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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
76 to 100 of 737 Research Studies DisplayedMetersky ML, Eldridge N, Wang Y
AHRQ Author: Eldridge N
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
This retrospective analysis aimed to determine whether patients in teaching hospitals are at greater risk of suffering from an adverse event during the July/August summer trainee changeover period. The Medicare Patient Safety Monitoring System was used to extract data on hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure. Adverse event rates in July and August were compared with the rest of the year. Hospitals were classified into major teaching, minor teaching, or nonteaching. The authors included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event was not significantly different at any of the hospital types.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation: Metersky ML, Eldridge N, Wang Y .
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
J Patient Saf 2022 Apr 1;18(3):253-59. doi: 10.1097/pts.0000000000000887..
Keywords: Adverse Events, Patient Safety, Provider: Physician
Eisenberg MT, Block AM, Vopat ML
Rates of infection after ACL reconstruction in pediatric and adolescent patients: a MarketScan database study of 44,501 patients.
This study’s objective was to describe and analyze the rates of surgical site infections after anterior cruciate ligament (ACL) surgery in pediatric patients. The Truven Health Analytics MarketScan Commercial Claims and Encounters database was used to access data for privately insured individuals aged 5 to 30 years old. ACL reconstruction operation records were accessed for operations performed from 2006 to 2018. The database identified 44,501 individuals up to 18 years old, and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction. No differences in infection rates were found between the two groups. However, among patients younger than 18 years, patients below 15 years old had a significantly lower infection rate at 0.37% compared with adolescents 15 to 17 years old at 0.55%. Among young adults, males had a higher infection rate than females, while no differences were observed in the pediatric and adolescent population.
AHRQ-funded; HS019455.
Citation: Eisenberg MT, Block AM, Vopat ML .
Rates of infection after ACL reconstruction in pediatric and adolescent patients: a MarketScan database study of 44,501 patients.
J Pediatr Orthop 2022 Apr;42(4):e362-e66. doi: 10.1097/bpo.0000000000002080..
Keywords: Children/Adolescents, Surgery, Orthopedics, Healthcare-Associated Infections (HAIs), Adverse Events, Injuries and Wounds
Blakeslee-Carter J, Beck AW, Spangler EL
Type III endoleaks in complex endovascular abdominal aortic aneurysm repair within the Vascular Quality Initiative.
The objective of this national multicenter cohort study was to evaluate the occurrence of Type III endoleaks (T3ELs) after complex endovascular aneurysm repair (c-EVAR) for abdominal aortic aneurysm, identify potential procedural characteristics, and determine their impact on c-EVAR clinical outcomes. Investigators reviewed elective c-EVAR for nonruptured aneurysms within the Vascular Quality Initiative. The findings indicated that T3ELs in c-EVAR remain relatively uncommon and are identified predominately at index hospitalization. T3EL development was associated with higher device modularity and modification. The presence of T3ELs did not appear to have a statistically significant relationship with aortic reinterventions or survival, but the authors note that these findings are not definitive.
AHRQ-funded; HS013852.
Citation: Blakeslee-Carter J, Beck AW, Spangler EL .
Type III endoleaks in complex endovascular abdominal aortic aneurysm repair within the Vascular Quality Initiative.
J Vasc Surg 2022 Apr; 75(4):1172-80. doi: 10.1016/j.jvs.2021.10.038..
Keywords: Cardiovascular Conditions, Surgery, Adverse Events
Lacson R, Khorasani R, Fiumara K
Collaborative case review: a systems-based approach to patient safety event investigation and analysis.
The objectives of this study were to assess a system-based approach to event investigation and analysis--collaborative case reviews (CCRs)--and to measure impact of clinical specialty on strength of action items prescribed. The institutional review board-approved study describes the program, including a percentage of CCR from an institutional Electronic Safety Reporting System. Findings showed that an integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments.
AHRQ-funded; HS024722.
Citation: Lacson R, Khorasani R, Fiumara K .
Collaborative case review: a systems-based approach to patient safety event investigation and analysis.
J Patient Saf 2022 Mar 1;18(2):e522-e27. doi: 10.1097/pts.0000000000000857..
Keywords: Patient Safety, Adverse Events, Diagnostic Safety and Quality, Imaging
Patel PB, Marcaccio CL, de Guerre L
Complications after thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms remain high compared with elective repair.
