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Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (3)
- Ambulatory Care and Surgery (1)
- Behavioral Health (1)
- Burnout (1)
- Cancer (1)
- Care Management (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (2)
- Communication (4)
- Depression (1)
- Education: Continuing Medical Education (2)
- Elderly (1)
- Electronic Health Records (EHRs) (2)
- Emergency Department (1)
- Guidelines (1)
- Healthcare-Associated Infections (HAIs) (3)
- Healthcare Delivery (2)
- Health Information Technology (HIT) (3)
- Health Literacy (1)
- Hospitals (4)
- Infectious Diseases (1)
- Inpatient Care (1)
- Intensive Care Unit (ICU) (1)
- Labor and Delivery (1)
- Maternal Care (1)
- Medical Errors (2)
- Medical Liability (1)
- Medication (5)
- Medication: Safety (4)
- Nursing (1)
- Obesity (1)
- Opioids (2)
- Organizational Change (1)
- (-) Patient Safety (22)
- Policy (1)
- Pregnancy (1)
- Prevention (4)
- (-) Provider (22)
- Provider: Clinician (4)
- Provider: Health Personnel (1)
- Provider: Nurse (4)
- Provider: Pharmacist (4)
- Provider: Physician (7)
- Public Health (1)
- Quality Indicators (QIs) (1)
- Quality of Care (3)
- Simulation (1)
- Sleep Problems (1)
- Substance Abuse (1)
- Surgery (4)
- Teams (2)
- Training (2)
- Transitions of Care (2)
- Trauma (1)
- Urinary Tract Infection (UTI) (1)
- Women (1)
- Workflow (1)
- Workforce (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 22 of 22 Research Studies DisplayedAilabouni NJ, Marcum ZA, Schmader KE
Medication use quality and safety in older adults: 2018 update.
This study identified four key articles from 2018 that address medication use quality and safety for older adults. The first study highlighted a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and doctors to deprescribe four types of inappropriate medications. The second study from the UK examined the association between anticholinergic exposure, overall and by medication class, and dementia risk in 40,770 older adults. The third study was a Swedish longitudinal cohort study examining the association between antihypertensive medications and incident dementia. The fourth and last study was a randomized, double-blind, placebo-controlled trial and examined the effect of daily low-dose aspirin for primary prevention of cardiac events and hemorrhage in 19,144 community-dwelling older adults.
AHRQ-funded; HS022982.
Citation: Ailabouni NJ, Marcum ZA, Schmader KE .
Medication use quality and safety in older adults: 2018 update.
J Am Geriatr Soc 2019 Dec;67(12):2458-62. doi: 10.1111/jgs.16243..
Keywords: Elderly, Medication, Medication: Safety, Patient Safety, Quality of Care, Provider: Pharmacist, Provider
Krein SL, Kuhn L, Ratz D
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
The authors identified the prevalence of and factors associated with having a designated nurse peripherally inserted central catheter (PICC) team among U.S. acute care hospitals. They found that nurse PICC teams inserted PICCs in more than 60% of U.S. hospitals during the study period. Moreover, certain practices to prevent central line-associated bloodstream infection, including maximum sterile barrier precautions, chlorhexidine gluconate for insertion site antisepsis, and facility-wide insertion checklists were regularly used by a higher percentage of hospitals with nurse PICC teams compared with those without. They concluded that nurse PICC teams play an integral role in PICC use at many hospitals and that use of such teams may promote key practices to prevent complications.
AHRQ-funded; HS022835.
Citation: Krein SL, Kuhn L, Ratz D .
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study.
J Patient Saf 2019 Dec;15(4):293-95. doi: 10.1097/pts.0000000000000246..
Keywords: Nursing, Teams, Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Inpatient Care, Hospitals, Patient Safety, Prevention, Provider: Nurse, Provider
Kurian S, Baloy B, Baird J
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.
AHRQ-funded; HS024021.
Citation: Kurian S, Baloy B, Baird J .
Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.
J Am Pharm Assoc 2019 Nov-Dec;59(6):824-31. doi: 10.1016/j.japh.2019.08.009..
