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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
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1 to 25 of 658 Research Studies Displayed
Eldridge N, Wang Y, Metersky M
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
Zrelak PA, Utter GH, McDonald KM
Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).
The purpose of this study was to reweight AHRQ’s Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90) from weights based solely on the frequency of component Patient Safety Indicators (PSIs) to those that incorporate excess harm reflecting patients' preferences for outcome-related health states. Findings showed that including harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11, 13, and 12 contributed the greatest harm. The investigators concluded that reformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination.
AHRQ-authored; AHRQ-funded; 290201200003I.
Citation:
Zrelak PA, Utter GH, McDonald KM .
Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).
Health Serv Res 2022 Jun;57(3):654-67. doi: 10.1111/1475-6773.13918..
Keywords:
Healthcare Cost and Utilization Project (HCUP), Patient Safety, Quality Indicators (QIs), Quality Measures, Quality of Care, Adverse Events, Medicare
Giannouchos TV, Gómez-Lumbreras A, Malone DC
Risk of tizanidine-induced adverse events after concomitant exposure to ciprofloxacin: a cohort study in the U.S.
This study’s aim was to assess the risk of hypotension with coadministration of tizanidine (a painkiller medicine) and ciprofloxacin (an antibiotic). An observational nested cohort study was conducted using patients 18 years or older on tizanidine using data from electronic health records from 2000 to 2018 in the US. The analysis included 70,110 encounters across 221 hospitals. Most encounters were female (65.7%), whites (82.4%) with an average age of 56 years and an Elixhauser comorbidity index of 1.6. Only 2487 encounters (3.6%) had a co-administration of ciprofloxacin. An increased likelihood of hypotension was associated with co-administration compared to patients who did not receive ciprofloxacin.
AHRQ-funded; HS025984.
Citation:
Giannouchos TV, Gómez-Lumbreras A, Malone DC .
Risk of tizanidine-induced adverse events after concomitant exposure to ciprofloxacin: a cohort study in the U.S.
Am J Emerg Med 2022 May;55:147-51. doi: 10.1016/j.ajem.2022.03.008..
Keywords:
Medication, Adverse Drug Events (ADE), Adverse Events, Risk
Butler AM, Durkin MJ, Keller MR
Association of adverse events with antibiotic treatment for urinary tract infection.
The purpose of this study was to compare the risk of relative harms associated with different antibiotics prescribed for the treatment of uncomplicated urinary tract infection (UTI). The researchers identified 1,169,033 healthy, nonpregnant women between the ages of 18 to 44 who had an uncomplicated UTI and who initiated an oral antibiotic regimen for the treatment of common uropathogens between July 2006 and September 2015. The study found that of the two first-line treatments, the drug trimethoprim-sulfamethoxazole (versus nitrofurantoin) was associated with a higher risk of adverse drug-related events including: hypersensitivity, acute renal failure, skin rash, urticaria, abdominal pain, and nausea/ vomiting, but a similar risk of adverse possible microbiome-related events. When researchers compared non-first line drugs with nitrofurantoin, the non-first line drugs were associated with a greater risk of adverse drug events and possible microbiome-related adverse events including non-Clostridium difficile diarrhea, C. difficile infection, vaginitis/vulvovaginal candidiasis, and pneumonia. The duration of the treatment influenced the risk of possible microbiome-related adverse events. The study concluded that the risk of adverse events differs widely by both antibiotic drug and duration of regimen.
AHRQ-funded; HS019455.
Citation:
Butler AM, Durkin MJ, Keller MR .
Association of adverse events with antibiotic treatment for urinary tract infection.
Clin Infect Dis 2022 Apr 28;74(8):1408-18. doi: 10.1093/cid/ciab637..
Keywords:
Antibiotics, Medication, Urinary Tract Infection (UTI), Adverse Drug Events (ADE), Adverse Events, Clostridium difficile Infections
Cheetham MS, Zhao J, McCullough K
International peritoneal dialysis training practices and the risk of peritonitis.
In peritoneal dialysis (PD), the impact of training on patient outcomes is not well understood, with a lack of evidence to inform best practices in training. The purpose of this study was to compare international PD training practices and evaluate their association with peritonitis. In this prospective study, a cohort of 1,376 adult patients from 120 facilities across 7 counties were included, all of whom were participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) and were on PD for greater than 3 months. Training characteristics were reported at patient and facility levels and included duration, location, and modality of training, use of individual/ group training, use of written/ oral competency assessments, training of family members, and nurse affiliation. The study found that training was most typically conducted in a one-on-one setting (79%) by facility-affiliated nurses (87%) at the facility (81%). In 5 of 14 United Kingdom facilities, receiving training from both facility and external, third-party nurses was associated with a reduced risk of peritonitis. However, no other training characteristics were significantly associated with risk of peritonitis. The study concluded that in this study, there was no evidence that risk of peritonitis was associate with the assessed characteristics of PD patient training.
AHRQ-funded; HS025756.
Citation:
Cheetham MS, Zhao J, McCullough K .
International peritoneal dialysis training practices and the risk of peritonitis.
Nephrol Dial Transplant 2022 Apr 25;37(5):937-49. doi: 10.1093/ndt/gfab298..
Keywords:
Kidney Disease and Health, Adverse Events, Training
Mao J, Sedrakyan A, Sun T
Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing.
This study’s objective was to develop an annotation model to develop natural language processing (NLP) to device adverse event reports and to implement the model to evaluate the most frequently experienced events among women reporting a sterilization device removal. Adverse event reports from the Manufacturer and User Facility Device Experience database from January 2005 to June 2018 were included. The authors used an iterative process to develop an annotation model that extracts six categories of desired information and applied the annotation model to train an NLP algorithm. A total of 16,535 reports of device removal were analyzed with the most frequently reported patient and device events being abdominal/pelvic/genital pain (79.6%) and device dislocation/migration (19.2%), respectively. A total of 7,932 patients reported an additional sterilization procedure of a hysterectomy or salpingectomy. One-fifth of the cases that had device removal timing specified reported a removal 7 years after original insertion.
AHRQ-funded; HS026291.
Citation:
Mao J, Sedrakyan A, Sun T .
Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing.
Pharmacoepidemiol Drug Saf 2022 Apr;31(4):442-51. doi: 10.1002/pds.5402..
Keywords:
Adverse Events, Surgery, Medical Devices, Patient Safety
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?
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
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
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
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 / 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
