectively. EDM(1) achieved a sensitivity of 96% and 88% on Institution 1 and Institution 2 test set, respectively. EDM(2) obtained a sensitivity of 95% on each institution's test set. EDM(3) achieved a sensitivity of 95% and 88% on Institution 1 and Institution 2 test set, respectively. The researchers concluded that in CBCT-guided radiotherapy, the proposed algorithm demonstrated accuracy in identifying off-by-one vertebral-body misalignments that was sufficiently high enough to justify implementation in practice.
AHRQ-funded; HS026486.
Citation: Luximon DC, Ritter T, Fields E .
Development and interinstitutional validation of an automatic vertebral-body misalignment error detector for cone-beam CT-guided radiotherapy.
Med Phys 2022 Oct;49(10):6410-23. doi: 10.1002/mp.15927..
Keywords: Imaging, Diagnostic Safety and Quality, Medical Errors, Patient Safety
Ozonoff A, Milliren CE, Fournier K A, Milliren CE, Fournier K
Electronic surveillance of patient safety events using natural language processing.
The purpose of this study was to describe the surveillance of reportable safety events captured in hospital data including free-text clinical notes. The researchers created a training data set for a machine learning model and applied the model to complete sets of clinical notes which were then reviewed to identify safety events of interest. The study found that in Phase 1, the researchers reviewed 2,342 clinical notes of the 21,362 gathered. 125 PIV events were identified, of which 44 cases (35%) were not identified by other patient safety systems. In Phase 2 of the study, the researchers identified 440 infiltrate events of the 60,735 clinical notes collected. The study classifier provided accuracy above 90%.
AHRQ-funded; HS026246.
Citation: Ozonoff A, Milliren CE, Fournier K A, Milliren CE, Fournier K .
Electronic surveillance of patient safety events using natural language processing.
Health Informatics J 2022 Oct-Dec; 28(4):14604582221132429. doi: 10.1177/14604582221132429..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Shafer GJ, Singh H, Thomas EJ
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
The objective of this study was to determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients. The "Safer Dx NICU Instrument" was used to review electronic health records. The reviewers discovered that the frequency of diagnostic error in inborn NICU patients during the first 7 days of admission was 6.2%.
AHRQ-funded; HS027363.
Citation: Shafer GJ, Singh H, Thomas EJ .
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
J Perinatol 2022 Oct;42(10):1312-18. doi: 10.1038/s41372-022-01359-9..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Bourgoin A, Balaban R, Hochman M
AHRQ Author: Perfetto D, Hogan EM
Improving quality and safety for patients after hospital discharge: primary care as the lead integrator in postdischarge care transitions.
The purpose of this study was to explain primary care-based transition workflow processes for hospitalized patients. The researchers conducted interviews with primary care thought leaders, staff at 9 primary care sites, community agency staff, and recently discharged patients. The researchers found that primary care postdischarge workflows vary across the different settings, rarely include communications with the patient or the inpatient team during the hospitalization and vary widely across settings. The researchers recommended the use of principles for primary care practices to encourage active participation in the full spectrum of postdischarge care, from admission through the first postdischarge visit to primary care.
AHRQ-authored; AHRQ-funded; 233201500019I/HHSP23337002T.
Citation: Bourgoin A, Balaban R, Hochman M .
Improving quality and safety for patients after hospital discharge: primary care as the lead integrator in postdischarge care transitions.
J Ambul Care Manage 2022 Oct-Dec;45(4):310-20. doi: 10.1097/jac.0000000000000433..
Keywords: Quality of Care, Patient Safety, Hospital Discharge, Transitions of Care, Hospitals, Workflow
Lusk C, Catchpole K, Neyens DM
Improving safety in the operating room: medication icon labels increase visibility and discrimination.