Keywords: Medication, Medication: Safety, Opioids, Substance Abuse, Provider: Pharmacist, Provider, Patient Safety
Manojlovich M, Ameling JM, Forman J
Contextual barriers to communication between physicians and nurses about appropriate catheter use.
This study identified contextual barriers to communication between physicians and nurses that contribute to inappropriate use of catheters and increased risk of health care-associated infections. The researchers conducted individual and small-group semistructured interviewed with physicians and nurses in a progressive care unit of an academic hospital. Common barriers included workflow misalignment between clinicians, issues with electronic medical records and pagers, and strained relationships between clinicians.
AHRQ-funded; HS024385.
Citation: Manojlovich M, Ameling JM, Forman J .
Contextual barriers to communication between physicians and nurses about appropriate catheter use.
Am J Crit Care 2019 Jul;28(4):290-98. doi: 10.4037/ajcc2019372..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Communication, Healthcare-Associated Infections (HAIs), Patient Safety, Provider, Provider: Nurse, Provider: Physician, Urinary Tract Infection (UTI), Workflow
McCarthy DM, Russell AM , Effler MR
Implementation fidelity of patient-centered prescription label to promote opioid safe use.
The authors assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording. They found that exact intervention adherence was not achieved in the majority of cases, limiting impact, but that community pharmacies were responsive to new instructions, with higher implementation reliability requiring additional supports.
AHRQ-funded; HS023459.
Citation: McCarthy DM, Russell AM , Effler MR .
Implementation fidelity of patient-centered prescription label to promote opioid safe use.
Pharmacoepidemiol Drug Saf 2019 Sep;28(9):1251-57. doi: 10.1002/pds.4795..
Keywords: Opioids, Patient Safety, Health Literacy, Medication, Provider: Pharmacist, Provider
Brunsberg KA, Landrigan CP, Garcia BM
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
The objective of this paper was to determine whether higher rates of medical errors were associated with positive screenings for depression or burnout among resident physicians. Results of this prospective cohort study showed that resident physicians with a positive depression screen were three times more likely than those who screened negative to make harmful errors, indicating the importance of determining what interventions might mitigate the patient safety risk.
AHRQ-funded; HS019456.
Citation: Brunsberg KA, Landrigan CP, Garcia BM .
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
Acad Med 2019 Aug;94(8):1150-56. doi: 10.1097/acm.0000000000002778..
Keywords: Children/Adolescents, Provider: Physician, Provider, Medical Errors, Adverse Events, Burnout, Patient Safety, Depression, Behavioral Health
Hoonakker PLT, Wooldridge AR, Hose BZ
Information flow during pediatric trauma care transitions: things falling through the cracks.
In order to investigate information flow during pediatric trauma care transitions, researchers interviewed 18 clinicians about communication and coordination between the emergency department, operating room, and pediatric intensive care unit, then surveyed the clinicians about patient safety during these transitions. They found that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To manage the transition of this fragile and complex population better, they recommend finding ways to manage the information flow during these transitions better by, for instance, providing technological support to ensure shared mental models.
AHRQ-funded; HS023837.
Citation: Hoonakker PLT, Wooldridge AR, Hose BZ .
Information flow during pediatric trauma care transitions: things falling through the cracks.
Intern Emerg Med 2019 Aug;14(5):797-805. doi: 10.1007/s11739-019-02110-7..
Keywords: Children/Adolescents, Communication, Emergency Department, Healthcare Delivery, Intensive Care Unit (ICU), Patient Safety, Provider, Provider: Clinician, Surgery, Transitions of Care, Trauma
Simpson KR, Lyndon A, Spetz J
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Labor and delivery nurses were surveyed to determine if their units adhere to Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines. Labor nurses in selected hospitals in California, Michigan and New Jersey were invited via email to participate in the study. Their nurse leaders facilitated the invitations. A total of 615 labor nurses from 67 hospitals participated. Most nurses did report that staffing guidelines were adhered to. The hospitals with smaller annual birth volumes (500-999 range) were significantly more like to be perceived as compliant than hospitals with 2,500 or more annual births.
AHRQ-funded; HS025715.
Citation: Simpson KR, Lyndon A, Spetz J .
