National Healthcare Quality and Disparities Report
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Topics
- Adverse Events (3)
- Antimicrobial Stewardship (1)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (1)
- Healthcare-Associated Infections (HAIs) (1)
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- Intensive Care Unit (ICU) (3)
- Medical Errors (1)
- Methicillin-Resistant Staphylococcus aureus (MRSA) (1)
- (-) Neonatal Intensive Care Unit (NICU) (10)
- (-) Newborns/Infants (10)
- Nursing (1)
- (-) Patient Safety (10)
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- Risk (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 10 of 10 Research Studies DisplayedFris 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
Brei BK, Sawyer T, Umoren R
Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS.
This study looked at whether the presence of family members had an impact on neonatal tracheal intubation (TI) outcomes. This retrospective analysis looked at TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS) at 13 academic NICUS from October 2014 to December 2017. Family members were present in less than 10% of TIs, but this varied by site. Success rates were not significantly different, with the first attempt success rate at 55% with family present versus 49% and success within 2 attempts was 74% versus 66%. Adverse TI-associated events (TIAEs) were 17% versus 20% and severe oxygen desaturation was 49% versus 52%. No independent association between any of these outcomes was found with family presence.
AHRQ-funded; HS027259; HS024511.
Citation: Brei BK, Sawyer T, Umoren R .
Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS.
Arch Dis Child Fetal Neonatal Ed 2021 Jul;106(4):392-97. doi: 10.1136/archdischild-2020-319709..
Keywords: Newborns/Infants, Neonatal Intensive Care Unit (NICU), Intensive Care Unit (ICU), Registries, Patient Safety
Dadiz R, Riccio J, Brown K
Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit.
This study’s objective was to identify 1) latent safety threats (LSTs) in a new neonatal intensive care unit (NICU) through simulation-based pre-occupancy operations testing, and 2) LSTs that remained unresolved 1-year post-occupancy. This qualitative study included 111 healthcare professionals who participated in patient care simulations and debriefings in a new NICU. Debriefing transcripts were analyzed to characterize LSTs. Three-hundred threats with four major themes affecting staff function and patient safety emerged: relay of information, workplace design, patient care processes, and patient family and staff focus. One-year post occupancy 29 (9%) LSTs were still unresolved.
AHRQ-funded; R18 HS023460.
Citation: Dadiz R, Riccio J, Brown K .
Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit.
J Perinatol 2020 Sep;40(Suppl 1):29-35. doi: 10.1038/s41372-020-0749-3..
Keywords: Newborns/Infants, Neonatal Intensive Care Unit (NICU), Intensive Care Unit (ICU), Patient Safety, Simulation
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Pouppirt NR, Nassar R, Napolitano N
Association between video laryngoscopy and adverse tracheal intubation-associated events in the neonatal intensive care unit.
The purpose of this single-site retrospective cohort study was to consider the possible effect of video laryngoscopy on adverse events during neonatal tracheal intubation. The researchers conclude that video laryngoscopy was independently associated with decreased risk for adverse events.
AHRQ-funded; HS022464; HS024511.
Citation: Pouppirt NR, Nassar R, Napolitano N .
Association between video laryngoscopy and adverse tracheal intubation-associated events in the neonatal intensive care unit.
J Pediatr 2018 Oct;201:281-84.e1. doi: 10.1016/j.jpeds.2018.05.046..
Keywords: Adverse Events, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Patient Safety
Dudding KM, Gephart SM, Carrington JM
Neonatal nurses experience unintended consequences and risks to patient safety with electronic health records.
The purposes of this study were to describe unintended consequences of use of electronic health records for neonatal nurses and to explore relationships between the phenomena and characteristics of the nurse and the electronic health record. The most frequent unintended consequences of electronic health record use were due to interruptions, followed by a heavier workload due to the electronic health record.
AHRQ-funded; HS022908.
Citation: Dudding KM, Gephart SM, Carrington JM .
Neonatal nurses experience unintended consequences and risks to patient safety with electronic health records.
Comput Inform Nurs 2018 Apr;36(4):167-76. doi: 10.1097/cin.0000000000000406.
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Keywords: Electronic Health Records (EHRs), Neonatal Intensive Care Unit (NICU), Newborns/Infants, Nursing, Patient Safety
Profit J, Lee HC, Sharek PJ
Comparing NICU teamwork and safety climate across two commonly used survey instruments.
The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)). It concluded that large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC.
AHRQ-funded; HS014246.
Citation: Profit J, Lee HC, Sharek PJ .
Comparing NICU teamwork and safety climate across two commonly used survey instruments.
BMJ Qual Saf 2016 Dec;25(12):954-61. doi: 10.1136/bmjqs-2014-003924.
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Keywords: Hospitals, Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), Newborns/Infants, Patient Safety, Teams
Reich PJ, Boyle MG, Hogan PG
Emergence of community-associated methicillin-resistant Staphylococcus aureus strains in the neonatal intensive care unit: an infection prevention and patient safety challenge.
Methicillin-resistant Staphylococcus aureus (MRSA) infections cause significant morbidity and mortality in neonatal intensive care units (NICUs). The researchers characterized the clinical and molecular epidemiology of MRSA strains colonizing NICU patients. They found that community-acquired MRSA strains are prominent in the NICU and associated with distinct risk factors.
AHRQ-funded; HS021736; HS024269.
Citation: Reich PJ, Boyle MG, Hogan PG .
Emergence of community-associated methicillin-resistant Staphylococcus aureus strains in the neonatal intensive care unit: an infection prevention and patient safety challenge.
Clin Microbiol Infect 2016 Jul;22(7):645.e1-8. doi: 10.1016/j.cmi.2016.04.013.
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Keywords: Methicillin-Resistant Staphylococcus aureus (MRSA), Neonatal Intensive Care Unit (NICU), Patient Safety, Prevention, Antimicrobial Stewardship, Newborns/Infants, Healthcare-Associated Infections (HAIs)
Foglia EE, Ades A, Napolitano N
Factors associated with adverse events during tracheal intubation in the NICU.
This study sought to determine the incidence of adverse tracheal intubation-associated events (TIAEs and to identify factors associated with TIAEs in the NICU. It found that adverse TIAEs occurred in 153 of 701 (22 percent) tracheal intubation encounters. Modifiable risk factors associated with TIAEs identified include intubator training level and use of paralytic medications.
AHRQ-funded; HS021583.
Citation: Foglia EE, Ades A, Napolitano N .
Factors associated with adverse events during tracheal intubation in the NICU.
Neonatology 2015;108(1):23-9. doi: 10.1159/000381252..
Keywords: Patient Safety, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Risk, Adverse Events
Profit J, Sharek PJ, Amspoker AB
Burnout in the NICU setting and its relation to safety culture.
The objectives of this study are three-fold: to test the psychometric properties of a brief four-item burnout scale; to provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types; and to examine the relationships between caregiver burnout and patient safety culture. The authors found that NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and is associated with lower perceptions of patient safety culture.
AHRQ-funded; HS014246.
Citation: Profit J, Sharek PJ, Amspoker AB .
Burnout in the NICU setting and its relation to safety culture.
BMJ Qual Saf 2014 Oct;23(10):806-13. doi: 10.1136/bmjqs-2014-002831.
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Keywords: Provider: Health Personnel, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Patient Safety