National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (9)
- Behavioral Health (1)
- Cardiovascular Conditions (1)
- Children/Adolescents (1)
- Clinician-Patient Communication (1)
- Diagnostic Safety and Quality (7)
- Electronic Health Records (EHRs) (1)
- (-) Emergency Department (15)
- Health Information Technology (HIT) (1)
- (-) Medical Errors (15)
- Medical Liability (1)
- Medication (1)
- Medication: Safety (1)
- Pain (1)
- Patient Safety (10)
- Public Reporting (1)
- Quality Improvement (1)
- Quality of Care (4)
- Risk (4)
- Sepsis (1)
- Shared Decision Making (1)
- Stroke (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 15 of 15 Research Studies DisplayedGriffey RT, Schneider RM, Todorov AA
Near-miss events detected using the emergency department trigger tool.
The purpose of this study was to explore near misses and their significance for quality and safety in the emergency department (ED). This study presents a secondary analysis of data from a retrospective investigation of the ED Trigger Tool (EDTT) at an urban, academic ED. The EDTT, a computerized query for triggers, was applied to 13 months of ED visit data, and 5582 selected records were reviewed using a two-tiered approach. Events were categorized by occurrence (ED vs. present on arrival [POA]), severity, omission/commission, and type, employing a taxonomy featuring categories, subcategories, and cross-cutting modifiers. The researchers identified 1458 ED near misses in 1269 of the 5582 records and 80 near misses that were POA. Patient care events constituted the majority of ED near misses, including diagnostic delays, treatment delays, and monitoring failures, primarily influenced by ED boarding and overcrowding. Medication events ranked second in frequency (17%), with 80 medication administration errors identified. Among the 80 POA events, 42% were linked to overanticoagulation. It was estimated that 19.3% of all ED visits involved a near miss.
AHRQ-funded; HS027811; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Near-miss events detected using the emergency department trigger tool.
J Patient Saf 2023 Mar 1; 19(2):59-66. doi: 10.1097/pts.0000000000001092..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors
Ostrovsky D, Novack V, Smulowitz PB
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
This cross-sectional study examined survey responses about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians regarding what might be considered excessive testing. The authors surveyed 1222 clinicians and the mean score was greater for fear of harm to patients than fear of a malpractice suit. This finding was true regardless of clinician subtype, experience, or sex.
AHRQ-funded; HS026730.
Citation: Ostrovsky D, Novack V, Smulowitz PB .
Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.
JAMA Netw Open 2022 Nov;5(11):e2241461. doi: 10.1001/jamanetworkopen.2022.41461..
Keywords: Emergency Department, Medical Errors, Adverse Events, Patient Safety
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
Vaghani V, Wei L, U
Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.
Diagnostic errors are major contributors to preventable patient harm. In this study, the investigators validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs). The investigators concluded that a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.
AHRQ-funded; HS017820; HS024459.
Citation: Vaghani V, Wei L, U .
Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.
J Am Med Inform Assoc 2021 Sep 18;28(10):2202-11. doi: 10.1093/jamia/ocab121..
Keywords: Stroke, Cardiovascular Conditions, Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events
Mahajan P, Pai CW, Cosby KS
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. In this study, the investigators sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.
AHRQ-funded; HS024953; HS027363.
Citation: Mahajan P, Pai CW, Cosby KS .
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
Diagnosis 2021 Aug 26;8(3):340-46. doi: 10.1515/dx-2020-0122..
Keywords: Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Cifra CL, Westlund E, Ten Eyck P
An estimate of missed pediatric sepsis in the emergency department.
AHRQ-funded; HS025753.
Citation: Cifra CL, Westlund E, Ten Eyck P .
An estimate of missed pediatric sepsis in the emergency department.
Diagnosis 2021;8(2):193-98. doi: 10.1515/dx-2020-0023..
Keywords: Children/Adolescents, Sepsis, Emergency Department, Diagnostic Safety and Quality, Medical Errors, Risk
Griffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: validation and testing to optimize yield.
Researchers validated the emergency department trigger tool (EDTT) in an independent sample and compared record selection approaches to optimize yield for quality improvement. In this single-site study of the EDTT, they observed high levels of validity in trigger selection, yield, and representativeness of adverse events, with yields that are superior to estimates for traditional approaches to adverse event detection. Record selection using weighted triggers outperformed a trigger count threshold approach and far outperformed random sampling from records with at least one trigger. They concluded that the EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the emergency department.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: validation and testing to optimize yield.
Acad Emerg Med 2020 Dec;27(12):1279-90. doi: 10.1111/acem.14101..
Keywords: Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Events, Patient Safety, Quality Improvement, Quality of Care
Griffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: a novel approach to screening for quality and safety events.
The goal of this study was to develop an automated version of a previously developed emergency department (ED) trigger tool to track the likelihood of an adverse event. Thirty triggers were associated with risk of harm. The authors identified 1,726 records out of 76,894 ED visits with greater than or equal to 1 trigger. They compared the results of the automated tool to the previous version and found it performed well. They began with a broad set of candidate triggers and validated a computerized query that eliminates the need for manual screening of triggers and also identified a refined set of triggers associated with adverse events in the ED.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: a novel approach to screening for quality and safety events.
