المؤلفون: Meyers D; Agency for Healthcare Research and Quality, Rockville, Maryland., Miller T; Agency for Healthcare Research and Quality, Rockville, Maryland Therese.Miller@ahrq.hhs.gov., De La Mare J; Agency for Healthcare Research and Quality, Rockville, Maryland., Gerteis JS; Abt Associates, Inc, Cambridge, Massachusetts., Makulowich G; Agency for Healthcare Research and Quality, Rockville, Maryland., Weber GH; Crosby Marketing Communications, Inc, Annapolis, Maryland., Zhan C; Agency for Healthcare Research and Quality, Rockville, Maryland., Genevro J; Independent consultant.

المصدر: Annals of family medicine [Ann Fam Med] 2024 Mar-Apr; Vol. 22 (2), pp. 161-166.

نوع المنشور: Journal Article

بيانات الدورية: Publisher: Annals of Family Medicine, Inc Country of Publication: United States NLM ID: 101167762 Publication Model: Print Cited Medium: Internet ISSN: 1544-1717 (Electronic) Linking ISSN: 15441709 NLM ISO Abbreviation: Ann Fam Med Subsets: MEDLINE

مواضيع طبية MeSH: Primary Health Care*/methods , Quality Improvement*, United States ; Humans ; United States Agency for Healthcare Research and Quality

مستخلص: Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.
(© 2024 Annals of Family Medicine, Inc.)

المؤلفون: Bierman AS; Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland, USA., Wang J; Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland, USA.; Florida State University College of Nursing, Tallahassee, Florida, USA.; Health and Aging Policy Fellows Program, Columbia University, New York, New York, USA., O'Malley PG; Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland, USA., Moss DK; Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland, USA.

المصدر: Health services research [Health Serv Res] 2021 Oct; Vol. 56 Suppl 1, pp. 973-979. Date of Electronic Publication: 2021 Sep 06.

نوع المنشور: Journal Article

بيانات الدورية: Publisher: Blackwell Country of Publication: United States NLM ID: 0053006 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1475-6773 (Electronic) Linking ISSN: 00179124 NLM ISO Abbreviation: Health Serv Res Subsets: MEDLINE

مواضيع طبية MeSH: Practice Guidelines as Topic* , United States Agency for Healthcare Research and Quality*, Delivery of Health Care/*standards , Multiple Chronic Conditions/*therapy , Primary Health Care/*standards , Quality of Health Care/*standards, Adult ; Aged ; Aged, 80 and over ; Female ; Humans ; Male ; Middle Aged ; United States

المؤلفون: Keller S; Johns Hopkins University School of Medicine, Baltimore, Maryland., Miller MA; Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland., Cosgrove SE; Johns Hopkins University School of Medicine, Baltimore, Maryland.

المصدر: American family physician [Am Fam Physician] 2023 May; Vol. 107 (5), pp. 456-457.

نوع المنشور: Editorial

بيانات الدورية: Publisher: American Academy of General Practice Country of Publication: United States NLM ID: 1272646 Publication Model: Print Cited Medium: Internet ISSN: 1532-0650 (Electronic) Linking ISSN: 0002838X NLM ISO Abbreviation: Am Fam Physician Subsets: MEDLINE

مواضيع طبية MeSH: Medical Errors*, Humans ; United States ; United States Agency for Healthcare Research and Quality

المؤلفون: Carpenter CR; Professors in the Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri., Jotte R; Professors in the Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri., Griffey RT; Professors in the Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri., Schwarz E; Associate Professor in the Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri.

المصدر: Missouri medicine [Mo Med] 2023 Mar-Apr; Vol. 120 (2), pp. 114-120.

نوع المنشور: Journal Article; Review

بيانات الدورية: Publisher: Missouri State Medical Association Country of Publication: United States NLM ID: 0400744 Publication Model: Print Cited Medium: Internet ISSN: 0026-6620 (Print) Linking ISSN: 00266620 NLM ISO Abbreviation: Mo Med Subsets: MEDLINE

مواضيع طبية MeSH: Health Services Research* , Emergency Medicine*, United States ; Humans ; Diagnostic Errors ; United States Agency for Healthcare Research and Quality

مستخلص: The Agency for Healthcare Research and Quality (AHRQ) report "Diagnostic Errors in the Emergency Department" generated significant mass media interest with negative implications for the safety of contemporary emergency care. The assumptions and methodology underlying this report are problematic, while multiple ongoing efforts to improve the quality and quantity of diagnostic research are missed, neglected, or ignored. The AHRQ report identifies reasonable target diseases for targeting diagnostic quality improvement efforts, as well as viable methods by which to measure any initiatives impact on diagnostic error. We note additional opportunities to improve the status quo by funding emergency department-based diagnostic research and healthcare system-level patient safety research and highlighting innovative approaches to diagnostic science within emergency medicine.
(Copyright 2023 by the Missouri State Medical Association.)

