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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
101 to 125 of 1293 Research Studies DisplayedMarshall TL, Rinke ML, Olson APJ
Diagnostic error in pediatrics: a narrative review.
This narrative review focuses on the relative paucity of large, high-quality studies of diagnostic errors and what is known at present about the incident and epidemiology as well as the established research for identifying, evaluating, and reducing diagnostic errors. The authors propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature. The authors state that additional research is needed to better establish the epidemiology of diagnostic errors in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses.
AHRQ-funded; HS023827; HS026644.
Citation: Marshall TL, Rinke ML, Olson APJ .
Diagnostic error in pediatrics: a narrative review.
Pediatrics 2022 Mar;149(Suppl 3). doi: 10.1542/peds.2020-045948D..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Patient Safety, Medical Errors
Wei YJ, Chen C, Lewis MO
Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare beneficiaries in the United States: a nested case-control study.
This study used a sample of older patients who are Medicare beneficiaries who were newly prescribed opioids to determine rates of 4 prescription opioid dose trajectories and the risk of opioid-related adverse events (ORAEs). A 5% random sample of Medicare beneficiaries from 2011 to 2018 was used to conduct a nested case-control study of patients age 65 and older who were newly diagnosed with chronic noncancer pain (CNCP). Among the cases and controls, 2,192 (70.6%) were women and mean age was 77.1 years. Four prescribed opioid trajectories before the incident ORAE diagnosis or matched date emerged: gradual dose discontinuation (from ≤3 to 0 daily morphine milligram equivalent (MME), 1,456 [23.5%]), gradual dose increase (from 0 to >3 daily MME, 1,878 [30.3%]), consistent low dose (between 3 and 5 daily MME, 1,510 [24.3%]), and consistent moderate dose (>20 daily MME, 1,362 [22.0%]). Less than 5% were prescribed a mean daily dose of ≥90 daily MME during 6 months before diagnosis or matched date. Patients with gradual dose discontinuation versus those with a consistent low or moderate dose, and increase dose were more likely to be 65 to 74 years, Midwest US residents, and receiving no low-income subsidy. Those with gradual dose increase and consistent moderate dose had a higher risk of ORAE, after adjustment for covariates.
AHRQ-funded; HS027230.
Citation: Wei YJ, Chen C, Lewis MO .
Trajectories of prescription opioid dose and risk of opioid-related adverse events among older Medicare beneficiaries in the United States: a nested case-control study.
PLoS Med 2022 Mar;19(3):e1003947. doi: 10.1371/journal.pmed.1003947..
Keywords: Elderly, Opioids, Medication, Adverse Drug Events (ADE), Adverse Events, Risk, Chronic Conditions, Pain, Substance Abuse, Behavioral Health, Medication: Safety, Patient Safety
Katz MJ, Tamma PD, Cosgrove SE
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
The purpose of this study was to determine if AHRQ’s Safety Program for Improving Antibiotic Use was associated with reductions in antibiotic use in long-term care (LTC) facilities in the US. Findings showed that participation in the AHRQ safety program was associated with the development of antibiotic stewardship programs (ASPs) that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in days of antibiotic therapy and starts, which was more pronounced in more engaged facilities, indicated that implementation of this multifaceted program may support successful ASPs in LTC settings.
AHRQ-funded; 233201500020I.
Citation: Katz MJ, Tamma PD, Cosgrove SE .
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
JAMA Netw Open 2022 Feb;5(2):e220181. doi: 10.1001/jamanetworkopen.2022.0181..
Keywords: Elderly, Antimicrobial Stewardship, Antibiotics, Long-Term Care, Medication, Implementation, Patient Safety
Dy SM, Acton RM, Yuan CT
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
This cross-case analysis study's objective was to explore which patient-centered medical home (PCMH) and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture using 25 diverse US PCMHs. Findings suggested that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists.
AHRQ-funded; HS024859.
Citation: Dy SM, Acton RM, Yuan CT .
