National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (19)
- (-) Adverse Events (38)
- Ambulatory Care and Surgery (1)
- Antibiotics (1)
- Blood Clots (2)
- Blood Pressure (1)
- Blood Thinners (2)
- Children/Adolescents (5)
- Chronic Conditions (1)
- Clinical Decision Support (CDS) (2)
- Communication (1)
- Comparative Effectiveness (1)
- COVID-19 (1)
- Critical Care (1)
- Decision Making (1)
- Dental and Oral Health (1)
- Diabetes (1)
- Diagnostic Safety and Quality (5)
- Education: Patient and Caregiver (1)
- Elderly (3)
- Electronic Health Records (EHRs) (5)
- Electronic Prescribing (E-Prescribing) (2)
- Emergency Department (4)
- Falls (3)
- Healthcare-Associated Infections (HAIs) (1)
- Health Information Technology (HIT) (10)
- Hospital Discharge (1)
- Hospitalization (1)
- Hospitals (5)
- Implementation (1)
- Infectious Diseases (1)
- Injuries and Wounds (1)
- Inpatient Care (2)
- Intensive Care Unit (ICU) (1)
- Maternal Care (2)
- Medical Errors (18)
- Medicare (1)
- Medication (19)
- Medication: Safety (16)
- Opioids (2)
- Patient-Centered Healthcare (1)
- (-) Patient Safety (38)
- Practice Patterns (1)
- Pregnancy (2)
- Prevention (4)
- Primary Care (1)
- Provider (3)
- Provider: Nurse (1)
- Provider: Pharmacist (4)
- Public Health (1)
- Quality Improvement (1)
- Quality of Care (1)
- Respiratory Conditions (1)
- Risk (5)
- Sepsis (2)
- Surgery (3)
- Telehealth (2)
- Transitions of Care (1)
- Transplantation (1)
- Vaccination (1)
- Women (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 DisplayedAdams KT, Pruitt Z, Kazi S
Identifying health information technology usability issues contributing to medication errors across medication process stages.
Researchers sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. They found that health IT usability issues were a prevalent contributing factor to medication errors, many of which reach the patient. They recommended that data entry, workflow support, and alerting be prioritized during usability and safety optimization efforts.
AHRQ-funded; HS025136.
Citation: Adams KT, Pruitt Z, Kazi S .
Identifying health information technology usability issues contributing to medication errors across medication process stages.
J Patient Saf 2021 Dec 1;17(8):e988-e94. doi: 10.1097/pts.0000000000000868..
Keywords: Medication, Health Information Technology (HIT), Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Ackerman SL, Gourley G, Le G
Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns
This study’s aim was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. Participants were invited leaders from five California safety net health systems. They participated in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute. The feasibility and validity of 13 proposed patient safety measures were discussed by the eight panelists and prioritized in three Delphi rounds. Consensus was unanimously reached to adopt 9 of the 13 proposed measures. However, concern was expressed about the feasibility of implementing several of the measures.
AHRQ-funded; HS024426; HS022047.
Citation: Ackerman SL, Gourley G, Le G .
Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns
J Patient Saf 2021 Dec 1;17(8):e773-e90. doi: 10.1097/pts.0000000000000480..
Keywords: Patient Safety, Medical Errors, Adverse Events, Hospitals
McGrath SP, McGovern KM, Perreard IM
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
The purpose of this study was to investigate the impact of surveillance monitoring on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was conducted. Findings showed that, for a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on prevention of death due to sedative/analgesic administration in the general care setting.
AHRQ-funded; HS024403.
Citation: McGrath SP, McGovern KM, Perreard IM .
Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity.
J Patient Saf 2021 Dec 1;17(8):557-61. doi: 10.1097/pts.0000000000000696..
Keywords: Respiratory Conditions, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety
Griffey RT, Schneider RM, Sharp BR
Multicenter test of an emergency department trigger tool for detecting adverse events.
