National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- (-) Adverse Events (38)
- Ambulatory Care and Surgery (1)
- Antimicrobial Stewardship (1)
- Blood Clots (1)
- Cancer: Colorectal Cancer (1)
- Cardiovascular Conditions (3)
- Care Management (1)
- Children/Adolescents (4)
- Clinician-Patient Communication (2)
- Colonoscopy (1)
- Communication (4)
- Dialysis (1)
- Disparities (1)
- Education: Continuing Medical Education (1)
- Education: Patient and Caregiver (2)
- Evidence-Based Practice (2)
- Guidelines (1)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Cost and Utilization Project (HCUP) (3)
- Healthcare Costs (1)
- Health Information Technology (HIT) (1)
- Heart Disease and Health (4)
- Hospitalization (4)
- Hospital Readmissions (1)
- Hospitals (5)
- Intensive Care Unit (ICU) (2)
- Kidney Disease and Health (2)
- Labor and Delivery (1)
- Long-Term Care (1)
- Medical Errors (9)
- Medical Liability (5)
- Medicare (2)
- Medication (1)
- Medication: Safety (1)
- Mortality (5)
- Neurological Disorders (1)
- Newborns/Infants (1)
- Nursing (1)
- Nursing Homes (1)
- Obesity (1)
- Orthopedics (1)
- Outcomes (3)
- Patient-Centered Healthcare (1)
- Patient-Centered Outcomes Research (2)
- (-) Patient Safety (38)
- Pneumonia (1)
- Practice Patterns (2)
- Pregnancy (1)
- Prevention (1)
- Provider Performance (1)
- Quality Improvement (2)
- Quality Indicators (QIs) (3)
- Quality Measures (1)
- Quality of Care (4)
- Respiratory Conditions (1)
- Risk (7)
- Stress (1)
- Surgery (9)
- Teams (2)
- Tools & Toolkits (1)
- Training (1)
- Transplantation (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 25 of 38 Research Studies DisplayedBurstein PD, Zalenski DM, Edwards JL
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
The researchers established a multifactorial shoulder dystocia response and management protocol to promote sustainable practice change. In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.
AHRQ-funded; HS019608.
Citation: Burstein PD, Zalenski DM, Edwards JL .
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2472-86. doi: 10.1111/1475-6773.12589.
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Keywords: Labor and Delivery, Newborns/Infants, Adverse Events, Quality Improvement, Quality of Care, Patient Safety, Patient-Centered Outcomes Research, Outcomes, Guidelines, Evidence-Based Practice, Pregnancy, Teams
Gallagher TH, Farrell ML, Karson H
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
The Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. After describing the process, the authors concluded that the CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Farrell ML, Karson H .
Collaboration with regulators to support quality and accountability following medical errors: The Communication and Resolution Program Certification Pilot.
Health Serv Res 2016 Dec;51 Suppl 3:2569-82. doi: 10.1111/1475-6773.12557.
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Keywords: Adverse Events, Communication, Medical Errors, Medical Liability, Patient Safety, Quality of Care
Brown JR, Rezaee ME, Marshall EJ
Hospital mortality in the United States following acute kidney injury.
This review discusses the epidemiology of acute kidney injury (AKI) and its association with in-hospital mortality in the United States. Also discussed is the importance of the 71 percent reduction in AKI-related mortality among hospitalized patients in the United States and whether or not this is a phenomenon of hospital billing (coding) or improvements to the management of AKI.
AHRQ-funded; HS018443.
Citation: Brown JR, Rezaee ME, Marshall EJ .
Hospital mortality in the United States following acute kidney injury.
Biomed Res Int 2016;2016:4278579. doi: 10.1155/2016/4278579.
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Keywords: Mortality, Hospitalization, Adverse Events, Patient Safety
Gallagher TH, Etchegaray JM, Bergstedt B
Improving communication and resolution following adverse events using a patient-created simulation exercise.
The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.
AHRQ-funded; HS019531.
Citation: Gallagher TH, Etchegaray JM, Bergstedt B .
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Health Serv Res 2016 Dec;51 Suppl 3:2537-49. doi: 10.1111/1475-6773.12601.
