National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (4)
- (-) Adverse Events (68)
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- Antibiotics (1)
- Back Health and Pain (1)
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- Caregiving (1)
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- Dialysis (1)
- Digestive Disease and Health (1)
- Disparities (1)
- Education: Patient and Caregiver (1)
- Elderly (4)
- Electronic Health Records (EHRs) (3)
- Evidence-Based Practice (1)
- Falls (7)
- Healthcare-Associated Infections (HAIs) (13)
- Healthcare Cost and Utilization Project (HCUP) (4)
- Healthcare Delivery (4)
- Healthcare Utilization (1)
- Health Information Technology (HIT) (4)
- Health Services Research (HSR) (1)
- Heart Disease and Health (5)
- Hospitalization (7)
- Hospital Readmissions (6)
- (-) Hospitals (68)
- Implementation (1)
- Infectious Diseases (3)
- Injuries and Wounds (8)
- Inpatient Care (10)
- Intensive Care Unit (ICU) (2)
- Kidney Disease and Health (2)
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- Medicare (3)
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- Methicillin-Resistant Staphylococcus aureus (MRSA) (1)
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- Nursing (2)
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- Patient-Centered Outcomes Research (3)
- Patient and Family Engagement (2)
- Patient Experience (1)
- Patient Safety (44)
- Payment (2)
- Pneumonia (1)
- Policy (1)
- Practice Patterns (5)
- Prevention (8)
- Provider Performance (5)
- Public Health (2)
- Quality Improvement (7)
- Quality Indicators (QIs) (5)
- Quality Measures (2)
- Quality of Care (13)
- Respiratory Conditions (1)
- Risk (7)
- Sepsis (1)
- Surgery (21)
- Surveys on Patient Safety Culture (1)
- Teams (4)
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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
1 to 25 of 68 Research Studies DisplayedAuerbach AD, Lee TM, Hubbard CC
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
The objective of this retrospective cohort study was to determine the prevalence, underlying causes, and harms of diagnostic errors in hospitalized adults who were transferred to an intensive care unit or who died. Data was taken from 29 academic medical centers in the U.S. in a random sample of adults hospitalized with general medical conditions. Errors were found to have contributed to temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error was judged to have contributed to death in 6.6% of cases. The researchers noted that problems with choosing and interpreting tests and the processes involved with clinician assessment were a high priority for improvement efforts.
AHRQ-funded; HS027369.
Citation: Auerbach AD, Lee TM, Hubbard CC .
Diagnostic errors in hospitalized adults who died or were transferred to intensive care.
JAMA Intern Med 2024 Feb; 184(2):164-73. doi: 10.1001/jamainternmed.2023.7347..
Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, Patient Safety, Adverse Events
Dalal AK, Schnipper JL, Raffel K
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in the hospital or are transferred to the intensive care unit (ICU) after the first 48 hours. This study was conducted at 31 hospitals with more than 2500 cases reviewed using electronic health records. The authors identified some insights into key requirements into building a robust DE surveillance program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error; 2) Use validated tools to identify diagnostic errors and classify process failures, but respect your context; 3) Develop a standard approach to using electronic health records for case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error case reviews to institutional safety programs. They also developed steps to establish a diagnosis error review process at the hospital level with six processes.
AHRQ-funded; HS027369; HS026613.
Citation: Dalal AK, Schnipper JL, Raffel K .
Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.
J Hosp Med 2024 Feb; 19(2):140-45. doi: 10.1002/jhm.13136..
Keywords: Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Quality of Care, Hospitals
Wang Y, Eldridge N, Metersky ML
AHRQ Author: Eldridge N and Rodrick D
Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure.
Researchers sought to evaluate the association between hospital performance on mortality and readmission with hospital performance on safety adverse event rates. Their cross-sectional study linked patient-level adverse events data from the Medicare Patient Safety Monitoring System to hospital-level, heart failure (HF)-specific, 30-day, all-cause mortality and readmissions data from CMS. The study included data on over 39,000 patients with HF from over 3000 hospitals. Patients admitted with HF to hospitals with high 30-day, all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. The researchers concluded that there might be common quality issues among the measure concepts in these hospitals that produce poor performance for patients with HF.
AHRQ-funded; AHRQ-authored; 290201800005C.
Citation: Wang Y, Eldridge N, Metersky ML .
Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure.