This study details a novel emergency department (ED) trigger tool to detect adverse events using a multidisciplinary, multicenter approach developed by the authors. They conducted a multicenter test of the tool and assessed its performance. The study was conducted during a 13-month period at 4 EDs. Patients age 18 years and older with Emergency Severity Index acuity levels of 1 to 3 by a provider were eligible. Fifty randomly selected visits at each site were reviewed a month. Events were classified by level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). They captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability was observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication related. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level at 35.4%. Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE. Ten triggers were individually associated with AEs. Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Multicenter test of an emergency department trigger tool for detecting adverse events.
J Patient Saf 2021 Dec 1;17(8):e843-e49. doi: 10.1097/pts.0000000000000516..
Keywords: Emergency Department, Adverse Events, Patient Safety
Griffey RT, Schneider RM, Sharp BR
Practical considerations in use of trigger tool methodology in the emergency department.
This article’s purpose was to provide general observations, guidance, and lessons learned in the use of a trigger tool in the emergency department (ED) for adverse events (AEs). The authors identified 46 triggers in the initial ED trigger tool. They tried to include triggers of various types to capture events related to different aspects of an ED visit. The trigger events were reviewed by first-level reviewers, who are typically nurses, and then by second-level reviewers, who are usually other clinicians. An AE was identified using the AHRQ definition adopted by the IHI GTT, which is limited to physical (but not emotional or mental) harm. It must be unintentional and attributable to healthcare. Acts of omission must be included not just acts of commission. They used a modified National Coordinating Council’s Medication Event Reporting and Prevention (MERP) Index to assess severity of harm. MERP E-I events are identified as those that had interventions, with MERP A-D events noted. They outlined several salient areas for consideration in implementing a trigger tool in the ED setting and also specified how to address the highlighted issues.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Sharp BR .
Practical considerations in use of trigger tool methodology in the emergency department.
J Patient Saf 2021 Dec 1;17(8):e837-e42. doi: 10.1097/pts.0000000000000448..
Keywords: Emergency Department, Adverse Events, Patient Safety
Tokede O, Walji M, Ramoni R
Quantifying dental office-originating adverse events: the dental practice study methods.
Investigators initiated the Dental Practice Study (DPS) with the goal of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit. In this article, they discussed the 6-month pilot phase of the DPS during which they explored the feasibility and efficiency of their multi-staged review process to detect AEs.
Citation: Tokede O, Walji M, Ramoni R .
Quantifying dental office-originating adverse events: the dental practice study methods.
J Patient Saf 2021 Dec 1;17(8):e1080-e87. doi: 10.1097/pts.0000000000000444..
Keywords: Dental and Oral Health, Adverse Events, Patient Safety, Medical Errors
Ernest EC, Hellar A, Varallo J
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
This study evaluated the impact of a multicomponent safe surgery intervention in Tanzania to reduce surgical site infection (SSI) rates and mortality after caesarean sections (CS). The authors used the WHO Surgical Safety Checklist (SSC) to measure WHO SSC utilization, SSI rates, and CS-related perioperative mortality rates (POMRs) before and 18 months after implementation. The SSC utilization rate for CS increased from 3.7% to 95.1%, which decreased the proportion of women with SSI after CS from 14% during baseline to 1%. CS-related POMR decreased by 38.5% after implementation of safe surgery interventions as well.
AHRQ-funded; HS024235.
Citation: Ernest EC, Hellar A, Varallo J .
Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention.
BMJ Glob Health 2021 Dec;6(12). doi: 10.1136/bmjgh-2021-006788..
Keywords: Maternal Care, Pregnancy, Healthcare-Associated Infections (HAIs), Surgery, Injuries and Wounds, Adverse Events, Patient Safety
Dykes PC, KhasnabishE S, Adkison LE
Use of a perceived efficacy tool to evaluate the FallTIPS program.
The authors assessed nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. They found that the nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program, and findings confirmed the importance of patient and family engagement with staff in the fall prevention process.
AHRQ-funded; HS025128.
Citation: Dykes PC, KhasnabishE S, Adkison LE .
Use of a perceived efficacy tool to evaluate the FallTIPS program.
J Am Geriatr Soc 2021 Dec;69(12):3595-601. doi: 10.1111/jgs.17436..