المؤلفون: Borsky AE, Savitz LA, Bindman AB, Mossburg S, Thompson L

المصدر: Joint Commission journal on quality and patient safety [Jt Comm J Qual Patient Saf] 2019 Nov; Vol. 45 (11), pp. 772-778.

نوع المنشور: Journal Article; Research Support, U.S. Gov't, P.H.S.

بيانات الدورية: Publisher: Elsevier Country of Publication: Netherlands NLM ID: 101238023 Publication Model: Print Cited Medium: Internet ISSN: 1938-131X (Electronic) Linking ISSN: 15537250 NLM ISO Abbreviation: Jt Comm J Qual Patient Saf Subsets: MEDLINE

مواضيع طبية MeSH: Evidence-Based Practice* , Translational Research, Biomedical* , United States Agency for Healthcare Research and Quality*, Learning Health System/*organization & administration, Humans ; United States

المؤلفون: Cuello-Garcia CA; World Health Organization Collaborating Center for Infectious Diseases, Research Methods and Recommendations, Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, L8S 4L8, Ontario, Canada. Electronic address: cuelloca@mcmaster.ca., Schünemann HJ; World Health Organization Collaborating Center for Infectious Diseases, Research Methods and Recommendations, Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, L8S 4L8, Ontario, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, L8S 4L8, Ontario, Canada.

المصدر: Journal of clinical epidemiology [J Clin Epidemiol] 2022 Dec; Vol. 152, pp. 307-308. Date of Electronic Publication: 2022 Oct 11.

نوع المنشور: Journal Article

بيانات الدورية: Publisher: Elsevier Country of Publication: United States NLM ID: 8801383 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1878-5921 (Electronic) Linking ISSN: 08954356 NLM ISO Abbreviation: J Clin Epidemiol Subsets: MEDLINE

مواضيع طبية MeSH: Health Services Research*, United States ; Humans ; United States Agency for Healthcare Research and Quality

مستخلص: ▪.
(Copyright © 2022 Elsevier Inc. All rights reserved.)

المؤلفون: Reeves BC; Bristol Medical School, University of Bristol, Bristol, UK. Electronic address: barney.reeves@bristol.ac.uk., Shea BJ; Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada., Wells GA; School of Epidemiology and Public Health, Faculty of Medicine and University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada., Sharma Waddington H; London International Development Centre, London School of Hygiene and Tropical Medicine, London, UK.

المصدر: Journal of clinical epidemiology [J Clin Epidemiol] 2022 Dec; Vol. 152, pp. 309-310. Date of Electronic Publication: 2022 Nov 10.

نوع المنشور: Journal Article

بيانات الدورية: Publisher: Elsevier Country of Publication: United States NLM ID: 8801383 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1878-5921 (Electronic) Linking ISSN: 08954356 NLM ISO Abbreviation: J Clin Epidemiol Subsets: MEDLINE

مواضيع طبية MeSH: Evidence-Based Medicine* , Health Services Research*, United States ; Humans ; Systematic Reviews as Topic ; United States Agency for Healthcare Research and Quality ; Delivery of Health Care

المؤلفون: Kim J, Choi EY, Lee W; Department of Nursing, Chung-Ang University., Oh HM; Asian Institute for Bioethics and Health Law, Yonsei University., Pyo J, Ock M, Kim SY; Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, Republic of Korea., Lee SI

المصدر: Journal of patient safety [J Patient Saf] 2022 Aug 01; Vol. 18 (5), pp. 404-409. Date of Electronic Publication: 2021 Dec 17.

نوع المنشور: Journal Article; Research Support, Non-U.S. Gov't

بيانات الدورية: Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 101233393 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1549-8425 (Electronic) Linking ISSN: 15498417 NLM ISO Abbreviation: J Patient Saf Subsets: MEDLINE

مواضيع طبية MeSH: Insurance* , International Classification of Diseases*, Feasibility Studies ; Humans ; Patient Safety ; Quality Indicators, Health Care ; United States ; United States Agency for Healthcare Research and Quality

مستخلص: Objective: The aim of the study was to investigate the feasibility of using administrative data to screen adverse events in Korea.
Methods: We used a diagnosis-related groups claims data set and the information of the checklist of healthcare quality improvement (a part of the value incentive program) to verify adverse events in fiscal year 2018. Adverse events were identified using patient safety indicator (PSI) clusters and a present on admission indicator (POA). The PSIs consisted of 19 clusters representing subcategories of adverse events, such as hospital-acquired infection. Among the adverse events identified using PSI clusters, "POA = N," which means not present at the time of admission, was only deemed as the case in the final stage. We compared the agreement on the occurrence of adverse events from claims data with a reference standard data set (i.e., checklist of healthcare quality improvement) and presented them by PSI cluster and institution.
Results: The cases of global PSI for any adverse event numbered 27,320 (2.32%) among all diagnostic codes in 2018. In terms of institutional distribution, considerable variation was observed throughout the clusters. For example, only 13.2% of institutions (n = 387) reported any global PSI for any adverse event throughout the whole year. The agreement between the reference standard and the claims data was poor, in the range of 2.2% to 10.8%, in 3 types of adverse events. The current claims data system (i.e., diagnostic codes coupled to POA indicators) failed to capture a large majority of adverse events identified using the reference standard.
Conclusions: Our results imply that the coding status of International Classification of Diseases, Tenth Revision, codes and POA indicators should be refined before using them as quality indicators.
Competing Interests: The authors disclose no conflict of interest.
(Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