Circ Cardiovasc Qual Outcomes 2023 Jul; 16(7):e009573. doi: 10.1161/circoutcomes.122.009573..
Keywords: Hospitals, Hospital Readmissions, Heart Disease and Health, Cardiovascular Conditions, Adverse Events, Provider Performance
Likosky DS, Strobel RJ, Wu X
Interhospital failure to rescue after coronary artery bypass grafting.
Researchers conducted an observational study to evaluate whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. Subjects were patients undergoing grafting surgery across 90 hospitals between 2011 and 2017. Results indicated the predicted mortality risk was similar across hospital observed:expected mortality terciles. Observed and expected failure to rescue rates were positively correlated among patients with major and overall complications. The researchers concluded that interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals; this includes early recognition and management of complications.
AHRQ-funded; HS026003.
Citation: Likosky DS, Strobel RJ, Wu X .
Interhospital failure to rescue after coronary artery bypass grafting.
J Thorac Cardiovasc Surg 2023 Jan;165(1):134-43.e3. doi: 10.1016/j.jtcvs.2021.01.064..
Keywords: Heart Disease and Health, Cardiovascular Conditions, Surgery, Hospitals, Adverse Events
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
Eldridge N, Wang Y, Metersky M
AHRQ Author: Eldridge N, Perdue-Puli J, Brady PJ, Grace E, Rodrick D
Trends in adverse event rates in hospitalized patients, 2010-2019.
This AHRQ-authored serial cross-sectional study’s objective was to determine the change in the rate of adverse events in hospitalized patients from 2010 to 2019. The study used data from the Medicare Patient Safety Monitoring System and included 244,542 adult patients hospitalized in 3156 acute care hospitals across 4 condition groups: acute myocardial infarction (17%), heart failure (17%) pneumonia (21%), major surgical procedures (22%), and all other conditions (22%). Information on adverse events collected included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events such as pressure ulcers and falls. The study sample included 190,286 hospital discharges in the combined 4 condition-based groups and 54,256 hospital discharges for all other conditions. From 2010 to 2019, the total change for adverse events per 1000 discharges for acute myocardial infarction decreased from 218 to 139, from 168 to 116 for heart failure, from 195 to 119 for pneumonia, and from 204 to 130 for major surgical procedures. The rate for all other conditions remained unchanged at 70 adverse events per 1000 discharges.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation: Eldridge N, Wang Y, Metersky M .
Trends in adverse event rates in hospitalized patients, 2010-2019.
JAMA 2022 Jul 12;328(2):173-83. doi: 10.1001/jama.2022.9600..
Keywords: Adverse Events, Patient Safety, Hospitals, Inpatient Care
Wang Y, Eldridge N, Metersky ML
AHRQ Author: Eldridge N, Rodrick D
Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States.
The purpose of this AHRQ-authored cross-sectional study was to assess whether patients with pneumonia who were admitted to hospitals with higher risk-standardized readmission rates had a higher risk of in-hospital adverse events. The researchers linked patient-level adverse events data from the Medicare Patient Safety Monitoring System (MPSMS) to the hospital-level pneumonia-specific all-cause readmissions data from the Centers for Medicare & Medicaid Services. The MPSMS data included 46,047 patients with pneumonia across 2,590 hospitals discharged from July 1, 2010, through December 31, 2019. For data from 2010 to 2017, analysis was completed from October 2019 through July 2020, and for data from 2018 to 2019 analysis was completed from March through April 2022. The study concluded that readmission rates are associated with the quality of hospital care for pneumonia; patients with pneumonia admitted to hospitals with high all-cause readmission rates had a higher likelihood of developing adverse events during the initial hospitalization.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation: Wang Y, Eldridge N, Metersky ML .
Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States.
JAMA Netw Open 2022 May 2;5(5):e2214586. doi: 10.1001/jamanetworkopen.2022.14586..
Keywords: Hospital Readmissions, Hospitals, Adverse Events, Pneumonia, Respiratory Conditions
Zhang J, Drawz PE, Zhu Y
Validation of administrative coding and clinical notes for hospital-acquired acute kidney injury in adults.
This retrospective study validated the quality of administrative coding for hospital-acquired acute kidney injury (AKI) and explored the opportunities to improve the phenotyping performance by utilizing additional data sources from the electronic health record. The researchers obtained significantly different quality measures of administrative coding from the previously reported ones in the U.S. They recommended the additional use of clinical notes by incorporating automatic natural language processing data extraction in order to increase the AUC in phenotyping AKI. Further, AKI was better recognized in patients with heart failure, indicating disparities in the coding and management of AKI.
