Article
Pediatrics
Pernilla Dillner, Maria Unbeck, Mikael Norman, Per Nydert, Karin Pukk Harenstam, Synnove Lindemalm, Dirk Wackernagel, Ulrika Forberg
Summary: This study aimed to investigate the occurrence and characteristics of inpatient neonatal adverse events in a Swedish setting. A retrospective record review was performed using a trigger tool by registered nurses and a neonatologist at a University Hospital. The results showed that adverse events were common in neonatal care, with a high rate of preventable events occurring during the first week of admission.
Article
Emergency Medicine
Richard T. Griffey, Ryan M. Schneider, Alexandre A. Todorov
Summary: The Emergency Department Trigger Tool (EDTT) is a novel approach to detecting adverse events in the ED and can be used for quality improvement. This study analyzed data from a retrospective observational study and categorized the adverse events detected by place of occurrence, severity, omission/commission, and type. The results showed that the EDTT identified a broad spectrum of adverse event types and most events resulted in temporary harm. The study highlights the opportunities for targeted improvement in the ED.
ANNALS OF EMERGENCY MEDICINE
(2022)
Article
Multidisciplinary Sciences
Angela Kannukene, Carola Orrego, Margus Lember, Anneli Uuskula, Kaja Polluste
Summary: This study aims to evaluate the characteristics and occurrence of adverse events (AEs) in multimorbid patients in hospitalised internal medicine patients of Estonia, and describes the development of a trigger tool for this purpose. The study will search for evidence on measuring AEs in multimorbid patients and translate triggers from English to Estonian. The results will be disseminated to healthcare providers and stakeholders at national and international conferences.
Article
Public, Environmental & Occupational Health
J. Wilson, H. Griffin, A. Gorzig, J. Prieto, K. Saeed, M. I. Garvey, E. Holden, A. Tingle, H. Loveday
Summary: This study developed a prognostic screening tool (PRHAPs) based on routine admission data to identify patients at high risk of NV-HAP, enabling targeted preventive interventions and reducing antimicrobial agent usage.
JOURNAL OF HOSPITAL INFECTION
(2023)
Review
Medicine, General & Internal
Nan Yu, Liuyun Wu, Qinan Yin, Shan Du, Xinxia Liu, Shan Wu, Rongsheng Tong, Junfeng Yan, Yuan Bian
Summary: This study demonstrated the value of Global Trigger Tool (GTT) in detecting adverse drug events (ADEs) in elderly inpatients in China. A high incidence of ADEs was found, with gastrointestinal and metabolic/nutritional disorders being the most commonly affected. Most ADEs were caused by drugs used for cardiovascular diseases. The number of medications was found to have a significant correlation with ADEs.
FRONTIERS IN MEDICINE
(2023)
Article
Health Care Sciences & Services
Lipika Samal, Srijesa Khasnabish, Cathy Foskett, Katherine Zigmont, Arild Faxvaag, Frank Chang, Marsha Clements, Sarah Collins Rossetti, Anuj K. Dalal, Kathleen Leone, Stuart Lipsitz, Anthony Massaro, Ronen Rozenblum, Kumiko O. Schnock, Catherine Yoon, David W. Bates, Patricia C. Dykes
Summary: There is a lack of research on adverse event (AE) detection in oncology patients, despite the propensity for iatrogenic harm. This study compared the frequency and type of AEs detected by a modified Global Trigger Tool (GTT) and voluntary safety reporting (VSR) system in oncology patients. The results showed that neither method alone was sufficient to detect all AEs in this patient population.
JOURNAL OF PATIENT SAFETY
(2022)
Article
Pediatrics
Ramnath Balasubramanian, Rachel Folwell, Arran Wheatley, Heidi Ramsey, Carmen Barton, Christopher J. D. Reid, Manish D. Sinha
Summary: This study developed a paediatric haemodialysis trigger tool (pHTT) to systematically monitor adverse events in children undergoing intermittent in-centre haemodialysis. The use of the pHTT significantly reduced harm rates per dialysis session, and the identified triggers could potentially improve patient safety.
