National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Events (2)
- (-) Care Coordination (10)
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- (-) Patient Safety (10)
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- Quality of Care (2)
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- Transitions of Care (3)
- Trauma (1)
- Young Adults (1)
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 10 of 10 Research Studies DisplayedSather J, Littauer R, Finn E
A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage.
Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. In this study, the researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT.
AHRQ-funded; HS023554.
Citation: Sather J, Littauer R, Finn E .
A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage.
Jt Comm J Qual Patient Saf 2021 Feb;47(2):99-106. doi: 10.1016/j.jcjq.2020.10.003..
Keywords: Transitions of Care, Hospitals, Patient Safety, Quality Improvement, Quality of Care, Care Coordination
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Wooldridge A, Carayon P, Hoonakker P
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, the investigators combined interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity.
AHRQ-funded; HS023837.
Citation: Wooldridge A, Carayon P, Hoonakker P .
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Cogn Technol Work 2019 Aug;21(3):397-416. doi: 10.1007/s10111-018-0520-0..
Keywords: Care Coordination, Children/Adolescents, Critical Care, Health Services Research (HSR), Healthcare Delivery, Inpatient Care, Patient Safety, Teams, Trauma, Young Adults
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Duckworth M, Leung E, Fuller T
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Differences emerged stemming from each group of end users' role on the care team.
AHRQ-funded; HS023535.
Citation: Duckworth M, Leung E, Fuller T .
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
J Gerontol Nurs 2017 Apr;43(4):15-22. doi: 10.3928/00989134-20170313-05.
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Keywords: Elderly, Electronic Health Records (EHRs), Health Information Technology (HIT), Caregiving, Patient Safety, Patient and Family Engagement, Care Coordination
Weinger MB, Slagle JM, Kuntz AH
A multimodal intervention improves postanesthesia care unit handovers.
The researchers introduced a multimodal intervention in an adult and a pediatric postanesthesia care unit (PACU) to improve postoperative handovers between anesthesia providers (APs) and PACU registered nurses (RNs). They concluded that a multimodal intervention substantially improved interprofessional PACU handovers, including those by clinicians who had not undergone formal simulation training.
AHRQ-funded; HS016651.
Citation: Weinger MB, Slagle JM, Kuntz AH .
A multimodal intervention improves postanesthesia care unit handovers.
Anesth Analg 2015 Oct;121(4):957-71. doi: 10.1213/ane.0000000000000670..
Keywords: Patient Safety, Care Coordination, Surgery
McElroy LM, Macapagal KR, Collins KM
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
The goal of this study is to use qualitative research methods to describe clinician perceptions of OR-to-ICU handoffs, and to elucidate attributes of the handoff process associated with high quality, as well as those with poor quality that can lead to patient harm. The findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm.
AHRQ-funded; HS000078.
Citation: McElroy LM, Macapagal KR, Collins KM .
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
Am J Surg 2015 Oct;210(4):629-35. doi: 10.1016/j.amjsurg.2015.05.008..
Keywords: Patient Safety, Intensive Care Unit (ICU), Surgery, Adverse Events, Care Coordination
Rosenbluth G, Bale JF, Starmer AJ
Variation in printed handoff documents: results and recommendations from a multicenter needs assessment.
The objective of this study was to determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents. It identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17 percent) were uniformly present in all sites’ handoff documents.
AHRQ-funded; HS019456.
Citation: Rosenbluth G, Bale JF, Starmer AJ .
Variation in printed handoff documents: results and recommendations from a multicenter needs assessment.
J Hosp Med 2015 Aug;10(8):517-24. doi: 10.1002/jhm.2380..
Keywords: Patient Safety, Medical Errors, Communication, Comparative Effectiveness, Care Coordination
Liao JM, Roy CL, Eibensteiner K
Lost in transition: discrepancies in how physicians perceive the actionability of the results of tests pending at discharge.
Effective communication of pending hospital test results between inpatient and primary care physicians is sometimes challenging or nonexistent. This communication is essential for safe, quality transactions at discharge. Health information technology (such as email and fax) is an effective strategy for improving and reporting test-result management.
AHRQ-funded; HS018229
Citation: Liao JM, Roy CL, Eibensteiner K .
Lost in transition: discrepancies in how physicians perceive the actionability of the results of tests pending at discharge.
J Hospital Med. 2014 Jun;9(6):407-9. doi: 10.1002/jhm.2177..
Keywords: Communication, Care Coordination, Health Information Technology (HIT), Hospital Discharge, Patient Safety
Arora VM, Reed DA, Fletcher KE
Building continuity in handovers with shorter residency duty hours.
The authors discuss how “continuity-enhanced handovers” differ from traditional handovers in several key aspects, including quality of information transferred, greater professional responsibility of senders and receivers, and a different philosophy of “coverage.” By reconceptualizing handover as a necessary bridge to continuity, and hence to safer patient care, this model of continuity-enhanced handovers has the potential to allay fears and improve patient care in an era of increasing fragmentation.
AHRQ-funded; HS018278.
Citation: Arora VM, Reed DA, Fletcher KE .
Building continuity in handovers with shorter residency duty hours.
BMC Med Educ 2014;14 Suppl 1:S16. doi: 10.1186/1472-6920-14-s1-s16..
Keywords: Quality of Care, Patient Safety, Care Coordination