National Healthcare Quality and Disparities Report
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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 25 of 265 Research Studies DisplayedNavis A, George MC, Nmashie A
Validation of the Safer Opioid Prescribing Evaluation Tool (SOPET) for assessing adherence to the Centers for Disease Control opioid prescribing guidelines.
This study assessed the use of the Safer Opioid Prescribing Evaluation Tool (SOPET) which was designed to improve the implementation of the 2016 Centers for Disease Control Guidelines on the prescription of opioids for chronic pain. Four raters with varying levels of clinical experience were trained to use the SOPET and then used it to evaluate 21 baseline patient scenarios. Inter-rater reliability was measured using intraclass correlation coefficient (ICC) estimates and their 95% confidence intervals for the total SOPET score based on a mean-rating absolute-agreement, two-way random-effects model. Inter-rater reliability was found to be good for the three physician raters (0.92, 0.97, and 0.99). However, inter-rater reliability for the non-physician rater was lower (0.67).
AHRQ-funded; HS025641.
Citation: Navis A, George MC, Nmashie A .
Validation of the Safer Opioid Prescribing Evaluation Tool (SOPET) for assessing adherence to the Centers for Disease Control opioid prescribing guidelines.
Pain Med 2020 Dec 25;21(12):3655-59. doi: 10.1093/pm/pnaa138..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Guidelines, Practice Patterns, Pain, Chronic Conditions, Evidence-Based Practice
Barnes GD
Combining antiplatelet and anticoagulant therapy in cardiovascular disease.
The author describes results of a number of randomized clinical trials that have explored different combinations of anticoagulation plus antiplatelet agents aimed at minimizing bleeding risk while preserving low thrombotic event rates. Findings include shorter courses with fewer antithrombotic agents as being effective, particularly when direct oral anticoagulants are combined with clopidogrel. Combined use of very low-dose rivaroxaban plus aspirin also demonstrated benefit in atherosclerotic diseases, including coronary and peripheral artery disease. Use of proton pump inhibitor therapy while patients were taking multiple antithrombotic agents had the potential to further reduce upper gastrointestinal bleeding risk in select populations. The author recommends that applying this evidence to patients with multiple thrombotic conditions will help to avoid costly and life-threatening adverse medication events.
AHRQ-funded; HS026874; HS026322.
Citation: Barnes GD .
Combining antiplatelet and anticoagulant therapy in cardiovascular disease.
Hematology Am Soc Hematol Educ Program 2020 Dec 4;2020(1):642-48. doi: 10.1182/hematology.2020000151..
Keywords: Blood Thinners, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Cardiovascular Conditions
O'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
Griffey RT, Schneider RM, Sharp BR
Description and yield of current quality and safety review in selected US academic emergency departments.
This study examined the impact of current quality and safety reviews used in US academic emergency departments (EDs). The authors hypothesized that current protocols are decades old and inefficient with low yield for identifying patient harm. They conducted a prospective observational study at five academic EDs for a 12-month procedure. Sites used the Institute for Healthcare Improvement’s definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for severity grading of events. They reviewed a total of 4735 cases and identified 381 events, of which 287 were near-misses, and 94 had adverse events (AEs). The overall AE rate was 1.99% (1.24-3.47%) across all sites. Quality concern rate (events without harms) was 6.06% (5.42-6.78%). Forty-seven percent of cases used 72 hour returns as their referral source but with only a 0.81% yield in identifying harm. Other referral sources also had similar low yields. External referrals in the 94 AE cases accounted for 41.49% of cases. The authors concluded that new approaches to quality and safety review in the ED are needed to optimize yield and efficiency for identifying harms and areas for improvement.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Description and yield of current quality and safety review in selected US academic emergency departments.
J Patient Saf 2020 Dec;16(4):e245-e49. doi: 10.1097/pts.0000000000000379..
Keywords: Emergency Department, Patient Safety, Quality Improvement, Quality of Care, Provider Performance
Soares WE, Schoenfeld EM, Visintainer P
Safety assessment of a noninvasive respiratory protocol for adults with COVID-19.
