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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
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1 to 25 of 1194 Research Studies Displayed
Mao J, Sedrakyan A, Sun T
Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing.
This study’s objective was to develop an annotation model to develop natural language processing (NLP) to device adverse event reports and to implement the model to evaluate the most frequently experienced events among women reporting a sterilization device removal. Adverse event reports from the Manufacturer and User Facility Device Experience database from January 2005 to June 2018 were included. The authors used an iterative process to develop an annotation model that extracts six categories of desired information and applied the annotation model to train an NLP algorithm. A total of 16,535 reports of device removal were analyzed with the most frequently reported patient and device events being abdominal/pelvic/genital pain (79.6%) and device dislocation/migration (19.2%), respectively. A total of 7,932 patients reported an additional sterilization procedure of a hysterectomy or salpingectomy. One-fifth of the cases that had device removal timing specified reported a removal 7 years after original insertion.
AHRQ-funded; HS026291.
Citation:
Mao J, Sedrakyan A, Sun T .
Assessing adverse event reports of hysteroscopic sterilization device removal using natural language processing.
Pharmacoepidemiol Drug Saf 2022 Apr;31(4):442-51. doi: 10.1002/pds.5402..
Keywords:
Adverse Events, Surgery, Medical Devices, Patient Safety
Schnipper JL, Reyes Nieva H, Mallouk M
Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.
This study was a follow-up of the first Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS1) that demonstrated mentored implementation of a medication reconciliation best practices toolkit. The toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The toolkit has been refined with lessons learned and retooled as MARQUIS2. The tool was implemented at 18 North American hospitals or hospital systems from 2016 to 2018, offering 17 system-level and 6-patient-level interventions. One of eight physicians coached each site remotely via monthly calls and one or two site visits. A total of 4947 patients were sampled, with 1229 preimplementation and 3718 postimplementation. A steady decline in medication discrepancy rates were experienced from 2.85 discrepancies per patient down to 0.98 discrepancies. An interrupted time series analysis of the 17 sites showed the intervention was associated with a 5% relative decrease in discrepancies per month.
AHRQ-funded; HS025486; HS023757.
Citation:
Schnipper JL, Reyes Nieva H, Mallouk M .
Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.
BMJ Qual Saf 2022 Apr;31(4):278-86. doi: 10.1136/bmjqs-2020-012709..
Keywords:
Medication, Evidence-Based Practice, Tools & Toolkits, Implementation, Quality Improvement, Quality of Care, Medication: Safety, Patient Safety
Metersky ML, Eldridge N, Wang Y
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
This retrospective analysis aimed to determine whether patients in teaching hospitals are at greater risk of suffering from an adverse event during the July/August summer trainee changeover period. The Medicare Patient Safety Monitoring System was used to extract data on hospital admissions from 2010 to 2017 for acute myocardial infarction, heart failure, pneumonia, or a major surgical procedure. Adverse event rates in July and August were compared with the rest of the year. Hospitals were classified into major teaching, minor teaching, or nonteaching. The authors included 185,652 hospital admissions. The adjusted odds ratios (ORs) of suffering from at least one adverse event was not significantly different at any of the hospital types.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation:
Metersky ML, Eldridge N, Wang Y .
Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?
J Patient Saf 2022 Apr 1;18(3):253-59. doi: 10.1097/pts.0000000000000887..
Keywords:
Adverse Events, Patient Safety, Provider: Physician
Raman DL, Bixby EC, Wang K
A Comprehensive Unit-based Safety Program to improve perioperative efficiency in adolescent idiopathic scoliosis.
In this study, the Comprehensive Unit-based Safety Program (CUSP) methodology was utilized to improve perioperative efficiency in pediatric spine surgery, and pre-implementation and post-implementation efficiency were compared. Findings showed that CUSP was effective in enhancing perioperative efficiency, demonstrating strong improvement in on-time starts over 5 years. These results indicated that process improvement in operating rooms requires consistent attention to sustain gains over time. Recommendations included engaging frontline staff in quality improvement in order to foster collaboration and provide employee buy-in to promoting a culture of safety and improving value in patient care.
AHRQ-funded; HS022198.
Citation:
Raman DL, Bixby EC, Wang K .
A Comprehensive Unit-based Safety Program to improve perioperative efficiency in adolescent idiopathic scoliosis.
J Pediatr Orthop 2022 Mar;42(3):123-30. doi: 10.1097/bpo.0000000000001992..