PEDIATRIC NEPHROLOGY
(2022)
Article
Health Care Sciences & Services
Kun Feng, Li Zhang, Huayun He, Xueqin You, Qiannan Zhang, Hong Wei, Ziyu Hua
Summary: This study aimed to develop and validate a trigger tool for detecting adverse events (AEs) in neonates. The trigger tool was developed using the random forest algorithm and validated using medical records of neonates. The tool efficiently and reliably identified AEs in hospitalized neonates.
JOURNAL OF PATIENT SAFETY
(2022)
Article
Medicine, General & Internal
Diego San Jose-Saras, Jose L. Valencia-Martin, Jorge Vicente-Guijarro, Paloma Moreno-Nunez, Alberto Pardo-Hernandez, Jesus M. Aranaz-Andres
Summary: This study conducted in hospitals in the Community of Madrid aimed to identify targets for improvement in the quality of care. The results show that the prevalence of adverse events is similar to other studies, and they lead to worse patient outcomes and are associated with patient death. Although avoidable adverse events are less severe, their higher frequency has a greater impact on patients and the healthcare system.
ANNALS OF MEDICINE
(2022)
Article
Behavioral Sciences
Michaela DuBay, John Sideris, Erica Rouch
Summary: Early identification of autism spectrum disorders in non-English speaking children is crucial. Traditional translation methods may result in poor psychometric properties, while a rigorous translation with cultural adaptation approach may yield better results.
Article
Medicine, General & Internal
Alexis F. Guedon, Jean-Baptiste De Freminville, Tristan Mirault, Nassim Mohamedi, Bastien Rance, Natalie Fournier, Jean-Louis Paul, Emmanuel Messas, Guillaume Goudot
Summary: This study found that higher levels of lipoprotein(a) (Lp[a]) were independently associated with an increased risk of major adverse limb events in hospitalized patients.
Article
Medicine, General & Internal
Martin Magneli, Paula Kelly-Pettersson, Cecilia Rogmark, Max Gordon, Olof Skoldenberg, Maria Unbeck
Summary: This study aimed to explore the timing, severity, and preventability of adverse events (AEs) in patients undergoing hip arthroplasty surgery. The majority of AEs occurred perioperatively and postoperatively, with a wide range of median days for different AE types. Most AEs were deemed preventable and/or of major severity, emphasizing the need for a better understanding of the timing and occurrence of AEs to improve patient safety in hip arthroplasty surgery.
Review
Multidisciplinary Sciences
Luisa C. Eggenschwiler, Anne W. S. Rutjes, Sarah N. Musy, Dietmar Ausserhofer, Natascha M. Nielen, Rene Schwendimann, Maria Unbeck, Michael Simon
Summary: This study conducted a systematic review and meta-analysis to assess the incidence of adverse events (AEs) in acute care inpatient settings. The findings revealed significant variations in reported AE incidence rates, which can be partially explained by study characteristics and quality.
Article
Pharmacology & Pharmacy
Ni Zhang, Ling-Yun Pan, Wan-Yi Chen, Huan-Huan Ji, Gui-Qin Peng, Zong-Wei Tang, Hui-Lai Wang, Yun-Tao Jia, Jun Gong
Summary: This study applied machine learning methods to evaluate the risk factors and predict the occurrence of serious adverse events (SAEs) in cancer inpatients using antineoplastic drugs. Risk factors such as the number of triggers, length of stay, age, number of combined drugs, ADEs occurred in previous chemotherapy, and sex were identified. Among the eight machine learning models, gradient-boosting decision tree (GBDT) showed the best predictive abilities.
FRONTIERS IN PHARMACOLOGY
(2022)
Article
Oncology
Felice Simnacher, Anna Gotz, Sabine Kling, Jan Ben Schulze, Roland von Kanel, Sebastian Euler, Moritz Philipp Gunther
Summary: International guidelines recommend screening for cancer patients’ distress, but rates are insufficient. This study developed a survey to assess systemic barriers to distress screening. Through a three-step approach, an initial survey with 53 questions was reduced to a final set of 14 validated questions using qualitative content analysis and factor analysis. Major barriers identified include timing of screening, lack of capacity, patient and staff overload, and refusal of patients to be referred to support services. The validated questions enable quick identification and improvement of screening programs.