As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)-related respiratory distress, the investigators implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, the investigators conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020).
AHRQ-funded; HS025701.
Citation: Soares WE, Schoenfeld EM, Visintainer P .
Safety assessment of a noninvasive respiratory protocol for adults with COVID-19.
J Hosp Med 2020 Dec;15(12):734-38. doi: 10.12788/jhm.3548..
Keywords: Patient Safety, COVID-19, Respiratory Conditions, Inpatient Care, Infectious Diseases
Hu QL, Grant MC, Hornor MA
Technical evidence review for emergency major abdominal operation conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.
This technical evidence review focuses on the use of enhanced recovery pathways (ERPs) for emergency major abdominal surgery conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR). This national ERP initiative is funded by AHRQ and implemented in 2017 through a collaboration with American College of Surgeons, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. Five common emergency general surgery (EGS) procedures were focused on: perforated peptic ulcer repair, colectomy, lysis of adhesions, small bowel resection, and exploratory laparotomy. The authors identified seventeen candidate components for emergency major abdominal ERP. The components span the continuum of care from preoperative setting to hospital discharge. For every component they conducted a systematic literature review to find relevant studies. Each component was examined for rationale, evidence, and summary and recommendations. Many were supported by evidence and guidelines specific to their particular operation. Key gaps in literature were highlighted, specifically lack of evidence specific to these operations across many ERP processes.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Grant MC, Hornor MA .
Technical evidence review for emergency major abdominal operation conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.
J Am Coll Surg 2020 Dec;231(6):743-64.e5. doi: 10.1016/j.jamcollsurg.2020.08.772..
Keywords: Evidence-Based Practice, Surgery, Patient Safety, Quality Improvement, Quality of Care, Patient-Centered Outcomes Research
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
Branca A, Tellez D, Berkenbosch J
The new trainee effect in tracheal intubation procedural safety across PICUs in North America: a report from National Emergency Airway Registry for Children.
Researchers evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation-associated events in a retrospective cohort study of 37 PICUs participating in the National Emergency Airway Registry for Children.. They found that the New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation-associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Branca A, Tellez D, Berkenbosch J .
The new trainee effect in tracheal intubation procedural safety across PICUs in North America: a report from National Emergency Airway Registry for Children.
Pediatr Crit Care Med 2020 Dec;21(12):1042-50. doi: 10.1097/pcc.0000000000002480..
Keywords: Children/Adolescents, Critical Care, Intensive Care Unit (ICU), Adverse Events, Patient Safety, Registries, Education: Continuing Medical Education, Training
Salmasian H, Blanchfield BB, Joyce K
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). The purpose of this study was to evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.
AHRQ-funded; HS024713.
Citation: Salmasian H, Blanchfield BB, Joyce K .
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
AMA Netw Open 2020 Nov 2;3(11):e2019652. doi: 10.1001/jamanetworkopen.2020.19652..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Diagnostic Safety and Quality
Yang J, Wang L, Phadke
Development and validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals,
Although critical to patient safety, health care-related allergic reactions are challenging to identify and monitor. The purpose of this study was to develop a deep learning model to identify allergic reactions in the free-text narrative of hospital safety reports and evaluate its generalizability, efficiency, productivity, and interpretability. The investigators concluded that their study showed that a deep learning model could accurately and efficiently identify allergic reactions using free-text narratives written by a variety of health care professionals.
AHRQ-funded; HS025375.
Citation: Yang J, Wang L, Phadke .
Development and validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals,
JAMA Netw Open 2020 Nov 2;3(11):e2022836. doi: 10.1001/jamanetworkopen.2020.22836..
Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Patient Safety
Luo B, McLoone M, Rasooly IR
Analysis: protocol for a new method to measure physiologic monitor alarm responsiveness.