Ann Emerg Med 2020 Aug;76(2):230-40. doi: 10.1016/j.annemergmed.2019.07.032..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors, Quality of Care, Risk
Griffey RT, Schneider RM, Todorov AA
Critical review, development, and testing of a taxonomy for adverse events and near misses in the emergency department.
Researchers created and tested a taxonomy for adverse events (AEs) and near misses for use in the emergency department (ED). This taxonomy is patient-centered, as opposed to most taxonomies which fail to describe harm experienced by patients and focus instead on errors and uses too broad categorizations. The authors reviewed candidate taxonomies using an iterative process and selected the Adventist Health Systems AE taxonomy and modified it for use in the ED. After testing with reviewers, agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Performance from individual raters ranged from very good (88%) to near perfect (98%) at the main category level.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Critical review, development, and testing of a taxonomy for adverse events and near misses in the emergency department.
Acad Emerg Med 2019 Jun;26(6):670-79. doi: 10.1111/acem.13724..
Keywords: Adverse Events, Emergency Department, Medical Errors, Patient Safety, Risk
Terp S, Wang B, Burner E
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
This study analyzed civil monetary penalties resulting from Emergency Medical and Treatment Act (EMTALA) violations involving psychiatric emergencies from 2002 to 2018. Psychiatric treatment settlements are larger with the average settlement being $85,488 compared to $32,004 for non-psychiatric-related cases. Five of six of the largest settlements during the study period were psychiatric-related. The penalties were for failure to provide appropriate medical screening examinations, receive stabilizing treatment, or arrange appropriate transfer. Almost half (41%) occurred in the Southeast Region and 20% in the Central region.
AHRQ-funded; HS022402; HS025281.
Citation: Terp S, Wang B, Burner E .
Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018.
Acad Emerg Med 2019 May;26(5):470-78. doi: 10.1111/acem.13710..
Keywords: Emergency Department, Medical Errors, Medical Liability, Behavioral Health, Quality of Care
Medford-Davis LN, Singh H, Mahajan P
Diagnostic decision-making in the emergency department.
Emergency providers must often diagnose from undifferentiated symptoms, without previous knowledge of the patient. Failure to provide an accurate assessment of the problem or to communicate the problem to the patient is diagnostic error. This article considers methods to monitor diagnostic error in emergency departments.
AHRQ-funded; HS024953.
Citation: Medford-Davis LN, Singh H, Mahajan P .
Diagnostic decision-making in the emergency department.
Pediatr Clin North Am 2018 Dec;65(6):1097-105. doi: 10.1016/j.pcl.2018.07.003..
Keywords: Emergency Department, Diagnostic Safety and Quality, Shared Decision Making, Medical Errors, Patient Safety
Kannampallil TG, Manning JD, Chestek DW
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
The authors examined the effect of number of open charts on intercepted wrong-patient medication orders in an emergency department using an interrupted time series analysis of intercepted wrong-patient medication orders in an emergency department during 2010-2016.
AHRQ-funded; HS024945.
Citation: Kannampallil TG, Manning JD, Chestek DW .
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
J Am Med Inform Assoc 2018 Jun;25(6):739-43. doi: 10.1093/jamia/ocx099..
Keywords: Adverse Drug Events (ADE), Emergency Department, Medical Errors, Medication, Medication: Safety, Patient Safety
Medford-Davis L, Park E, Shlamovitz G
Diagnostic errors related to acute abdominal pain in the emergency department.
This study reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results).
AHRQ-funded; HS022087.
Citation: Medford-Davis L, Park E, Shlamovitz G .
Diagnostic errors related to acute abdominal pain in the emergency department.
Emerg Med J 2016 Apr;33(4):253-9. doi: 10.1136/emermed-2015-204754.
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Keywords: Pain, Emergency Department, Diagnostic Safety and Quality, Medical Errors, Clinician-Patient Communication
Okafor N, Payne VL, Chathampally Y
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
The researchers analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Among the 209 incidents, they identified 214 diagnostic errors associated with 65 unique diseases/conditions. Most diagnostic errors in ED appeared to relate to common disease conditions.
AHRQ-funded; HS017586; HS022087.
Citation: Okafor N, Payne VL, Chathampally Y .
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
Emerg Med J 2016 Apr;33(4):245-52. doi: 10.1136/emermed-2014-204604.
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Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Risk, Patient Safety
Okafor NG, Doshi PB, Miller SK
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The researchers found that the utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012.
AHRQ-funded; HS017586.
Citation: Okafor NG, Doshi PB, Miller SK .
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
West J Emerg Med 2015 Dec;16(7):1073-8. doi: 10.5811/westjem.2015.8.27390.
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Keywords: Emergency Department, Adverse Events, Medical Errors, Patient Safety, Public Reporting, Quality of Care