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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 1212 Research Studies Displayed
Beeber AS, Hoben M, Leeman J
Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.
This paper describes an AHRQ-funded study protocol (Engage) to develop a toolkit for increasing resident and family engagement in assisted living (AL) safety. The study goals are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. Methods, including qualitative interviews, a scoping review of persona and family engagement (PFE) interventions, and stakeholder panel meetings are discussed. The authors also detail how the protocol was modified to address the unique challenges of the COVID-19 pandemic.
AHRQ-funded; HS026473.
Citation:
Beeber AS, Hoben M, Leeman J .
Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.
Res Nurs Health 2022 Aug;45(4):413-23. doi: 10.1002/nur.22232..
Keywords:
Patient and Family Engagement, Patient Safety, Caregiving, Public Health, Long-Term Care
Eldridge N, Wang Y, Metersky M
Trends in adverse event rates in hospitalized patients, 2010-2019.
This AHRQ-authored serial cross-sectional study’s objective was to determine the change in the rate of adverse events in hospitalized patients from 2010 to 2019. The study used data from the Medicare Patient Safety Monitoring System and included 244,542 adult patients hospitalized in 3156 acute care hospitals across 4 condition groups: acute myocardial infarction (17%), heart failure (17%) pneumonia (21%), major surgical procedures (22%), and all other conditions (22%). Information on adverse events collected included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events such as pressure ulcers and falls. The study sample included 190,286 hospital discharges in the combined 4 condition-based groups and 54,256 hospital discharges for all other conditions. From 2010 to 2019, the total change for adverse events per 1000 discharges for acute myocardial infarction decreased from 218 to 139, from 168 to 116 for heart failure, from 195 to 119 for pneumonia, and from 204 to 130 for major surgical procedures. The rate for all other conditions remained unchanged at 70 adverse events per 1000 discharges.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation:
Eldridge N, Wang Y, Metersky M .
Trends in adverse event rates in hospitalized patients, 2010-2019.
JAMA 2022 Jul 12;328(2):173-83. doi: 10.1001/jama.2022.9600..
Keywords:
Adverse Events, Patient Safety, Hospitals, Inpatient Care
Atkinson MK, Benneyan JC, Bambury EA
Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.
A patient safety learning laboratory (lab) can be a critical element of nurturing interdisciplinary team innovation across multiple projects and organizations. The purpose of this mixed-methods study was to evaluate a patient safety learning lab to examine the role and activities of a learning ecosystem that support interdisciplinary team innovation. The study found that successful learning ecosystems continuously facilitate alignment between interdisciplinary teams' activities, organizational context, and innovation project objectives. The researchers concluded that Interdisciplinary learning ecosystems have the capacity to facilitate health care improvement and innovation through alignment of team activities, project goals, and organizational contexts.
AHRQ-funded; HS024453.
Citation:
Atkinson MK, Benneyan JC, Bambury EA .
Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.
Health Care Manage Rev 2022 Jul-Sep;47(3):E50-E61. doi: 10.1097/hmr.0000000000000330..
Keywords:
Patient Safety, Innovations and Emerging Issues, Healthcare Delivery
Zebrak K, Yount N, Sorra J
Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture™ (SOPS(®)) workplace safety supplemental items for hospitals.
The purpose of this AHRQ-funded study was to develop and test survey items that can be utilized together with the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture™ (SOPS(®)) Hospital Survey to evaluate how hospitals’ organizational cultures support workplace safety for both providers and staff. Based on a literature review and qualitative interviews with experts in workplace safety, the researchers identified prime areas of workplace safety culture (workplace hazards, moving patients, workplace aggression, management support for workplace safety, workplace safety reporting, and work stress or burnout) and drafted survey items to evaluate these areas. The survey items were then pilot tested on providers and staff in 28 U.S. hospitals using the SOPS Hospital Survey 2.0. Data from 6,684 respondents was analyzed and demonstrated conceptual convergence among the survey measures. The researchers concluded that both researchers and hospitals can utilize the Workplace Safety Supplemental items to evaluate the dimensions of organizational culture that support provider and staff safety and to pinpoint organizational strengths and areas for improvement.