This study evaluated the outcomes associated with presentation of ruptured aneurysms and outcomes after thoracic endovascular aortic repair (TEVAR). The Vascular Quality Initiative (VQI) registry was queried for ten years (2010-2020) to identify patients who had undergone TEVAR for ruptured and intact thoracic aortic aneurysms. Primary outcome was to identify the factors associated with ruptured thoracic aortic aneurysms and secondary outcomes including perioperative mortality and morbidity, 5-year survival, and the identification of factors associated with adverse outcomes after TEVAR. The majority of the 3039 patients identified with a thoracic aortic aneurysm (92%) had undergone repair for an intact aneurysm and 8% had undergone repair for a ruptured aneurysm. Chronic kidney disease was associated with greater odds of a presentation with ruptured aneurysm. Lower odds of rupture included prior aortic aneurysm repair, prior smoker, preoperative beta-blocker therapy, and preoperative statin therapy. TEVAR for ruptured thoracic aortic aneurysms was associated with higher perioperative mortality (rupture vs intact, 27% vs 4.6%) and the composite outcome of mortality, new dialysis, paralysis, and stroke (38% vs 9.5%). The 5-year survival was significantly lower after TEVAR for ruptured thoracic aortic aneurysms (50% vs 76%). Preoperative statin therapy was associated with higher 5-year survival.
AHRQ-funded; HS027285.
Citation: Patel PB, Marcaccio CL, de Guerre L .
Complications after thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms remain high compared with elective repair.
J Vasc Surg 2022 Mar; 75(3):842-50. doi: 10.1016/j.jvs.2021.09.047..
Keywords: Cardiovascular Conditions, Surgery, Adverse Events
Chen C, Winterstein AG, Lo-Ciganic WH
Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: a population-based cohort study.
This study compared the risk of fall-related injury in two cohorts who used gabapentinoids concurrently with opioid use and those who used opioids only. The authors created 2 cohorts based on whether concurrent users initiated gabapentinoids on the day of opioid initiation (Cohort 1) or after opioid initiation (Cohort 2). Both cohorts were identified from a sample of older Medicare beneficiaries with chronic non-cancer pain (CNCP). Four concurrent users were matched up with 1 opioid-only user. They identified 6,733 concurrent users and 27,092 matched opioid-only users in Cohort 1 and 5,709 concurrent users and 22,388 matched opioid-only users in Cohort 2. Cohort 1’s incidence rate of fall-related injury was 24.5 per 100 person-users during follow-up and was 18.0 per 100-person-years during follow-up for Cohort 2. Concurrent users had had similar risk of fall-related injury as opioid-only users in Cohort 1 but had higher risk for fall-related injury than opioid-only users in Cohort 2.
AHRQ-funded; HS027230.
Citation: Chen C, Winterstein AG, Lo-Ciganic WH .
Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: a population-based cohort study.
PLoS Med 2022 Mar;19(3):e1003921. doi: 10.1371/journal.pmed.1003921..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Falls, Patient Safety, Injuries and Wounds, Pain, Chronic Conditions
Tzeng HM, Raji MA, Chou LN
Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.
The American Geriatrics Society regularly updates the Beers Criteria for Potentially Inappropriate Medication (PIM) to improve prescribing safety. This study assessed the impact of nurse practitioner (NP) practices on PIM prescribing across states in the United States and compared the change in PIM prescribing rates between 2016 and 2018. The investigators found that the PIM prescription rate was lower in states with full NP practice and lower among NPs than among physicians; these rates for both physicians and NPs decreased from 2016 to 2018.
AHRQ-funded; HS020642.
Citation: Tzeng HM, Raji MA, Chou LN .
Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.
J Nurs Care Qual 2022 Jan-Mar;37(1):6-13. doi: 10.1097/ncq.0000000000000595..
Keywords: Medication, Medication: Safety, Provider: Nurse, Adverse Drug Events (ADE), Adverse Events, Policy
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
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
Yunusa I, Gagne JJ, Yoshida K
Risk of opioid overdose associated with concomitant use of oxycodone and selective serotonin reuptake inhibitors.
