National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (3)
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- (-) Patient Safety (23)
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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
1 to 23 of 23 Research Studies DisplayedYoung RA, Gurses AP, Fulda KG
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
The purpose of this qualitative study was to examine actions by primary care teams to improve medication safety. During 2019-2020, the researchers utilized one-on-one, semi-structured interviews with 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in the Southwest United States. The study found that primary care teams described their actions in medication safety primarily in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. The majority of the actions required individual-level customization, such as restricting the supply of specific medications prescribed and simplifying the medication regimens of specific patients. Primary care teams engaged high reliability organization principles taking steps to improve resilience in patient work systems and by anticipating and moderating risks. The actions of the primary care teams demonstrated their safety organizing efforts as responses to many other agents in multiple settings that they could neither control nor coordinate easily.
AHRQ-funded; HS027277.
Citation: Young RA, Gurses AP, Fulda KG .
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.
BMJ Open Qual 2023 Sep; 12(3). doi: 10.1136/bmjoq-2023-002350..
Keywords: Medication: Safety, Medication, Primary Care, Patient Safety
White A, Fulda KG, Blythe R
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
The purpose of this narrative review was to further define the nature of collaboration between pharmacists and primary care providers in improving medication safety in community settings, and to describe related barriers and strategies. The researchers searched PubMed studies published between January 2000 and December 2020 using search terms including: "collaboration," "community pharmacy," "patient safety," "medication safety," and "primary care physician." The identified articles were placed into 3 categories: 1) defining collaboration, 2) types of collaboration, and 3) barriers and solutions to collaboration. The authors concluded that medication review and other strategies are a common form of collaboration between pharmacists and primary care providers, and that barriers to that collaboration can include erroneous beliefs regarding roles, variation in access to clinical information, and differences in community pharmacy practice.
AHRQ-funded; HS027277.
Citation: White A, Fulda KG, Blythe R .
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.
Expert Opin Drug Saf 2022 Nov;21(11):1357-64. doi: 10.1080/14740338.2022.2147923..
Keywords: Provider: Pharmacist, Primary Care, Medication, Patient Safety, Community-Based Practice
Campbell NL, Pitts C, Corvari C
Deprescribing anticholinergics in primary care older adults: experience from two models and impact on a continuous measure of exposure.
The purpose of this study was to assess two pilot pharmacist-based advanced practice deprescribing intervention models and their impact on patients’ exposure to high-risk anticholinergics. The researchers conducted pilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention. Deprescribing was defined as a discontinuation or dose reduction. Patients participating in the clinic-based pharmacy model were aged 55 years and older and were referred for deprescribing at a specialty clinic. Patients participating in the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. The study found that among the 24 medications deemed eligible for deprescribing for the18 patients in the clinic-based model, 23 were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 17% of medications were represcribed within 6 months. Among the 24 medications deemed eligible for deprescribing for the 24 patients in the telephone-based pharmacy model, 50% were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months. The researchers concluded that pharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in the study population.
AHRQ-funded; HS24384.
Citation: Campbell NL, Pitts C, Corvari C .
Deprescribing anticholinergics in primary care older adults: experience from two models and impact on a continuous measure of exposure.
Journal of the American College of Pharmacy 2022 Oct;5(10):1039-47. doi: 10.1002/jac5.1682..
Keywords: Elderly, Primary Care, Medication, Provider: Pharmacist, Medication: Safety, Patient Safety
Oberlander T, Scholle SH, Marsteller J
Implementation of patient safety structures and processes in the patient-centered medical home.
This study's objectives were to identify patient-centered medical home (PCMH) standards relevant to patient safety, to construct a measure of patient safety activity implementation, and to examine differences in adoptions of these activities by practice and community characteristics. Findings showed that implementation of patient safety activities varied; the few military practices studied had the highest, and community clinics the lowest, patient safety score, both overall and across specific domains, while other practice and community characteristics were not associated with the patient safety score.
AHRQ-funded; HS024859.
Citation: Oberlander T, Scholle SH, Marsteller J .
Implementation of patient safety structures and processes in the patient-centered medical home.
J Healthc Qual 2021 Nov-Dec;43(6):324-39. doi: 10.1097/jhq.0000000000000312..
Keywords: Patient-Centered Healthcare, Patient Safety, Implementation, Primary Care
Lasser EC, Heughan JA, Lai AY
Patient perceptions of safety in primary care: a qualitative study to inform care.