Adherence to the AWHONN staffing guidelines as perceived by labor nurses.
Nurs Womens Health 2019 Jun;23(3):217-23. doi: 10.1016/j.nwh.2019.03.003..
Keywords: Care Management, Guidelines, Labor and Delivery, Maternal Care, Patient Safety, Pregnancy, Provider, Provider: Nurse, Women
Patel MR, Friese CR, Mendelsohn-Victor K
Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices.
This study examined the effects of electronic health records (EHRs) on communication and patient safety in oncology practices. The authors conducted a survey of 297 oncology nurses and prescribers in a statewide collaborative. They found there was an inverse relationship between reliance on EHRs and safety.
AHRQ-funded; HS024914.
Citation: Patel MR, Friese CR, Mendelsohn-Victor K .
Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices.
J Oncol Pract 2019 Jun;15(6):e529-e36. doi: 10.1200/jop.18.00507..
Keywords: Cancer, Communication, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety, Provider, Provider: Clinician
Mueller SK, Schnipper JL
Physician perspectives on interhospital transfers.
This study examined physician perspectives of the common problems that occur during acute care hospital interhospital transfers. The process tends to be nonstandardized which creates a number of issues. These issues include: patients sometimes, frequently, or always arriving without required specialized care (56% of the time), arriving with unrealistic expectations of care (77.2% of responses), arrived more than 24 hours after accepted transfer in 80.1% of responses, and arrived without necessary transfer records 86.9% of the time. The last issue and also time of day of arrival many physicians felt posed a risk to the transferred patients.
AHRQ-funded; HS023331.
Citation: Mueller SK, Schnipper JL .
Physician perspectives on interhospital transfers.
J Patient Saf 2019 Jun;15(2):86-89. doi: 10.1097/pts.0000000000000312..
Keywords: Healthcare Delivery, Hospitals, Patient Safety, Provider, Provider: Physician, Transitions of Care
Woodard JA, Leekha S, Jackson SS
Beyond entry and exit: Hand hygiene at the bedside.
This study assessed compliance with, knowledge of, and attitudes toward the World Health Organization (WHO) 5 moments for hand hygiene (HH) using a modified WHO HH observation form and a survey that assessed health care personnel (HCP) knowledge, opinions, and barriers to HH. Of the 218 HCPs who completed the survey, less than one-third were familiar with the WHO 5 moments and only 21& of that group could recall the 5 moments. 302 HH opportunities in 104 unique HCP-patient interactions were observed, but with infrequent compliance. The researchers conclude that lack of recognition of opportunities at the bedside and for glove use may contribute to low compliance.
AHRQ-funded; HS024108.
Citation: Woodard JA, Leekha S, Jackson SS .
Beyond entry and exit: Hand hygiene at the bedside.
Am J Infect Control 2019 May;47(5):487-91. doi: 10.1016/j.ajic.2018.10.026..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Patient Safety, Prevention, Provider, Public Health
St Hilaire MA, Anderson C, Anwar J
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
This study examines the impact of reinstating extended duration (24-28) work shifts (EDWS) for postgraduate year 1 resident physicians. The performance of residents was studied for 23 male residents between 2002-2004 during a three-week on-call rotation schedule at the Medical and Intensive Care Units at Brigham and Women’s Hospital in Boston. If the sleep episodes were four hours or less then the odds of >1 attentional failure was 2.72 times higher during post-call compared to matched sessions during non-EDWS.
AHRQ-funded; HS012032.
Citation: St Hilaire MA, Anderson C, Anwar J .
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
Sleep 2019 May;42(5):pii: zsz041. doi: 10.1093/sleep/zsz041..
Keywords: Adverse Events, Education: Continuing Medical Education, Medical Errors, Patient Safety, Provider, Provider: Physician, Quality of Care, Sleep Problems, Training
de Cordova PB, Rogowski J, Riman KA
Effects of public reporting legislation of nurse staffing: a trend analysis.
The authors examined nurse staffing trends after the New Jersey enactment of P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. They found that the number of patients per registered nurse decreased for ten specialties, and conclude that this indicates the importance of public reporting in improving patient safety.
AHRQ-funded; HS024339.