Oxycodone is a potent prescription opioid. Some Selective Serotonin Reuptake Inhibitors (SSRIs) inhibit oxycodone metabolism in the body, but the clinical consequences of this interaction on overdose risk have not been adequately determined. The study researchers compared the rates of opioid overdoses in patients who had initiated oxycodone while taking enzyme-inhibiting SSRIs with the overdose rates of patents who had initiated oxycodone while taking non-enzyme inhibiting SSRIs. Data from 3 U.S. health insurance databases was used to analyze a cohort of adults who initiated oxycodone while receiving SSRI therapy between the years 2000 and 2020. Of the total of 2,037,490 who initiated oxycodone, 69.6% were receiving SSRIs at the time of the initiation of the oxycodone. One-thousand-thirty-five overdose events were observed during this time, and the resulting incidence rate in those initiating oxycodone while using enzyme-inhibiting SSRI’s was higher than in those using other SSRIs. The researchers concluded that in the study cohort of U.S. adults, there is a small increased risk of opioid overdose when initiating oxycodone in patients taking enzyme-inhibiting SSRIs.
AHRQ-funded; HS027623.
Citation: Yunusa I, Gagne JJ, Yoshida K .
Risk of opioid overdose associated with concomitant use of oxycodone and selective serotonin reuptake inhibitors.
JAMA Netw Open 2022 Feb;5(2):e220194. doi: 10.1001/jamanetworkopen.2022.0194..
Keywords: Opioids, Medication, Risk, Depression, Adverse Drug Events (ADE), Adverse Events
Fatemi P, Zhang Y, Han SS
A, et al. External validation of a predictive model of adverse events following spine surgery.
The authors externally validated a previously developed predictive model for common 30-day adverse events after spine surgery, the Risk Assessment Tool for Adverse Events after Spine Surgery (RAT-Spine). Their results are presented as low-, moderate-, and high-risk designations.
AHRQ-funded; HS023800.
Citation: Fatemi P, Zhang Y, Han SS .
A, et al. External validation of a predictive model of adverse events following spine surgery.
Spine J 2022 Jan;22(1):104-12. doi: 10.1016/j.spinee.2021.06.006..
Keywords: Surgery, Adverse Events, Orthopedics, Risk
Mallela DP, Canner JK, Zarkowsky DS
Association between race and perioperative outcomes after carotid endarterectomy for asymptomatic carotid artery stenosis in NSQIP.
This study investigated the association of race on carotid endarterectomy (CEA) outcomes. Perioperative outcomes (at 30 days) were compared for Black vs. White patients adjusting for age/sex, comorbidities and disease characteristics. Out of 16,764 patients from the ACS-NSQIP targeted vascular database (2011-2019), 95.2% were White and 4.8% were Black. Black patients were slightly younger and more frequently (79.5% vs 74.0%) had high-grade carotid artery stenosis compared to White patients. Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients. Crude perioperative stroke and stroke/death were higher for Black patients, but myocardial infarction leading to death were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke and stroke/death remained significantly higher for Black patients than White patients.
AHRQ-funded; HS024547.
Citation: Mallela DP, Canner JK, Zarkowsky DS .
Association between race and perioperative outcomes after carotid endarterectomy for asymptomatic carotid artery stenosis in NSQIP.
J Am Coll Surg 2022 Jan;234(1):65-73. doi: 10.1097/xcs.0000000000000016..
Keywords: Racial and Ethnic Minorities, Surgery, Cardiovascular Conditions, Stroke, Risk, Adverse Events
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
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
Herzig SJ, Anderson TS,, Jung y
Risk factors for opioid-related adverse drug events among older adults after hospital discharge.
This study examined patient- and prescribing-related risk factors for opioid-related adverse drug events (ADEs) after hospital discharge among medical patients. Administrative billing codes and medication claims were used to define potential opioid-related ADEs within 30 days of hospital discharge. Findings showed that potential opioid-related ADEs occurred in 7% of older adults discharged from a medical hospitalization with an opioid prescription. Recommendations included using identified risk factors to inform physician decision-making, having conversations with older adults about risk, and increasing development and targeting of harm reduction strategies.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS,, Jung y .
Risk factors for opioid-related adverse drug events among older adults after hospital discharge.
J Am Geriatr Soc 2022 Jan;70(1):228-34. doi: 10.1111/jgs.17453..
Keywords: Elderly, Opioids, Risk, Adverse Drug Events (ADE), Adverse Events, Medication, Hospital Discharge
Nanji KC, Shaikh SD, Jaffari A
A Monte Carlo simulation to estimate the additional cost associated with adverse medication events leading to intraoperative hypotension and/or hypertension in the United States.