The purpose of this study was to assess whether the addition of icons to medication labels in an operating room setting would improve visibility and reduce medication administration errors. The multi-disciplinary team of researchers added icons to medication labels applied to vasoactive medication infusions, and the study found that participants were 1.12 times more likely to correctly identify medications with icons from farther away. In addition, when icons were present on the labels, participants were 2.16 times more likely to be more confident in their identifications.
AHRQ-funded; HS026625.
Citation: Lusk C, Catchpole K, Neyens DM .
Improving safety in the operating room: medication icon labels increase visibility and discrimination.
Appl Ergon 2022 Oct;104:103831. doi: 10.1016/j.apergo.2022.103831..
Keywords: Medication: Safety, Medication, Patient Safety, Medical Errors, Adverse Drug Events (ADE), Adverse Events
Leland NE, Lekovitch C, Martínez J
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
The purpose of this scoping review was to describe the evidence for multifactorial post-acute care (PAC) fall prevention interventions for older patients. The researchers included 33 studies and characterized common intervention domains including: evaluating patient-specific fall risk factors, developing an individualized risk profile and treatment plan that targets each patient's fall risk factors, and implementing facility-based strategies such as staff education. There was not consensus across studies in how the domains were addressed and to what extent. The researchers concluded that health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach.
AHRQ-funded; HS022907.
Citation: Leland NE, Lekovitch C, Martínez J .
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
J Appl Gerontol 2022 Oct;41(10):2187-96. doi: 10.1177/07334648221104375..
Keywords: Elderly, Falls, Prevention, Patient Safety, Evidence-Based Practice
Bradford A, Shofer M, Singh H
AHRQ Author: Shofer M, Singh H
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
This paper discusses Measure Dx, a new AHRQ resource that translates knowledge from diagnostic measurement research into actionable recommendations. This resource guides healthcare organizations to detect, analyze, and learn from diagnostic safety events as part of a continuous learning and feedback cycle. The goal of Measure Dx is to advance new frontiers in reducing preventable diagnostic harm to patients.
AHRQ-authored; AHRQ-funded; 233201500022I; HS027363.
Citation: Bradford A, Shofer M, Singh H .
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
Int J Qual Health Care 2022 Sep 10;34(3). doi: 10.1093/intqhc/mzac068..
Keywords: Diagnostic Safety and Quality, Patient Safety, Quality Improvement, Quality of Care, Electronic Health Records (EHRs), Health Information Technology (HIT), Health Systems, Learning Health Systems
Bradford A, Shahid U, Schiff GD
AHRQ Author: DiStabile P, Timashenka A, Jalal H, and Brady PJ
Development and usability testing of the Agency for Healthcare Research and Quality common formats to capture diagnostic safety events.
The purpose of this study was to conduct a usability assessment of the Agency for Healthcare Research and Quality (AHRQ) Common Formats for Event Reporting for Diagnostic Safety Events (CFER-DS) to assist in informing future revisions and implementation. The researchers recruited quality and safety personnel from 8 U.S. healthcare organizations and invited them to use the CFER-DS to simulate reporting and then provide written and verbal qualitative feedback. The study found that feedback about item clarity and content coverage was generally positive, but that reporter burden was a potential concern. Participants also identified opportunities to improve the CFER-DS, including clarifying several conceptual definitions, improving applicability across different care settings, and creating guidance to operationalize use of the tool.
AHRQ-authored; AHRQ-funded; HS027363, 233201500022I.
Citation: Bradford A, Shahid U, Schiff GD .
Development and usability testing of the Agency for Healthcare Research and Quality common formats to capture diagnostic safety events.
J Patient Saf 2022 Sep 1;18(6):521-25. doi: 10.1097/pts.0000000000001006..
Keywords: Diagnostic Safety and Quality, Patient Safety, Health Information Technology (HIT), Adverse Events
Kalenderian E, Lee JH, Obadan-Udoh EM
Development of an inventory of dental harms: methods and rationale.
The authors sought to standardize the language of dental adverse events (AEs). Using a multimodal approach, they developed a broad list of dental AEs in which the AEs were classed into 12 categories, with hard tissue injury being noted frequently. Pain was the unexpected AE that was consistently identified with every modality used.