Keywords:
Children/Adolescents, Patient Safety, Quality Improvement, Quality of Care
Lacson R, Khorasani R, Fiumara K
Collaborative case review: a systems-based approach to patient safety event investigation and analysis.
The objectives of this study were to assess a system-based approach to event investigation and analysis--collaborative case reviews (CCRs)--and to measure impact of clinical specialty on strength of action items prescribed. The institutional review board-approved study describes the program, including a percentage of CCR from an institutional Electronic Safety Reporting System. Findings showed that an integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments.
AHRQ-funded; HS024722.
Citation:
Lacson R, Khorasani R, Fiumara K .
Collaborative case review: a systems-based approach to patient safety event investigation and analysis.
J Patient Saf 2022 Mar 1;18(2):e522-e27. doi: 10.1097/pts.0000000000000857..
Keywords:
Patient Safety, Adverse Events, Diagnostic Safety and Quality, Imaging
Dykes PC, Khasnabish S, Burns Z
Development and validation of a fall prevention efficiency scale.
This study examined nurses’ perception of implementing the Fall TIPS (Tailoring Interventions for Patient Safety) tool, which is an evidence-based fall prevention program which was shown to reduce falls in hospitalized adults by 25%. The authors conducted a 3-phase mixed method study at 3 hospitals in Massachusetts and 3 in New York to assess nurses’ perceptions of burdens imposed on them by using Fall TIPS or other fall prevention programs. A 20-item prototype Fall Prevention Efficiency Scale was developed and administered to 383 clinical nurses. This scale was reduced to 13 items. The scale achieved excellent internal consistency values when examined with the test, validation, and paired (both test and retest) samples.
AHRQ-funded; HS025128.
Citation:
Dykes PC, Khasnabish S, Burns Z .
Development and validation of a fall prevention efficiency scale.
J Patient Saf 2022 Mar 1;18(2):94-101. doi: 10.1097/pts.0000000000000811..
Keywords:
Falls, Prevention, Patient Safety, Hospitals
Katz MJ, Tamma PD, Cosgrove SE
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
The purpose of this study was to determine if AHRQ’s Safety Program for Improving Antibiotic Use was associated with reductions in antibiotic use in long-term care (LTC) facilities in the US. Findings showed that participation in the AHRQ safety program was associated with the development of antibiotic stewardship programs (ASPs) that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in days of antibiotic therapy and starts, which was more pronounced in more engaged facilities, indicated that implementation of this multifaceted program may support successful ASPs in LTC settings.
AHRQ-funded; 233201500020I.
Citation:
Katz MJ, Tamma PD, Cosgrove SE .
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
JAMA Netw Open 2022 Feb;5(2):e220181. doi: 10.1001/jamanetworkopen.2022.0181..
Keywords:
Elderly, Antimicrobial Stewardship, Antibiotics, Long-Term Care, Medication, Implementation, Patient Safety
Dy SM, Acton RM, Yuan CT
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
This cross-case analysis study's objective was to explore which patient-centered medical home (PCMH) and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture using 25 diverse US PCMHs. Findings suggested that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists.
AHRQ-funded; HS024859.
Citation:
Dy SM, Acton RM, Yuan CT .
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
J Patient Saf 2022 Jan;18(1):e249-e56. doi: 10.1097/pts.0000000000000752..
Keywords:
Patient-Centered Healthcare, Surveys on Patient Safety Culture, Patient Safety
Cofran L, Cohen T, Alfred M
Barriers to safety and efficiency in robotic surgery docking.
The authors sought to explore operating room variation in robotic-assisted surgery across multiple clinical sites and procedures and further sought to examine the sources of those flow disruptions. They concluded that direct observation of surgical procedures can help to identify approaches to improve the design of technology and procedures, the training of staff, and the configuration of the operating room environment, with the eventual goal of improving safety, efficiency, and teamwork in high technology surgery.
AHRQ-funded; HS026491.
Citation:
Cofran L, Cohen T, Alfred M .
Barriers to safety and efficiency in robotic surgery docking.
Surg Endosc 2022 Jan;36(1):206-15. doi: 10.1007/s00464-020-08258-0..
Keywords:
Patient Safety, Surgery
Penfold RB, Thompson EE, Hilt RJ
Development of a symptom-focused model to guide the prescribing of antipsychotics in children and adolescents: results of the first phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.
