National Healthcare Quality and Disparities Report
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- Access to Care (1)
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- Patient and Family Engagement (19)
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- Quality of Care (202)
- Quality of Life (3)
- Racial and Ethnic Minorities (7)
- Registries (15)
- Rehabilitation (1)
- Research Methodologies (8)
- Respiratory Conditions (19)
- Risk (100)
- Rural/Inner-City Residents (1)
- Rural Health (3)
- Screening (3)
- Sepsis (7)
- Sex Factors (1)
- Simulation (10)
- Skin Conditions (5)
- Sleep Problems (2)
- Social Determinants of Health (3)
- Social Media (3)
- Social Stigma (1)
- Stress (2)
- Stroke (5)
- Substance Abuse (8)
- Surgery (191)
- Surveys on Patient Safety Culture (11)
- System Design (4)
- Teams (27)
- TeamSTEPPS (8)
- Telehealth (8)
- Tools & Toolkits (19)
- Training (30)
- Transitions of Care (33)
- Transplantation (6)
- Trauma (2)
- Treatments (11)
- Uninsured (1)
- Urban Health (4)
- Urinary Tract Infection (UTI) (24)
- Vaccination (7)
- Vulnerable Populations (4)
- Web-Based (5)
- Women (15)
- Workflow (13)
- Workforce (6)
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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
1201 to 1225 of 1293 Research Studies DisplayedAli KJ, Farley DO, Speck K
Measurement of implementation components and contextual factors in a two-state healthcare quality initiative to reduce ventilator-associated pneumonia.
The authors sought to develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative. They found that a relatively small number of barriers were found to have important negative effects on implementation progress, including barriers related to workload and time issues. They modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified.
AHRQ-funded; 290201000027I.
Citation: Ali KJ, Farley DO, Speck K .
Measurement of implementation components and contextual factors in a two-state healthcare quality initiative to reduce ventilator-associated pneumonia.
Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S116-23. doi: 10.1086/677832.
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Keywords: Healthcare-Associated Infections (HAIs), Patient Safety, Pneumonia, Prevention, Quality Improvement
Calderwood MS, Kleinman K, Bratzler DW
Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.
This study found that among Medicare patients who underwent vascular surgery at 2,512 U.S. hospitals, a patient undergoing surgery in a hospital ranked in the worst-performing decile based on claims had a 2.5 times greater likelihood of developing a chart-confirmed surgical site infection relative to a patient characteristics in a hospital in the best-performing decile.
AHRQ-funded; HS018878
Citation: Calderwood MS, Kleinman K, Bratzler DW .
Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.
Med Care. 2014 Oct;52(10):918-25. doi: 10.1097/MLR.0000000000000212..
Keywords: Medicare, Surgery, Healthcare-Associated Infections (HAIs), Patient Safety, Hospitals, Adverse Events
Kahvecioglu D, Ramiah K, McMaughan D
Multidrug-resistant organism infections in US nursing homes: a national study of prevalence, onset, and transmission across care settings, October 1, 2010-December 31, 2011.
The investigators sought to understand the prevalence of multidrug-resistant organism (MDRO) infections among nursing home (NH) residents and the potential for their spread between NHs and acute care hospitals (ACHs). They found that, although NHs are the most likely setting where residents would acquire MDROs after admission to an NH, a significant fraction of NH residents acquire MDRO infection at ACHs, suggesting a need for effective MDRO infection control for NH residents with simultaneous, cooperative interventions among NHs and ACHs in the same community.
AHRQ-funded; HS019989.
Citation: Kahvecioglu D, Ramiah K, McMaughan D .
Multidrug-resistant organism infections in US nursing homes: a national study of prevalence, onset, and transmission across care settings, October 1, 2010-December 31, 2011.
Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S48-55. doi: 10.1086/677835.
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Keywords: Elderly, Healthcare-Associated Infections (HAIs), Medication, Nursing Homes, Patient Safety
Rosenman MB, Szucs KA, Finnell SM
Nascent regional system for alerting infection preventionists about patients with multidrug-resistant gram-negative bacteria: implementation and initial results.
