National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (3)
- (-) Adverse Events (21)
- Ambulatory Care and Surgery (1)
- Blood Clots (1)
- Cardiovascular Conditions (1)
- Caregiving (2)
- Children/Adolescents (7)
- Clinician-Patient Communication (2)
- Communication (2)
- COVID-19 (1)
- Cultural Competence (1)
- Dialysis (1)
- Disparities (2)
- Elderly (3)
- Electronic Health Records (EHRs) (2)
- Healthcare-Associated Infections (HAIs) (1)
- Healthcare Cost and Utilization Project (HCUP) (3)
- Health Information Technology (HIT) (2)
- Heart Disease and Health (2)
- Hospital Discharge (1)
- (-) Hospitalization (21)
- Hospitals (5)
- Infectious Diseases (1)
- Injuries and Wounds (1)
- Inpatient Care (4)
- Kidney Disease and Health (1)
- Long-Term Care (1)
- Medical Errors (4)
- Medication (3)
- Medication: Safety (2)
- Mortality (1)
- Nursing Homes (1)
- Obesity (1)
- Opioids (1)
- Orthopedics (1)
- Patient and Family Engagement (1)
- (-) Patient Safety (21)
- Practice Patterns (1)
- Prevention (2)
- Public Health (1)
- Quality Improvement (1)
- Quality Indicators (QIs) (1)
- Quality of Care (2)
- Racial and Ethnic Minorities (1)
- Risk (2)
- Sepsis (1)
- Social Determinants of Health (1)
- Surgery (3)
- Transitions of Care (2)
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 21 of 21 Research Studies DisplayedHerzig SJ, Anderson TS, Urman RD
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
The purpose of this retrospective cohort study was to identify risk factors for opioid-related adverse drug events (ORADEs) after hospital discharge following orthopedic procedures. The participants of this study included a national sample of Medicare beneficiaries who underwent major orthopedic surgery during hospitalization in 2016 and had an opioid prescription filled within 2 days of discharge. The study found that among 30,514 hospitalizations with a major orthopedic procedure and an opioid claim, a potential ORADE requiring hospital revisit occurred in 2.5%. After adjustment for patient characteristics, prior opioid use, co-prescribed sedating medications, and opioid prescription characteristics were not related with ORADEs. Independent risk factors did include age of 80 years or older, female sex, and clinical conditions, including heart failure, respiratory illness, kidney disease, dementia/delirium, anxiety disorder, and musculoskeletal/nervous system injuries.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Urman RD .
Risk factors for opioid-related adverse drug events among older adults after hospitalization for major orthopedic procedures.
J Patient Saf 2023 Oct 1; 19(6):379-85. doi: 10.1097/pts.0000000000001144..
Keywords: Elderly, Opioids, Adverse Drug Events (ADE), Adverse Events, Hospitalization, Orthopedics, Surgery, Medication, Risk, Medication: Safety, Patient Safety
Halvorson EE, Thurtle DP, Easter A
Disparities in adverse event reporting for hospitalized children.
The authors compared the adverse event (AE) rate identified by voluntary event reporting (VER) with that identified using the Global Assessment of Pediatric Patient Safety (GAPPS) between hospitalized children by weight category, race, and English proficiency. In the population studied, they identified 288 total AEs, 270 by the GAPPS and 18 by VER. They found a disparity in AE reporting for children with limited English proficiency, with fewer AEs by VER compared with no difference in AEs by GAPPS. They identified no disparities by weight category or race. They concluded that voluntary event reporting may systematically underreport AEs in hospitalized children with limited English proficiency.
AHRQ-funded; HS026038.
Citation: Halvorson EE, Thurtle DP, Easter A .
Disparities in adverse event reporting for hospitalized children.
J Patient Saf 2022 Sep 1;18(6):e928-e33. doi: 10.1097/pts.0000000000001049..
Keywords: Children/Adolescents, Disparities, Adverse Events, Medical Errors, Patient Safety, Hospitals, Hospitalization, Inpatient Care
Masonbrink AR, Harris M, Hall M
Safety events in children's hospitals during the COVID-19 pandemic.
The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. The objective of this study was to compare pediatric hospitalization safety events during the pandemic versus previous years. The investigators concluded that postoperative sepsis rates increased among children hospitalized during COVID-19. They suggest that efforts are needed to improve safety of postoperative care for hospitalized children.
AHRQ-funded; HS024554; HS024592.
Citation: Masonbrink AR, Harris M, Hall M .