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
J Patient Saf 2022 Jan;18(1):e249-e56. doi: 10.1097/pts.0000000000000752..
Keywords: Patient-Centered Healthcare, Surveys on Patient Safety Culture, Patient Safety
Cofran L, Cohen T, Alfred M
Barriers to safety and efficiency in robotic surgery docking.
The authors sought to explore operating room variation in robotic-assisted surgery across multiple clinical sites and procedures and further sought to examine the sources of those flow disruptions. They concluded that direct observation of surgical procedures can help to identify approaches to improve the design of technology and procedures, the training of staff, and the configuration of the operating room environment, with the eventual goal of improving safety, efficiency, and teamwork in high technology surgery.
AHRQ-funded; HS026491.
Citation: Cofran L, Cohen T, Alfred M .
Barriers to safety and efficiency in robotic surgery docking.
Surg Endosc 2022 Jan;36(1):206-15. doi: 10.1007/s00464-020-08258-0..
Keywords: Patient Safety, Surgery
Penfold RB, Thompson EE, Hilt RJ
Development of a symptom-focused model to guide the prescribing of antipsychotics in children and adolescents: results of the first phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.
The purpose of this study was to develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. The investigators indicated that their approach addressed some of these concerns.
AHRQ-funded; HS026001; HS023258.
Citation: Penfold RB, Thompson EE, Hilt RJ .
Development of a symptom-focused model to guide the prescribing of antipsychotics in children and adolescents: results of the first phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.
J Am Acad Child Adolesc Psychiatry 2022 Jan;61(1):93-102. doi: 10.1016/j.jaac.2021.04.010..
Keywords: Children/Adolescents, Medication, Behavioral Health, Patient Safety, Guidelines, Evidence-Based Practice
Martin BA, Breslow RM, Sims A
Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions in older adults: a national survey of pharmacists.
This study’s objective was to determine which information on over-the-counter (OTC) Drug Facts Labels (DFS) is most critical in reducing adverse drug reactions (ADRs) among older adults and should be placed in front of the label. A national survey of practicing pharmacists knowledgeable about OTC medication use by older adults asked respondents to rank order the importance of the DFL sections to reduce ADRs. A total of 318 responses were analyzed. There was high consensus that uses and purposes, active ingredient, warnings, and directions for use were the most important sections on the label. Two specific warnings “Do not use” and “Ask a doctor or pharmacist” were deemed most important in the warnings section.
AHRQ-funded; HS025386.
Citation: Martin BA, Breslow RM, Sims A .
Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions in older adults: a national survey of pharmacists.
J Am Pharm Assoc 2022 Jan-Feb;62(1):167-75.e1. doi: 10.1016/j.japh.2021.08.019..
Keywords: Elderly, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Health Literacy, Education: Patient and Caregiver
Yount N, Zebrak KA, Famolaro T
Linking patient safety culture to quality ratings in the nursing home setting.
This study examined the relationship between scores on the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey (NH SOPS) and Centers for Medicare and Medicaid Services Nursing Home Five-Star Quality Ratings. The authors used data on 186 nursing homes to conduct multiple regression analyses predicting the Five-Star Quality Ratings from the NH SOPS survey measures. Five NH SOPS measures were related to the Overall, Health Inspections, and Quality Five-Star Ratings; four NH SOPS measures were related to at least two of the four Five-Star Quality Ratings and three SOPS measures were related to one Five-Star Rating. No NH SOPS measures were significantly associated with the Staffing Five-Star Rating.
AHRQ-funded; 233201500026I.
Citation: Yount N, Zebrak KA, Famolaro T .
Linking patient safety culture to quality ratings in the nursing home setting.
J Appl Gerontol 2022 Jan;41(1):73-81. doi: 10.1177/0733464820969283..
Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Patient Safety, Nursing Homes, Long-Term Care, Quality Indicators (QIs), Quality Measures, Quality Improvement, Quality of Care
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
Zimolzak AJ, Shahid U, Giardina TD
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm. As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff.