The authors sought to understand the patient perspective on patient safety in patient-centered medical homes (PCMHs). Using focus groups/interviews, they found overarching themes focused on (1) clear and timely communication with and between clinicians and (2) trust in the care team, including being heard, respected, and treated as a whole person. Other themes included sharing of and access to information, patient education and patient-centered medication reconciliation process, clear documentation for the diagnostic process, patient-centered comprehensive visits, and timeliness of care.
AHRQ-funded; HS024859.
Citation: Lasser EC, Heughan JA, Lai AY .
Patient perceptions of safety in primary care: a qualitative study to inform care.
Curr Med Res Opin 2021 Nov;37(11):1991-99. doi: 10.1080/03007995.2021.1976736..
Keywords: Patient Safety, Patient Experience, Primary Care, Patient-Centered Healthcare
Nehls N, Yap TS, Salant T
Systems engineering analysis of diagnostic referral closed-loop processes.
This systems engineering (SE) analysis of diagnostic referral closed-loop processes examines process logic, variation, reliability, and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. Research has shown that there is a 65-73% failure rate in completing diagnostic referrals, which is a significant patient safety problem. An interdisciplinary team collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health center and a teaching practice within a large academic medical center. Results were used to conduct an engineering process analysis, assess variation between and within practices, and identify common failure modes and potential solutions.
AHRQ-funded; HS027282.
Citation: Nehls N, Yap TS, Salant T .
Systems engineering analysis of diagnostic referral closed-loop processes.
BMJ Open Qual 2021 Nov;10(4). doi: 10.1136/bmjoq-2021-001603..
Keywords: Diagnostic Safety and Quality, Primary Care, Patient Safety
Poghosyan L, Norful AA, Ghaffari A L, Norful AA, Ghaffari A
Psychometric testing of errors of care omission survey: a new tool on patient safety in primary care.
The goal of this study was to evaluate the psychometric properties of a newly developed survey tool, the Errors of Care Omission Survey (ECOS), measuring omissions in primary care. Four factors emerged representing domains of omissions in primary care. Findings showed that the ECOS can be used in primary care to identify critical omissions, so actions can be taken by clinicians and administrators to prevent them before they result in patient harm. Recommendations included further testing with diverse samples.
AHRQ-funded; HS024758.
Citation: Poghosyan L, Norful AA, Ghaffari A L, Norful AA, Ghaffari A .
Psychometric testing of errors of care omission survey: a new tool on patient safety in primary care.
J Patient Saf 2021 Mar 1;17(2):e107-e14. doi: 10.1097/pts.0000000000000575..
Keywords: Primary Care, Medical Errors, Adverse Events, Patient Safety
Lai AY, Yuan CT, Marsteller JA
Patient safety in primary care: conceptual meanings to the health care team and patients.
This study’s goal was to describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care and to compare and contrast these conceptual meanings from the patient's perspective. Findings indicated that frontline personnel conceptualized patient safety in terms of work functions; frontline personnel and patients conceptualized patient safety in largely consistent ways.
Citation: Lai AY, Yuan CT, Marsteller JA .
Patient safety in primary care: conceptual meanings to the health care team and patients.
J Am Board Fam Med 2020 Sep-Oct;33(5):754-64. doi: 10.3122/jabfm.2020.05.200042..
Keywords: Primary Care, Patient Safety, Teams
Ricciardi R
AHRQ Author: Ricciardi R
The next frontier for nurses: improving quality and safety in primary care.
Nurses’ role in advancing quality and protecting the safety of patients in primary care settings is becoming more important. As primary care moves to team-based practice models to meet the needs of Accountable Care Organizations and the Quality Payment Program, RNs are well positioned to take on leading roles and new responsibilities. The author discusses the challenges and opportunities faced by the nursing profession and AHRQ’s role in assisting this process.
AHRQ-authored.
Citation: Ricciardi R .
The next frontier for nurses: improving quality and safety in primary care.
J Nurs Care Qual 2018 Jan/Mar;33(1):1-4. doi: 10.1097/ncq.0000000000000304.
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Keywords: Quality of Care, Nursing, Patient Safety, Primary Care
Singh H, Schiff GD, Graber ML
The global burden of diagnostic errors in primary care.
In this narrative review, the authors discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. They then synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. Finally, they summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors.
AHRQ-funded; HS022087; HS023602.
Citation: Singh H, Schiff GD, Graber ML .
The global burden of diagnostic errors in primary care.
