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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
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1 to 25 of 52 Research Studies DisplayedErvin JN, Vitous CA, Wells EE
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
The objective of this study was to understand the effectiveness of the Rescue Improvement Conference, a forum that addresses failure to rescue (FTR). FTR is the phenomenon where delayed recognition or response to surgical complications leads to a progressive cascade of adverse events culminating in patient death. The authors used 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and opportunities for improvement and conducted semi-structured interviews. The results showed that conference felt that the Rescue Improvement Conference was effective in all five indicators. The authors concluded that the conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications that contribute to FTR.
AHRQ-funded; HS024403; HS023621.
Citation: Ervin JN, Vitous CA, Wells EE .
Rescue Improvement Conference: a novel tool for addressing failure to rescue.
Ann Surg 2023 Feb; 277(2):233-37. doi: 10.1097/sla.0000000000004832..
Keywords: Surgery, Adverse Events, Patient Safety, Quality of Care, Quality Improvement
Giardina TD, Hunte H, Hill MA
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
This study looked at peer-reviewed published literature to explore how researchers operationalize the National Academies of Science, Engineering, and Medicine’s (NASEM) definition of diagnostic error that was defined in their 2015 publication “Improving Diagnosis in Health Care”. Published literature was identified from October 2015 to February 2021. The authors also conducted subject matter expert interviews. Of the 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by four themes: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies identified used the NASM definition. Five of those studies also operationalized with existing definitions proposed before the NASEM report, four operationalized the components of the NASEM definition, and three studies operationalized error using existing definitions only. Subject matter experts concluded that the NASEM definition functions as a foundation for researchers to conceptualize diagnostic error.
AHRQ-funded; 233201500022I; HS027280; HS025474; HS027363.
Citation: Giardina TD, Hunte H, Hill MA .
Defining diagnostic error: a scoping review to assess the impact of the National Academies' report improving diagnosis in Health Care.
J Patient Saf 2022 Dec 1;18(8):770-78. doi: 10.1097/pts.0000000000000999..
Keywords: Diagnostic Safety and Quality, Quality of Care, Medical Errors, Adverse Events, Healthcare Delivery
Zrelak PA, Utter GH, McDonald KM
Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).
The purpose of this study was to reweight AHRQ’s Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90) from weights based solely on the frequency of component Patient Safety Indicators (PSIs) to those that incorporate excess harm reflecting patients' preferences for outcome-related health states. Findings showed that including harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11, 13, and 12 contributed the greatest harm. The investigators concluded that reformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination.
AHRQ-authored; AHRQ-funded; 290201200003I.
Citation: Zrelak PA, Utter GH, McDonald KM .
Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).
Health Serv Res 2022 Jun;57(3):654-67. doi: 10.1111/1475-6773.13918..
Keywords: Healthcare Cost and Utilization Project (HCUP), Patient Safety, Quality Indicators (QIs), Quality Measures, Quality of Care, Adverse Events, Medicare
Chopra V, O'Malley M, Horowitz J
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.
It is unknown whether implementing the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) reduces complications and improves peripherally inserted central catheter (PICC) use. The purpose of this quasi-experimental study design was to utilize MAGIC in 52 Michigan hospitals and collect data from medical records to measure hospital performance on three appropriateness criteria. The three criteria included: PICC use of less than 5 days, PICC placement in patients with chronic kidney disease, and the use of multi-lumen PICCs. The researchers compared PICC device complications and appropriateness preintervention and post intervention. The study found that among 38,592 PICCs, PICC appropriateness post-intervention increased 17.1% to 49%, and complications decreased 4% to 10.7%. Patients with appropriate PICC use had lower rate of complications than those with inappropriate PICC placement. The study concluded that the utilization of MAGIC in Michigan hospitals was associated with less complications for patients and increased PICC appropriateness.
AHRQ-funded; HS025891.
Citation: Chopra V, O'Malley M, Horowitz J .
Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.
BMJ Qual Saf 2022 Jan;31(1):23-30. doi: 10.1136/bmjqs-2021-013015..
Keywords: Quality Improvement, Quality of Care, Hospitals, Adverse Events
Shi J, Hurdle JF, Johnson SA
Natural language processing for the surveillance of postoperative venous thromboembolism.
The objective of the study was to develop a portal natural language processing approach to aid in the identification of postoperative venous thromboembolism events from free-text clinical notes. The investigators concluded that accurate surveillance of postoperative venous thromboembolism may be achieved using natural language processing on clinical notes in 2 independent health care systems. They indicated that these findings suggest natural language processing may augment manual chart abstraction for large registries such as National Surgical Quality Improvement Program.
