National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (13)
- Ambulatory Care and Surgery (1)
- Children/Adolescents (4)
- Diagnostic Safety and Quality (9)
- Elderly (1)
- Electronic Health Records (EHRs) (1)
- Emergency Department (1)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (2)
- Hospitals (2)
- Imaging (1)
- Implementation (1)
- Long-Term Care (1)
- (-) Medical Errors (17)
- Medication (1)
- Medication: Safety (1)
- Nursing Homes (1)
- Patient-Centered Outcomes Research (1)
- Patient Safety (14)
- Prevention (1)
- Primary Care (4)
- Public Reporting (1)
- (-) Quality Improvement (17)
- Quality of Care (10)
- Risk (1)
- Teams (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 17 of 17 Research Studies DisplayedMarshall 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
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
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
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
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
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
Rinke ML, Singh H, Heo M
Diagnostic errors in primary care pediatrics: Project RedDE.
The objective of this study was to investigate the frequency of two high-frequency/subacute diagnostic errors (DEs), and one missed opportunity for diagnosis (MOD) in primary care pediatrics. DE or MOD rates in pediatric primary care were found to be 54 percent for patients with elevated BP, 11 percent for patients with abnormal laboratory values, and 62 percent for adolescents with an opportunity to evaluate for depression.
AHRQ-funded; HS022087; HS023608; HS023602.
Citation: Rinke ML, Singh H, Heo M .
Diagnostic errors in primary care pediatrics: Project RedDE.
Acad Pediatr 2018 Mar;18(2):220-27. doi: 10.1016/j.acap.2017.08.005.
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Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Primary Care, Quality Improvement
Arnold S
AHRQ Author: Arnold S
The imperative to address diagnostic safety.
Diagnostic errors are likely to impact most of us in our lifetime. The author discusses two studies pointing to the vastness of the challenge and the urgency to act now. He also discusses other aspects of this issue and highlights two current AHRQ dedicated research opportunities on diagnostic safety: one to look at the incidence and causes of diagnostic errors in ambulatory care, and the second to look at improvement strategies and interventions.
AHRQ-authored.
Citation: Arnold S .
The imperative to address diagnostic safety.
Diagnosis 2017 Jun 27;4(2):55-56. doi: 10.1515/dx-2017-0017.
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Keywords: Diagnostic Safety and Quality, Medical Errors, Ambulatory Care and Surgery, Patient Safety, Quality Improvement
Walsh KE, Harik P, Mazor KM
Measuring harm in health care: optimizing adverse event review.
The objective of this study was to identify modifiable factors that improve the reliability of ratings of severity of health care-associated harm in clinical practice improvement and research. Using a generalizability theory framework to estimate the impact of number of raters, rater experience, and rater provider type on reliability, the researchers found that reliability was greatly improved with 2 reviewers.
AHRQ-funded; 290201000022I.
Citation: Walsh KE, Harik P, Mazor KM .
Measuring harm in health care: optimizing adverse event review.
Med Care 2017 Apr;55(4):436-41. doi: 10.1097/mlr.0000000000000679.
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Keywords: Medical Errors, Adverse Events, Quality Improvement, Adverse Drug Events (ADE), Patient Safety
Al-Mutairi A, Meyer AN, Thomas EJ
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
The researchers aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews. They found that their Safer Dx Instrument helped quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence.
AHRQ-funded; HS022087.
Citation: Al-Mutairi A, Meyer AN, Thomas EJ .
Accuracy of the safer Dx instrument to identify diagnostic errors in primary care.
J Gen Intern Med 2016 Jun;31(6):602-8. doi: 10.1007/s11606-016-3601-x.
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Keywords: Primary Care, Diagnostic Safety and Quality, Medical Errors, Patient Safety, Quality Improvement
Fernandez R, Grand JA
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
This article highlights guiding team science principles from the organizational psychology literature that can be applied to the study of teams in healthcare. The authors' goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
AHRQ-funded; HS020295; HS022458.
Citation: Fernandez R, Grand JA .
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
Curr Probl Pediatr Adolesc Health Care 2015 Dec;45(12):370-7. doi: 10.1016/j.cppeds.2015.10.005.
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Keywords: Patient Safety, Teams, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Crane S, Sloane PD, Elder N
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
This study assessed the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. It found that all 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 quality improvement projects based on the reports.
AHRQ-funded; HS019558.
Citation: Crane S, Sloane PD, Elder N .
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
J Am Board Fam Med 2015 Jul-Aug;28(4):452-60. doi: 10.3122/jabfm.2015.04.140050..
Keywords: Adverse Events, Medical Errors, Patient Safety, Primary Care, Public Reporting, Quality Improvement, Quality of Care
Clancy C, Fraser I
AHRQ Author: Clancy C, Fraser I
High-quality health care.
This chapter describes the current state of health care quality (including avoidable harms from care); reviews selected efforts to conceptualize, measure, and improve quality; describes how measures are used to guide improvements in care; addresses promising initiatives to improve care; and predicts how the health care landscape will evolve in the coming years.
AHRQ-authored
Citation: Clancy C, Fraser I .
High-quality health care.
In: Knickman J, Kovner AR, editors. Jonas and Kovner's health care delivery in the United States. 11 ed. New York: Springer; 2015. p. 273-96..
Keywords: Quality of Care, Patient Safety, Medical Errors, Adverse Events, Quality Improvement
Meeks DW, Meyer AN, Rose B
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
The researchers described outcomes of peer review within the Department of Veterans Affairs (VA) healthcare system and identified opportunities to leverage peer review data for measurement and improvement of safety. Results showed that the most common process contributing to substandard care was 'timing and appropriateness of treatment'; approximately 16% had diagnosis-related performance concerns. The authors concluded that peer review may be a useful tool for healthcare organizations to assess their sharp end clinical performance, particularly safety events related to diagnostic and treatment errors.
AHRQ-funded; HS022087.
Citation: Meeks DW, Meyer AN, Rose B .
Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data.
BMJ Qual Saf 2014 Dec;23(12):1023-30. doi: 10.1136/bmjqs-2014-003239.
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Keywords: Adverse Events, Medical Errors, Patient Safety, Quality Improvement
Henriksen K, Brady J
AHRQ Author: Henriksen K, Brady J
The pursuit of better diagnostic performance: a human factors perspective.
Improving diagnostic performance is increasingly recognised as a multifaceted challenge. This paper addresses a few of these challenges, including questions that focus on who owns the problem, treating cognitive and system shortcomings as separate issues, why knowledge in the head is not enough, and what we are learning from health information technology and the use of checklists. The authors propose a systems engineering approach making use of rapid-cycle prototyping and simulation, and they call for the formation of substantive partnerships with those in disciplines beyond the clinical domain.
AHRQ-authored.
Citation: Henriksen K, Brady J .
The pursuit of better diagnostic performance: a human factors perspective.
BMJ Qual Saf 2013 Oct;22 Suppl 2:ii1-ii5. doi: 10.1136/bmjqs-2013-001827.
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Keywords: Diagnostic Safety and Quality, Health Information Technology (HIT), Medical Errors, Health Information Technology (HIT), Quality Improvement