The purpose of this study was to develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. The investigators indicated that their approach addressed some of these concerns.
AHRQ-funded; HS026001; HS023258.
Citation:
Penfold RB, Thompson EE, Hilt RJ .
Development of a symptom-focused model to guide the prescribing of antipsychotics in children and adolescents: results of the first phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.
J Am Acad Child Adolesc Psychiatry 2022 Jan;61(1):93-102. doi: 10.1016/j.jaac.2021.04.010..
Keywords:
Children/Adolescents, Medication, Behavioral Health, Patient Safety, Guidelines, Evidence-Based Practice
Martin BA, Breslow RM, Sims A
Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions in older adults: a national survey of pharmacists.
This study’s objective was to determine which information on over-the-counter (OTC) Drug Facts Labels (DFS) is most critical in reducing adverse drug reactions (ADRs) among older adults and should be placed in front of the label. A national survey of practicing pharmacists knowledgeable about OTC medication use by older adults asked respondents to rank order the importance of the DFL sections to reduce ADRs. A total of 318 responses were analyzed. There was high consensus that uses and purposes, active ingredient, warnings, and directions for use were the most important sections on the label. Two specific warnings “Do not use” and “Ask a doctor or pharmacist” were deemed most important in the warnings section.
AHRQ-funded; HS025386.
Citation:
Martin BA, Breslow RM, Sims A .
Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions in older adults: a national survey of pharmacists.
J Am Pharm Assoc 2022 Jan-Feb;62(1):167-75.e1. doi: 10.1016/j.japh.2021.08.019..
Keywords:
Elderly, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Health Literacy, Education: Patient and Caregiver
Schnock KO, Snyder JE, Gershanik E
Unique patient-reported hospital safety concerns with online tool: MySafeCare.
This study evaluated the MySafeCare (MSC) application at six acute care units for 18 months as part of a patient-centered health information technology intervention to promote engagement and safety in the acute care setting. This web-based application allowed hospitalized patients to submit safety concerns anonymously and in real time. The authors evaluated rates of submissions to MSC and compared them to the hospital’s submissions to the Patient Family Relations Department. They received 46 submissions to MSC, and 33% of them were received anonymously. The overall rate of submissions was 0.6 submissions per 1000 patient-days, which was considerably lower than the rate of submissions to the Patient Family Relations Department during the same time period (4.1 per 1000 patient-days). MSC did capture important content concerning unmet care needs and preferences, inadequate communication, and concerns about safety of care.
AHRQ-funded; HS023535.
Citation:
Schnock KO, Snyder JE, Gershanik E .
Unique patient-reported hospital safety concerns with online tool: MySafeCare.
J Patient Saf 2022 Jan;18(1):e33-e39. doi: 10.1097/pts.0000000000000697..
Keywords:
Patient Safety, Health Information Technology (HIT), Hospitals, Patient-Centered Healthcare, Patient and Family Engagement
Zimolzak AJ, Shahid U, Giardina TD
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm. As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff.
AHRQ-funded; HS27363.
Citation:
Zimolzak AJ, Shahid U, Giardina TD .
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
J Gen Intern Med 2022 Jan;37(1):137-44. doi: 10.1007/s11606-021-06772-y..
Keywords:
Diagnostic Safety and Quality, Patient Safety, Quality Improvement, Quality of Care
Fong A, Behzad S, Pruitt Z
A machine learning approach to reclassifying miscellaneous patient safety event reports.
This research paper describes an effort to develop a machine learning natural language processing model to reclassify medical adverse events that were classified as “miscellaneous” as opposed to a specific event-type category. The authors integrated the model into a clinical workflow dashboard, evaluated user feedback, and compared differences in user thresholds for model performance to reclassify those reports.
AHRQ-funded; HS026481.
Citation:
Fong A, Behzad S, Pruitt Z .
A machine learning approach to reclassifying miscellaneous patient safety event reports.
J Patient Saf 2021 Dec 1;17(8):e829-e33. doi: 10.1097/pts.0000000000000731..
Keywords:
Patient Safety, Health Information Technology (HIT), Medical Errors
Sankaran RR, Ameling JM, Cohn AEM
A practical guide for building collaborations between clinical researchers and engineers: lessons learned from a multidisciplinary patient safety project.