AHRQ-funded; HS024406.
Citation: Kalenderian E, Lee JH, Obadan-Udoh EM .
Development of an inventory of dental harms: methods and rationale.
J Patient Saf 2022 Sep 1;18(6):559-64. doi: 10.1097/pts.0000000000001033..
Keywords: Dental and Oral Health, Patient Safety, Research Methodologies
Halvorson EE, Thurtle DP, Easter A
Disparities in adverse event reporting for hospitalized children.
The authors compared the adverse event (AE) rate identified by voluntary event reporting (VER) with that identified using the Global Assessment of Pediatric Patient Safety (GAPPS) between hospitalized children by weight category, race, and English proficiency. In the population studied, they identified 288 total AEs, 270 by the GAPPS and 18 by VER. They found a disparity in AE reporting for children with limited English proficiency, with fewer AEs by VER compared with no difference in AEs by GAPPS. They identified no disparities by weight category or race. They concluded that voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.
AHRQ-funded; HS026038.
Citation: Halvorson EE, Thurtle DP, Easter A .
Disparities in adverse event reporting for hospitalized children.
J Patient Saf 2022 Sep 1;18(6):e928-e33. doi: 10.1097/pts.0000000000001049..
Keywords: Children/Adolescents, Disparities, Adverse Events, Medical Errors, Patient Safety, Hospitals, Hospitalization, Inpatient Care
Morey DA, Rayo MF, Li M
From reactive to proactive safety: joint activity monitoring for infection prevention.
The authors explored Joint Activity Monitoring (JAM) as one key component of a proactive safety program within infection prevention. This paper described their strategies and challenges in developing this capability and discussed the implications for supporting a successful proactive safety implementation.
AHRQ-funded; HS027200.
Citation: Morey DA, Rayo MF, Li M .
From reactive to proactive safety: joint activity monitoring for infection prevention.
Proc Int Symp Hum Factors Ergon Healthc 2022 Sep; 11(1):48-52. doi: 10.1177/2327857922111009..
Keywords: Prevention, Healthcare-Associated Infections (HAIs), Patient Safety
Sheehan JG, Howe JL, Fong A
Usability and accessibility of publicly available patient safety databases.
This study’s aims were to identify publicly available patient safety report databases and to determine whether these databases support safety analyst and data scientist use to identify patterns and trends. Seven databases (7 hosted by federal agencies and 1 by a nonprofit organization) containing more than 28.3 million safety reports were identified. Over half (57.1%) provided the ability to sort/compare/filter data, 42.9% provided data visualization, and 85.7% enabled free-text search. None of the databases provided regular updates or monitoring. Features were analyzed to support data scientist use and only 42.9% provided an application programing interface, most (85.7%) provided batch downloading, all provided documentation about the database, and 71.4% provided a data dictionary. All databases were open access.
AHRQ-funded; HS026481.
Citation: Sheehan JG, Howe JL, Fong A .
Usability and accessibility of publicly available patient safety databases.
J Patient Saf 2022 Sep 1;18(6):565-69. doi: 10.1097/pts.0000000000001018..
Keywords: Patient Safety, Health Information Technology (HIT)
Villa-Zapata L, Gómez-Lumbreras A, Horn J
A disproportionality analysis of drug-drug interactions of tizanidine and CYP1A2 inhibitors from the FDA Adverse Event Reporting System (FAERS).
This study’s aim was to examine the occurrence of adverse events reported in the FDA Adverse Event Reporting System (FAERS) involving the combination of tizanidine and drugs that inhibit the metabolic activity of CYP1A2. Tizanidine is used to help control muscle spasticity. From 2004 quarter 1 through 2020 quarter 3 a total of 89 reports were identified mentioning tizanidine, at least one CYP1A2 inhibitor, and one of the adverse events of interest including: hypotension, bradycardia, syncope, shock, cardiorespiratory arrest, and fall or fracture. More than half the reports identified tizanidine as having a suspect or interacting role, and the reports more frequently involved women (65.1%). The median age was 56.1 years. Hypotension had the highest odds for adverse event reports involving tizanidine and a CYP1A2 inhibitor which can lead to falls and fractures.