BMJ Qual Saf 2017 Jun;26(6):484-94. doi: 10.1136/bmjqs-2016-005401.
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Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Medical Errors, Patient Safety, Primary Care
Schiff GD, Reyes Nieva H, Griswold P
Addressing ambulatory safety and malpractice: the Massachusetts PROMISES Project.
The researchers assembled a coalition of safety, regulatory, malpractice, and academic groups and recruited 25 primary care practices of which 16 were selected to receive a multifaceted improvement intervention. They describe how they developed and fielded the intervention, delineating some of the lessons learned in the course of the project and implications for future efforts in this field.
AHRQ-funded; HS019508.
Citation: Schiff GD, Reyes Nieva H, Griswold P .
Addressing ambulatory safety and malpractice: the Massachusetts PROMISES Project.
Health Serv Res 2016 Dec;51 Suppl 3:2634-41. doi: 10.1111/1475-6773.12621.
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Keywords: Patient Safety, Medical Liability, Primary Care
Walley AY, Green TC
Mainstreaming naloxone through coprescription to patients receiving long-term opioid therapy for chronic pain.
This editorial comments on the Coffin and colleagues' report of the Naloxone for Opioid Safety Evaluation (NOSE) study. The authors concluded that the NOSE study is a substantial step forward in demonstrating the feasibility of coprescription of rescue kits in primary care settings. (Coffin et al., Ann Intern Med. 2016 Aug 16;165(4):245-52.)
AHRQ-funded; HS024021.
Citation: Walley AY, Green TC .
Mainstreaming naloxone through coprescription to patients receiving long-term opioid therapy for chronic pain.
Ann Intern Med 2016 Aug 16;165(4):292-3. doi: 10.7326/m16-1348.
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Keywords: Chronic Conditions, Medication, Patient Safety, Primary Care
Fiscella K, Fogarty C, Salas E
What can primary care learn from sports teams?
The authors used sports teams to illustrate key principles from team science and to extract practical lessons for primary care teams.
AHRQ-funded; HS022440.
Citation: Fiscella K, Fogarty C, Salas E .
What can primary care learn from sports teams?
J Ambul Care Manage 2016 Jul-Sep;39(3):279-85. doi: 10.1097/jac.0000000000000120.
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Keywords: Patient Safety, Primary Care, Quality Improvement, Teams
Al-Mutairi A, Meyer AN, Thomas EJ
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
The researchers aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews. They found that their Safer Dx Instrument helped quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence.
AHRQ-funded; HS022087.
Citation: Al-Mutairi A, Meyer AN, Thomas EJ .
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
J Gen Intern Med 2016 Jun;31(6):602-8. doi: 10.1007/s11606-016-3601-x.
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Keywords: Primary Care, Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality Improvement
Robinson JD, Tate A, Heritage J
Agenda-setting revisited: when and how do primary-care physicians solicit patients' additional concerns?
The authors assessed the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions. They found that physicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits. Further, those that were formatted so as to allow for 'concerns' were significantly more likely to generate some type of agenda item.
AHRQ-funded; HS010922; HS013343.
Citation: Robinson JD, Tate A, Heritage J .
Agenda-setting revisited: when and how do primary-care physicians solicit patients' additional concerns?
Patient Educ Couns 2016 May;99(5):718-23. doi: 10.1016/j.pec.2015.12.009.
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Keywords: Communication, Primary Care, Patient-Centered Healthcare, Patient Safety, Clinician-Patient Communication
Rabatin J, Williams E, Baier Manwell L
Predictors and outcomes of burnout in primary care physicians.
This study assessed relationships between primary care work conditions, physician burnout, quality of care, and medical errors. It found that burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians.
AHRQ-funded; HS011955.
Citation: Rabatin J, Williams E, Baier Manwell L .
Predictors and outcomes of burnout in primary care physicians.
J Prim Care Community Health 2016 Jan;7(1):41-3. doi: 10.1177/2150131915607799.
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Keywords: Provider: Health Personnel, Primary Care, Medical Errors, Patient Safety, Quality of Care
Chen LM, Sakshaug JW, Miller DC
The association among medical home readiness, quality, and care of vulnerable patients.
The researchers sought to examine the association among patient-centered medical home (PCMH) readiness, quality, and the care of vulnerable patients. They found that performance at PCMH-ready practices was higher for 3 of 9 quality indicators related to chronic disease management and preventive counseling (beta-blocker or diuretic prescribed for hypertension, diet counseling, exercise counseling).