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Keywords: Adverse Events, Clinician-Patient Communication, Medical Errors, Medical Liability, Patient-Centered Healthcare, Patient Safety
Battles JB, Reback KA, Azam I
AHRQ Author: Battles JB, Reback KA, Azam I
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
AHRQ launched the Patient Safety and Medical Liability (PSML) initiative in 2009. The papers in this issue cover a breadth of topics related to the PSML initiative. Members of the individual Demonstration project teams have authored the majority of the papers. Seven of these papers report outcomes associated with the individual Demonstrations and another four describe tools generated as a part of the interventions.
AHRQ-funded; 233201500029P.
Citation: Battles JB, Reback KA, Azam I .
Paving the way for progress: the Agency for Healthcare Research and Quality Patient Safety and Medical Liability Demonstration Initiative.
Health Serv Res 2016 Dec;51 Suppl 3:2401-13. doi: 10.1111/1475-6773.12632.
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Keywords: Adverse Events, Medical Errors, Medical Liability, Patient Safety, Prevention
Ridgely MS, Greenberg MD, Pillen MB
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
This article identifies lessons learned from the experience of AHRQ’s Patient Safety and Medical Liability (PSML) Demonstration Program. The demonstration lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm.
AHRQ-funded; 290200710073T.
Citation: Ridgely MS, Greenberg MD, Pillen MB .
Progress at the intersection of patient safety and medical liability: insights from the AHRQ Patient Safety and Medical Liability Demonstration Program.
Health Serv Res 2016 Dec;51 Suppl 3:2414-30. doi: 10.1111/1475-6773.12625.
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Keywords: Patient Safety, Medical Liability, Adverse Events, Medical Errors
Brown JR, Rezaee ME, Hisey WM
Reduced mortality associated with acute kidney injury requiring dialysis in the United States.
The researchers describe the epidemiology of dialysis-requiring acute kidney injury (AKI-D) as well as associated in-hospital mortality in the US. They found that the incidence rate of AKI-D has increased considerably in the US since 2001. However, in-hospital mortality associated with AKI-D hospital admissions has decreased significantly. AHRQ-funded; HS018443.
AHRQ-funded; HS018443.
Citation: Brown JR, Rezaee ME, Hisey WM .
Reduced mortality associated with acute kidney injury requiring dialysis in the United States.
Am J Nephrol 2016;43(4):261-70. doi: 10.1159/000445846.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Events, Mortality, Patient Safety, Kidney Disease and Health
Lambert BL, Centomani NM, Smith KM
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
This study's objective was to determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes. It found that the intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs. The study found that a communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.
AHRQ-funded; HS019565.
Citation: Lambert BL, Centomani NM, Smith KM .
The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2491-515. doi: 10.1111/1475-6773.12548.
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Keywords: Adverse Events, Medical Liability, Medical Errors, Communication, Patient Safety
Kesselheim AS, Bykov K, Gagne JJ
Switching generic antiepileptic drug manufacturer not linked to seizures: a case-crossover study.
The researchers estimated the risk of seizure-related events associated with refilling antiepileptic drugs (AED) with generic AEDs and the effect of switching between different manufacturers of the same generic drug. They found that among patients on a generic AED, refilling the same AED was associated with an elevated risk of seizure-related event; however, there was no additional risk from switching during that refill to a different manufacturer.
AHRQ-funded; HS022193.
Citation: Kesselheim AS, Bykov K, Gagne JJ .
Switching generic antiepileptic drug manufacturer not linked to seizures: a case-crossover study.
Neurology 2016 Oct 25;87(17):1796-801. doi: 10.1212/wnl.0000000000003259.
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Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Neurological Disorders, Patient Safety, Risk
Pradarelli JC, Healy MA, Osborne NH
Variation in Medicare expenditures for treating perioperative complications: the cost of rescue.
The researchers evaluated differences across hospitals in the costs of care for patients surviving perioperative complications after major inpatient surgery. After 4 selected inpatient operations, substantial variation was observed across hospitals regarding Medicare episode payments for patients rescued from perioperative complications. Notably, higher Medicare payments were not associated with improved clinical performance.
AHRQ-funded; HS017765.