Keywords: Falls, Patient Safety, Prevention, Provider: Nurse, Adverse Events
Giardina TD, Korukonda S, Shahid U
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
This retrospective cohort study evaluated the use of patient complaint data to identify patient safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement. Patient complaints submitted to the Geisinger healthcare system were reviewed with 2 cohorts from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). The authors selected complaints more likely to be associated with diagnostic concerns in Geisinger’s existing complaint taxonomy. In cohort 1, 1865 complaint summaries were reviewed and 177 (9.5%) were identified as concerning. The review identified 39 diagnostic errors. In cohort 2, 2423 patient complaints were reviewed and 310 (12.8%) concerning reports were identified. A 10% sample contained give diagnostic errors. Most errors were categorized as “Clinical Care” issues.
AHRQ-funded; HS025474; HS027363.
Citation: Giardina TD, Korukonda S, Shahid U .
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
BMJ Qual Saf 2021 Dec;30(12):996-1001. doi: 10.1136/bmjqs-2020-011593..
Keywords: Diagnostic Safety and Quality, Patient Safety, Medical Errors, Adverse Events
Reese TJ, Del Fiol G, Morgan K
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
Exposure to life-threatening drug-drug interactions (DDIs) occurs despite the widespread use of clinical decision support. The DDI between warfarin and nonsteroidal anti-inflammatory drugs is common and potentially life-threatening. Patients can play a substantial role in preventing harm from DDIs; however, the current model for DDI decision-making is clinician centric. This study aimed to design and examine the usability of DDInteract, a tool to support shared decision-making (SDM) between a patient and provider for the DDI between warfarin and nonsteroidal anti-inflammatory drugs.
AHRQ-funded; HS026198.
Citation: Reese TJ, Del Fiol G, Morgan K .
A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: design and usability study.
JMIR Hum Factors 2021 Oct 26;8(4):e28618. doi: 10.2196/28618..
Keywords: Blood Thinners, Medication: Safety, Medication, Clinical Decision Support (CDS), Decision Making, Electronic Health Records (EHRs), Health Information Technology (HIT), Adverse Drug Events (ADE), Adverse Events, Patient Safety
Herzig SJ, Anderson TS, Jung Y
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
This retrospective cohort study’s objective was to determine the incidence and risk of post-discharge adverse events among opioid claims in the week after hospital discharge, compared to those with nonsteroidal anti-inflammatory drugs (NSAIDs) claims alone. A national sample of Medicare beneficiaries age 65 and older who were hospitalized in the United States in 2016 was used. Beneficiaries who were admitted from or discharged to a facility were excluded. The authors used 3:1 propensity matching to match beneficiaries with an opioid claim in the week after discharge (13,385) with beneficiaries with NSAID claim alone (4,677). Beneficiaries receiving opioids had a higher incidence of death, healthcare utilization, and any potential adverse effect compared to those with an NSAID claim only. Specific adverse effects included higher relative risk of fall/fracture, nausea/vomiting, and slowed colonic motility.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Jung Y .
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
PLoS Med 2021 Sep 27;18(9):e1003804. doi: 10.1371/journal.pmed.1003804..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Risk, Hospital Discharge
Mahajan P, Pai CW, Cosby KS
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. In this study, the investigators sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.
AHRQ-funded; HS024953; HS027363.
Citation: Mahajan P, Pai CW, Cosby KS .
Identifying trigger concepts to screen emergency department visits for diagnostic errors.
Diagnosis 2021 Aug 26;8(3):340-46. doi: 10.1515/dx-2020-0122..
Keywords: Emergency Department, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety
Piatkowski M, Taylor E, Wong B
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
This multi-year study aimed to better understand how patient room design can increase stability during ambulation, serving as a fall protection strategy for frail and/or elderly patients. Specifically, the aim of this portion of the study was to ascertain the architect's perspective on designing a room to mitigate the risk of falls, as well as to evaluate the face validity of a predictive algorithm to assess risk in room design using the input of a design advisory council (AC).
AHRQ-funded; HS025606.
Citation: Piatkowski M, Taylor E, Wong B .
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
Int J Environ Res Public Health 2021 Aug 19;18(16). doi: 10.3390/ijerph18168769..