Article
Health Care Sciences & Services
Jeffrey L. Schnipper, Harry Reyes Nieva, Meghan Mallouk, Amanda Mixon, Stephanie Rennke, Eugene Chu, Stephanie Mueller, Gregory (Randy) R. Smith, Mark Williams, Tosha B. Wetterneck, Jason Stein, Anuj Dalal, Stephanie Labonville, Anirudh Sridharan, Deonni P. Stolldorf, E. John Orav, Brian Levin, Marcus Gresham, Cathy Yoon, Jenna Goldstein, Sara Platt, Christopher Tugbeh Nyenpan, Eric Howell, Sunil Kripalani
Summary: A multicenter medication reconciliation quality improvement initiative, utilizing a refined toolkit with system-level and patient-level interventions, led to a significant decrease in unintentional medication discrepancies over time. Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. Focus on sustainability and spread of these interventions is recommended for future efforts.
BMJ QUALITY & SAFETY
(2022)
Article
Health Care Sciences & Services
Sabina B. Gesell, Janet Prvu Bettger, Raymona H. Lawrence, Jing Li, Jeanne Hoffman, Barbara J. Lutz, Corita Grudzen, Anna M. Johnson, Jerry A. Krishnan, Lewis L. Hsu, Dorien Zwart, Mark V. Williams, Jeffrey L. Schnipper
Summary: This study presents lessons learned from nine transitional care study teams in implementing and evaluating complex transitional care interventions, including distinguishing between function and form, evaluating implementation processes and impact of adaptations, and engaging stakeholders in intervention design and dissemination of results.
Article
Medicine, General & Internal
Jessica Miller Clouser, Matthew Sirrine, Colleen A. McMullen, Amy M. Cowley, Susan S. Smyth, Vedant Gupta, Mark Williams, Jing Li
Summary: When presenting to the emergency department with syncope, patients and family caregivers desire clarity in diagnosis, context of care plan and diagnostic approach, as well as to feel recognized, listened to, and cared about by the healthcare team. Addressing these expectations through a patient-engaged communication approach and shared decision-making may help clinicians adhere to guideline recommendations while meeting patient needs.
PATIENT PREFERENCE AND ADHERENCE
(2021)
Editorial Material
Health Care Sciences & Services
Kendall G. Fancher, Mark V. Williams
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
(2021)
Article
Urology & Nephrology
Catherine R. Butler, Paul S. Appelbaum, Heather Ascani, Mark Aulisio, Catherine E. Campbell, Ian H. de Boer, Ashveena L. Dighe, Daniel E. Hall, Jonathan Himmelfarb, Richard Knight, Karla Mehl, Raghavan Murugan, Sylvia E. Rosas, John R. Sedor, John F. O'Toole, Katherine R. Tuttle, Sushrut S. Waikar, Michael Freeman
Summary: This article emphasizes the importance of critically examining the ethical basis of human subjects research involving some risks without anticipated clinical benefits. It provides a comprehensive conceptualization of the types of benefits that may be important to research participants and proposes a model to better respect and support participants in future research.
AMERICAN JOURNAL OF KIDNEY DISEASES
(2022)
Editorial Material
Nursing
Ryan P. Merkow, Jeanette W. Chung, Jennifer M. Slota, Cynthia Barnard, Ann Hall, Kristin Ramsey, Karl Y. Bilimoria
JOURNAL OF NURSING CARE QUALITY
(2022)
Article
Health Care Sciences & Services
Jing Li, Jessica Miller Clouser, Jane Brock, Terry Davis, Brian Jack, Carol Levine, Glen P. Mays, Brian Mittman, Huong Nguyen, Joann Sorra, Arnold Stromberg, Gaixin Du, Chen Dai, Akosua Adu, Nikita Vundi, Mark Williams
Summary: The study by Project ACHIEVE found that clear communication and establishing trust with patients, combined with care coordination activities from hospital to home, can improve patient-reported outcomes and reduce healthcare utilization.
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
(2022)
Article
Health Care Sciences & Services
Stephanie L. LaBedz, Valentin Prieto-Centurion, Amelia Mutso, Sanjib Basu, Nina E. Bracken, Elizabeth A. Calhoun, Robert J. DiDomenico, Min Joo, A. Simon Pickard, Barry Pittendrigh, Mark Williams, Sai Illendula, Jerry A. Krishnan
Summary: This study compared the effectiveness of a stakeholder-supported Navigator intervention and Usual care on patient outcomes in minority-serving hospitals. The results showed that the Navigator intervention did not significantly improve anxiety, informational support, or other outcomes compared to Usual care. However, there were potential benefits observed in certain patient subgroups.