A team of researchers including biomedical engineers, human factors engineers, information technology specialists, nurses, physicians, facilitators from a hospital’s simulation center, clinical informaticians, and hospital administrative leadership worked with three units at a pediatric hospital to design and conduct simulations on newly implemented monitoring technology that will be used for patient critical alarms. The system was tested using a simulation with existing hospital technology to transmit an unambiguously critical alarm that appeared to originate from an actual patient to the nurse’s mobile device, with discreet observers measuring responses.
AHRQ-funded; HS026620.
Citation: Luo B, McLoone M, Rasooly IR .
Analysis: protocol for a new method to measure physiologic monitor alarm responsiveness.
Biomed Instrum Technol 2020 Nov/Dec;54(6):389-96. doi: 10.2345/0899-8205-54.6.389..
Keywords: Children/Adolescents, Hospitals, Simulation, Quality Improvement, Quality of Care, Patient Safety, Health Information Technology (HIT)
Hu QL, Fischer CP, Wescott AB
Evidence review for the American College of Surgeons Quality Verification part I: building quality and safety resources and infrastructure.
The goal of this review was to synthesize the evidence supporting the first 4 of 12 American College of Surgeons (ACS) Quality Verification Program core principles of building quality and safety resources and infrastructure. Findings showed that, despite heterogeneous study design and lack of randomized controlled trials, the available literature supports the importance of committed top-level hospital leadership, mid-level leadership, and committee dedicated to surgical quality and culture of safety and high reliability. In conclusion, adequate resources and infrastructure integral to the ACS Quality Verification Program are critical to achieving safe and high-quality surgical outcomes.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Fischer CP, Wescott AB .
Evidence review for the American College of Surgeons Quality Verification part I: building quality and safety resources and infrastructure.
J Am Coll Surg 2020 Nov;231(5):557-69.e1. doi: 10.1016/j.jamcollsurg.2020.08.758..
Keywords: Quality Improvement, Quality of Care, Patient Safety, Surgery, Evidence-Based Practice
Mangrum R, Stewart MD, Gifford DR
Omissions of care in nursing homes: a uniform definition for research and quality improvement.
The goal of this study was to create a uniform definition of omission of care in US nursing homes. Lack of a uniform definition has made efforts to prevent them challenging. Subject matter experts and a broad range of nursing home stakeholders were brought together in iterative rounds of engagement to identify key concepts and aspects of omissions of care and develop a consensus-based definition. The concise definition decided on was: “Omissions of care in nursing homes encompass situations when care–either clinical or nonclinical–is not provided for a resident and results in additional monitoring or intervention or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident."
AHRQ-funded; 233201500014I.
Citation: Mangrum R, Stewart MD, Gifford DR .
Omissions of care in nursing homes: a uniform definition for research and quality improvement.
J Am Med Dir Assoc 2020 Nov;21(11):1587-91.e2. doi: 10.1016/j.jamda.2020.08.016..
Keywords: Elderly, Nursing Homes, Long-Term Care, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety, Risk, Patient-Centered Outcomes Research
Anderson DJ, Ilieş I, Foy K
Early recognition and response to increases in surgical site infections using optimized statistical process control charts-the Early 2RIS Trial: a multicenter cluster randomized controlled trial with stepped wedge design.
This paper discusses the study protocol that was used to conduct the Early 2RIS Trial, which was a multicenter cluster randomized controlled trial from 2016 to 2020 to reduce surgical site infection (SSI) rates. The trial was performed in 29 hospitals in the Duke Infection Control Outreach Network (DICON) and 105 clusters over 4 years. All patients who underwent one of 13 targeted procedures at study hospitals were included. Six clusters were identified: cardiac, orthopedic, gastrointestinal, OB-GYN, vascular, and spinal. Clusters were randomized to intervention, and also underwent surveillance and feedback using optimized SPC charts. Surveillance data feedback was provided to all clusters, regardless of allocation or type of surveillance. The goal was to lower SSI through SPC intervention compared to traditional surveillance and feedback alone.
AHRQ-funded; HS023821.
Citation: Anderson DJ, Ilieş I, Foy K .