AHRQ-funded; HS024532.
Citation: Zhang J, Drawz PE, Zhu Y .
Validation of administrative coding and clinical notes for hospital-acquired acute kidney injury in adults.
AMIA Annu Symp Proc 2022 Feb 21;2021:1234-43..
Keywords: Adverse Events, Kidney Disease and Health, Health Information Technology (HIT), Hospitals
Chopra V, O'Malley M, Horowitz J
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.
It is unknown whether implementing the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) reduces complications and improves peripherally inserted central catheter (PICC) use. The purpose of this quasi-experimental study design was to utilize MAGIC in 52 Michigan hospitals and collect data from medical records to measure hospital performance on three appropriateness criteria. The three criteria included: PICC use of less than 5 days, PICC placement in patients with chronic kidney disease, and the use of multi-lumen PICCs. The researchers compared PICC device complications and appropriateness preintervention and post intervention. The study found that among 38,592 PICCs, PICC appropriateness post-intervention increased 17.1% to 49%, and complications decreased 4% to 10.7%. Patients with appropriate PICC use had lower rate of complications than those with inappropriate PICC placement. The study concluded that the utilization of MAGIC in Michigan hospitals was associated with less complications for patients and increased PICC appropriateness.
AHRQ-funded; HS025891.
Citation: Chopra V, O'Malley M, Horowitz J .
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.
BMJ Qual Saf 2022 Jan;31(1):23-30. doi: 10.1136/bmjqs-2021-013015..
Keywords: Quality Improvement, Quality of Care, Hospitals, Adverse Events
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
Herzig SJ, Rothberg MB, Moss CR
Risk of in-hospital falls among medications commonly used for insomnia in hospitalized patients.
This study investigated the risk of in-hospital falls among patients receiving medications commonly used for insomnia. This retrospective cohort study was conducted at a large academic medical center from January 2007 to July 2013. Adults admitted for a primary psychiatric disorder were excluded. Medications of interest included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists, trazodone, atypical antipsychotics, and diphenhydramine. Among 225,498 hospitalizations, 37.7% had exposure to at least one of the medication classes of interest with benzodiazepines being the most commonly prescribed. A fall occurred in 1.1% (2,427) of hospitalizations. The rate of falls per 1,000 hospital days was greater among patients with exposure to each of the medications of interest compared to unexposed patients.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Rothberg MB, Moss CR .
Risk of in-hospital falls among medications commonly used for insomnia in hospitalized patients.
Sleep 2021 Sep 13;44(9):zsab064. doi: 10.1093/sleep/zsab064..
Keywords: Falls, Medication, Adverse Events, Risk, Hospitals
Greenberg JK, Olsen MA, Poe J
Administrative data are unreliable for ranking hospital performance based on serious complications after spine fusion.
The authors evaluated the extent to which a metric of serious complications determined from administrative data can reliably profile hospital performance in spine fusion surgery. They found that a metric of serious complications was unreliable for benchmarking cervical fusion outcomes and only modestly reliable for thoracolumbar fusion. They concluded that, when assessed using administrative datasets, these measures appeared to be inappropriate for high-stakes applications, such as public reporting or pay-for-performance.
AHRQ-funded; HS027075; HS019455.
Citation: Greenberg JK, Olsen MA, Poe J .
Administrative data are unreliable for ranking hospital performance based on serious complications after spine fusion.
Spine 2021 Sep 1;46(17):1181-90. doi: 10.1097/brs.0000000000004017..
Keywords: Surgery, Provider Performance, Hospitals, Adverse Events, Back Health and Pain
Leung WY, Adelman J, Bates DW
Validating fall prevention icons to support patient-centered education.
Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. The investigators indicated that all 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.
AHRQ-funded; HS023535.
Citation: Leung WY, Adelman J, Bates DW .
Validating fall prevention icons to support patient-centered education.
J Patient Saf 2021 Aug 1;17(5):e413-e22. doi: 10.1097/pts.0000000000000354..
Keywords: Falls, Prevention, Patient Safety, Patient-Centered Healthcare, Education: Patient and Caregiver, Hospitals, Adverse Events
Masonbrink AR, Harris M, Hall M
Safety events in children's hospitals during the COVID-19 pandemic.
