National Healthcare Quality and Disparities Report
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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 25 of 138 Research Studies DisplayedLeland NE, Lekovitch C, Martínez J
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
The purpose of this scoping review was to describe the evidence for multifactorial post-acute care (PAC) fall prevention interventions for older patients. The researchers included 33 studies and characterized common intervention domains including: evaluating patient-specific fall risk factors, developing an individualized risk profile and treatment plan that targets each patient's fall risk factors, and implementing facility-based strategies such as staff education. There was not consensus across studies in how the domains were addressed and to what extent. The researchers concluded that health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach.
AHRQ-funded; HS022907.
Citation: Leland NE, Lekovitch C, Martínez J .
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
J Appl Gerontol 2022 Oct;41(10):2187-96. doi: 10.1177/07334648221104375..
Keywords: Elderly, Falls, Prevention, Patient Safety, Evidence-Based Practice
Morey DA, Rayo MF, Li M
From reactive to proactive safety: joint activity monitoring for infection prevention.
The authors explored Joint Activity Monitoring (JAM) as one key component of a proactive safety program within infection prevention. This paper described their strategies and challenges in developing this capability and discussed the implications for supporting a successful proactive safety implementation.
AHRQ-funded; HS027200.
Citation: Morey DA, Rayo MF, Li M .
From reactive to proactive safety: joint activity monitoring for infection prevention.
Proc Int Symp Hum Factors Ergon Healthc 2022 Sep; 11(1):48-52. doi: 10.1177/2327857922111009..
Keywords: Prevention, Healthcare-Associated Infections (HAIs), Patient Safety
Huang J, Park GW, Jones RM
Efficacy of EPA-registered disinfectants against two human norovirus surrogates and Clostridioides difficile endospores.
This study’s goal was to determine the efficacy of a panel of nine EPA-registered disinfectants against two human norovirus (HuNoV) surrogates (feline calicivirus [FCV] and Tulane virus [TuV]) and Clostridioides difficile endospores. These products, five of which contained H2O2 (hydrogen peroxide) as the active ingredient, were tested against infectious FCV, TuV, and C. difficile endospores using two ASTM methods, a suspension and carrier test. Products containing hydrogen peroxide were the most efficacious. Of the five products containing hydrogen peroxide, no strong correlation was observed between disinfection efficacy and hydrogen peroxide concentration. Addition of 0.025% ferrous sulphate to 1% hydrogen peroxide solution improved efficacy against FCV, TuV and C. difficile.
AHRQ-funded; HS025987.
Citation: Huang J, Park GW, Jones RM .
Efficacy of EPA-registered disinfectants against two human norovirus surrogates and Clostridioides difficile endospores.
J Appl Microbiol 2022 Jun;132(6):4289-99. doi: 10.1111/jam.15524..
Keywords: Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Prevention, Patient Safety
Dykes PC, Khasnabish S, Burns Z
Development and validation of a fall prevention efficiency scale.
This study examined nurses’ perception of implementing the Fall TIPS (Tailoring Interventions for Patient Safety) tool, which is an evidence-based fall prevention program which was shown to reduce falls in hospitalized adults by 25%. The authors conducted a 3-phase mixed method study at 3 hospitals in Massachusetts and 3 in New York to assess nurses’ perceptions of burdens imposed on them by using Fall TIPS or other fall prevention programs. A 20-item prototype Fall Prevention Efficiency Scale was developed and administered to 383 clinical nurses. This scale was reduced to 13 items. The scale achieved excellent internal consistency values when examined with the test, validation, and paired (both test and retest) samples.
AHRQ-funded; HS025128.
Citation: Dykes PC, Khasnabish S, Burns Z .
Development and validation of a fall prevention efficiency scale.
J Patient Saf 2022 Mar 1;18(2):94-101. doi: 10.1097/pts.0000000000000811..
Keywords: Falls, Prevention, Patient Safety, Hospitals
Dykes PC, KhasnabishE S, Adkison LE
Use of a perceived efficacy tool to evaluate the FallTIPS program.
The authors assessed nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. They found that the nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program, and findings confirmed the importance of patient and family engagement with staff in the fall prevention process.
AHRQ-funded; HS025128.
Citation: Dykes PC, KhasnabishE S, Adkison LE .
Use of a perceived efficacy tool to evaluate the FallTIPS program.
J Am Geriatr Soc 2021 Dec;69(12):3595-601. doi: 10.1111/jgs.17436..