Citation: de Cordova PB, Rogowski J, Riman KA .
Effects of public reporting legislation of nurse staffing: a trend analysis.
Policy Polit Nurs Pract 2019 May;20(2):92-104. doi: 10.1177/1527154419832112..
Keywords: Hospitals, Patient Safety, Workforce, Policy, Provider, Provider: Nurse
Baloh J, Thom KA, Perencevich E
Hand hygiene before donning nonsterile gloves: healthcareworkers' beliefs and practices.
The purpose of this study was to examine the practices and beliefs of health care workers related to the use of nonsterile gloves and associated hand hygiene (HH) before gloving. Gloving and HH practices of health care workers at three large academic hospitals were observed as they entered patient rooms, and interviews were conducted with providers, nurses, and nursing assistants to elicit their beliefs and perceptions of these hygiene practices. While interviewed health care workers reported 100% HH compliance before gloving, observed HH compliance was only 42% and observed gloving before entering contact precaution rooms was 78%. Most health care workers described glove use more often than was necessary, and generally used gloves for their own safety, and sanitized their hands before gloving for patient safety. The authors conclude that HH and glove use are intertwined in clinical practice and should be considered jointly to improve infection prevention improvement efforts.
AHRQ-funded; HS024108.
Citation: Baloh J, Thom KA, Perencevich E .
Hand hygiene before donning nonsterile gloves: healthcareworkers' beliefs and practices.
Am J Infect Control 2019 May;47(5):492-97. doi: 10.1016/j.ajic.2018.11.015..
Keywords: Provider: Clinician, Provider, Provider: Health Personnel, Patient Safety, Prevention
Vergis A, Hardy K, Stogryn S
Fellow and attending surgeon operative notes are deficient in reporting established quality indicators for Roux-en-y gastric bypass: a preliminary retrospective analysis of operative dictation.
This retrospective analysis investigated the completeness of reporting documentation for Roux-en-Y Gastric Bypass (RYGB) surgery. A total of 40 bariatric fellow and 40 attending RYGB narrative reports were analyzed. Fellows had a mean completion rate of 66.4% compared to 61.5% for attendings. Fellows also did a better job of completing subsections, with the exception of closure details. This information is important to communicating operative events and can make an impact on patient safety and quality.
AHRQ-funded; HS018546.
Citation: Vergis A, Hardy K, Stogryn S .
Fellow and attending surgeon operative notes are deficient in reporting established quality indicators for Roux-en-y gastric bypass: a preliminary retrospective analysis of operative dictation.
Cureus 2019 Apr 24;11(4):e4535. doi: 10.7759/cureus.4535..
Keywords: Obesity, Quality of Care, Quality Indicators (QIs), Patient Safety, Provider, Provider: Physician, Surgery
P Dellsperger, KC Fallaw, D
AHRQ Author: Rangachari
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
This study sought to identify issues related to electronic health record (EHR) medication reconciliation (MedRec) from the perspective of practitioners directly involved in the EHR MedRec process, with the goal of reducing medication discrepancies during transitions of care and improving the accuracy of patient medication lists. The study was conducted in two rounds: individual interviews, then a survey of physicians, nurses, and pharmacists based in the outpatient and inpatient medicine service at AU Health. The survey elicited practitioner ratings of the importance of issues identified during the interviews. Issues that were rated as important by more than 70 percent of respondents include care coordination, patient education, ownership and accountability, processes-of-care, IT-related issues, and workforce training. From these issues, the authors conclude that there is an absence of shared understanding among practitioners regarding the value of EHR MedRec in promoting patient safety, which contributes to work-arounds and the suboptimal use of the EHR MedRec system, and there is also a sociotechnical dimension to many of these issues which creates an additional layer of complexity.
AHRQ-funded; HS024335.
Citation: P Dellsperger, KC Fallaw, D .
A mixed-method study of practitioners' perspectives on issues related to EHR medication reconciliation at a health system.
Qual Manag Health Care 2019 Apr/Jun;28(2):84-95. doi: 10.1097/qmh.0000000000000208..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety, Provider, Provider: Clinician
Frasier LL, Pavuluri Quamme SR, Ma Y
Familiarity and communication in the operating room.
