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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 94 Research Studies DisplayedKang H, Zhou S, Yao B
A prototype of knowledge-based patient safety event reporting and learning system.
In this study, a hierarchical list of contributing factors for patient falls, based on the key contributing factors defined by AHRQ Common Formats 2.0, was established by expert review and discussion. Using the list as an infrastructure, the investigators designed and developed a novel reporting system, where a strategy to identify contributing factors was intended to provide reporters knowledge support, in the form of similar cases and potential solutions.
AHRQ-funded; HS022895.
Citation: Kang H, Zhou S, Yao B .
A prototype of knowledge-based patient safety event reporting and learning system.
BMC Med Inform Decis Mak 2018 Dec 7;18(Suppl 5):110. doi: 10.1186/s12911-018-0688-5..
Keywords: Adverse Events, Patient Safety, Falls
Ancker JS, Stabile C, Carter J
Informing, reassuring, or alarming? Balancing patient needs in the development of a postsurgical symptom reporting system in cancer.
After ambulatory surgeries, patients who recover at home have multiple questions about wound healing, symptoms and medication side effects, and recovery expectations. In this study, the investigators conducted user testing and rapid application development of a symptom reporting system that supports home-based recovery by inviting patients to self-report symptoms in the days after surgery and receive an immediate feedback report giving context for their reported symptoms.
AHRQ-funded; HS021531.
Citation: Ancker JS, Stabile C, Carter J .
Informing, reassuring, or alarming? Balancing patient needs in the development of a postsurgical symptom reporting system in cancer.
AMIA Annu Symp Proc 2018 Dec 5;2018:166-74..
Keywords: Adverse Events, Ambulatory Care and Surgery, Cancer, Education: Patient and Caregiver, Health Information Technology (HIT), Patient Safety, Surgery
Khan A, Spector ND, Baird JD
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
The objective of this prospective, multicenter before and after intervention was to determine whether medical errors, family experience, and communication processes improved after implementation of the intervention to standardize the structure of healthcare provider-family communication on family centered rounds. The investigators concluded that although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved.
AHRQ-funded; HS00063.
Citation: Khan A, Spector ND, Baird JD .
Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.
BMJ 2018 Dec 5;363:k4764. doi: 10.1136/bmj.k4764..
Keywords: Adverse Events, Clinician-Patient Communication, Communication, Medical Errors, Patient and Family Engagement, Patient Safety
Lowenstern A, Al-Khatib SM, Sharan L
Interventions for preventing thromboembolic events in patients with atrial fibrillation: a systematic review.
The purpose of this review was to compare the effectiveness of therapies to prevent thromboembolic events and bleeding complications in adults with nonvalvular atrial fibrillation (AF). Two independent reviewers screened citations in order to identify comparative studies of treatments to prevent stroke in adults with nonvalvular AF who reported thromboembolic or bleeding complications, then abstracted data from 220 selected articles, assessed study quality and applicability, and rated the strength of evidence. The article concludes that available direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular AF and had similar benefits across several patient subgroups.
AHRQ-funded; 290201500004I.
Citation: Lowenstern A, Al-Khatib SM, Sharan L .
Interventions for preventing thromboembolic events in patients with atrial fibrillation: a systematic review.
Ann Intern Med 2018 Dec 4;169(11):774-87. doi: 10.7326/m18-1523..
Keywords: Cardiovascular Conditions, Heart Disease and Health, Blood Thinners, Adverse Drug Events (ADE), Adverse Events, Medication, Comparative Effectiveness, Patient-Centered Outcomes Research, Evidence-Based Practice
Horwood CR, Moffatt-Bruce SD, Fitzgerald M
A qualitative analysis of clinical decompensation in the surgical patient: perceptions of nurses and physicians.
This study is a quantitative analysis of nurse and physician perception of clinical decompensation in postsurgical patients. The study aims to assess how nurses and physicians perceive early warning signs that predict clinical decompensation, changes in clinical acuity, and the need for escalation of care. Many areas showed strong agreement, but there were differences between nurses and physicians in primary indicators of patient stability. There were also differences in the methods and frequency used to monitor medically unstable patients.
AHRQ-funded; HS024379.
Citation: Horwood CR, Moffatt-Bruce SD, Fitzgerald M .
A qualitative analysis of clinical decompensation in the surgical patient: perceptions of nurses and physicians.
Surgery 2018 Dec;164(6):1311-15. doi: 10.1016/j.surg.2018.06.006..