Safety events in children's hospitals during the COVID-19 pandemic.
Hosp Pediatr 2021 Jun;11(6):e95-e100. doi: 10.1542/hpeds.2020-004937..
Keywords: Children/Adolescents, COVID-19, Patient Safety, Sepsis, Adverse Events, Hospitalization, Hospitals, Inpatient Care, Infectious Diseases, Public Health
Clark-Cutaia MN, Jarrin OF, Thomas-Hawkins C
The perfect storm: stakeholder perspectives on factors contributing to hospital admissions for patients undergoing maintenance hemodialysis.
This study examined reasons why end stage renal disease (ESRD) patients undergoing hemodialysis experience frequent complications and hospitalizations. Interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. There were four main themes that came out of the discussions: graft site/catheter/access issues, low resistance, breathing problems, and “The perfect storm”. The goal of these interviews were to promote more research to improve transitional care and care delivery for hemodialysis patients.
AHRQ-funded; HS022406.
Citation: Clark-Cutaia MN, Jarrin OF, Thomas-Hawkins C .
The perfect storm: stakeholder perspectives on factors contributing to hospital admissions for patients undergoing maintenance hemodialysis.
Nephrol Nurs J 2020 Jan-Feb;47(1):11-20..
Keywords: Kidney Disease and Health, Dialysis, Adverse Events, Hospitalization, Patient Safety
Khan A, Yin HS, Brach C
AHRQ Author: Brach C
Association between parent comfort with English and adverse events among hospitalized children.
The purpose of this study was to examine the association between parents’ limited comfort with English (LCE) and adverse events in a cohort of hospitalized children. Participants included Arabic-, Chinese-, English-, and Spanish-speaking parents of patients 17 years and younger in the pediatric units of seven North American hospitals. Findings showed that hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.
AHRQ-authored; AHRQ-funded; HS022986.
Citation: Khan A, Yin HS, Brach C .
Association between parent comfort with English and adverse events among hospitalized children.
JAMA Pediatr 2020 Dec;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215..
Keywords: Children/Adolescents, Caregiving, Cultural Competence, Clinician-Patient Communication, Communication, Adverse Events, Patient Safety, Inpatient Care, Hospitalization
Angraal S, Nuti SV, Masoudi FA
Digoxin use and associated adverse events among older adults.
The authors describe national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over the past two decades. They found that, while digoxin prescriptions have decreased, the drug is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. They concluded that these findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines.
AHRQ-funded; HS025164; HS025402; HS025517.
Citation: Angraal S, Nuti SV, Masoudi FA .
Digoxin use and associated adverse events among older adults.
Am J Med 2019 Oct;132(10):1191-98. doi: 10.1016/j.amjmed.2019.04.022.
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Keywords: Medication, Elderly, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Heart Disease and Health, Cardiovascular Conditions, Hospitalization, Practice Patterns
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
AHRQ-funded; HS024596.
Citation: Kapoor A, Field T, Handler S .
Adverse events in long-term care residents transitioning from hospital back to nursing home.
JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Stockwell DC, Landrigan CP, Toomey SL
Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.
Previous studies have revealed racial/ethnic and socioeconomic disparities in quality of care and patient safety. However, these disparities have not been examined in a pediatric inpatient environment by using a measure of clinically confirmed adverse events (AEs). In this study, the investigators do so using the Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool. The investigators concluded that the GAPPS analysis revealed racial and/or ethnic and socioeconomic disparities in rates of AEs experienced by hospitalized children across a broad range of geographic and hospital settings.
AHRQ-funded; HS020513; HS025299.
Citation: Stockwell DC, Landrigan CP, Toomey SL .
Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children.
Hosp Pediatr 2019 Jan;9(1):1-5. doi: 10.1542/hpeds.2018-0131..
Keywords: Children/Adolescents, Disparities, Racial and Ethnic Minorities, Social Determinants of Health, Hospitalization, Patient Safety, Quality of Care, Adverse Events
Prey JE, Polubriaginof F, Grossman LV
Engaging hospital patients in the medication reconciliation process using tablet computers.
Researchers conducted a pilot study to determine whether patients’ use of an electronic home medication review tool on a table computer could improve medication safety before or after hospitalization. Patients were randomized to the tool and out of 76 patients approached, 65 participated. About three-quarters (74%) made changes to their home medication list. Out of that total, 74% of the changes identified had a significant or greater potential severity, and 49% had a greater than 50-50 chance of harm. This medication reconciliation tool showed great potential to improve medication safety during and after hospitalization.