Researchers sought to evaluate the relationship between familiarity, communication rates, and communication ineffectiveness of health care providers in the operating room. They found that team members do not compensate for unfamiliarity by increasing their verbal communication, and dyad familiarity is not protective against ineffective communication. Cross-disciplinary communication remains vulnerable in the operating room, suggesting poor crosstalk across disciplines in the operative setting. They recommended further investigation to explore these relationships and identify effective interventions, ensuring that all team members have the necessary information to optimize their performance.
AHRQ-funded; HS022403.
Citation: Frasier LL, Pavuluri Quamme SR, Ma Y .
Familiarity and communication in the operating room.
J Surg Res 2019 Mar;235:395-403. doi: 10.1016/j.jss.2018.09.079..
Keywords: Communication, Patient Safety, Surgery, Teams, Provider: Physician, Provider
Werzen A, Thom KA, Robinson GL
Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: a multicenter cohort study.
The purpose of this study was to examine and compare the effect of covert observers versus brief observation periods on hand hygiene compliance. The authors conclude that compliance rates were greater when reported by infection prevention programs than when reported by covert observers over brief observation periods.
AHRQ-funded; HS024108.
Citation: Werzen A, Thom KA, Robinson GL .
Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: a multicenter cohort study.
Am J Infect Control 2019 Mar;47(3):346-48. doi: 10.1016/j.ajic.2018.08.015..
Keywords: Patient Safety, Prevention, Provider
Anton NE, Mizota T, Timsina LR
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
The objective of this study was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room. The investigators concluded that promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. They indicated that mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal.
AHRQ-funded; HS022080.
Citation: Anton NE, Mizota T, Timsina LR .
Attentional selectivity, automaticity, and self-efficacy predict simulator-acquired skill transfer to the clinical environment.
Am J Surg 2019 Feb;217(2):266-71. doi: 10.1016/j.amjsurg.2018.11.028..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider, Provider: Physician, Simulation, Surgery, Training
Schiff GD, Klinger E, Salazar A
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
In this study, the investigators evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist- to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, depression, and insomnia. Systematic automated telephone outreach monitoring coupled with real-time phone referral to a pharmacist identified a substantial number of previously unidentified potentially drug-related symptoms, many of which were validated as probably or possibly related to the drug by the pharmacist or their physicians.
AHRQ-funded; HS021094.
Citation: Schiff GD, Klinger E, Salazar A .
Screening for adverse drug events: a randomized trial of automated calls coupled with phone-based pharmacist counseling.
J Gen Intern Med 2019 Feb;34(2):285-92. doi: 10.1007/s11606-018-4672-7..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Health Information Technology (HIT), Provider: Pharmacist, Provider, Patient Safety
Singer SJ, Reyes Nieva H, Brede N
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
This study reports findings from the baseline practice staff and administrator surveys designed as part of the PROMISES Project to assess safety and malpractice risks in the ambulatory setting. It found that administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems were related to staff perceptions of their quality.
AHRQ-funded; HS019508.
Citation: Singer SJ, Reyes Nieva H, Brede N .
Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.
Med Care 2015 Feb;53(2):141-52. doi: 10.1097/mlr.0000000000000269..
Keywords: Ambulatory Care and Surgery, Patient Safety, Medical Liability, Provider
Sokas R, Braun B, Chenven L
AHRQ Author: Hogan E
Frontline hospital workers and the worker safety/patient safety nexus.
This article reported on panels and small-group discussions from a day-long workshop held in Washington, D.C., on October 25, 2012, to explore whether and how hospital-based frontline health care workers (HCWs) affect patient safety and how they experience safety in their work settings. Conference sponsors included AHRQ, and workshop sessions focused on the intersection of worker safety and patient safety and on specific steps that health care institutions have used to implement a culture of safety in the workplace.
AHRQ-authored.
Citation: Sokas R, Braun B, Chenven L .
Frontline hospital workers and the worker safety/patient safety nexus.
Jt Comm J Qual Patient Saf 2013 Apr;39(4):185-92.
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Keywords: Provider, Organizational Change, Patient Safety, Hospitals