AHRQ-funded; HS27363.
Citation: Zimolzak AJ, Shahid U, Giardina TD .
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
J Gen Intern Med 2022 Jan;37(1):137-44. doi: 10.1007/s11606-021-06772-y..
Keywords: Diagnostic Safety and Quality, Patient Safety, Quality Improvement, Quality of Care
Fong A, Behzad S, Pruitt Z
A machine learning approach to reclassifying miscellaneous patient safety event reports.
This research paper describes an effort to develop a machine learning natural language processing model to reclassify medical adverse events that were classified as “miscellaneous” as opposed to a specific event-type category. The authors integrated the model into a clinical workflow dashboard, evaluated user feedback, and compared differences in user thresholds for model performance to reclassify those reports.
AHRQ-funded; HS026481.
Citation: Fong A, Behzad S, Pruitt Z .
A machine learning approach to reclassifying miscellaneous patient safety event reports.
J Patient Saf 2021 Dec 1;17(8):e829-e33. doi: 10.1097/pts.0000000000000731..
Keywords: Patient Safety, Health Information Technology (HIT), Medical Errors
Sankaran RR, Ameling JM, Cohn AEM
A practical guide for building collaborations between clinical researchers and engineers: lessons learned from a multidisciplinary patient safety project.
The objective of this study was to prepare research teams that are embarking on collaborations regarding common challenges and training needs to anticipate while developing multidisciplinary teams. Researchers developed a practical guide to describe anticipated challenges and solutions to consider for developing successful partnerships between engineering and clinical researchers. They also developed and shared a checklist for project managers as well as the training materials as adaptable resources to facilitate other teams' initiation into these types of collaborations.
AHRQ-funded; HS019767; HS024385.
Citation: Sankaran RR, Ameling JM, Cohn AEM .
A practical guide for building collaborations between clinical researchers and engineers: lessons learned from a multidisciplinary patient safety project.
J Patient Saf 2021 Dec 1;17(8):e1420-e27. doi: 10.1097/pts.0000000000000667..
Keywords: Patient Safety
Manojlovich M, Hofer TP, Krein SL
Advancing patient safety through the clinical application of a framework focused on communication.
The purpose of this review article was to describe a conceptual framework of communication drawn from multiple academic disciplines and to apply it to health care, specifically for examining communication between providers about the clinical care of their patients. Findings showed that poor communication remained a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. The proposed conceptual framework suggested ways to build relationships and trust, addressed hierarchical differences between communicators, and illuminated the role of technology in communication.
AHRQ-funded; HS022305; HS024760.
Citation: Manojlovich M, Hofer TP, Krein SL .
Advancing patient safety through the clinical application of a framework focused on communication.
J Patient Saf 2021 Dec 1;17(8):e732-e37. doi: 10.1097/pts.0000000000000547..
Keywords: Patient Safety, Communication, Healthcare Delivery
Fris E, Sedlock E, Etchegaray J
Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS).
The authors created a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention. Through a cross-sectional survey of QI stakeholders, they found that The Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and it identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention.
AHRQ-funded; HS024459.
Citation: Fris E, Sedlock E, Etchegaray J .
Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS).
BMJ Open Qual 2021 Dec;10(4). doi: 10.1136/bmjoq-2020-001332..
Keywords: Quality Improvement, Quality of Care, Neonatal Intensive Care Unit (NICU), Patient Safety, Newborns/Infants
Shapiro J, Robins L, Galowitz P
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
The authors developed an "Ask-Tell-Ask" model and materials to guide the disclosure coaching process. In this paper, they described a comprehensive approach to coaching developed over years of coaching experience that incorporates their model, its rationale, step-by-step coaching strategies and guidance, and organizational considerations regarding implementation of a coaching program to support patient-centered transparent communication after harmful events.
AHRQ-funded; HS019531.
Citation: Shapiro J, Robins L, Galowitz P .
Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations.