Early recognition and response to increases in surgical site infections using optimized statistical process control charts-the Early 2RIS Trial: a multicenter cluster randomized controlled trial with stepped wedge design.
Trials 2020 Oct 28;21(1):894. doi: 10.1186/s13063-020-04802-4..
Keywords: Surgery, Healthcare-Associated Infections (HAIs), Infectious Diseases, Patient Safety
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
Yuce TK, Yang AD, Johnson JK
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.
Hospital safety culture remains a critical consideration when seeking to reduce medical errors and improve quality of care. Little is known regarding whether participation in a comprehensive, multicomponent, statewide quality collaborative is associated with changes in hospital safety culture. The purpose of this study was to examine whether implementation of a comprehensive, multicomponent, statewide surgical quality improvement collaborative was associated with changes in hospital safety culture.
AHRQ-funded; HS024516.
Citation: Yuce TK, Yang AD, Johnson JK .
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.
JAMA Surg 2020 Oct;155(10):934-40. doi: 10.1001/jamasurg.2020.2842..
Keywords: Hospitals, Patient Safety, Organizational Change, Quality Improvement, Quality of Care, Implementation
Toce MS, Michelson K, Hudgins J
Association of state-level opioid-reduction policies with pediatric opioid poisoning.
Opioid-reduction policies have been enacted by US states to address the opioid epidemic. Evidence of an association between policy implementation and decreased rates of pediatric opioid poisoning provides further justification for expanded implementation of these policies. The purpose of this study was to examine the association of 3 state-level opioid-reduction policies with the rate of opioid poisoning in children and adolescents.
AHRQ-funded; HS026503.
Citation: Toce MS, Michelson K, Hudgins J .
Association of state-level opioid-reduction policies with pediatric opioid poisoning.
JAMA Pediatr 2020 Oct;174(10):961-68. doi: 10.1001/jamapediatrics.2020.1980..
Keywords: Children/Adolescents, Opioids, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Policy
Yao X, Inselman JW, Ross JS
Comparative effectiveness and safety of oral anticoagulants across kidney function in patients with atrial fibrillation.
Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. This study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation.
AHRQ-funded; HS025517; HS025164; HS025402; HS022882; HS024075.
Citation: Yao X, Inselman JW, Ross JS .
Comparative effectiveness and safety of oral anticoagulants across kidney function in patients with atrial fibrillation.
Circ Cardiovasc Qual Outcomes 2020 Oct;13(10):e006515. doi: 10.1161/circoutcomes.120.006515..
Keywords: Kidney Disease and Health, Cardiovascular Conditions, Blood Thinners, Medication, Medication: Safety, Patient Safety, Comparative Effectiveness, Patient-Centered Outcomes Research, Evidence-Based Practice, Outcomes
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
Yen PY, Lehmann LS, Snyder J
Development and validation of WeCares, a survey instrument to assess hospitalized patients' and family members' "Willingness to engage in your care and safety."
Patient engagement is recognized as a method to improve care quality and safety. A research team developed WeCares (Willingness to Engage in Your Care and Safety), a survey instrument assessing patients' and families' engagement in the safety of their care during their hospital stay. The objective of this study was to establish the preliminary construct validity and internal consistency of WeCares.
AHRQ-funded; HS0235335.
Citation: Yen PY, Lehmann LS, Snyder J .
Development and validation of WeCares, a survey instrument to assess hospitalized patients' and family members' "Willingness to engage in your care and safety."
Jt Comm J Qual Patient Saf 2020 Oct;46(10):565-72. doi: 10.1016/j.jcjq.2020.07.002..
Keywords: Patient and Family Engagement, Patient Safety, Inpatient Care, Hospitalization
Slatnick LR, Thornhill D, Deakyne Davies
Disseminated intravascular coagulation is an independent predictor of adverse outcomes in children in the emergency department with suspected sepsis.
