National Healthcare Quality and Disparities Report
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Search All Research Studies
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- Adverse Drug Events (ADE) (1)
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- Evidence-Based Practice (1)
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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 5 of 5 Research Studies DisplayedMiller J, Vitous CA, Boothman RC
Medical error professionals' perspectives on Inter-system medical error discovery (IMED): consensus, divergence, and uncertainty.
Best practices for how to respond are unclear when a medical error is discovered in a different system (inter-system medical error discovery or IMED). This qualitative study explored medical error professionals' views on disclosure, feedback, and reporting in these scenarios. The investigators found that while medical error professionals expressed consensus regarding obligations to disclose obvious errors, they differed on particulars.
AHRQ-funded; HS026030.
Citation: Miller J, Vitous CA, Boothman RC .
Medical error professionals' perspectives on Inter-system medical error discovery (IMED): consensus, divergence, and uncertainty.
Medicine 2020 Jul 31;99(31):e21425. doi: 10.1097/md.0000000000021425..
Keywords: Medical Errors, Adverse Events, Patient Safety, Guidelines
Yang AD, Hewitt DB, Blay E
Multi-institution evaluation of adherence to comprehensive postoperative VTE chemoprophylaxis.
The aims of this study were to: (1) measure the rate of failure to provide defect-free postoperative venous thromboembolism (VTE) chemoprophylaxis, (2) identify reasons for failure to provide defect-free VTE chemoprophylaxis, and (3) examine patient- and hospital-level factors associated with failure. The investigators concluded that in contrast to SCIP-VTE-2, their novel quality measure unmasked VTE chemoprophylaxis failures in 18% of colectomies. They found that most failures were due to patient refusals or ordering errors.
AHRQ-funded; HS024516.
Citation: Yang AD, Hewitt DB, Blay E .
Multi-institution evaluation of adherence to comprehensive postoperative VTE chemoprophylaxis.
Ann Surg 2020 Jun;271(6):1072-79. doi: 10.1097/sla.0000000000003124..
Keywords: Patient Adherence/Compliance, Guidelines, Blood Clots, Blood Thinners, Medication, Medication: Safety, Patient Safety, Adverse Events
Abraham NS
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
This article is a review of current best practice recommendations focusing on the risk of immediate and delayed postpolypectomy bleeding in the context of drug discontinuation or continuation of antiplatelet and anticoagulant drugs. Data was assessed whether cold snare vs conventional thermal-based polypectomy technology and prophylactic placement of hemostatic clips are endoscopic techniques that are beneficial in reducing polypectomy bleeding. Clinical takeaways are also provided to facilitate safer polypectomy among patients on antiplatelet and anticoagulant agents.
AHRQ-funded; HS025402.
Citation: Abraham NS .
Antiplatelets, anticoagulants, and colonoscopic polypectomy.
Gastrointest Endosc 2020 Feb;91(2):257-65. doi: 10.1016/j.gie.2019.09.033..
Keywords: Blood Thinners, Medication, Medication: Safety, Colonoscopy, Adverse Drug Events (ADE), Adverse Events, Guidelines, Prevention, Patient Safety
Burstein PD, Zalenski DM, Edwards JL
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
The researchers established a multifactorial shoulder dystocia response and management protocol to promote sustainable practice change. In the first year, there was a threefold increase in shoulder dystocia reporting, which continued in years 2 and 3. In the first year, 96 percent of clinicians completed all training elements. Overall teams reached a 99 percent adoption rate of the shoulder dystocia protocol.
AHRQ-funded; HS019608.
Citation: Burstein PD, Zalenski DM, Edwards JL .
Changing labor and delivery practice: focus on achieving practice and documentation standardization with the goal of improving neonatal outcomes.
Health Serv Res 2016 Dec;51 Suppl 3:2472-86. doi: 10.1111/1475-6773.12589.
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Keywords: Labor and Delivery, Newborns/Infants, Adverse Events, Quality Improvement, Quality of Care, Patient Safety, Patient-Centered Outcomes Research, Outcomes, Guidelines, Evidence-Based Practice, Pregnancy, Teams
Chopra V, Flanders SA, Saint S
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA Appropriateness Method.
The authors organized and conducted a multidisciplinary meeting of national and international experts to develop appropriateness criteria for use, care, and management of peripherally inserted central catheters (PICCs) and related ventricular assist devices (VADs) in hospitalized patients. Among the objectives were developing a list of appropriate indications for use of PICCs in relation to other VADs, and defining the appropriateness of practices associated with the insertion and care of PICCs.
AHRQ-funded; HS022835.
Citation: Chopra V, Flanders SA, Saint S .
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA Appropriateness Method.
Ann Intern Med 2015 Sep 15;163(6 Suppl):S1-40. doi: 10.7326/m15-0744..
Keywords: Adverse Events, Guidelines, Inpatient Care, Patient Safety