National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (2)
- Ambulatory Care and Surgery (1)
- Communication (1)
- Dental and Oral Health (1)
- Education: Continuing Medical Education (1)
- Hospitals (1)
- Long-Term Care (1)
- Medical Errors (2)
- Medical Liability (1)
- Medication (2)
- Medication: Safety (2)
- Nursing Homes (1)
- Opioids (2)
- Outcomes (1)
- (-) Patient Safety (9)
- (-) Provider (9)
- Provider: Clinician (1)
- Provider: Nurse (2)
- Provider: Pharmacist (1)
- Provider: Physician (4)
- Provider Performance (1)
- Substance Abuse (2)
- Surgery (3)
- Surveys on Patient Safety Culture (2)
- Teams (1)
- Tools & Toolkits (1)
- Training (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 9 of 9 Research Studies DisplayedO'Leary KJ, Manojlovich M, Johnson JK
A multisite study of interprofessional teamwork and collaboration on general medical services.
This multisite study of four mid-sized hospitals measured teamwork climate of nurses, nurse assistants, and physicians working on general medical services. Teamwork climate scores for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurses) were measured using the Safety Attitudes Questionnaire. Hospitalists had the highest median teamwork climate score and nurses had the lowest, but it was not a statistically significant difference. A higher percentage of hospitalists (63.3%) rated the quality of collaboration with nurses as high or very high, but only 48.7% of nurses rated the collaboration with hospitalists as high or very high. There were significant differences in perceptions of teamwork climate across sites and across professional categories.
AHRQ-funded; HS025649.
Citation: O'Leary KJ, Manojlovich M, Johnson JK .
A multisite study of interprofessional teamwork and collaboration on general medical services.
Jt Comm J Qual Patient Saf 2020 Dec;46(12):667-72. doi: 10.1016/j.jcjq.2020.09.009..
Keywords: Teams, Hospitals, Patient Safety, Provider: Clinician, Provider: Physician, Provider: Nurse, Provider
Yansane A, Lee JH, Hebballi N
Assessing the patient safety culture in dentistry.
Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016.
AHRQ-funded; HS024406.
Citation: Yansane A, Lee JH, Hebballi N .
Assessing the patient safety culture in dentistry.
JDR Clin Trans Res 2020 Oct;5(4):399-408. doi: 10.1177/2380084419897614..
Keywords: Surveys on Patient Safety Culture, Patient Safety, Dental and Oral Health, Provider, Medical Errors, Adverse Events
Alley L, Novak K, Havlin T
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
The authors developed the Resources Encouraging Safe Prescription Opioid and Naloxone Dispensing (RESPOND) Toolkit to enhance community pharmacists' understanding of their role in addressing opioid safety; to improve integration of prescription drug monitoring program (PDMP) into daily workflow; and to enhance communication between pharmacists, prescribers, and patients. In this paper, they described the development of the RESPOND Toolkit and summarized their findings from initial pilot testing. They concluded that the RESPOND Toolkit has promise as an effective and scalable approach to providing community pharmacist-tailored training to promote behavioral shifts supporting opioid safety for patients.
AHRQ-funded; HS024227.
Citation: Alley L, Novak K, Havlin T .
Development and pilot of a prescription drug monitoring program and communication intervention for pharmacists
Res Social Adm Pharm 2020 Oct;16(10):1422-30. doi: 10.1016/j.sapharm.2019.12.023..
Keywords: Opioids, Substance Abuse, Medication, Medication: Safety, Patient Safety, Tools & Toolkits, Communication, Provider: Pharmacist, Provider, Training
Temkin-Greener H, Cen X, Li Y
Nursing home staff turnover and perceived patient safety culture: results from a national survey.
In this study, the investigators examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs). The investigators suggest that the effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.
AHRQ-funded; HS024923.
Citation: Temkin-Greener H, Cen X, Li Y .
Nursing home staff turnover and perceived patient safety culture: results from a national survey.
Gerontologist 2020 Sep 15;60(7):1303-11. doi: 10.1093/geront/gnaa015..
Keywords: Nursing Homes, Long-Term Care, Surveys on Patient Safety Culture, Patient Safety, Provider: Nurse, Provider
McClellan C, Flottemesch TJ, Ali MM
AHRQ Author: McClellan C
Physician networks and potentially inappropriate opioid prescriptions.