Keywords: Falls, Patient Safety, Prevention, Adverse Events, Inpatient Care
Cifra CL, Custer JW, Singh H
Diagnostic errors in pediatric critical care: a systematic review.
This study is a systematic review on the prevalence, impact, and contributing factors related to diagnostic errors in the PICU. A database search was done for literature up through December 2019. Using specific criteria, 396 abstracts were screened, and 17 studies were included. Fifteen of 17 studies had an observational research design. Autopsy studies showed a 10-23% rate of missed major diagnosis with 5-16% of the errors having a potential adverse impact on survival and would have changed care management. Retrospective record review studies reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions. About a quarter of those patients were discussed at PICU morbidity and mortality conferences. Most misdiagnosed conditions were cardiovascular, infectious, congenital, or neurologic. System, cognitive, and both system and cognitive factors were associated with diagnostic error but there is limited information on the impact of misdiagnosis.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Singh H .
Diagnostic errors in pediatric critical care: a systematic review.
Pediatr Crit Care Med 2021 Aug;22(8):701-12. doi: 10.1097/pcc.0000000000002735..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Intensive Care Unit (ICU), Critical Care
De Oliveira GS, Castro-Alves LJ, Kendall MC
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition-of-care interventions on the reduction of medication errors after hospital discharge. Findings showed that pharmacist transition-of-care intervention is an effective strategy to reduce medication errors after hospital discharge and also reduces subsequent emergency room visits.
AHRQ-funded; HS024158.
Citation: De Oliveira GS, Castro-Alves LJ, Kendall MC .
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
J Patient Saf 2021 Aug 1;17(5):375-80. doi: 10.1097/pts.0000000000000283..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Provider: Pharmacist, Transitions of Care
Caballero ML, Krantz MS, Quirce S
Hidden dangers: recognizing excipients as potential causes of drug and vaccine hypersensitivity reactions.
In this paper, the authors provided a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provided strategies for heightened recognition and allergy testing.
AHRQ-funded; HS026395.
Citation: Caballero ML, Krantz MS, Quirce S .
Hidden dangers: recognizing excipients as potential causes of drug and vaccine hypersensitivity reactions.
J Allergy Clin Immunol Pract 2021 Aug;9(8):2968-82. doi: 10.1016/j.jaip.2021.03.002..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Medication: Safety, Vaccination, Patient Safety
Leung WY, Adelman J, Bates DW
Validating fall prevention icons to support patient-centered education.
Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. The investigators indicated that all 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.
AHRQ-funded; HS023535.
Citation: Leung WY, Adelman J, Bates DW .
Validating fall prevention icons to support patient-centered education.
J Patient Saf 2021 Aug 1;17(5):e413-e22. doi: 10.1097/pts.0000000000000354..
Keywords: Falls, Prevention, Patient Safety, Patient-Centered Healthcare, Education: Patient and Caregiver, Hospitals, Adverse Events
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y
Wrong-patient orders in obstetrics.
The objective of this observational study was to compare rates of wrong-patient orders among patients on obstetric units compared with reproductive-aged women admitted to medical-surgical units. The investigators concluded that order errors occurred more frequently on obstetric units compared with medical-surgical units.
AHRQ-funded; HS024538; HS026121.
Citation: Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y .
Wrong-patient orders in obstetrics.
Obstet Gynecol 2021 Aug 1;138(2):229-35. doi: 10.1097/aog.0000000000004474..
Keywords: Medical Errors, Maternal Care, Pregnancy, Women, Adverse Events, Patient Safety
Watterson TL, Stone JA, Brown R
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software.
AHRQ-funded; HS025793.
Citation: Watterson TL, Stone JA, Brown R .
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
J Am Med Inform Assoc 2021 Jul 14;28(7):1526-33. doi: 10.1093/jamia/ocab038..
Keywords: Medication: Safety, Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT), Ambulatory Care and Surgery
Wu P, Nelson SD, Zhao J
DDIWAS: high-throughput electronic health record-based screening of drug-drug interactions.