Keywords: Adverse Events, Health Status, Provider: Clinician, Provider: Nurse, Provider: Physician, Surgery
Govindan S, Snyder A, Flanders SA
Peripherally inserted central catheters in the ICU: a retrospective study of adult medical patients in 52 hospitals.
This study quantified use of peripherally inserted central catheters in the ICU versus the general ward in 52 Michigan hospitals. Variation in complications and outcomes of use were compared. Use in the ICU produced worse outcomes than those inserted in the general ward.
AHRQ-funded; HS022835.
Citation: Govindan S, Snyder A, Flanders SA .
Peripherally inserted central catheters in the ICU: a retrospective study of adult medical patients in 52 hospitals.
Crit Care Med 2018 Dec;46(12):e1136-e44. doi: 10.1097/ccm.0000000000003423..
Keywords: Adverse Events, Healthcare-Associated Infections (HAIs), Inpatient Care, Intensive Care Unit (ICU), Patient Safety
Borre ED, Goode A, Raitz G
Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review.
This systematic review compared the strength of tools to predict stroke and bleeding risk in patients with atrial fibrillation (AF) taking blood thinners. Sixty-one studies were found to predict thromboembolic risk and 38 to predict bleeding risk.
AHRQ-funded; 290201500004I.
Citation: Borre ED, Goode A, Raitz G .
Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review.
Thromb Haemost 2018 Dec;118(12):2171-87. doi: 10.1055/s-0038-1675400..
Keywords: Heart Disease and Health, Cardiovascular Conditions, Stroke, Blood Clots, Blood Thinners, Medication, Adverse Drug Events (ADE), Adverse Events, Risk, Patient-Centered Outcomes Research, Evidence-Based Practice
Amin AP, Miller S, Rahn B
Reversing the "risk-treatment paradox" of bleeding in patients undergoing percutaneous coronary intervention: risk-concordant use of bleeding avoidance strategies is associated with reduced bleeding and lower costs.
Bleeding avoidance strategies (BAS) are effective, but are paradoxically used less often with patients at high risk of bleeding. This article describes the implementation of an intervention in a St. Louis, MO, hospital intended to reverse the bleeding risk-treatment paradox. Temporal trends in BAS use and the association of risk-concordant BAS use with bleeding as well as hospital costs of percutaneous coronary intervention were examined. Patient-centered care that aimed directly toward making treatment-related decisions based on predicted risk of bleeding led to a more risk-concordant use of BAS and a reversal of the risk-treatment paradox. The authors conclude that larger multicentered studies will be needed to corroborate these results.
AHRQ-funded; HS022481.
Citation: Amin AP, Miller S, Rahn B .
Reversing the "risk-treatment paradox" of bleeding in patients undergoing percutaneous coronary intervention: risk-concordant use of bleeding avoidance strategies is associated with reduced bleeding and lower costs.
J Am Heart Assoc 2018 Nov 6;7(21):e008551. doi: 10.1161/jaha.118.008551..
Keywords: Adverse Events, Patient Safety, Heart Disease and Health, Risk, Surgery, Cardiovascular Conditions, Healthcare Costs
Wright A, Aaron S, Seger DL
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
This study examined the effects of conversion from a homegrown electronic health record (EHR) system to a commercial system on the effectiveness of drug-drug interaction (DDI) alert. The EHR system included 3277 clinicians in the before and after studies. There was a marked decrease in the acceptance rate (100 to 8.4% for severe alerts, 29.3 to 7.5% for medium severity) at first. The least severe alerts were then disabled, which lowered the alert burden by 50.5% which rose the acceptance of Tier 1 alerts to 12.7%. However, there was no clear explanation after that why the acceptance rate remained so much lower. The authors believe that workflow factors were probably the predominant reasons.
AHRQ-funded; HS016970.
Citation: Wright A, Aaron S, Seger DL .
Reduced effectiveness of interruptive drug-drug interaction alerts after conversion to a commercial electronic health record.
J Gen Intern Med 2018 Nov;33(11):1868-76. doi: 10.1007/s11606-018-4415-9..
Keywords: Adverse Drug Events (ADE), Medication, Adverse Events, Medical Errors, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Shaker M, Lindholm C, Low J
Summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
Epinephrine is first-line treatment for anaphylaxis. The Food and Drug Administration reported that adverse events from epinephrine are infrequent. This paper provides a summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
AHRQ-funded; HS024599.
Citation: Shaker M, Lindholm C, Low J .