Keywords: Falls, Patient Safety, Prevention, Provider: Nurse, Adverse Events
Arntson E, Dimick JB, Nuliyalu U
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
This study evaluated changes in Hospital-Acquired Conditions (HACs) and 30-day mortality after the announcement of the Centers for Medicare and Medicare Services’ Hospital-Acquired Condition Reduction Program (HACRP) in August 2013. The authors evaluated models to test for changes in HACs and 30-day mortality before and after the Affordable Care Act (ACA), and after the HACRP. Fee-for-service Medicare claims from 2009 to 2015 were used. The HAC rate declined after the ACA was passed and declined further after the HACRP announcement. However, 30-day mortality rates were unchanged.
AHRQ-funded; HS026244.
Citation: Arntson E, Dimick JB, Nuliyalu U .
Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.
Ann Surg 2021 Oct 1;274(4):e301-e07. doi: 10.1097/sla.0000000000003641..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Mortality, Medicare, Payment, Prevention, Patient Safety
Piatkowski M, Taylor E, Wong B
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
This multi-year study aimed to better understand how patient room design can increase stability during ambulation, serving as a fall protection strategy for frail and/or elderly patients. Specifically, the aim of this portion of the study was to ascertain the architect's perspective on designing a room to mitigate the risk of falls, as well as to evaluate the face validity of a predictive algorithm to assess risk in room design using the input of a design advisory council (AC).
AHRQ-funded; HS025606.
Citation: Piatkowski M, Taylor E, Wong B .
Designing a patient room as a fall protection strategy: the perspectives of healthcare design experts.
Int J Environ Res Public Health 2021 Aug 19;18(16). doi: 10.3390/ijerph18168769..
Keywords: Falls, Patient Safety, Prevention, Adverse Events, Inpatient Care
Leung WY, Adelman J, Bates DW
Validating fall prevention icons to support patient-centered education.
Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. The investigators indicated that all 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.
AHRQ-funded; HS023535.
Citation: Leung WY, Adelman J, Bates DW .
Validating fall prevention icons to support patient-centered education.
J Patient Saf 2021 Aug 1;17(5):e413-e22. doi: 10.1097/pts.0000000000000354..
Keywords: Falls, Prevention, Patient Safety, Patient-Centered Healthcare, Education: Patient and Caregiver, Hospitals, Adverse Events
McGrath SP, Perreard IM, MacKenzie T
Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.
This study’s objective was to understand if features derived from continuous pulse oximetry data can provide advanced warning of pulseless electrical activity arrest in general care inpatients. A retrospective analysis of SpO2 and pulse rate data derived from continuous pulse oximetry was performed for patients with electrical pulseless activity (n = 38) and control patients (n = 42). The pulseless electrical activity arrest group tended to have lower mean SpO2 and higher mean pulse rates over time intervals ranging from 1 minute to 1 hour. Several hours to the rescue event changes in variability were observed. Up to 20 minutes before rescue events, pulse rate features were significantly different from feature values for the preceding 30-minute interval. Similar results were found at 10 minutes before the event. These differences might be useful for predicting and preventing rescue events.
AHRQ-funded; HS024403.
Citation: McGrath SP, Perreard IM, MacKenzie T .
Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting.
J Clin Monit Comput 2021 May;35(3):537-45. doi: 10.1007/s10877-020-00509-8..
Keywords: Patient Safety, Inpatient Care, Hospitals, Prevention, Cardiovascular Conditions
Harris AD, Morgan DJ, Pineles L
Acquisition of antibiotic-resistant gram-negative bacteria in the Benefits of Universal Glove and Gown (BUGG) cluster randomized trial.
This study is a secondary analysis of a randomized trial in 20 hospital intensive units called Benefits of Universal Glove and Gown (BUGG) to see if intervention decreases the acquisition of antibiotic-resistant gram-negative bacteria. The primary outcome included 40,492 admission and discharge perianal swabs from 20,246 individual patient admissions. A non-statistically significant decrease in acquisition of antibiotic-resistant gram-negative bacteria was associated with universal glove and gown use.
AHRQ-funded; HS024045.
Citation: Harris AD, Morgan DJ, Pineles L .
Acquisition of antibiotic-resistant gram-negative bacteria in the Benefits of Universal Glove and Gown (BUGG) cluster randomized trial.
Clin Infect Dis 2021 Feb 1;72(3):431-37. doi: 10.1093/cid/ciaa071..