AHRQ-funded; HS025776.
Citation: Shi J, Hurdle JF, Johnson SA .
Natural language processing for the surveillance of postoperative venous thromboembolism.
Surgery 2021 Oct;170(4):1175-82. doi: 10.1016/j.surg.2021.04.027..
Keywords: Blood Clots, Health Information Technology (HIT), Quality Improvement, Quality of Care, Surgery, Adverse Events
Zhu Y, Simon GJ, Wick EC
Applying machine learning across sites: external validation of a surgical site infection detection algorithm.
Surgical complications have tremendous consequences and costs. Complication detection is important for quality improvement, but traditional manual chart review is burdensome. Automated mechanisms are needed to make this more efficient. The purpose of the study was to understand the generalizability of a machine learning algorithm between sites; automated surgical site infection (SSI) detection algorithms developed at one center were tested at another distinct center.
AHRQ-funded; HS024532.
Citation: Zhu Y, Simon GJ, Wick EC .
Applying machine learning across sites: external validation of a surgical site infection detection algorithm.
J Am Coll Surg 2021 Jun;232(6):963-71.e1. doi: 10.1016/j.jamcollsurg.2021.03.026..
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Quality Improvement, Quality of Care
Aasen DM, Bronsert Rozeboom, PD
Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database.
This study looked at the relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned hospital readmissions after surgery. Data from the American College of Surgeons National Surgical Quality Improvement database from 2012 to 2017 across nine surgical specialties was used to analyze 30-day postoperative infectious complications including sepsis, surgical site infections, pneumonia, and urinary tract infections. Postoperative infectious complications were identified in 5.2% of cases, of which 59.8% were postdischarge. The specific postdischarge complications identified were 73.4% of surgical site infections, 34.9% of sepsis cases, 26.5% of pneumonia cases, and 53.2% of urinary tract infections. These postoperative infections were associated with an increased risk of readmission. Most infections were diagnosed postdischarge. The trend towards shorter length of stays postoperation also contribute to the increase in infections detected after discharge and the rate of unplanned related postoperative readmissions.
AHRQ-funded; HS026019.
Citation: Aasen DM, Bronsert Rozeboom, PD .
Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database.
Surgery 2021 Feb;169(2):325-32. doi: 10.1016/j.surg.2020.08.009..
Keywords: Hospital Readmissions, Adverse Events, Healthcare-Associated Infections (HAIs), Infectious Diseases, Quality Improvement, Quality of Care, Surgery
Marshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
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
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
Merkow RP, Shan Y, Gupta AR
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.
The objective of this study was to define the cost of individual, 30-day postoperative complications using robust cost data from a diverse group of hospitals. Findings showed that the three complications associated with the highest independent adjusted cost per event were prolonged ventilation, unplanned intubation, and renal failure, while the three complications associated with the lowest independent adjusted cost per event were urinary tract infection, superficial surgical site infection and venous thromboembolism. The authors indicated that the actual hospital costs of complications were estimated using cost data from four diverse hospitals, and that these data can be used by hospitals to estimate the financial benefit of reducing surgical complications.
AHRQ-funded; HS024516; HS026385.
Citation: Merkow RP, Shan Y, Gupta AR .
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.
The objective of this study was to define the cost of individual, 30-day postoperative .
Keywords: Surgery, Healthcare Costs, Adverse Events, Quality Improvement, Quality of Care
Griffey RT, Schneider RM, Todorov AA
The emergency department trigger tool: a novel approach to screening for quality and safety events.
The goal of this study was to develop an automated version of a previously developed emergency department (ED) trigger tool to track the likelihood of an adverse event. Thirty triggers were associated with risk of harm. The authors identified 1,726 records out of 76,894 ED visits with greater than or equal to 1 trigger. They compared the results of the automated tool to the previous version and found it performed well. They began with a broad set of candidate triggers and validated a computerized query that eliminates the need for manual screening of triggers and also identified a refined set of triggers associated with adverse events in the ED.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
The emergency department trigger tool: a novel approach to screening for quality and safety events.
Ann Emerg Med 2020 Aug;76(2):230-40. doi: 10.1016/j.annemergmed.2019.07.032..
Keywords: Emergency Department, Patient Safety, Adverse Events, Medical Errors, Quality of Care, Risk
Khaneki S, Bronsert MR, Henderson WG
Comparison of accuracy of prediction of postoperative mortality and morbidity between a new, parsimonious risk calculator (SURPAS) and the ACS Surgical Risk Calculator.