Citation: Pradarelli JC, Healy MA, Osborne NH .
Variation in Medicare expenditures for treating perioperative complications: the cost of rescue.
JAMA Surg 2016 Oct 5:e163340. doi: 10.1001/jamasurg.2016.3340.
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Keywords: Medicare, Adverse Events, Surgery, Healthcare Costs, Patient Safety
Strobel RJ, Liang Q, Zhang M
A preoperative risk model for postoperative pneumonia after coronary artery bypass grafting.
The authors developed a preoperative prediction model for postoperative pneumonia after coronary artery bypass grafting (CABG). In this article, they describe and discuss their model, which may be used to provide individualized risk estimation and to identify opportunities to reduce a patient's preoperative risk of pneumonia through prehabilitation.
AHRQ-funded; HS022535.
Citation: Strobel RJ, Liang Q, Zhang M .
A preoperative risk model for postoperative pneumonia after coronary artery bypass grafting.
Ann Thorac Surg 2016 Oct;102(4):1213-9. doi: 10.1016/j.athoracsur.2016.03.074.
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Keywords: Cardiovascular Conditions, Pneumonia, Adverse Events, Risk, Patient Safety
Waljee JF, Ghaferi A, Cassidy R
Are patient-reported outcomes correlated with clinical outcomes after surgery? A population-based study.
The researchers evaluated the extent to which patient-reported outcomes (eg, health-related quality of life) are distinct from clinical outcomes following bariatric surgery. They concluded that patient-reported outcomes are not correlated with early perioperative events, but are correlated with measures of clinical effectiveness after bariatric surgery.
AHRQ-funded; HS023313.
Citation: Waljee JF, Ghaferi A, Cassidy R .
Are patient-reported outcomes correlated with clinical outcomes after surgery? A population-based study.
Ann Surg 2016 Oct;264(4):682-9. doi: 10.1097/sla.0000000000001852.
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Keywords: Surgery, Obesity, Adverse Events, Patient-Centered Outcomes Research, Patient Safety
Krouss M, Croft L, Morgan DJ
Physician understanding and ability to communicate harms and benefits of common medical treatments.
The researchers evaluated physician understanding of harms and benefits of common tests and therapies. They found that most clinicians overestimate harms and benefits for most treatments. Likewise, most of the clinicians in our study reported rarely or never using statistical terms to explain treatment options to patients. However, they were interested in resources to improve understanding of treatment effect size.
AHRQ-funded; HS018111.
Citation: Krouss M, Croft L, Morgan DJ .
Physician understanding and ability to communicate harms and benefits of common medical treatments.
JAMA Intern Med 2016 Oct;176(10):1565-67. doi: 10.1001/jamainternmed.2016.5027.
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Keywords: Adverse Events, Communication, Education: Patient and Caregiver, Patient Safety, Clinician-Patient Communication
Tedesco D, Hernandez-Boussard T, Carretta E
Evaluating patient safety indicators in orthopedic surgery between Italy and the USA.
The authors compared patient safety in major orthopedic procedures between an orthopedic hospital in Italy and 26 Florida hospitals of similar size. AHRQ Patient Safety Indicators (PSIs) were used to identify inpatient adverse events (AEs). They found that US patients had lower adjusted odds of developing a PSI compared to Italy for pressure ulcers, hemorrhage or hematoma, and physiologic and metabolic derangement. while Italian patients had lower odds of pulmonary embolism/deep vein thrombosis compared to US patients.
AHRQ-funded; HS018558.
Citation: Tedesco D, Hernandez-Boussard T, Carretta E .
Evaluating patient safety indicators in orthopedic surgery between Italy and the USA.
Int J Qual Health Care 2016 Sep;28(4):486-91. doi: 10.1093/intqhc/mzw053.
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Keywords: Adverse Events, Orthopedics, Patient Safety, Quality Indicators (QIs), Surgery
Mueller SK, Schnipper JL, Giannelli K
Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services.
This study regionalized 3 inpatient general medical teams to nursing units and examined the association with communication and preventable adverse events (AEs). It found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs.
AHRQ-funded; HS023331.
Citation: Mueller SK, Schnipper JL, Giannelli K .
Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services.