AHRQ-funded; 233201500026I.
Citation:
Zebrak K, Yount N, Sorra J .
Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture™ (SOPS(®)) workplace safety supplemental items for hospitals.
Int J Environ Res Public Health 2022 Jun 2;19(11). doi: 10.3390/ijerph19116815..
Keywords:
Surveys on Patient Safety Culture, Patient Safety, Hospitals, Organizational Change
Besagar S, Robles PLA, Rojas C
"What's in a name?" Identification of newborn infants at birth using their given names.
This study’s objective was to determine the proportion of pregnant women who selected names for their babies before they were born or at birth and were willing to disclose them for use in hospital systems, thereby reducing infant identification errors. A survey of pregnant women admitted to postpartum or antepartum units at a large academic hospital was conducted. Of postpartum participants, 79% had names for their newborns at birth. The proportion was significantly lower in self-identified non-Hispanic, white, and married women. Of antepartum participants, 65.7% had selected a name by the time they were surveyed.
AHRQ-funded; HS026121.
Citation:
Besagar S, Robles PLA, Rojas C .
"What's in a name?" Identification of newborn infants at birth using their given names.
J Perinatol 2022 Jun;42(6):752-55. doi: 10.1038/s41372-021-01270-9..
Keywords:
Newborns/Infants, Patient Safety
Huang J, Park GW, Jones RM
Efficacy of EPA-registered disinfectants against two human norovirus surrogates and Clostridioides difficile endospores.
This study’s goal was to determine the efficacy of a panel of nine EPA-registered disinfectants against two human norovirus (HuNoV) surrogates (feline calicivirus [FCV] and Tulane virus [TuV]) and Clostridioides difficile endospores. These products, five of which contained H2O2 (hydrogen peroxide) as the active ingredient, were tested against infectious FCV, TuV, and C. difficile endospores using two ASTM methods, a suspension and carrier test. Products containing hydrogen peroxide were the most efficacious. Of the five products containing hydrogen peroxide, no strong correlation was observed between disinfection efficacy and hydrogen peroxide concentration. Addition of 0.025% ferrous sulphate to 1% hydrogen peroxide solution improved efficacy against FCV, TuV and C. difficile.
AHRQ-funded; HS025987.
Citation:
Huang J, Park GW, Jones RM .
Efficacy of EPA-registered disinfectants against two human norovirus surrogates and Clostridioides difficile endospores.
J Appl Microbiol 2022 Jun;132(6):4289-99. doi: 10.1111/jam.15524..
Keywords:
Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Prevention, Patient Safety
Bardach NS, Stotts JR, Fiore DM
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.
This study’s goal was to test a real-time mobile-responsive website called Family Input for Quality and Safety (FIQS) for inpatient reporting from families and patients. The tool was piloted from June 2017 to April 2018 on the medical-surgical unit of a children’s hospital. The authors enrolled 253 patients aged 13 and older and patient family members. This resulted in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one reports met incident reporting (IR) criteria with only 1 having been reported via the IR system. White participants submitted more observations than Latinx participants.
AHRQ-funded; HS028477; HS024553.
Citation:
Bardach NS, Stotts JR, Fiore DM .
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.
J Hosp Med 2022 Jun;17(6):456-65. doi: 10.1002/jhm.2777..
Keywords:
Quality of Care, Patient Safety, Health Information Technology (HIT), Patient and Family Engagement
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
Milliren CE, Bailey G, Graham DA
Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.
This observational study aimed to explore the covariance of pediatric hospital quality indicators and evaluate the use of a single composite score. Pediatric hospital performance across 13 safety indicators were extracted from the Pediatric Health Information System, a comparative database of children’s hospitals in the U.S. Patients discharged from 36 hospitals from 2016 to 2019 were included. The authors investigated relationships among patient safety measures from AHRQ pediatric quality indicators and Center for Medicare and Medicaid Services hospital-acquired conditions. They identified 5 orthogonal variance components accounting for 68% of variation in pediatric hospital quality indicators. The ranking comparison and summary found greater within-hospital variation compared with between-hospital variation. They observed discordant rankings among commonly used summary measures and concluded that these measures demonstrate at least 2 underlying variance components.