The purpose of this study was to compare the accuracy of the Surgical Risk Preoperative Assessment System (SURPAS) to that of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). Data from 1006 selected ACS National Surgical Quality Improvement Program (NSQIP) patients with known outcomes were used to calculate predicted risk of postoperative mortality and morbidity. Findings showed that the SURPAS risk predictions were more accurate than the ACS-SRC's for overall morbidity, particularly for high risk patients.
AHRQ-funded; HS024124.
Citation: Khaneki S, Bronsert MR, Henderson WG .
Comparison of accuracy of prediction of postoperative mortality and morbidity between a new, parsimonious risk calculator (SURPAS) and the ACS Surgical Risk Calculator.
Am J Surg 2020 Jun;219(6):1065-72. doi: 10.1016/j.amjsurg.2019.07.036..
Keywords: Surgery, Risk, Adverse Events, Quality Improvement, Quality of Care
Dadlez NM, Adelman J, Bundy DG
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
This study examined root causes of three common pediatric diagnostic errors by having 31 practices enrolled in a national QI collaborative perform monthly “mini-RCAs” (mini root cause analyses). The diagnoses errors studied were missed adolescent depression, missed elevated blood pressure, and missed actionable laboratory values. Twenty-eight practices submitted 184 mini-RCAs with the most common causes being patient volume (adolescent depression and elevated BP), inadequate staffing (adolescent depression), clinic milieu (elevated BP), written communication and provider knowledge (actionable laboratory values), and electronic health records (EHRs) – (elevated BP and actionable laboratory values). The median number of mini-RCAs submitted was 6.
AHRQ-funded; HS024538; HS024713; HS026121.
Citation: Dadlez NM, Adelman J, Bundy DG .
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Pediatr Qual Saf 2020 May-Jun;5(3):e299. doi: 10.1097/pq9.0000000000000299..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Quality Improvement, Quality of Care, Medical Errors, Adverse Events, Patient Safety
Giardina TD, Royse KE, Khanna A
Health care provider factors associated with patient-reported adverse events and harm.
This research examined associations between patient-reported contributory factors and patient-related harms experienced after an adverse event (AE). A secondary analysis was conducted of a national sample of patient-reported AEs gathered from an online questionnaire from 2010 to February 2016. Harms were categorized as nonphysical harm only, physical harm only, physical harm and emotional or financial harm, or all three harms. One third (32.6%) of patients reported experiencing all three harms, 25.5% physical harms only, and 14.7% reported nonphysical harms only. Patients reporting all three harms were 2.5 times more likely to have filed a report with authorities and 3.3 times more likely to also have experienced a surgical complication. Odds were also 13% higher of reporting problems related to communication between clinician and patients/families or clinician-related behavioral issues with patients experiencing all three harms.
AHRQ-funded; HS025474.
Citation: Giardina TD, Royse KE, Khanna A .
Health care provider factors associated with patient-reported adverse events and harm.
Jt Comm J Qual Patient Saf 2020 May;46(5):282-90. doi: 10.1016/j.jcjq.2020.02.004.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Quality of Care
Ogletree AM, Mangrum R, Harris Y
Omissions of care in nursing home settings: a narrative review.
This review aimed to (1) examine existing definitions of omissions of care in the healthcare environment and associated characteristics and (2) outline adverse events that may be attributable to omissions of care among nursing home populations. The investigators concluded that definitions of omissions of care for nursing homes varied in scope and level of detail. Substantial evidence connected omissions of care with an array of adverse events in nursing home populations.
AHRQ-authored; AHRQ-funded; 233201500014I.
Citation: Ogletree AM, Mangrum R, Harris Y .
Omissions of care in nursing home settings: a narrative review.
J Am Med Dir Assoc 2020 May;21(5):604-14. doi: 10.1016/j.jamda.2020.02.016..
Keywords: Nursing Homes, Long-Term Care, Adverse Events, Medical Errors, Patient Safety, Quality of Care
Griffey RT, Schneider RM, Todorov AA
Adverse events present on arrival to the emergency department: the ED as a dual safety net.
This study examined the prevalence of adverse events due to medication-related or patient care-related events that present on arrival (POA) to the emergency department (ED). This retrospective observation study tested the ED Trigger Tool from data at an urban academic medical center. Adults who completed an ED visit were eligible (N=92,859). A total of 5,582 visits gave a trigger. The majority of AEs (1,181) identified were from patients who were white and older. In total, POA AEs accounted for an estimated 7.65% of ED visits.
AHRQ-funded; HS025052.
Citation: Griffey RT, Schneider RM, Todorov AA .