J Hosp Med 2016 Sep;11(9):620-7. doi: 10.1002/jhm.2566.
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Keywords: Adverse Events, Communication, Hospitals, Patient Safety, Teams
Lavin JM, Boss EF, Brereton J
Responses to errors and adverse events: the need for a systems approach in otolaryngology.
The authors reported otolaryngologists' reactions to errors and adverse events and determined if temporal changes in physician efforts to assume responsibility; ameliorate patients' conditions; or change personal, group-wide, or hospital practices have occurred. Members of the American Academy of Otolaryngology-Head and Neck Surgery were surveyed. The undertaking of corrective actions was reported, and these events led to changes in personal, group/departmental, and hospital practice. The authors found that efforts to change personal practice were much more common than efforts to improve systems.
AHRQ-funded; HS022932.
Citation: Lavin JM, Boss EF, Brereton J .
Responses to errors and adverse events: the need for a systems approach in otolaryngology.
Laryngoscope 2016 Sep;126(9):1999-2002. doi: 10.1002/lary.25837.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Practice Patterns
Wang Y, Eldridge N, Metersky ML
AHRQ Author: Eldridge N, Battles J
National trends in patient safety for four common conditions, 2005-2011.
The researchers estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery.
AHRQ-authored; AHRQ-funded; 290201200003C.
AHRQ-authored; AHRQ-funded; 290201200003C.
AHRQ-authored; AHRQ-funded; 290201200003C.
Citation: Wang Y, Eldridge N, Metersky ML .
National trends in patient safety for four common conditions, 2005-2011.
N Engl J Med 2014 Jan 23;370(4):341-51. doi: 10.1056/NEJMsa1300991..
Keywords: Patient Safety, Adverse Events, Hospitalization, Heart Disease and Health
Healy MA, Grenda TR, Suwanabol PA
Colon cancer operations at high- and low-mortality hospitals.
The authors sought to evaluate causes of mortality following colon cancer operations across hospitals. They found significant variation in mortality across hospitals for colon cancer operations, reflecting a need for improved operative decision-making to enhance outcomes and quality of care.
AHRQ-funded; HS020937; HS023621; HS000053.
Citation: Healy MA, Grenda TR, Suwanabol PA .
Colon cancer operations at high- and low-mortality hospitals.
Surgery 2016 Aug;160(2):359-65. doi: 10.1016/j.surg.2016.04.035.
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Keywords: Adverse Events, Cancer: Colorectal Cancer, Mortality, Patient Safety, Surgery
Wang Y, Eldridge N, Metersky ML
AHRQ Author: Eldridge N
Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction.
The researchers studied the relationship between hospital performance on adverse event rates and hospital performance on 30-day mortality and unplanned readmission rates for Medicare fee-for-service patients hospitalized for acute myocardial infarction (AMI). They found that for Medicare fee-for-service patients discharged with AMI, hospitals with poorer patient safety performance were also more likely to have poorer performance on 30-day all-cause mortality and on unplanned readmissions.
AHRQ-authored.
Citation: Wang Y, Eldridge N, Metersky ML .
Association between hospital performance on patient safety and 30-day mortality and unplanned readmission for Medicare fee-for-service patients with acute myocardial infarction.
J Am Heart Assoc 2016 Jul;5(7):pii: e003731. doi: 10.1161/jaha.116.003731.
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Keywords: Adverse Events, Hospital Readmissions, Hospitals, Medicare, Mortality, Heart Disease and Health, Patient Safety, Provider Performance
Keller SC, Gurses AP, Abaje AI
Learning from the patient: Human factors engineering in outpatient parenteral antimicrobial therapy.
When used in hospital settings, many of the complex devices adapted for use in outpatient parenteral antimicrobial therapy (OPAT) can lead to errors that may lead to patient harm. To reduce complications from OPAT in the home, such as catheter-associated venous thromboembolism, adverse drug events, or other side effects of OPAT, the authors argue that we need to understand how OPAT is performed by patients and their caregivers and the ways in which human factors engineering can contribute to their reduction.
AHRQ-funded; HS022916.
Citation: Keller SC, Gurses AP, Abaje AI .