AHRQ-funded; HS026246.
Citation:
Milliren CE, Bailey G, Graham DA .
Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.
J Patient Saf 2022 Jun 1;18(4):e741-e46. doi: 10.1097/pts.0000000000000938..
Keywords:
Children/Adolescents, Quality Indicators (QIs), Quality Measures, Patient Safety, Hospitals, Quality of Care
Evans LV, Ray JM, Bonz JW
Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.
The purpose of this study will be to simultaneously assess the challenges and facilitators of COVID-19 preparedness in the emergency department (ED) and the mitigation of emergency physician stress, test the effectiveness of a simulation preparedness intervention on physician physiological stress, and improve physician preparedness while decreasing physician stress and anxiety.
AHRQ-funded; HS028340.
Citation:
Evans LV, Ray JM, Bonz JW .
Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.
BMJ Open 2022 May 19;12(5):e058980. doi: 10.1136/bmjopen-2021-058980..
Keywords:
COVID-19, Patient Safety, Simulation, Burnout, Provider: Clinician
Giardina TD, Choi DT, Upadhyay DK
Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.
This study’s objective was to test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes in an electronic health record (EHR) system. Patients aged 18-85 years in a large integrated health system who actively used the patient portal were invited to respond to an online questionnaire if an EHR algorithm detected any recent visit following an initial primary care consultation. The authors developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to the diagnostic process based on notes review and recall of recent “at-risk” visits. The algorithm identified 1282 eligible patients, of whom 486 responded. Of the 418 patients included in the analysis, 51 patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements "The care plan the provider developed for me addressed all my medical concerns", "I trust the provider that I saw during my visit" and agreed with the statement "I did not have a good feeling about my visit".
AHRQ-funded; HS027363; HS025474.
Citation:
Giardina TD, Choi DT, Upadhyay DK .
Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.
J Am Med Inform Assoc 2022 May 11;29(6):1091-100. doi: 10.1093/jamia/ocac036..
Keywords:
Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient Experience, Patient Safety
Hannum SM, Oladapo-Shittu O, Salinas AB
A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy.
This study’s objective was to describe barriers to, facilitators for, and suggested strategies for successful home infusion central line associated bloodstream infection (CLABSI) surveillance. The authors conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members for home infusion. They analyzed 21 transcribed interviews qualitatively for themes. Eight steps for performing CLABSI surveillance were revealed. Major surveillance barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support.
AHRQ-funded; HS027819.
Citation:
Hannum SM, Oladapo-Shittu O, Salinas AB .
A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy.
Am J Infect Control 2022 May;50(5):555-62. doi: 10.1016/j.ajic.2022.01.008..
Keywords:
Central Line-Associated Bloodstream Infections (CLABSI), Healthcare-Associated Infections (HAIs), Patient Safety, Sepsis
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
Marshall TL, Rinke ML, Olson APJ
Diagnostic error in pediatrics: a narrative review.
This narrative review focuses on the relative paucity of large, high-quality studies of diagnostic errors and what is known at present about the incident and epidemiology as well as the established research for identifying, evaluating, and reducing diagnostic errors. The authors propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature. The authors state that additional research is needed to better establish the epidemiology of diagnostic errors in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses.
AHRQ-funded; HS023827; HS026644.
Citation:
Marshall TL, Rinke ML, Olson APJ .
Diagnostic error in pediatrics: a narrative review.
Pediatrics 2022 Mar;149(Suppl 3). doi: 10.1542/peds.2020-045948D..
Keywords:
Children/Adolescents, Diagnostic Safety and Quality, Patient Safety, Medical Errors
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