The purpose of this study was to evaluate the impact of early disseminated intravascular coagulation (DIC) on illness severity in children using a database of emergency department ED encounters for children with suspected sepsis, in view of similar associations in adults. The investigators concluded that a DIC score of ≥3 was an independent predictor for both vasopressor use and mortality in this pediatric cohort, distinct from the adult overt DIC score cutoff of ≥5.
AHRQ-funded; HS025696.
Citation: Slatnick LR, Thornhill D, Deakyne Davies .
Disseminated intravascular coagulation is an independent predictor of adverse outcomes in children in the emergency department with suspected sepsis.
J Pediatr 2020 Oct;225:198-206.e2. doi: 10.1016/j.jpeds.2020.06.022..
Keywords: Children/Adolescents, Emergency Department, Sepsis, Adverse Events, Mortality, Patient Safety, Outcomes
Isbell LM, Tager J, Beals K
Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety.
Emergency department (ED) physicians and nurses frequently interact with emotionally evocative patients, which can impact clinical decision-making and behaviour. This study introduced well-established methods from social psychology to investigate ED providers' reported emotional experiences and engagement in their own recent patient encounters, as well as perceived effects of emotion on patient care.
AHRQ-funded; HS025752.
Citation: Isbell LM, Tager J, Beals K .
Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety.
BMJ Qual Saf 2020 Oct;29(10):1-2. doi: 10.1136/bmjqs-2019-010110..
Keywords: Emergency Department, Patient Safety
Emeriaud G, Napolitano N, Polikoff P
Impact of failure of noninvasive ventilation on the safety of pediatric tracheal intubation.
This prospective multicenter cohort study’s objective was to assess whether noninvasive ventilation failure in critically ill children was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. Data from the National Emergency Airway Registry for Children was used to examine data from thirteen PICUs (in 12 institutions) in the United States and Canada. The study included 956 tracheal intubation encounters, with 424 (44%) occurring after noninvasive ventilation failure with a median of 13 hours of noninvasive ventilation. The failure group included more infants (47% vs 33%) and patients with a respiratory diagnosis (56% vs 30%). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events without noninvasive ventilation but was associated with severe desaturation (15% vs 9%) without noninvasive ventilation.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Emeriaud G, Napolitano N, Polikoff P .
Impact of failure of noninvasive ventilation on the safety of pediatric tracheal intubation.
Crit Care Med 2020 Oct;48(10):1503-12. doi: 10.1097/ccm.0000000000004500..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Patient Safety, Adverse Events
Feldman AG, Parsons JA, Dutmer CM
Subacute liver failure following gene replacement therapy for spinal muscular atrophy type 1.
This paper reports on two cases of transient, drug-induced liver failure after gene replacement therapy using an adeno-associated virus vector containing the survival motor neuron 1 gene.
AHRQ-funded; HS026510.
Citation: Feldman AG, Parsons JA, Dutmer CM .
Subacute liver failure following gene replacement therapy for spinal muscular atrophy type 1.
J Pediatr 2020 Oct;225:252-58.e1. doi: 10.1016/j.jpeds.2020.05.044..
Keywords: Newborns/Infants, Neurological Disorders, Genetics, Treatments, Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Patient Safety, Case Study
Robbins j, McAlearney AS
Toward a high-performance management system in health care, part 5: how high-performance work practices facilitate speaking up in health care organizations.
Employees' reluctance to speak up about problems and/or make suggestions for improvement is a noted barrier to quality and patient safety improvement in health care organizations. High-performance work practices (HPWPs) offer a framework for considering how management practices can encourage speaking up in these organizations. In this study, the investigators aimed to explore how implementation of HPWPs in U.S. health care organizations could facilitate or remove barriers to speaking up.
AHRQ-funded; 290200600022.
Citation: Robbins j, McAlearney AS .
Toward a high-performance management system in health care, part 5: how high-performance work practices facilitate speaking up in health care organizations.
Health Care Manage Rev 2020 Oct/Dec;45(4):278-89. doi: 10.1097/hmr.0000000000000228..
Keywords: Quality Improvement, Quality of Care, Patient Safety, Provider Performance