المؤلفون: Austin JM; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.; Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland., Kirley EM; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland., Rosen MA; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland.; Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland., Winters BD; Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

المصدر: Health services research [Health Serv Res] 2019 Jun; Vol. 54 (3), pp. 613-622. Date of Electronic Publication: 2018 Nov 25.

نوع المنشور: Journal Article; Research Support, U.S. Gov't, Non-P.H.S.

بيانات الدورية: Publisher: Blackwell Country of Publication: United States NLM ID: 0053006 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1475-6773 (Electronic) Linking ISSN: 00179124 NLM ISO Abbreviation: Health Serv Res Subsets: MEDLINE

مواضيع طبية MeSH: Documentation/*standards , Hospital Administration/*statistics & numerical data , International Classification of Diseases/*standards , Patient Harm/*statistics & numerical data , United States Agency for Healthcare Research and Quality/*standards, Adult ; Aged ; District of Columbia ; Female ; Humans ; Male ; Maryland ; Middle Aged ; Patient Safety/standards ; Safety Management/standards ; United States ; United States Agency for Healthcare Research and Quality/statistics & numerical data

مستخلص: Objective: To compare the Agency for Healthcare Research and Quality's Quality and Safety Review System (QSRS) and the proposed triadic structure for the 11th version of the International Classification of Disease (ICD-11) in their ability to capture adverse events in U.S. hospitals.
Data Sources/study Setting: One thousand patient admissions between 2014 and 2016 from three general, acute care hospitals located in Maryland and Washington D.C.
Study Design: The admissions chosen for the study were a random sample from all three hospitals.
Data Collection/extraction Methods: All 1000 admissions were abstracted through QSRS by one set of Certified Coding Specialists and a different set of coders assigned the draft ICD-11 codes. Previously assigned ICD-10-CM codes for 230 of the admissions were also used.
Principal Findings: We found less than 20 percent agreement between QSRS and ICD-11 in identifying the same adverse event. The likelihood of a mismatch between QSRS and ICD-11 was almost twice that of a match. The findings were similar to the agreement found between QSRS and ICD-10-CM in identifying the same adverse event. When coders were provided with a list of potential adverse events, the sensitivity and negative predictive value of ICD-11 improved.
Conclusions: While ICD-11 may offer an efficient way of identifying adverse events, our analysis found that in its draft form, it has a limited ability to capture the same types of events as QSRS. Coders may require additional training on identifying adverse events in the chart if ICD-11 is going to prove its maximum benefit.
(© Health Research and Educational Trust.)

المؤلفون: Kahwati LC; Social and Health Organizational Research and Evaluation Program, RTI International; Research Triangle Park, North Carolina. Electronic address: lkahwati@rti.org., Sorensen AV; RTI International., Teixeira-Poit S; RTI International., Jacobs S; RTI International., Sommerness SA; School of Nursing, University of Minnesota, Minneapolis., Miller KK; Lakeville, Minnesota., Pleasants E; RTI International., Clare HM; RTI International., Hirt CL; Allina Health; Minneapolis., Davis SE; Metro OBGYN; St. Paul., Ivester T; Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill., Caldwell D; National Perinatal Information Center; Providence, Rhode Island., Muri JH; National Perinatal Information Center., Mistry KB; Agency for Healthcare Research and Quality; Rockville, Maryland.

المصدر: Joint Commission journal on quality and patient safety [Jt Comm J Qual Patient Saf] 2019 Apr; Vol. 45 (4), pp. 231-240. Date of Electronic Publication: 2019 Jan 11.

نوع المنشور: Journal Article; Research Support, U.S. Gov't, P.H.S.

بيانات الدورية: Publisher: Elsevier Country of Publication: Netherlands NLM ID: 101238023 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1938-131X (Electronic) Linking ISSN: 15537250 NLM ISO Abbreviation: Jt Comm J Qual Patient Saf Subsets: MEDLINE

مواضيع طبية MeSH: United States Agency for Healthcare Research and Quality*, Patient Safety/*standards , Perinatal Care/*standards , Quality Assurance, Health Care/*standards, Cesarean Section/standards ; Delivery, Obstetric/standards ; Female ; Follow-Up Studies ; Health Plan Implementation/standards ; Humans ; Infant, Newborn ; Pregnancy ; Safety Management/standards ; United States

مستخلص: Background: The Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events.
Methods: We supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators.
Results: Forty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged.
Conclusions: The SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.
(Copyright © 2018 The Joint Commission. All rights reserved.)