The authors sought to build and to begin evaluating a regional automated system to notify infection preventionists (IPs) when a patient with a history of gram-negative rod multidrug-resistant organism (GNRMDRO) is admitted to an emergency department (ED) or inpatient setting. They found it feasible to create a regional microbiology-based alert system and observed substantial crossover between institutions. They concluded that this system, if it contributes to timely isolation, may help reduce the spread of GNRMDROs.
AHRQ-funded; HS020014.
Citation: Rosenman MB, Szucs KA, Finnell SM .
Nascent regional system for alerting infection preventionists about patients with multidrug-resistant gram-negative bacteria: implementation and initial results.
Infect Control Hosp Epidemiol 2014 Oct;35 Suppl 3:S40-7. doi: 10.1086/677833.
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Keywords: Emergency Department, Infectious Diseases, Inpatient Care, Patient Safety, Prevention
Bakullari A, Metersky ML, Wang Y
Racial and ethnic disparities in healthcare-associated infections in the United States, 2009-2011.
This study examined racial and ethnic disparities in the occurrence of healthcare-associated infections (HAIs) in 79,019 Medicare patients hospitalized with acute cardiovascular disease, pneumonia, and major surgery. It found that Asian and Hispanic patients, but not non-Hispanic blacks, had significantly higher rates of HAIs than white non-Hispanic patients.
AHRQ-funded; 290201200003C
Citation: Bakullari A, Metersky ML, Wang Y .
Racial and ethnic disparities in healthcare-associated infections in the United States, 2009-2011.
Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S10-6. doi: 10.1086/677827..
Keywords: Healthcare-Associated Infections (HAIs), Disparities, Racial and Ethnic Minorities, Critical Care, Patient Safety
Greene MT, Fakih MG, Fowler KE
Regional variation in urinary catheter use and catheter-associated urinary tract infection: results from a national collaborative.
The researchers explored nationwide variation in the use of urinary catheters and catheter-associated urinary tract infections (CAUTI) across a diverse set of units within acute care U.S. hospitals. Using data from 1,101 units in 726 hospitals across 34 States, they found regional differences in catheter use, appropriateness, and CAUTI rates, with possibly 30-40 percent of urinary catheters placed in non-ICU settings lacking an appropriate indication.
AHRQ-funded; HS018334; HS019767; 290201000025I; 29032001T
Citation: Greene MT, Fakih MG, Fowler KE .
Regional variation in urinary catheter use and catheter-associated urinary tract infection: results from a national collaborative.
Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S99-S106. doi: 10.1086/677825..
Keywords: Urinary Tract Infection (UTI), Healthcare-Associated Infections (HAIs), Patient Safety, Quality of Care, Catheter-Associated Urinary Tract Infection (CAUTI)
Eckenrode S, Bakullari A, Metersky ML
The association between age, sex, and hospital-acquired infection rates: results from the 2009-2011 National Medicare Patient Safety Monitoring System.
The researchers, using six different measures of hospital-acquired infections (HAIs), analyzed data from a large national sample of patients admitted to the hospital with acute cardiovascular disease, pneumonia, and major surgery to determine to determine age- and sex-related differences in HAI rates. They found that there are no simple ways to focus HAI-prevention efforts based solely on age or sex.
AHRQ-funded; 290201200003C
Citation: Eckenrode S, Bakullari A, Metersky ML .
The association between age, sex, and hospital-acquired infection rates: results from the 2009-2011 National Medicare Patient Safety Monitoring System.
Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S3-9. doi: 10.1086/677831..
Keywords: Healthcare-Associated Infections (HAIs), Patient Safety, Medicare, Critical Care
Greene MT, Kiyoshi-Teo H, Reichert H
Urinary catheter indications in the United States: results from a national survey of acute care hospitals.
The researchers sought to determine how often various indications for catheter use were reported among a nationally representative sample of acute care hospitals. They found that many hospitals were using several indications deemed in appropriated by CAUTI prevention guidelines such as urinary incontinence without outlet obstruction and patient/family request.
AHRQ-funded; 290201000025I; 29032001T
Citation: Greene MT, Kiyoshi-Teo H, Reichert H .
Urinary catheter indications in the United States: results from a national survey of acute care hospitals.
Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S96-8. doi: 10.1086/677823..
Keywords: Urinary Tract Infection (UTI), Patient Safety, Healthcare-Associated Infections (HAIs), Quality of Care, Catheter-Associated Urinary Tract Infection (CAUTI)
Hennessy S, Strom BL
Improving postapproval drug safety surveillance: getting better information sooner.
There are often long delays between when a drug is approved and when serious adverse drug events are identified. This article discusses ways to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
AHRQ-funded; HS018372.
Citation: Hennessy S, Strom BL .
Improving postapproval drug safety surveillance: getting better information sooner.
Annu Rev Pharmacol Toxicol 2015;55:75-87. doi: 10.1146/annurev-pharmtox-011613-135955.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Communication, Medication, Medication: Safety, Patient Safety
Checchi KD, Huybrechts KF, Avorn J
Electronic medication packaging devices and medication adherence: a systematic review.
The authors conducted a systematic review of studies testing the effectiveness of electronic medication packaging (EMP) devices. From the 37 studies included in the review, they determined that although many varieties of EMP devices exist, data supporting their use are limited, with variability in the quality of studies testing EMP devices.
AHRQ-funded; HS18465
Citation: Checchi KD, Huybrechts KF, Avorn J .
Electronic medication packaging devices and medication adherence: a systematic review.
JAMA. 2014 Sep 24;312(12):1237-47. doi: 10.1001/jama.2014.10059..
Keywords: Medication, Health Information Technology (HIT), Patient Safety, Patient Adherence/Compliance
Dollarhide AW, Rutledge T, Weinger MB
A real-time assessment of factors influencing medication events.
This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. It found that medication events were associated with 36.1 percent higher perceived workload, 8.6 percent higher inpatient caseloads and 55.9 percent higher emotional stress scores. Also, there was a trend for reported events to be associated with less sleep.
AHRQ-funded; HS014283.
Citation: Dollarhide AW, Rutledge T, Weinger MB .
A real-time assessment of factors influencing medication events.
J Healthc Qual 2014 Sep-Oct;36(5):5-12. doi: 10.1111/jhq.12012..
Keywords: Medication, Medical Errors, Patient Safety, Quality of Care
Goode AP, Richardson WJ, Schectman RM
Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions.
The authors sought to determine the 1-year risk of complications, cervical revision fusions, hospital readmissions, and health care services utilization after bone morphogenetic protein (BMP) use with cervical spine fusions. They found that patients receiving BMP were 29% more likely to have a complication and a nervous system complication; cervical revision fusions were more likely among patients receiving BMP; the risk of 30-day readmission was greater with BMP use; and readmission occurred 27.4% sooner on an average. Additionally, patients receiving BMP were more likely to receive computed tomography scans and epidurals with anterior surgical approaches.
AHRQ-funded; HS019479.
Citation: Goode AP, Richardson WJ, Schectman RM .
Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions.
Spine J 2014 Sep;14(9):2051-9. doi: 10.1016/j.spinee.2013.11.042.
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Keywords: Adverse Events, Hospital Readmissions, Patient Safety, Outcomes, Patient-Centered Outcomes Research, Surgery, Treatments
Ranji SR, Rennke S, Wachter RM
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
The authors searched AHRQ's Patient Safety Net to identify reviews of the effect of computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) on adverse drug event (ADE) rates in inpatient and outpatient settings. They found that CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, often leading to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects.
AHRQ-funded; 2902007100621.
Citation: Ranji SR, Rennke S, Wachter RM .
Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.
BMJ Qual Saf 2014 Sep;23(9):773-80. doi: 10.1136/bmjqs-2013-002165.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinical Decision Support (CDS), Health Information Technology (HIT), Medication, Patient Safety
Islam R, Weir C, Del Fiol G
Heuristics in managing complex clinical decision tasks in experts' decision making.
The authors sought to understand how clinicians manage complexity while dealing with complex clinical decision tasks. They found that experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes, and focusing on only the most relevant information.
AHRQ-funded; HS023349.
Citation: Islam R, Weir C, Del Fiol G .
Heuristics in managing complex clinical decision tasks in experts' decision making.