Adverse events present on arrival to the emergency department: the ED as a dual safety net.
Jt Comm J Qual Patient Saf 2020 Apr;46(4):192-98. doi: 10.1016/j.jcjq.2019.12.003..
Keywords: Adverse Events, Adverse Drug Events (ADE), Emergency Department, Medication, Patient Safety, Quality of Care
Sheehan SE, Safdar N, Singh H
Detection and remediation of misidentification errors in radiology examination ordering.
In this study, the investigators described the pilot testing of a quality improvement methodology using electronic trigger tools and preimaging checklists to detect "wrong-side" misidentification errors in radiology examination ordering, and to measure staff adherence to departmental policy in error remediation. The investigators concluded that their trigger tool enabled the detection of substantially more imaging ordering misidentification errors than preimaging safety checklists alone, with a high positive predictive value.
AHRQ-funded; HS022087; HS017820.
Citation: Sheehan SE, Safdar N, Singh H .
Detection and remediation of misidentification errors in radiology examination ordering.
Appl Clin Inform 2020 Jan;11(1):79-87. doi: 10.1055/s-0039-3402730..
Keywords: Medical Errors, Adverse Events, Diagnostic Safety and Quality, Patient Safety, Imaging, Quality Improvement, Quality of Care
Hu QL, Livhits MJ, Ko CY MJ, Ko CY
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
The purpose of this study was to determine whether same-day discharge following thyroid surgery resulted in increased rehospitalization. Data from the American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database was used to identify patients who underwent thyroid resections. Results showed that, in a national cohort of patients undergoing thyroid surgery, same-day discharge was not associated with greater rates of readmission or complications when compared with discharge 1 or 2 days after thyroid surgery.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Livhits MJ, Ko CY MJ, Ko CY .
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
Surgery 2020 Jan;167(1):117-23. doi: 10.1016/j.surg.2019.06.054..
Keywords: Surgery, Ambulatory Care and Surgery, Hospital Readmissions, Hospital Discharge, Adverse Events, Patient-Centered Outcomes Research, Quality Improvement, Quality of Care
Napolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Schwarzkopf R, Behery OA, Yu H
Patterns and costs of 90-day readmission for surgical and medical complications following total hip and knee arthroplasty.
Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. In this study, the investigators compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.
AHRQ-funded; HS022882.
Citation: Schwarzkopf R, Behery OA, Yu H .
Patterns and costs of 90-day readmission for surgical and medical complications following total hip and knee arthroplasty.
J Arthroplasty 2019 Oct;34(10):2304-07. doi: 10.1016/j.arth.2019.05.046..
Keywords: Orthopedics, Surgery, Hospital Readmissions, Adverse Events, Quality Improvement, Quality of Care, Medicare, Hospitals
St Hilaire MA, Anderson C, Anwar J
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
This study examines the impact of reinstating extended duration (24-28) work shifts (EDWS) for postgraduate year 1 resident physicians. The performance of residents was studied for 23 male residents between 2002-2004 during a three-week on-call rotation schedule at the Medical and Intensive Care Units at Brigham and Women’s Hospital in Boston. If the sleep episodes were four hours or less then the odds of >1 attentional failure was 2.72 times higher during post-call compared to matched sessions during non-EDWS.
AHRQ-funded; HS012032.
Citation: St Hilaire MA, Anderson C, Anwar J .
Brief (<4 hour) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts.
Sleep 2019 May;42(5):pii: zsz041. doi: 10.1093/sleep/zsz041..
Keywords: Adverse Events, Education: Continuing Medical Education, Medical Errors, Patient Safety, Provider, Provider: Physician, Quality of Care, Sleep Problems, Training
Bundy DG, Singh H, Stein RE
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
This paper discusses the results of Project RedDE, which was a virtual collaborative quality improvement study to reduce diagnostic errors in pediatric primary care practices. Forty-three practices were initially recruited, with a total of 31 practices left at the end due to practice dropout and two participating practices merging. This study was a randomized controlled trial targeting three common diagnostic errors (missed diagnoses of adolescent depression, abnormal blood pressure, and lack of followup for abnormal laboratory results). Contamination across study groups was a recurring problem, but risk mitigations were used. Electronic health records contributed to teams’ success.
AHRQ-funded; HS203608.
Citation: Bundy DG, Singh H, Stein RE .
The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.
Clin Trials 2019 Apr;16(2):154-64. doi: 10.1177/1740774518820522..
Keywords: Adverse Events, Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Prevention, Primary Care, Quality of Care, Quality Improvement