The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. The objective of this study was to compare pediatric hospitalization safety events during the pandemic versus previous years. The investigators concluded that postoperative sepsis rates increased among children hospitalized during COVID-19. They suggest that efforts are needed to improve safety of postoperative care for hospitalized children.
AHRQ-funded; HS024554; HS024592.
Citation: Masonbrink AR, Harris M, Hall M .
Safety events in children's hospitals during the COVID-19 pandemic.
Hosp Pediatr 2021 Jun;11(6):e95-e100. doi: 10.1542/hpeds.2020-004937..
Keywords: Children/Adolescents, COVID-19, Patient Safety, Sepsis, Adverse Events, Hospitalization, Hospitals, Inpatient Care, Infectious Diseases, Public Health
Ghaferi AA, Wells EE
Improving postoperative rescue through a multifaceted approach.
Through structured engagement of clinical champions, the authors present rescue improvement tools that may decrease rates of secondary and tertiary complications and enhance staff culture, confidence, and competence. They indicate that their interventions lay the groundwork for the further development, testing, and implementation of larger scale rescue-focused initiatives.
AHRQ-funded.
Citation: Ghaferi AA, Wells EE .
Improving postoperative rescue through a multifaceted approach.
Surg Clin North Am 2021 Feb;101(1):71-80. doi: 10.1016/j.suc.2020.09.004..
Keywords: Surgery, Adverse Events, Patient Safety, Hospitals
Kohn R, Harhay MO, Bayes B
Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study.
The objective of this cohort study was to assess the association of bedspacing with patient-centered outcomes among United States patients admitted to general medicine services. The study compared internal medicine, family medicine and geriatric service patients who were bedspaced versus cohorted for the entirety of their hospital stay within three large, urban hospitals. Findings showed that bedspacing was associated with adverse patient-centered outcomes. Recommendations for future work included a need to confirm these findings, to understand mechanisms contributing to adverse outcomes, and to identify factors that mitigate these adverse effects in order to provide high-value, patient-centered care to hospitalized patients.
AHRQ-funded; HS026372.
Citation: Kohn R, Harhay MO, Bayes B .
Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study.
BMJ Qual Saf 2021 Feb;30(2):116-22. doi: 10.1136/bmjqs-2019-010675..
Keywords: Patient-Centered Outcomes Research, Outcomes, Inpatient Care, Hospitals, Healthcare Delivery, Care Management, Adverse Events
Marshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
Reeder B, Makic MBF, Morrow C
AHRQ Author: Rodrick D
Design and evaluation of low-fidelity visual display prototypes for multiple hospital-acquired conditions.
Hospital-acquired conditions such as catheter-associated urinary tract infection, stage 3 or 4 hospital-acquired pressure injury, and falls with injury are common, costly, and largely preventable. This study used participatory design methods to design and evaluate low-fidelity prototypes of clinical dashboards to inform high-fidelity prototype designs to visualize integrated risks based on patient profiles.
AHRQ-authored; AHRQ-funded; 233201500025I; 23337003T.
Citation: Reeder B, Makic MBF, Morrow C .
Design and evaluation of low-fidelity visual display prototypes for multiple hospital-acquired conditions.
Comput Inform Nurs 2020 Nov;38(11):562-71. doi: 10.1097/cin.0000000000000668..
Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Risk, Hospitals, Prevention
Oslock WM, Ricci KB, Ingraham AM
Role of interprofessional teams in emergency general surgery patient outcomes.
This paper discusses the results of a 2015 survey of acute care hospitals, which asked whether residents and advanced practice providers participate in emergency general surgery care. The data was then linked to patient data from 17 State Inpatient Databases using American Hospital Association identifiers to determine if that was associated with better management of patients, mortality, or complications. Eighty-three hospitals and 49,271 unique emergency general surgery admissions were included in the dataset. Hospitals with residents had reduced odds of systemic complications compared with hospitals without them or other clinical support. Hospitals with only residents had the lowest odds of operative complication.
AHRQ-funded; HS022694.
Citation: Oslock WM, Ricci KB, Ingraham AM .
Role of interprofessional teams in emergency general surgery patient outcomes.
Surgery 2020 Aug;168(2):347-53. doi: 10.1016/j.surg.2020.04.046..