IEEE Int Conf Healthc Inform 2014 Sep;2014:186-93. doi: 10.1109/ichi.2014.32.
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Keywords: Clinical Decision Support (CDS), Decision Making, Patient Safety
Wang SV, Schneeweiss S, Rassen JA
Optimal matching ratios in drug safety surveillance.
The researchers used a simulation design to generate 48 scenarios varying in the baseline outcome rate, proportion of exposed, true effect size (without effect modification), and strength of unmeasured residual confounding. They found that except for the most extreme combination of rare outcome and exposure, in scenarios with no residual confounding, 1:1 matching removed 98% to 99% of the bias.
AHRQ-funded; HS022193.
Citation: Wang SV, Schneeweiss S, Rassen JA .
Optimal matching ratios in drug safety surveillance.
Epidemiology 2014 Sep;25(5):772-3. doi: 10.1097/ede.0000000000000148..
Keywords: Adverse Drug Events (ADE), Health Information Technology (HIT), Patient Safety, Medication
Agos F, Shoda C, Bransford D
Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries.
Perioperative hyperglycemia management is an important factor in reducing the risk of surgical site infections (SSIs) in all patients whether they have diabetes or not. This article describes the impact of an evidence-based practice standard for perioperative hyperglycemia management in the reduction of SSIs in patients having total hip and knee replacement surgery.
AHRQ-funded; HS017892
Citation: Agos F, Shoda C, Bransford D .
Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries.
Nurs Clin North Am. 2014 Sep;49(3):299-308. doi: 10.1016/j.cnur.2014.05.004..
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Patient Safety, Orthopedics, Injuries and Wounds
Wang F, Skubic M, Rantz M
Quantitative gait measurement with pulse-Doppler radar for passive in-home gait assessment.
The researchers proposed and validated a low-cost Doppler radar system for passive and continuous in-home gait assessment. Using signal processing techniques, they estimated human torso velocity and leg swing for step recognition. They found that the radar system has achieved a high accuracy on the step time estimation, while the walking speed estimation is systematically affected by the walking path direction.
AHRQ-funded; HS018477.
Citation: Wang F, Skubic M, Rantz M .
Quantitative gait measurement with pulse-Doppler radar for passive in-home gait assessment.
IEEE Trans Biomed Eng 2014 Sep;61(9):2434-43. doi: 10.1109/tbme.2014.2319333..
Keywords: Health Information Technology (HIT), Patient Safety, Falls, Elderly
Brown JR, Solomon RJ, Sarnak MJ
Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.
The researchers sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary interventions. They found that benchmark hospitals had no significant changes in CI-AKI, while rates of CI-AKI were significantly reduced in hospitals receiving the intervention. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration.
AHRQ-funded; HS018443.
Citation: Brown JR, Solomon RJ, Sarnak MJ .
Reducing contrast-induced acute kidney injury using a regional multicenter quality improvement intervention.
Circ Cardiovasc Qual Outcomes 2014 Sep;7(5):693-700. doi: 10.1161/circoutcomes.114.000903.
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Keywords: Adverse Drug Events (ADE), Injuries and Wounds, Patient Safety, Heart Disease and Health, Quality Improvement
Brown SE, Ratcliffe SJ, Halpern SD
An empirical comparison of key statistical attributes among potential ICU quality indicators.
The researchers assessed the performance of candidate indicators of ICU quality based on face validity, relevance to patients, ability to be measured reliably, sufficient variability to identify poor performers, relative insensitivity to severity adjustment, and the ability to capture what providers do rather than patients' characteristics. They concluded that no indicator performed optimally across assessments and recommended that future research seek to define and operationalize quality in a way that is relevant to both patients and providers.
AHRQ-funded; HS018406.
Citation: Brown SE, Ratcliffe SJ, Halpern SD .
An empirical comparison of key statistical attributes among potential ICU quality indicators.
Crit Care Med 2014 Aug;42(8):1821-31. doi: 10.1097/ccm.0000000000000334.