AHRQ-funded; HS021816.
Citation: Prey JE, Polubriaginof F, Grossman LV .
Engaging hospital patients in the medication reconciliation process using tablet computers.
J Am Med Inform Assoc 2018 Nov;25(11):1460-69. doi: 10.1093/jamia/ocy115..
Keywords: Adverse Drug Events (ADE), Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Prevention
Bhise V, Sittig DF, Vaghani V
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Researchers refined the methods of the Institute of Healthcare Improvement's Global Trigger Tool application and leveraged electronic health record data to improve detection of preventable adverse events, including diagnostic errors. In the studied sample, preventable adverse events were identified, including adverse drug events, patient falls, procedure-related complications, and hospital-associated infections. The authors concluded that such e-triggers can help overcome limitations of currently available methods to detect preventable harm in hospitalized patients.
AHRQ-funded; HS022087; HS023602.
Citation: Bhise V, Sittig DF, Vaghani V .
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
BMJ Qual Saf 2018 Mar;27(3):241-46. doi: 10.1136/bmjqs-2017-006975..
Keywords: Adverse Events, Electronic Health Records (EHRs), Health Information Technology (HIT), Hospitalization, Hospitals, Patient Safety, Prevention, Quality of Care, Quality Improvement, Quality Indicators (QIs)
Hernandez-Boussard T, Davies S, McDonald K
Interhospital facility transfers in the United States: a nationwide outcomes study.
This study identified and compared characteristics and outcomes of transfer and nontransfer patients. In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients. Study results suggest that transfer patients have inferior outcomes compared with nontransfer patients.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard T, Davies S, McDonald K .
Interhospital facility transfers in the United States: a nationwide outcomes study.
J Patient Saf 2017 Dec;13(4):187-91. doi: 10.1097/pts.0000000000000148.
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Keywords: Adverse Events, Healthcare Cost and Utilization Project (HCUP), Hospitalization, Patient Safety, Transitions of Care
Khan A, Furtak SL, Melvin P
Parent-provider miscommunications in hospitalized children.
The objectives of this study were to: (1) examine characteristics of parent-provider miscommunications about hospitalized children; (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience; and (3) compare parent and attending physician reports of parent-provider miscommunications. The investigators found that parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.
AHRQ-funded; HS022986; HS000063.
Citation: Khan A, Furtak SL, Melvin P .
Parent-provider miscommunications in hospitalized children.
Hosp Pediatr 2017 Sep;7(9):505-15. doi: 10.1542/hpeds.2016-0190..
Keywords: Adverse Events, Caregiving, Children/Adolescents, Clinician-Patient Communication, Communication, Hospitalization, Hospitals, Medical Errors, Patient Safety
Brown JR, Rezaee ME, Marshall EJ
Hospital mortality in the United States following acute kidney injury.
This review discusses the epidemiology of acute kidney injury (AKI) and its association with in-hospital mortality in the United States. Also discussed is the importance of the 71 percent reduction in AKI-related mortality among hospitalized patients in the United States and whether or not this is a phenomenon of hospital billing (coding) or improvements to the management of AKI.
AHRQ-funded; HS018443.
Citation: Brown JR, Rezaee ME, Marshall EJ .
Hospital mortality in the United States following acute kidney injury.
Biomed Res Int 2016;2016:4278579. doi: 10.1155/2016/4278579.
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Keywords: Mortality, Hospitalization, Adverse Events, Patient Safety
Wang Y, Eldridge N, Metersky ML
AHRQ Author: Eldridge N, Battles J
National trends in patient safety for four common conditions, 2005-2011.
The researchers estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery.
AHRQ-authored; AHRQ-funded; 290201200003C.
AHRQ-authored; AHRQ-funded; 290201200003C.
AHRQ-authored; AHRQ-funded; 290201200003C.
Citation: Wang Y, Eldridge N, Metersky ML .
National trends in patient safety for four common conditions, 2005-2011.
N Engl J Med 2014 Jan 23;370(4):341-51. doi: 10.1056/NEJMsa1300991..
Keywords: Patient Safety, Adverse Events, Hospitalization, Heart Disease and Health
Grant PJ, Greene MT, Chopra V
Assessing the Caprini score for risk assessment of venous thromboembolism in hospitalized medical patients.
The authors examined how well the Caprini risk assessment model predicts venous thromboembolism in hospitalized medical patients. They concluded that the Caprini risk assessment model was unable to identify a subset of medical patients who benefit from pharmacologic prophylaxis.