J Patient Saf 2021 Dec 1;17(8):e1364-e70. doi: 10.1097/pts.0000000000000491..
Keywords: Clinician-Patient Communication, Communication, Medical Liability, Patient Safety
Pruitt ZM, Howe JL, Hettinger AZ
Emergency physician perceptions of electronic health record usability and safety.
Investigators sought to identify emergency physicians' perceived electronic health record (EHR) usability and safety strengths and shortcomings across major EHR vendor products. They found that the 3 most commonly discussed usability topics were Workflow Support (shortcoming), Visual Display (strength), and Data Entry. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes emerged as well.
AHRQ-funded; HS025136.
Citation: Pruitt ZM, Howe JL, Hettinger AZ .
Emergency physician perceptions of electronic health record usability and safety.
J Patient Saf 2021 Dec 1;17(8):e983-e87. doi: 10.1097/pts.0000000000000849..
Keywords: Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Iqbal AR, Parau CA, Kazi S
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.
This study investigated the contribution of usability challenges associated with the electronic medication administration record (eMAR) to medication errors using patient safety event reports (PSEs). The authors analyzed free-text descriptions of 849 medication-related PSEs selected from 2.3 million reports. Specific health IT components, usability challenge categories, and nuanced usability themes that contributed to each PSE were identified by coders. Usability challenges included workflow support, alerting, and display/visual clutter.
AHRQ-funded; HS025136.
Citation: Iqbal AR, Parau CA, Kazi S .
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.
Jt Comm J Qual Patient Saf 2021 Dec;47(12):793-801. doi: 10.1016/j.jcjq.2021.09.004..
Keywords: Electronic Prescribing (E-Prescribing), Health Information Technology (HIT), Medication, Medical Errors, Patient Safety
Adams KT, Pruitt Z, Kazi S
Identifying health information technology usability issues contributing to medication errors across medication process stages.
Researchers sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. They found that health IT usability issues were a prevalent contributing factor to medication errors, many of which reach the patient. They recommended that data entry, workflow support, and alerting be prioritized during usability and safety optimization efforts.
AHRQ-funded; HS025136.
Citation: Adams KT, Pruitt Z, Kazi S .
Identifying health information technology usability issues contributing to medication errors across medication process stages.
J Patient Saf 2021 Dec 1;17(8):e988-e94. doi: 10.1097/pts.0000000000000868..
Keywords: Medication, Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Ackerman SL, Gourley G, Le G
Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns
This study’s aim was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. Participants were invited leaders from five California safety net health systems. They participated in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute. The feasibility and validity of 13 proposed patient safety measures were discussed by the eight panelists and prioritized in three Delphi rounds. Consensus was unanimously reached to adopt 9 of the 13 proposed measures. However, concern was expressed about the feasibility of implementing several of the measures.
AHRQ-funded; HS024426; HS022047.
Citation: Ackerman SL, Gourley G, Le G .
Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns
J Patient Saf 2021 Dec 1;17(8):e773-e90. doi: 10.1097/pts.0000000000000480..
Keywords: Patient Safety, Medical Errors, Adverse Events, Hospitals
Burden A, Potestio C, Pukenas E
Influence of perioperative handoffs on complications and outcomes.
The authors describe the perioperative environment, calling it dynamic and complex, and indicate that there are multiple distractions that can interfere with effective communication and safe patient care. They discuss various aspects involved in handoffs, concluding that an institutional culture that highlights the importance of patient safety and that encourages team collaboration has demonstrated that harm can be decreased and patient safety can be improved.
AHRQ-funded; HS026158.
Citation: Burden A, Potestio C, Pukenas E .
Influence of perioperative handoffs on complications and outcomes.
Adv Anesth 2021 Dec;39:133-48. doi: 10.1016/j.aan.2021.07.008..
Keywords: Patient Safety, Transitions of Care, Workflow
McGrath SP, McGovern KM, Perreard IM
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
AHRQ-funded; HS024403.
Citation: McGrath SP, McGovern KM, Perreard IM .