AHRQ-funded; HS025984.
Citation: Villa-Zapata L, Gómez-Lumbreras A, Horn J .
A disproportionality analysis of drug-drug interactions of tizanidine and CYP1A2 inhibitors from the FDA Adverse Event Reporting System (FAERS).
Drug Saf 2022 Aug;45(8):863-71. doi: 10.1007/s40264-022-01200-4..
Keywords: Health Information Technology (HIT), Medication, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Patient Safety
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.
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
Mercer AN, Mauskar S, Baird J
Family safety reporting in hospitalized children with medical complexity.
This prospective cohort study was conducted to evaluate safety concerns from families of hospitalized children with medical complexity (CMC) who are at high risk of medical errors. This survey was done predischarge with English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. A total of 155 parents and 214 staff completed surveys, with 43% (n = 66) having ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). A physician review found that 69% of concerns were medical errors, and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses, but only 32% of parents recalled being told how to report safety concerns. Higher education and longer length of stay were associated with family safety concerns.
AHRQ-funded; HS025781.
Citation: Mercer AN, Mauskar S, Baird J .
Family safety reporting in hospitalized children with medical complexity.
Pediatrics 2022 Aug 1; 150(2):e2021055098. doi: 10.1542/peds.2021-055098..
Keywords: Children/Adolescents, Family Health and History, Chronic Conditions, Patient Safety, Medical Errors, Adverse Events, Inpatient Care
Lai LY, Oerline MK, Caram MEV
Risk of metabolic and cardiovascular adverse events with abiraterone or enzalutamide among men with advanced prostate cancer.
Investigators examined the association between the use of abiraterone or enzalutamide and the risk of metabolic or cardiovascular adverse events while on treatment for advanced prostate cancer. They found that, compared with men not receiving abiraterone, men receiving abiraterone were at increased risk of both a major composite adverse event and a minor composite adverse event. Compared with men not receiving enzalutamide, men receiving enzalutamide were at an increased risk of a major composite adverse event but not a minor composite adverse event. They recommended careful monitoring and management of men on abiraterone or enzalutamide through team-based approaches.
AHRQ-funded; HS027507.
Citation: Lai LY, Oerline MK, Caram MEV .
Risk of metabolic and cardiovascular adverse events with abiraterone or enzalutamide among men with advanced prostate cancer.
J Natl Cancer Inst 2022 Aug 8;114(8):1127-34. doi: 10.1093/jnci/djac081..
Keywords: Cardiovascular Conditions, Cancer: Prostate Cancer, Cancer, Risk, Adverse Events, Medication, Adverse Drug Events (ADE), Medication: Safety, Patient Safety
Waters TM, Burns N, Kaplan CM
Combined impact of medicare's hospital pay for performance programs on quality and safety outcomes is mixed.
The authors examined the combined impact of Medicare's pay for performance (P4P) programs on clinical areas and populations targeted by the programs, as well as those outside their focus. Using HCUP data, and consistent with previous studies for individual programs, they detected minimal, if any, effect of Medicare's hospital P4P programs on quality and safety. They recommended a redesigning of the P4P programs before continuing to expand them.
AHRQ-funded; HS025148.
Citation: Waters TM, Burns N, Kaplan CM .
Combined impact of medicare's hospital pay for performance programs on quality and safety outcomes is mixed.
BMC Health Serv Res 2022 Jul 28;22(1):958. doi: 10.1186/s12913-022-08348-w..
Keywords: Healthcare Cost and Utilization Project (HCUP), Medicare, Payment, Provider Performance, Hospitals, Quality Indicators (QIs), Quality Measures, Quality Improvement, Quality of Care, Patient Safety