AHRQ-funded; HS022835.
Citation: Grant PJ, Greene MT, Chopra V .
Assessing the Caprini score for risk assessment of venous thromboembolism in hospitalized medical patients.
Am J Med 2016 May;129(5):528-35. doi: 10.1016/j.amjmed.2015.10.027.
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Keywords: Adverse Events, Blood Clots, Hospitalization, Risk, Patient Safety
Khan A, Furtak SL, Melvin P
Parent-reported errors and adverse events in hospitalized children.
The researchers sought to determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). They found that parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record.
AHRQ-funded; HS022986.
Citation: Khan A, Furtak SL, Melvin P .
Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr 2016 Apr 4;170(4):e154608. doi: 10.1001/jamapediatrics.2015.4608..
Keywords: Children/Adolescents, Hospitalization, Patient Safety, Adverse Events, Medical Errors
Hernandez-Boussard T, McDonald KM, Rhoads KF
Patient safety in plastic surgery: identifying areas for quality improvement efforts.
The study’s aim was to assess risk-adjusted rates of inpatient adverse events (AEs) for general reconstructive soft tissue procedures using established measures. It found that plastic surgery patients had a significantly lower risk-adjusted rate compared to other surgical inpatients for all events evaluated except for failure to rescue and postoperative hemorrhage or hematoma.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard T, McDonald KM, Rhoads KF .
Patient safety in plastic surgery: identifying areas for quality improvement efforts.
Ann Plast Surg 2015 May;74(5):597-602. doi: 10.1097/SAP.0b013e318297791e..
Keywords: Healthcare Cost and Utilization Project (HCUP), Adverse Events, Inpatient Care, Hospitalization, Patient Safety
O'Leary KJ, Turner J, Christensen N
The effect of hospitalist discontinuity on adverse events.
The researchers sought to determine the association between hospital physician continuity and the incidence of adverse events (AEs). Based on an analysis including data from 474 hospitalizations, they found that hospitalist physician continuity does not appear to be associated with the incidence of AEs.
AHRQ-funded; HS019630.
Citation: O'Leary KJ, Turner J, Christensen N .
The effect of hospitalist discontinuity on adverse events.
J Hosp Med 2015 Mar;10(3):147-51. doi: 10.1002/jhm.2308..
Keywords: Patient Safety, Adverse Events, Hospitalization
Aterburn D, Powers JD, Toh S
Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass.
A retrospective study of 7,457 patients undergoing laparoscopic bariatric surgery found that patients receiving gastric bypass experienced much greater weight loss than those receiving gastric banding but they had a higher risk of short-term complications and long-term subsequent hospitalizations. However, gastric bypass patients had a lower risk of long-term subsequent intervention procedures than did gastric banding patients.
AHRQ-funded; HS019912
Citation: Aterburn D, Powers JD, Toh S .
Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass.
JAMA Surg. 2014 Dec;149(12):1279-87. doi: 10.1001/jamasurg.2014.1674..
Keywords: Obesity, Surgery, Adverse Events, Patient Safety, Hospitalization
Owens PL, Barrett ML, Raetzman S
AHRQ Author: Owens PL, Steiner CA
Surgical site infections following ambulatory surgery procedures.
The authors determined the incidence of clinically significant surgical site infections (CS-SSIs) following low- to moderate-risk ambulatory surgery in patients with low risk for surgical complications. They found that among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes but may represent a substantial number of adverse outcomes in aggregate, thus meriting quality improvement efforts to minimize their occurrence.
AHRQ-authored; AHRQ-funded; 290201300002C.
Citation: Owens PL, Barrett ML, Raetzman S .
Surgical site infections following ambulatory surgery procedures.
JAMA 2014 Feb 19;311(7):709-16. doi: 10.1001/jama.2014.4.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Healthcare-Associated Infections (HAIs), Injuries and Wounds, Ambulatory Care and Surgery, Surgery, Hospitalization, Patient Safety, Adverse Events
Starmer AJ, Sectish TC, Simon DW
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
The researchers sought to determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. They found that implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children.
AHRQ-funded; HS019456.
Citation: Starmer AJ, Sectish TC, Simon DW .
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
JAMA 2013 Dec 4;310(21):2262-70. doi: 10.1001/jama.2013.281961..
Keywords: Medical Errors, Adverse Events, Children/Adolescents, Hospitalization, Patient Safety