In this study, the investigators developed and evaluated Drug-Drug Interaction Wide Association Study (DDIWAS). This novel method detected potential drug-drug interactions (DDIs) by leveraging data from the electronic health record (EHR) allergy list. The investigators concluded that they demonstrated the value of incorporating information mined from existing allergy lists to detect DDIs in a real-world clinical setting. They indicate that since allergy lists are routinely collected in EHRs, DDIWAS has the potential to detect and validate DDI signals across institutions.
AHRQ-funded; HS026395.
Citation: Wu P, Nelson SD, Zhao J .
DDIWAS: high-throughput electronic health record-based screening of drug-drug interactions.
J Am Med Inform Assoc 2021 Jul 14;28(7):1421-30. doi: 10.1093/jamia/ocab019..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Medication, Medication: Safety, Patient Safety
King CR, Abraham J, Fritz BA
Predicting self-intercepted medication ordering errors using machine learning.
Current approaches to understanding medication ordering errors rely on relatively small manually captured error samples. These approaches are resource-intensive, do not scale for computerized provider order entry (CPOE) systems, and are likely to miss important risk factors associated with medication ordering errors. Previously, the investigators described a dataset of CPOE-based medication voiding accompanied by univariable and multivariable regression analyses. In this paper, they updated the analysis using machine learning (ML) models to predict erroneous medication orders and identify its contributing factors.
AHRQ-funded; HS025443.
Citation: King CR, Abraham J, Fritz BA .
Predicting self-intercepted medication ordering errors using machine learning.
PLoS One 2021 Jul 14;16(7):e0254358. doi: 10.1371/journal.pone.0254358..
Keywords: Medication, Medical Errors, Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
Worsham CM, Woo J, Jena AB
Adverse events and emergency department opioid prescriptions in adolescents.
Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, the investigators exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transitioned from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events.
AHRQ-funded; HS026753.
Citation: Worsham CM, Woo J, Jena AB .
Adverse events and emergency department opioid prescriptions in adolescents.
Health Aff 2021 Jun;40(6):970-78. doi: 10.1377/hlthaff.2020.01762..
Keywords: Children/Adolescents, Emergency Department, Opioids, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Practice Patterns
Stolldorf DP, Ridner SH, Vogus TJ
Implementation strategies in the context of medication reconciliation: a qualitative study.
Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, the authors report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit).
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Ridner SH, Vogus TJ .
Implementation strategies in the context of medication reconciliation: a qualitative study.
Implement Sci Commun 2021 Jun 10;2(1):63. doi: 10.1186/s43058-021-00162-5..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Medical Errors, Adverse Events, Patient Safety, Implementation, Communication
Masonbrink AR, Harris M, Hall M
Safety events in children's hospitals during the COVID-19 pandemic.
The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. The objective of this study was to compare pediatric hospitalization safety events during the pandemic versus previous years. The investigators concluded that postoperative sepsis rates increased among children hospitalized during COVID-19. They suggest that efforts are needed to improve safety of postoperative care for hospitalized children.
AHRQ-funded; HS024554; HS024592.
Citation: Masonbrink AR, Harris M, Hall M .
Safety events in children's hospitals during the COVID-19 pandemic.
Hosp Pediatr 2021 Jun;11(6):e95-e100. doi: 10.1542/hpeds.2020-004937..
Keywords: Children/Adolescents, COVID-19, Patient Safety, Sepsis, Adverse Events, Hospitalization, Hospitals, Inpatient Care, Infectious Diseases, Public Health
Michelson KA, Williams DN, Dart AH
Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis.
This study’s objective was to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. Case vignettes were constructed for each condition and then presented to expert Delphi panels for review. In each vignette, the patient had a previous emergency department visit within 7 days of the delayed diagnosis. The panels graded the likelihood of a delayed diagnosis on a five-point scale. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes, and 77% of DKA vignettes. The authors created a case review guide from the consensus scores that will aid researchers and quality improvement specialists in objective case review to determine if delayed diagnosis had occurred for those three conditions.
AHRQ-funded; HS026503.
Citation: Michelson KA, Williams DN, Dart AH .
Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis.
Diagnosis 2021;8(2):219-25. doi: 10.1515/dx-2020-0035..
Keywords: Diagnostic Safety and Quality, Sepsis, Medical Errors, Adverse Events, Patient Safety