Keywords: Healthcare Cost and Utilization Project (HCUP), Teams, Surgery, Adverse Events, Hospitals, Healthcare Delivery
Furukawa MF, Eldridge N, Wang Y
AHRQ Author: Furukawa MF, Eldridge N
Electronic health record adoption and rates of in-hospital adverse events.
Researchers examined the association of hospitals' electronic health record (EHR) adoption and occurrence rates of adverse events among exposed patients. The study included patients hospitalized for acute cardiovascular disease, pneumonia, or conditions requiring surgery. The researchers found that patients exposed to a fully electronic EHR were less likely to experience in-hospital adverse events.
AHRQ-authored.
Citation: Furukawa MF, Eldridge N, Wang Y .
Electronic health record adoption and rates of in-hospital adverse events.
J Patient Saf 2020 Jun;16(2):137-42. doi: 10.1097/pts.0000000000000257..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Events, Inpatient Care, Hospitals, Patient Safety
Cifra CL, Ten Eyck P, Dawson JD
Factors associated with diagnostic error on admission to a PICU: a pilot study.
This pilot retrospective cohort study examined errors in pediatric ICUs (PICUs) for children during the first 12 hours after PICU admission. A structured tool (Safer Dx) was used to identify diagnostic error in an academic tertiary institution. Out of 50 patients, 4 (8%) had diagnostic errors. The errors were in diagnoses of chronic ear infection, intracranial pressure (two cases), and Bartonella encephalitis. This pilot study will be expanded into a larger and more definitive multicenter study.
AHRQ-funded; HS022087.
Citation: Cifra CL, Ten Eyck P, Dawson JD .
Factors associated with diagnostic error on admission to a PICU: a pilot study.
Pediatr Crit Care Med 2020 May;21(5):e311-e15. doi: 10.1097/pcc.0000000000002257..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Critical Care, Intensive Care Unit (ICU), Hospitals
Pruitt LCC, Skarda DE, Rollins MD
Hirschsprung-associated enterocolitis in children treated at US children's hospitals.
The incidence of and risk factors for Hirschsprung's-associated enterocolitis (HAEC) following pull-through have been limited to single institutions studies. In this retrospective cohort study, the investigators characterized the incidence of, risk factors for, and consequences of post-operative HAEC. The investigators concluded that HAEC following pull-through occurs in a large proportion of infants with HD and predicts reoperation. They suggest that multicenter studies are needed to develop prediction models and treatment protocols for HAEC.
AHRQ-funded; HS025776.
Citation: Pruitt LCC, Skarda DE, Rollins MD .
Hirschsprung-associated enterocolitis in children treated at US children's hospitals.
J Pediatr Surg 2020 Mar;55(3):535-40. doi: 10.1016/j.jpedsurg.2019.10.060.
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Keywords: Children/Adolescents, Digestive Disease and Health, Surgery, Adverse Events, Risk, Hospitals
Venema DM, Skinner AM, Nailon R
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.
AHRQ-funded; HS021429.
Citation: Venema DM, Skinner AM, Nailon R .
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
BMC Geriatr 2019 Dec 11;19(1):348. doi: 10.1186/s12877-019-1368-8..
Keywords: Falls, Injuries and Wounds, Patient Safety, Elderly, Risk, Hospitals, Adverse Events
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
Yarrington ME, Anderson DJ, Dodds Ashley E
Impact of FDA black box warning on fluoroquinolone and alternative antibiotic use in southeastern US hospitals.
This study’s objective was the quantify the effect of the 2016 FDA “black box” update on the use of fluoroquinolone antibiotics among a cohort of southeastern US hospitals. Fluoroquinolone was given a black box warning after many serious adverse events were reported. Antibiotic use data from 29 southeastern US hospitals over a 5-year period was analyzed. Fluoroquinolone use declined both and before after the FDA advisory update in 2016.
AHRQ-funded; HS023866.
Citation: Yarrington ME, Anderson DJ, Dodds Ashley E .
Impact of FDA black box warning on fluoroquinolone and alternative antibiotic use in southeastern US hospitals.
Infect Control Hosp Epidemiol 2019 Nov;40(11):1297-300. doi: 10.1017/ice.2019.247..
Keywords: Antibiotics, Medication, Practice Patterns, Healthcare Utilization, Hospitals, Adverse Drug Events (ADE), Adverse Events