Summary and simulation of reported adverse events from epinephrine autoinjectors and a review of the literature.
J Allergy Clin Immunol Pract 2018 Nov - Dec;6(6):2143-45.e4. doi: 10.1016/j.jaip.2018.04.006..
Keywords: Adverse Events, Adverse Drug Events (ADE), Medication, Patient Safety, Prevention
Schiff G, Mirica MM, Dhavle AA
A prescription for enhancing electronic prescribing safety.
The authors review six areas in which electronic prescribing areas can be improved to transform medication ordering quality and safety. They recommend incorporating medication indications into electronic prescribing, establishing a single shared online medication list, implementing an electronic cancellation mechanism for pharmacies, implementing standardized structured and codified prescription instruction, reengineering clinical decision support, and redesigning electronic prescribing to facilitate ordering of nondrug alternatives.
AHRQ-funded; HS023694.
Citation: Schiff G, Mirica MM, Dhavle AA .
A prescription for enhancing electronic prescribing safety.
Health Aff 2018 Nov;37(11):1877-83. doi: 10.1377/hlthaff.2018.0725..
Keywords: Adverse Drug Events (ADE), Adverse Events, Health Information Technology (HIT), Healthcare Delivery, Medical Errors, Medication, Medication: Safety, Patient Safety
Gallagher TH, Mello MM, Sage WM
Can communication-and-resolution programs achieve their potential? Five key questions.
Communication-and-resolution programs (CRPs) are intended to promote accountability, transparency, and learning after adverse events. In this article the authors address five key challenges to the programs' future success: implementation fidelity, the evidence base for CRPs and their link to patient safety, fair compensation of harmed patients, alignment of CRP design with participants' needs, and public policy on CRPs.
AHRQ-funded; HS024504.
Citation: Gallagher TH, Mello MM, Sage WM .
Can communication-and-resolution programs achieve their potential? Five key questions.
Health Aff 2018 Nov;37(11):1845-52. doi: 10.1377/hlthaff.2018.0727..
Keywords: Adverse Events, Communication, Medical Liability
Barbash IJ
Cognitive impairment, anesthesia, and critical illness: learning from the past to gain perspective on the future.
This study examined the link between cognitive impairment, ICU admission and anesthesia. The author’s hypothesis was that patients with cognitive impairment would be more likely to undergo surgical procedures. However, analysis using data from the Mayo Clinical Study on Aging on 1,977 cognitive normal patients, 387 patients with mild cognitive impairment (MCI), and 72 patients with established dementia found that patients with MCI were more likely to undergo anesthesia and those with dementia were less likely to undergo procedural anesthesia. The author hypothesizes this may be linked to impaired decision-making of the patient and the risk-benefit analysis of performing surgery on patients with established dementia. However, ICU admissions were increased in patients with MCI and dementia.
AHRQ-funded; HS025455.
Citation: Barbash IJ .
Cognitive impairment, anesthesia, and critical illness: learning from the past to gain perspective on the future.
Mayo Clin Proc 2018 Nov;93(11):1537-39. doi: 10.1016/j.mayocp.2018.09.007..
Keywords: Adverse Events, Critical Care, Medication, Intensive Care Unit (ICU), Neurological Disorders
Wang SV, Maro JC, Baro E
Data mining for adverse drug events with a propensity score-matched tree-based scan statistic.
In this study, the investigators propose a method that combines tree-based scan statistics with propensity score-matched analysis of new initiator cohorts, a robust design for investigations of drug safety. They subsequently conducted plasmode simulations to evaluate performance. The authors suggest that TreeScan with propensity score matching shows promise as a method for screening and prioritization of potential adverse events.
AHRQ-funded; HS022193.
Citation: Wang SV, Maro JC, Baro E .
Data mining for adverse drug events with a propensity score-matched tree-based scan statistic.
Epidemiology 2018 Nov;29(6):895-903. doi: 10.1097/ede.0000000000000907..
Keywords: Adverse Drug Events (ADE), Adverse Events, Patient Safety, Medication, Medication: Safety, Data, Research Methodologies
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Noureldin M, Hass Z, Abrahamson K
Fall risk, supports and services, and falls following a nursing home discharge.
The purpose of this study was to examine whether the presence of supports and services have an impact on the relationship between fall-related risk factors and fall occurrence following a nursing-home discharge. The study sample was comprised of 1459 participants in the Minnesota Return to Community Initiative, who had been assisted in achieving a community discharge; 15 percent of participants fell within 30 days of nursing-home discharge. A structural equation model was used to determine relationship between emerging latent variables and falls. Results indicated that use of high-risk medications and fall concerns/history had a direct, positive effect on falling. Receiving supports/services did not have a direct effect on falls, but the authors note that it reduced the effect of high-risk medication use on falling.