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Keywords: Quality of Care, Intensive Care Unit (ICU), Patient Safety, Quality Indicators (QIs), Hospital Readmissions
Pohl JM, Tanner C, Hamilton A
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
This study, conducted in five safety-net practices, examined the impact of implementing a commercial electronic health records system on medication safety. The authors found 130 "true" drug-drug interaction (DDI) pairs, representing 149,087 visits and 62 providers, with the largest DDI categories being related to antihypertensive medications, which are often prescribed together. They found no significant differences between physicians and nurse practitioners on the rate of DDI pairs.
AHRQ-funded; HS017191.
Citation: Pohl JM, Tanner C, Hamilton A .
Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.
J Am Assoc Nurse Pract 2014 Aug;26(8):438-44. doi: 10.1002/2327-6924.12089.
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Keywords: Medication: Safety, Medication, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety
Huang LC, Conley D, Lipsitz S
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
The authors assessed the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork. They found that both the Checklist Coaching Tool and the Surgical Teamwork Tool demonstrated substantial IRR and required limited training to use, indicating that both instruments may be used to observe checklist performance and teamwork in the operating room. They recommended that further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.
AHRQ-funded; HS019631.
Citation: Huang LC, Conley D, Lipsitz S .
The Surgical Safety Checklist and teamwork coaching tools: a study of inter-rater reliability.
BMJ Qual Saf 2014 Aug;23(8):639-50. doi: 10.1136/bmjqs-2013-002446.
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Keywords: Patient Safety, Surgery, Tools & Toolkits, Teams, Adverse Events, Medical Errors, Prevention
Drake FT, Mottey NE, Farrokhi ET
Time to appendectomy and risk of perforation in acute appendicitis.
This study sought to determine whether there is an association between time and perforation after acute appendicitis patients arrive at the hospital. Using data on 7,505 patients treated at 52 hospitals, they found that there was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy.
AHRQ-funded; SCOAP-CERTAIN
Citation: Drake FT, Mottey NE, Farrokhi ET .
Time to appendectomy and risk of perforation in acute appendicitis.
JAMA Surg. 2014 Aug;149(8):837-44. doi: 10.1001/jamasurg.2014.77..
Keywords: Surgery, Quality of Care, Patient Safety, Critical Care
Smith CS, Hill W, Francovich C
Diagnostic reasoning across the medical education continuum.
The researchers aimed to study linguistic and non-linguistic elements of diagnostic reasoning across the continuum of medical education. They identified three major findings: (1) The "apprentice effect" in novices (high stress and low narrative competence); (2) logistic concept growth in intermediates; and (3) a cognitive state transition (between analytical and intuitive approaches) in experts.
AHRQ-funded; HS018063.
Citation: Smith CS, Hill W, Francovich C .
Diagnostic reasoning across the medical education continuum.
Healthcare 2014 Jul 15;2(3):253-71. doi: 10.3390/healthcare2030253.
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Keywords: Education: Continuing Medical Education, Education: Continuing Medical Education, Patient Safety, Training
Galanter WL, Bryson ML, Falck S
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
The authors measured whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. They found that indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts and recommended that institutions with CPOE consider using indication prompts to intercept drug name confusion errors.
AHRQ-funded; HS021093.
Citation: Galanter WL, Bryson ML, Falck S .
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
PLoS One 2014 Jul 15;9(7):e101977. doi: 10.1371/journal.pone.0101977.
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Keywords: Clinical Decision Support (CDS), Adverse Drug Events (ADE), Adverse Events, Medical Errors, Health Information Technology (HIT), Medication, Patient Safety
Maggard-Gibbons M
The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.
This review summarized the history of American College of Surgeons National Surgical Quality Improvement Project and its components, and described the evidence that feeding outcomes back to providers, along with real-time comparisons with other hospital rates, leads to quality improvement, better patient outcomes, cost savings and overall improved patient safety.
AHRQ-funded; 2902007100621.
Citation: Maggard-Gibbons M .
The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.
BMJ Qual Saf 2014 Jul;23(7):589-99. doi: 10.1136/bmjqs-2013-002223..
Keywords: Quality Improvement, Quality Indicators (QIs), Quality Measures, Quality of Care, Surgery, Patient Safety, Outcomes, Patient-Centered Outcomes Research, Provider Performance