This study’s objective was to estimate the rates of clinically significant intraoperative hypotension and hypertension. Systematic literature reviews were conducted to estimate incidence and additional costs of acute kidney injury (AKI), acute myocardial injury, and stroke after intraoperative hypotension and hypertension. The authors used Monte Carlo simulation to estimate annual costs to the U.S. healthcare system. Intraoperative hypotension occurred in 11 of 277 operations (3.97%), a >30% drop in baseline mean arterial pressure hypotension in patients with coronary artery disease in 9 operations (3.25%), and hypertension in 14 operations (5.05%). After hypertension, incremental stroke incidence was 4.76%. The authors estimated 11,513 cases of AKI, 5914 cases of acute myocardial injury, 345 cases of stroke after intraoperative hypotension, and 47,774 cases of stroke after intraoperative hypertension. Estimated costs were $1.7 billion, of which $923 million are preventable.
AHRQ-funded; HS024764.
Citation: Nanji KC, Shaikh SD, Jaffari A .
A Monte Carlo simulation to estimate the additional cost associated with adverse medication events leading to intraoperative hypotension and/or hypertension in the United States.
J Patient Saf 2021 Dec 1;17(8):e758-e64. doi: 10.1097/pts.0000000000000926..
Keywords: Medication, Adverse Drug Events (ADE), Adverse Events, Healthcare Costs
Mahajan P, Mollen C, Alpern ER
An operational framework to study diagnostic errors in emergency departments: findings from a consensus panel.
The purpose of this study was to create an operational definition and framework to study diagnostic error in the emergency department setting. A multidisciplinary panel defined diagnostic errors, modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework, and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis.
AHRQ-funded; HS024953.
Citation: Mahajan P, Mollen C, Alpern ER .
An operational framework to study diagnostic errors in emergency departments: findings from a consensus panel.
J Patient Saf 2021 Dec 1;17(8):570-75. doi: 10.1097/pts.0000000000000624..
Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Adverse Events
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
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
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
Tokede O, Walji M, Ramoni R
Quantifying dental office-originating adverse events: the dental practice study methods.
Investigators initiated the Dental Practice Study (DPS) with the goal of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit. In this article, they discussed the 6-month pilot phase of the DPS during which they explored the feasibility and efficiency of their multi-staged review process to detect AEs.
Citation: Tokede O, Walji M, Ramoni R .
Quantifying dental office-originating adverse events: the dental practice study methods.
J Patient Saf 2021 Dec 1;17(8):e1080-e87. doi: 10.1097/pts.0000000000000444..
Keywords: Dental and Oral Health, Adverse Events, Patient Safety, Medical Errors
Ernest EC, Hellar A, Varallo J
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
This study evaluated the impact of a multicomponent safe surgery intervention in Tanzania to reduce surgical site infection (SSI) rates and mortality after caesarean sections (CS). The authors used the WHO Surgical Safety Checklist (SSC) to measure WHO SSC utilization, SSI rates, and CS-related perioperative mortality rates (POMRs) before and 18 months after implementation. The SSC utilization rate for CS increased from 3.7% to 95.1%, which decreased the proportion of women with SSI after CS from 14% during baseline to 1%. CS-related POMR decreased by 38.5% after implementation of safe surgery interventions as well.
AHRQ-funded; HS024235.
Citation: Ernest EC, Hellar A, Varallo J .
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
BMJ Glob Health 2021 Dec;6(12). doi: 10.1136/bmjgh-2021-006788..
Keywords: Maternal Care, Pregnancy, Healthcare-Associated Infections (HAIs), Surgery, Injuries and Wounds, Adverse Events, Patient Safety
Dykes PC, KhasnabishE S, Adkison LE
Use of a perceived efficacy tool to evaluate the FallTIPS program.
The authors assessed nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. They found that the nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program, and findings confirmed the importance of patient and family engagement with staff in the fall prevention process.
AHRQ-funded; HS025128.
Citation: Dykes PC, KhasnabishE S, Adkison LE .
Use of a perceived efficacy tool to evaluate the FallTIPS program.
J Am Geriatr Soc 2021 Dec;69(12):3595-601. doi: 10.1111/jgs.17436..
Keywords: Falls, Patient Safety, Prevention, Provider: Nurse, Adverse Events