Learning from the patient: Human factors engineering in outpatient parenteral antimicrobial therapy.
Am J Infect Control 2016 Jul;44(7):758-60. doi: 10.1016/j.ajic.2016.01.010.
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Keywords: Adverse Events, Antimicrobial Stewardship, Education: Patient and Caregiver, Ambulatory Care and Surgery, Patient Safety
Gong Y, Hua L, Wang S
Leveraging user's performance in reporting patient safety events by utilizing text prediction in narrative data entry.
This study examined two functions of text prediction intended for increasing efficiency and data quality of text data entry reporting patient safety events. It concluded that, while both groups of participants exhibited a good capacity for accomplishing the assigned task of reporting patient falls, the results from the treatment group showed an overall increase of 70.5 percent in text generation rate and an increase of 34.1 percent in reporting comprehensiveness score.
AHRQ-funded; HS022895.
Citation: Gong Y, Hua L, Wang S .
Leveraging user's performance in reporting patient safety events by utilizing text prediction in narrative data entry.
Comput Methods Programs Biomed 2016 Jul;131:181-9. doi: 10.1016/j.cmpb.2016.03.031.
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Keywords: Adverse Events, Patient Safety, Health Information Technology (HIT)
Simmons SF, Schnelle JF, Sathe NA
Defining safety in the nursing home setting: Implications for future research.
AHRQ’s Common Format for nursing homes (NHs) accommodates voluntary reporting for 4 adverse events: falls with injury, pressure ulcers, medication errors, and infections. In 2015, AHRQ funded a technical brief to describe the state of the science related to safety in the NH setting to inform a research agenda. Thirty-six recent systematic reviews evaluated NH safety-related interventions to address these 4 adverse events and reported mostly mixed evidence about effective approaches to ameliorate them.
AHRQ-funded; 290201500003I.
Citation: Simmons SF, Schnelle JF, Sathe NA .
Defining safety in the nursing home setting: Implications for future research.
J Am Med Dir Assoc 2016 Jun;17(6):473-81. doi: 10.1016/j.jamda.2016.03.005..
Keywords: Nursing Homes, Long-Term Care, Adverse Events, Patient Safety, Evidence-Based Practice
Landrigan CP, Stockwell D, Toomey SL
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool.
This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of adverse events (AEs) and preventable AEs. In total, 3,814 medical records were reviewed. It found that both primary and secondary reviewers agreed 92 percent of the time on presence or absence of a suspected AE.
AHRQ-funded; HS020513.
Citation: Landrigan CP, Stockwell D, Toomey SL .
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool.
Pediatrics 2016 Jun;137(6):pii: e20154076. doi: 10.1542/peds.2015-4076.
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Keywords: Patient Safety, Children/Adolescents, Tools & Toolkits, Adverse Events, Children/Adolescents
Hernandez-Boussard TM, McDonald KM, Morrison DE
Risks of adverse events in colorectal patients: population-based study.
The authors sought to assess adverse events in colorectal surgical patients. They found important differential rates of adverse events by diagnostic category, with the highest odds ratio occurring in patients undergoing surgery for ischemic colitis.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard TM, McDonald KM, Morrison DE .
Risks of adverse events in colorectal patients: population-based study.
J Surg Res 2016 May 15;202(2):328-34. doi: 10.1016/j.jss.2016.01.013.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Events, Surgery, Patient Safety, Risk, Quality Indicators (QIs), Quality of Care, Quality Measures
Grant PJ, Greene MT, Chopra V
Assessing the Caprini score for risk assessment of venous thromboembolism in hospitalized medical patients.
The authors examined how well the Caprini risk assessment model predicts venous thromboembolism in hospitalized medical patients. They concluded that the Caprini risk assessment model was unable to identify a subset of medical patients who benefit from pharmacologic prophylaxis.
AHRQ-funded; HS022835.
Citation: Grant PJ, Greene MT, Chopra V .
Assessing the Caprini score for risk assessment of venous thromboembolism in hospitalized medical patients.
Am J Med 2016 May;129(5):528-35. doi: 10.1016/j.amjmed.2015.10.027.
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Keywords: Adverse Events, Blood Clots, Hospitalization, Risk, Patient Safety