AHRQ-funded; HS020224.
Citation: Noureldin M, Hass Z, Abrahamson K .
Fall risk, supports and services, and falls following a nursing home discharge.
Gerontologist 2018 Nov 3;58(6):1075-84. doi: 10.1093/geront/gnx133..
Keywords: Adverse Events, Elderly, Falls, Nursing Homes, Risk
Brennan MB, Guihan M, Budiman-Mak E
Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers.
This study evaluated the relationship between increased systolic blood pressure (SBP) variability and risk of incident diabetic foot ulceration using a nested case-control design. The investigators found a graded relationship between SBP variability and risk of diabetic foot ulceration, providing a potential new and modifiable target to reduce this common complication.
AHRQ-funded; HS018542.
Citation: Brennan MB, Guihan M, Budiman-Mak E .
Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers.
J Hypertens 2018 Nov;36(11):2177-84. doi: 10.1097/hjh.0000000000001783..
Keywords: Adverse Events, Diabetes, Risk
Smith ME, Wells EE, Friese CR
Interpersonal and organizational dynamics are key drivers of failure to rescue.
This qualitative study of providers from hospitals with high and low rescue rates identified key factors that providers believe influence the successful rescue of surgical patients. These factors are: teamwork, action taking, psychological safety, recognition of complications, and communication. Providers surveyed agreed on two targets for improvement: delayed recognition of developing complications, and poor interprofessional communication and inability to express clinical concerns. The authors conclude that, to improve perioperative outcomes, hospitals and payers should shift their attention to improving early detection and increasing communication effectiveness when major complications occur.
AHRQ-funded; HS023621; HS024403.
Citation: Smith ME, Wells EE, Friese CR .
Interpersonal and organizational dynamics are key drivers of failure to rescue.
Health Aff 2018 Nov;37(11):1870-76. doi: 10.1377/hlthaff.2018.0704..
Keywords: Adverse Events, Communication, Hospitals, Mortality, Organizational Change, Patient Safety, Surgery
Bates DW, Singh H
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
This paper comments on the progress made in improving patient safety since the 1999 report from The Institute of Medicine titled “To Err is Human” was published. This landmark report highlighted problem areas, and since then there has been a number of effective interventions to prevent hospital-acquired infections and improve medication safety. Additional areas for improvement have also been identified in the past two decades, including outpatient care, diagnostic, errors and the use of health information technology. The authors believe that electronic data developments can help increase patient safety even further.
AHRQ-funded; HS022087; HS017820.
Citation: Bates DW, Singh H .
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Health Aff 2018 Nov;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738..
Keywords: Adverse Drug Events (ADE), Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Medication: Safety, Patient Safety, Prevention
Blumenthal KG, Li Y, Acker WW
Multiple drug intolerance syndrome and multiple drug allergy syndrome: epidemiology and associations with anxiety and depression.
In this study, the authors used electronic health record (EHR) data to describe prevalences of MDIS and MDAS and to examine associations with anxiety and depression. The investigators concluded that: 1.) while 6% of patients had MDIS, only 1% had MDAS; 2.) MDIS was associated with both anxiety and depression; 3.) patients with both anxiety and depression had an almost twofold increased odds of MDIS; 4.) MDAS was associated with a 40% increased odds of depression, but there was no significant association with anxiety.
AHRQ-funded; HS022728.
Citation: Blumenthal KG, Li Y, Acker WW .
Multiple drug intolerance syndrome and multiple drug allergy syndrome: epidemiology and associations with anxiety and depression.
Allergy 2018 Oct;73(10):2012-23. doi: 10.1111/all.13440..
Keywords: Adverse Drug Events (ADE), Adverse Events, Anxiety, Depression, Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Behavioral Health, Patient Safety
Pouppirt NR, Nassar R, Napolitano N
Association between video laryngoscopy and adverse tracheal intubation-associated events in the neonatal intensive care unit.
The purpose of this single-site retrospective cohort study was to consider the possible effect of video laryngoscopy on adverse events during neonatal tracheal intubation. The researchers conclude that video laryngoscopy was independently associated with decreased risk for adverse events.
AHRQ-funded; HS022464; HS024511.
Citation: Pouppirt NR, Nassar R, Napolitano N .