JOURNAL OF GENERAL INTERNAL MEDICINE
(2022)
Article
Health Care Sciences & Services
Cynthia Barnard, Jeanette W. Chung, Vanessa Flaherty, Julie K. Johnson, Kathryn Thomas, Dea Hughes, Monica Locker, Karl Y. Bilimoria
Summary: This study aimed to develop a shortened Culture of Safety (COS) survey to easily measure patient safety. Using Item Response Theory (IRT), a 19-item survey was condensed to 4 items, and cognitive interviews and validation were conducted. The results showed that the 4-item survey had comparable measurement properties to the original, but had limitations in assessing error-reporting culture.
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
(2022)
Article
Health Care Sciences & Services
Laura M. Perry, Victoria Morken, John D. Peipert, Betina Yanez, Sofia F. Garcia, Cynthia Barnard, Lisa R. Hirschhorn, Jeffrey A. Linder, Neil Jordan, Ronald T. Ackermann, Alexandra Harris, Sheetal Kircher, Nisha Mohindra, Vikram Aggarwal, Rebecca Frazier, Ava Coughlin, Katy Bedjeti, Melissa Weitzel, Eugene C. Nelson, Glyn Elwyn, Aricca D. Van Citters, Mary O'Connor, David Cella
Summary: This study aims to co-design a dashboard that integrates patient-reported outcomes with other clinical data and evaluate its association with improved shared decision-making and disease management outcomes through a demonstration trial. By collaborating to develop the dashboard and implementing it for clinical testing, researchers will work with clinic staff to assess the impact. Results will be disseminated in at least one manuscript per study objective.
JMIR RESEARCH PROTOCOLS
(2022)
Editorial Material
Health Care Sciences & Services
Mark Williams, Jing Li
BMJ QUALITY & SAFETY
(2023)
Article
Medicine, General & Internal
Kevin J. O'Leary, Julie K. Johnson, Mark V. Williams, Ronald Estrella, Krystal Hanrahan, Luci K. Leykum, G. Randy Smith, Jenna D. Goldstein, Jane S. Kim, Sara Thompson, Iva Terwilliger, Jing Song, Jungwha Lee, Milisa Manojlovich
Summary: This study aimed to evaluate the impact of redesigning hospital care delivery on teamwork and patient outcomes. Although there was an improvement in the teamwork climate among nurses, the interventions did not lead to significant improvements in patient outcomes.
ANNALS OF INTERNAL MEDICINE
(2023)
Article
Health Care Sciences & Services
Jing Li, Glen Mays, Jessica Miller Clouser, Gaixin Du, Arnold Stromberg, Brian W. Jack, Huong Q. Nguyen, Mark Williams
Summary: This study found that there is an association between the use of different combinations of transitional care strategies by hospitals and changes in readmission rates. Strategies such as timely information sharing, patient engagement, and education are associated with lower readmission rates.
HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION
(2022)
Article
Obstetrics & Gynecology
Stephanie A. Fisher, Allie Sakowicz, Cynthia Barnard, Seth Kidder, Emily S. Miller
Summary: The study found that populations residing in socioeconomically disadvantaged neighborhoods experienced reductions in preterm delivery during the COVID-19 pandemic. Neighborhood-level social determinants of health offer insight into the complex etiologies that contribute to preterm delivery and provide opportunities for public health and equity-focused prevention strategies.
AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY MFM
(2022)
Review
Medicine, General & Internal
Jing Li, Susan S. Smyth, Jessica M. Clouser, Colleen A. McMullen, Vedant Gupta, Mark Williams
Summary: In the evaluation and management of syncope, overuse and inappropriate use of testing and hospital admissions are common issues. Current clinical guidelines have not significantly impacted resource utilization in emergency department evaluations of syncope. By applying implementation science principles, a research team collaborated with stakeholders to develop implementation strategies, identifying low awareness of guidelines among clinicians, communication challenges with patients, and lack of transparency in care plans and diagnostic testing as major barriers to guideline implementation.
MEDICINA-LITHUANIA
(2021)