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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.
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1 to 4 of 4 Research Studies DisplayedShafer GJ, Singh H, Thomas EJ
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
The objective of this study was to determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients. The "Safer Dx NICU Instrument" was used to review electronic health records. The reviewers discovered that the frequency of diagnostic error in inborn NICU patients during the first 7 days of admission was 6.2%.
AHRQ-funded; HS027363.
Citation: Shafer GJ, Singh H, Thomas EJ .
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
J Perinatol 2022 Oct;42(10):1312-18. doi: 10.1038/s41372-022-01359-9..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Pfeifer E, Lozovatsky M, Abraham J
Effect of an alternative newborn naming strategy on wrong-patient errors: a quasi-experimental study.
Newborns are often assigned temporary names at birth. Temporary newborn names-often a combination of the mother's last name and the newborn's gender-are vulnerable to patient misidentification due to similarities with other newborns or between a mother and her newborn. In this study, the investigators developed and implemented an alternative distinct naming strategy, and then compared its effectiveness on reducing the number of wrong-patient orders with the standard distinct naming strategy.
AHRQ-funded; HS025443.
Citation: Pfeifer E, Lozovatsky M, Abraham J .
Effect of an alternative newborn naming strategy on wrong-patient errors: a quasi-experimental study.
Appl Clin Inform 2020 Mar;11(2):235-41. doi: 10.1055/s-0040-1705175..
Keywords: Newborns/Infants, Medical Errors, Adverse Events, Patient Safety
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Yamada NK, Yaeger KA, Halamek LP
Analysis and classification of errors made by teams during neonatal resuscitation.
This study was performed to determine and characterize common deviations from The Neonatal Resuscitation Program (NRP) algorithm during neonatal resuscitation. It concluded that errors of commission, especially when performing advanced life support interventions such as positive pressure ventilation, intubation, and chest compressions, are common during neonatal resuscitation and are sources of potential harm.
AHRQ-funded; HS012022.
Citation: Yamada NK, Yaeger KA, Halamek LP .
Analysis and classification of errors made by teams during neonatal resuscitation.
Resuscitation 2015 Nov;96:109-13. doi: 10.1016/j.resuscitation.2015.07.048.
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Keywords: Medical Errors, Newborns/Infants, Newborns/Infants, Guidelines