Association between video laryngoscopy and adverse tracheal intubation-associated events in the neonatal intensive care unit.
J Pediatr 2018 Oct;201:281-84.e1. doi: 10.1016/j.jpeds.2018.05.046..
Keywords: Adverse Events, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Patient Safety
George M, Iramiot JS, Muhindo R
Bacterial aetiology and antibiotic susceptibility profile of post-operative sepsis among surgical patients in a tertiary hospital in rural Eastern Uganda.
This study aimed at determining the prevalence and antimicrobial resistance patterns of bacterial pathogens isolated from post-operative wound infections at Mbale Regional Referral Hospital. The investigators found that Staphylococcus aureus was the most common causative agent associated with postoperative sepsis with most of the strains being MRSA. Multi-drug resistance was observed in 60.6% of the isolated organisms in their study.
AHRQ-funded; HS020098.
Citation: George M, Iramiot JS, Muhindo R .
Bacterial aetiology and antibiotic susceptibility profile of post-operative sepsis among surgical patients in a tertiary hospital in rural Eastern Uganda.
Microbiol Res J Int 2018;24(2). doi: 10.9734/mrji/2018/41690..
Keywords: Adverse Events, Healthcare-Associated Infections (HAIs), Sepsis, Surgery
Fong A, Adams KT, Gaunt MJ
Identifying health information technology related safety event reports from patient safety event report databases.
The objective of this paper was to identify health information technology (HIT) related events from patient safety event (PSE) report free-text descriptions. A difference-based scoring approach was used to prioritize and select model features. A feature-constraint model was developed and evaluated to support the analysis of PSE reports. The feature-constraint model provides a method to identify HIT-related patient safety hazards using a method that is applicable across healthcare systems with variability in their PSE report structures.
AHRQ-funded; HS023701.
Citation: Fong A, Adams KT, Gaunt MJ .
Identifying health information technology related safety event reports from patient safety event report databases.
J Biomed Inform 2018 Oct;86:135-42. doi: 10.1016/j.jbi.2018.09.007..
Keywords: Health Information Technology (HIT), Patient Safety, Adverse Events, Data
Yokoe DS, Avery TR, Platt R
Ranking hospitals based on colon surgery and abdominal hysterectomy surgical site infection outcomes: impact of limiting surveillance to the operative hospital.
This study examined how hospitals are ranked based on colon surgery and abdominal surgical site infection (SSI) outcomes. This ranking can impact how financial penalties are determined. Currently SSI surveillance focuses mainly on the operative hospital, but patients sometimes go to a different hospital after an SSI as opposed to readmission in the operative hospital. The authors used data from a California statewide hospital registry to assess for evidence of SSI for surgeries performed from March 2011 through November 2013. This analysis showed show that operational hospital surveillance alone would have missed 7.2% of colon surgery and 13.4% of abdominal hysterectomy SSIs. This leads to an inaccurate assignment or avoidance of financial penalties for approximately 1 in 11-16 hospitals.
AHRQ-funded; HS021424.
Citation: Yokoe DS, Avery TR, Platt R .
Ranking hospitals based on colon surgery and abdominal hysterectomy surgical site infection outcomes: impact of limiting surveillance to the operative hospital.
Clin Infect Dis 2018 Sep 14;67(7):1096-102. doi: 10.1093/cid/ciy223..
Keywords: Surgery, Healthcare-Associated Infections (HAIs), Infectious Diseases, Injuries and Wounds, Adverse Events, Hospitals, Payment, Patient Safety, Provider Performance
Wahl TS, Graham LA, Morris MS
Association between preoperative proteinuria and postoperative acute kidney injury and readmission.
This retrospective cohort study investigated whether preoperative proteinuria is associated with surgical outcomes including postoperative acute kidney injury (AKI) and readmission. The cohort used were undergoing elective inpatient surgery at 119 Veterans Affairs facilities from October 2007 to September 2014. The data collected was for a 7-month period in 2016. A higher probability of 30-day unplanned readmission was associated with preoperative proteinuria and postoperative AKI.
AHRQ-funded; HS013852.
Citation: Wahl TS, Graham LA, Morris MS .
Association between preoperative proteinuria and postoperative acute kidney injury and readmission.
JAMA Surg 2018 Sep;153(9):e182009. doi: 10.1001/jamasurg.2018.2009..
Keywords: Kidney Disease and Health, Injuries and Wounds, Adverse Events, Surgery, Risk, Hospital Readmissions, Outcomes