AHRQ-funded; HS018346; HS020671; HS020927.
Citation: Chen LM, Sakshaug JW, Miller DC .
The association among medical home readiness, quality, and care of vulnerable patients.
Am J Manag Care 2015 Aug;21(8):e480-6..
Keywords: Patient-Centered Healthcare, Patient Safety, Quality of Care, Primary Care
Ricciardi R
AHRQ Author: Ricciardi R
AHRQ focuses on ambulatory patient safety.
As AHRQ looks to expand its ambulatory safety research efforts, the agency seeks the involvement of a variety of nurses to provide expert opinion and consultation and to conduct research. The author emphasizes that this is an opportunity for both PhD and Doctor of Nursing Practice prepared nurses to lead interprofessional teams to conduct research that can translate into meaningful improvements in ambulatory quality.
AHRQ-authored.
Citation: Ricciardi R .
AHRQ focuses on ambulatory patient safety.
J Nurs Care Qual 2015 Jul-Sep;30(3):193-6. doi: 10.1097/ncq.0000000000000124..
Keywords: Patient Safety, Nursing, Primary Care, Adverse Events, Health Services Research (HSR)
Dalal AK, Pesterev BM, Eibensteiner K
Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.
This study measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. It then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. Most (64 percent) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful.
AHRQ-funded; HS019603.
Citation: Dalal AK, Pesterev BM, Eibensteiner K .
Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.
J Am Med Inform Assoc 2015 Jul;22(4):905-8. doi: 10.1093/jamia/ocv007..
Keywords: Patient Safety, Electronic Health Records (EHRs), Primary Care, Health Information Technology (HIT)
Crane S, Sloane PD, Elder N
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
This study assessed the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. It found that all 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 quality improvement projects based on the reports.
AHRQ-funded; HS019558.
Citation: Crane S, Sloane PD, Elder N .
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
J Am Board Fam Med 2015 Jul-Aug;28(4):452-60. doi: 10.3122/jabfm.2015.04.140050..
Keywords: Adverse Events, Medical Errors, Patient Safety, Primary Care, Public Reporting, Quality Improvement, Quality of Care
Singh H, Sittig DF
Setting the record straight on measuring diagnostic errors. Reply to: 'Bad assumptions on primary care diagnostic errors' by Dr Richard Young.
This letter responds to a letter by Dr. Richard Young who criticizes Singh’s article on measuring diagnostic error. Singh defends his systems-based approach to advancing the science of measuring diagnostic error and acknowledges some of the uncertainties and evolution in the diagnostic process that Dr. Young writes about.
AHRQ-funded; HS022087
Citation: Singh H, Sittig DF .
Setting the record straight on measuring diagnostic errors. Reply to: 'Bad assumptions on primary care diagnostic errors' by Dr Richard Young.
BMJ Qual Saf. 2015 May;24(5):345-8. doi: 10.1136/bmjqs-2015-004140..
Keywords: Diagnostic Safety and Quality, Medical Errors, Patient Safety, Primary Care, Quality Measures
Schiff GD, Puopolo AL, Huben-Kearney A
Primary care closed claims experience of Massachusetts malpractice insurers.
The researchers studied patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. In Massachusetts, most primary care claims filed were related to alleged misdiagnosis.
AHRQ-funded; HS019508.
Citation: Schiff GD, Puopolo AL, Huben-Kearney A .
Primary care closed claims experience of Massachusetts malpractice insurers.
JAMA Intern Med 2013 Dec 9-23;173(22):2063-8. doi: 10.1001/jamainternmed.2013.11070..
Keywords: Primary Care, Medical Errors, Health Insurance, Patient Safety, Medical Liability
Pohl JM, Nath R, Zheng K
Use of a comprehensive patient safety tool in primary care practices.
This article describes experiences with the use of the Physician Practice Patient Safety Assessment tool in six safety net practices—three of which were primary care nurse-managed health centers and three were physician-led federally qualified health centers. The authors concluded that this tool has enormous relevance for primary care settings, especially those preparing themselves for patient-centered medical home status and meaningful use.
AHRQ-funded; HS017191.
Citation: Pohl JM, Nath R, Zheng K .
Use of a comprehensive patient safety tool in primary care practices.
J Am Assoc Nurse Pract 2013 Aug;25(8):415-8. doi: 10.1111/1745-7599.12021..
Keywords: Patient Safety, Primary Care, Patient-Centered Healthcare, Practice Patterns, Tools & Toolkits