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
J Patient Saf 2021 Dec 1;17(8):557-61. doi: 10.1097/pts.0000000000000696..
Keywords: Respiratory Conditions, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Duffy B, Miller J, Vitous CA
Intersystem medical error discovery: a document analysis of ethical guidelines.
The authors conducted a document analysis of ethical guidelines concerning how providers should respond to other providers' errors, especially when they occur outside the provider's facility or system (intersystem medical error discovery [IMED]). They found that ethics codes provided little guidance on communication regarding IMED scenarios, and in some cases, the guidance was internally conflicting.
AHRQ-funded; HS026030.
Citation: Duffy B, Miller J, Vitous CA .
Intersystem medical error discovery: a document analysis of ethical guidelines.
J Patient Saf 2021 Dec 1;17(8):e1765-e73. doi: 10.1097/pts.0000000000000625..
Keywords: Medical Errors, Patient Safety, Provider: Health Personnel, Communication
Griffey RT, Schneider RM, Sharp BR
Multicenter test of an emergency department trigger tool for detecting adverse events.
This study details a novel emergency department (ED) trigger tool to detect adverse events using a multidisciplinary, multicenter approach developed by the authors. They conducted a multicenter test of the tool and assessed its performance. The study was conducted during a 13-month period at 4 EDs. Patients age 18 years and older with Emergency Severity Index acuity levels of 1 to 3 by a provider were eligible. Fifty randomly selected visits at each site were reviewed a month. Events were classified by level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). They captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability was observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication related. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level at 35.4%. Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE. Ten triggers were individually associated with AEs. Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Multicenter test of an emergency department trigger tool for detecting adverse events.
J Patient Saf 2021 Dec 1;17(8):e843-e49. doi: 10.1097/pts.0000000000000516..
Keywords: Emergency Department, Adverse Events, Patient Safety
Griffey RT, Schneider RM, Sharp BR
Practical considerations in use of trigger tool methodology in the emergency department.
This article’s purpose was to provide general observations, guidance, and lessons learned in the use of a trigger tool in the emergency department (ED) for adverse events (AEs). The authors identified 46 triggers in the initial ED trigger tool. They tried to include triggers of various types to capture events related to different aspects of an ED visit. The trigger events were reviewed by first-level reviewers, who are typically nurses, and then by second-level reviewers, who are usually other clinicians. An AE was identified using the AHRQ definition adopted by the IHI GTT, which is limited to physical (but not emotional or mental) harm. It must be unintentional and attributable to healthcare. Acts of omission must be included not just acts of commission. They used a modified National Coordinating Council’s Medication Event Reporting and Prevention (MERP) Index to assess severity of harm. MERP E-I events are identified as those that had interventions, with MERP A-D events noted. They outlined several salient areas for consideration in implementing a trigger tool in the ED setting and also specified how to address the highlighted issues.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Practical considerations in use of trigger tool methodology in the emergency department.
J Patient Saf 2021 Dec 1;17(8):e837-e42. doi: 10.1097/pts.0000000000000448..
Keywords: Emergency Department, Adverse Events, Patient Safety
Henriksen K, Rodrick D, Grace EN
AHRQ Author: Henriksen K, Rodrick D, Grace EN, Shofer M, Brady, JP
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
This article describes a grant initiative undertaken by AHRQ that brings design, systems engineering, and health care delivery research together to test new ideas that could make health care safer. Based on feedback received from project teams, lessons learned are emerging that find considerable variation among project teams in deploying the methodology and a longer-than-anticipated amount of time in bringing team members from different disciplines together where they learn to communicate and function as a team. Three narratives are generated in terms of what success might look like.
AHRQ-authored.
Citation: Henriksen K, Rodrick D, Grace EN .
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
J Patient Saf 2021 Dec 1;17(8):e1685-e90. doi: 10.1097/pts.0000000000000577..
Keywords: Patient Safety, Healthcare Delivery, Learning Health Systems, Health Systems