The objective of this study was to prepare research teams that are embarking on collaborations regarding common challenges and training needs to anticipate while developing multidisciplinary teams. Researchers developed a practical guide to describe anticipated challenges and solutions to consider for developing successful partnerships between engineering and clinical researchers. They also developed and shared a checklist for project managers as well as the training materials as adaptable resources to facilitate other teams' initiation into these types of collaborations.
AHRQ-funded; HS019767; HS024385.
Citation:
Sankaran RR, Ameling JM, Cohn AEM .
A practical guide for building collaborations between clinical researchers and engineers: lessons learned from a multidisciplinary patient safety project.
J Patient Saf 2021 Dec 1;17(8):e1420-e27. doi: 10.1097/pts.0000000000000667..
Keywords:
Patient Safety
Manojlovich M, Hofer TP, Krein SL
Advancing patient safety through the clinical application of a framework focused on communication.
The purpose of this review article was to describe a conceptual framework of communication drawn from multiple academic disciplines and to apply it to health care, specifically for examining communication between providers about the clinical care of their patients. Findings showed that poor communication remained a stubborn problem in health care in part because of a narrow theoretical and definitional approach to resolving it. The proposed conceptual framework suggested ways to build relationships and trust, addressed hierarchical differences between communicators, and illuminated the role of technology in communication.
AHRQ-funded; HS022305; HS024760.
Citation:
Manojlovich M, Hofer TP, Krein SL .
Advancing patient safety through the clinical application of a framework focused on communication.
J Patient Saf 2021 Dec 1;17(8):e732-e37. doi: 10.1097/pts.0000000000000547..
Keywords:
Patient Safety, Communication, Healthcare Delivery
Fris E, Sedlock E, Etchegaray J
Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS).
The authors created a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention. Through a cross-sectional survey of QI stakeholders, they found that The Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and it identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention.
AHRQ-funded; HS024459.
Citation:
Fris E, Sedlock E, Etchegaray J .
Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS).
BMJ Open Qual 2021 Dec;10(4). doi: 10.1136/bmjoq-2020-001332..
Keywords:
Quality Improvement, Quality of Care, Neonatal Intensive Care Unit (NICU), Patient Safety, Newborns/Infants
Pruitt ZM, Howe JL, Hettinger AZ
Emergency physician perceptions of electronic health record usability and safety.
Investigators sought to identify emergency physicians' perceived electronic health record (EHR) usability and safety strengths and shortcomings across major EHR vendor products. They found that the 3 most commonly discussed usability topics were Workflow Support (shortcoming), Visual Display (strength), and Data Entry. Fourteen cross-hospital/cross-vendor themes, 6 vendor-specific themes, and 4 hospital-specific themes emerged as well.
AHRQ-funded; HS025136.
Citation:
Pruitt ZM, Howe JL, Hettinger AZ .
Emergency physician perceptions of electronic health record usability and safety.
J Patient Saf 2021 Dec 1;17(8):e983-e87. doi: 10.1097/pts.0000000000000849..
Keywords:
Emergency Department, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Safety
Adams 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
Burden A, Potestio C, Pukenas E
Influence of perioperative handoffs on complications and outcomes.
The authors describe the perioperative environment, calling it dynamic and complex, and indicate that there are multiple distractions that can interfere with effective communication and safe patient care. They discuss various aspects involved in handoffs, concluding that an institutional culture that highlights the importance of patient safety and that encourages team collaboration has demonstrated that harm can be decreased and patient safety can be improved.
AHRQ-funded; HS026158.
Citation:
Burden A, Potestio C, Pukenas E .
Influence of perioperative handoffs on complications and outcomes.
Adv Anesth 2021 Dec;39:133-48. doi: 10.1016/j.aan.2021.07.008..
Keywords:
Patient Safety, Transitions of Care, Workflow
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
Duffy B, Miller J, Vitous CA
Intersystem medical error discovery: a document analysis of ethical guidelines.
The authors conducted a document analysis of ethical guidelines concerning how providers should respond to other providers' errors, especially when they occur outside the provider's facility or system (intersystem medical error discovery [IMED]). They found that ethics codes provided little guidance on communication regarding IMED scenarios, and in some cases, the guidance was internally conflicting.
AHRQ-funded; HS026030.
Citation:
Duffy B, Miller J, Vitous CA .
Intersystem medical error discovery: a document analysis of ethical guidelines.
J Patient Saf 2021 Dec 1;17(8):e1765-e73. doi: 10.1097/pts.0000000000000625..
Keywords:
Medical Errors, Patient Safety, Provider: Health Personnel, Communication
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