The authors examined associations between care networks defined by shared patients and problematic opioid prescribing using four behaviors defined by the CDC guidelines. They found that greater provider integration was associated with a lower risk of a provider's patients repeatedly having potentially inappropriate prescription fills; however, the association with a provider having any potentially problematic prescription was more ambiguous.
AHRQ-authored.
Citation: McClellan C, Flottemesch TJ, Ali MM .
Physician networks and potentially inappropriate opioid prescriptions.
J Addict Dis 2020 Jul-Sep;38(3):301-10. doi: 10.1080/10550887.2020.1760655..
Keywords: Opioids, Medication, Medication: Safety, Substance Abuse, Patient Safety, Provider
Khorfan R, Yuce TK, Love R
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.
The authors investigated the long-term effect of flexible duty-hour policies on resident outcomes. They found that cumulative time under flexible duty-hour policies had no detrimental effects on duty-hour violations or resident well-being. After multiple years of flexibility, residents continue to report a high rate of satisfaction and positive effects on continuity of care.
Citation: Khorfan R, Yuce TK, Love R .
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.
Ann Surg 2020 May;271(5):791-98. doi: 10.1097/sla.0000000000003802..
Keywords: Education: Continuing Medical Education, Patient Safety, Provider: Physician, Provider, Surgery
Sheetz KH, Nuliyalu U, Nathan H
Association of surgeon case numbers of pancreaticoduodenectomies vs related procedures with patient outcomes to inform volume-based credentialing.
The purpose of this study was to evaluate whether surgeon experience with related procedures was associated with better outcomes for pancreaticoduodenectomy compared with procedure-specific experience alone. In this proof-of-concept cohort study, few surgeons met even modest annual volume thresholds for pancreaticoduodenectomy. The investigators indicated that inclusion of related procedure volumes may safely expand the cohort of surgeons credentialed to perform certain procedures under volume-based standards.
AHRQ-funded; HS000053; HS024763.
Citation: Sheetz KH, Nuliyalu U, Nathan H .
Association of surgeon case numbers of pancreaticoduodenectomies vs related procedures with patient outcomes to inform volume-based credentialing.
JAMA Netw Open 2020 Apr;3(4):e203850. doi: 10.1001/jamanetworkopen.2020.3850..
Keywords: Surgery, Provider: Physician, Provider, Outcomes, Patient Safety
Banerjee A, Burden A, Slagle JM
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
This study analyzed performance gaps of practicing anesthesiologists, and used 4 different scenarios that illustrate those gaps and how they contribute to hazards in anesthesiology and proposals for addressing them. The authors used 4 standardized simulated scenarios of common events that anesthesiologists would expect to see in their practice. The 4 perioperative crisis events are: (1) local anesthetic systemic toxicity (LAST) leading to hemodynamic collapse; (2) retroperitoneal bleeding from insertion of a laparoscopic surgery trocar leading to hemorrhagic shock; (3) malignant hyperthermia (MH) presenting in the postanesthesia care unit; and (4) acute atrial fibrillation with hemodynamic instability, followed by signs of a ST-elevation myocardial infarction (AFib-MI). These scenarios came from a 2017 paper by Weinger, et al. A group of subject matter experts defined a set of clinical performance elements (CPEs) that they would expect to be performed in the scenarios. Only 4% of encounters in these scenarios had perfect performance by anesthesiologists where all prescribed CPEs were performed. Recommendations for improvement included providing high-fidelity simulation training, incorporating clinical lessons about gaps, fostering regular use by anesthesiologists and OR teams of clinical guidance, modifying organizational arrangements at clinical sites to ensure backup help is readily available, and implementing periodic formative performance assessments.
AHRQ-funded; HS020415.
Citation: Banerjee A, Burden A, Slagle JM .
Key performance gaps of practicing anesthesiologists: how they contribute to hazards in anesthesiology and proposals for addressing them.
Int Anesthesiol Clin 2020 Winter;58(1):13-20. doi: 10.1097/aia.0000000000000262..
Keywords: Medical Errors, Adverse Events, Adverse Drug Events (ADE), Patient Safety, Provider Performance, Provider: Physician, Provider, Surgery
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