Keywords: Methicillin-Resistant Staphylococcus aureus (MRSA), Healthcare-Associated Infections (HAIs), Infectious Diseases, Prevention, Patient Safety
Lee BY, Bartsch SM, Lin MY
How long-term acute care hospitals can play an important role in controlling carbapenem-resistant Enterobacteriaceae in a region: a simulation modeling study.
Researchers investigated how implementing control measures in long-term acute care hospitals (LTACHs) can impact carbapenem-resistant Enterobacteriaceae (CRE) spread regionwide. They used their own Chicago metropolitan region agent-based model to simulate CRE spread and control. They found that a prevention bundle in only LTACHs decreased prevalence and averted new carriers, infections, and deaths over 3 years compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased further. They concluded that LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.
AHRQ-funded; HS023317.
Citation: Lee BY, Bartsch SM, Lin MY .
How long-term acute care hospitals can play an important role in controlling carbapenem-resistant Enterobacteriaceae in a region: a simulation modeling study.
Am J Epidemiol 2021 Feb 1;190(3):448-58. doi: 10.1093/aje/kwaa247..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Prevention, Hospitals, Patient Safety, Implementation
Lee BY, Bartsch SM, Hayden MK
How to choose target facilities in a region to implement carbapenem-resistant Enterobacteriaceae control measures.
The authors investigated how best to choose the highest-yield facilities to target for interventions when trying to control regional spread of antibiotic-resistant pathogens such as carbapenem-resistant Enterobacteriaceae (CRE). They used their own Regional Healthcare Ecosystem Analyst-generated agent-based model of Chicago metropolitan area inpatient facilities to simulate the spread of CRE and to choose facilities to apply prevention bundles. They found that, while choosing target facilities based on single metrics (including most inpatient beds, most connections to other facilities) achieved better control than randomly choosing facilities, more effective targeting occurred when considering how these and other factors (including patient length of stay, care for higher-risk patients) interacted as a system.
AHRQ-funded; HS023317.
Citation: Lee BY, Bartsch SM, Hayden MK .
How to choose target facilities in a region to implement carbapenem-resistant Enterobacteriaceae control measures.
Clin Infect Dis 2021 Feb 1;72(3):438-47. doi: 10.1093/cid/ciaa072..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Implementation, Prevention, Patient Safety
Kane-Gill SL, Wong A, Culley CM
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for nursing home (NH) residents using medication reconciliation and prospective medication regimen reviews (MRRs) on admission plus ongoing clinical decision support alerts throughout the residents' stay. Studying residents in four NHs in Southwestern Pennsylvania, findings showed that the intervention group had a 92% lower incidence of alert-specific ADEs than usual care, and all-cause hospitalization was similar between groups, as were 30-day readmissions.
AHRQ-funded; HS02420.
Citation: Kane-Gill SL, Wong A, Culley CM .
JA, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events.
J Am Geriatr Soc 2021 Feb;69(2):530-38. doi: 10.1111/jgs.16946..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Telehealth, Health Information Technology (HIT), Provider: Pharmacist, Provider, Clinical Decision Support (CDS), Prevention
Gall E, Long A, Hall KK
Chlorhexidine bathing strategies for multidrug-resistant organisms: a summary of recent evidence.
This systematic literature review investigated the latest evidence for patient bathing with a 2%-4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection. Three databases were searched for articles from 2008 through 2018, as well as any key articles published after 2018. Findings focused on health care-associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine reduced MRSA acquisition and carriage, but no studies found significant reductions in infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage. Two very large studies found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already controlled with other anti-infection measures.
AHRQ-funded; HHSP233201500013I.
Citation: Gall E, Long A, Hall KK .
Chlorhexidine bathing strategies for multidrug-resistant organisms: a summary of recent evidence.
J Patient Saf 2020 Sep;16(3S Suppl 1):S16-s22. doi: 10.1097/pts.0000000000000743..
Keywords: Healthcare-Associated Infections (HAIs), Methicillin-Resistant Staphylococcus aureus (MRSA), Prevention, Patient Safety, Infectious Diseases
Schoyer E, Hall K
Environmental cleaning and decontamination to prevent clostridioides difficile infection in health care settings: a systematic review.
The aim of this systematic review was to examine the most effective and feasible methods for environmental cleaning and decontamination to prevent Clostridioides difficile infection (CDI) in health care settings. The investigators concluded that the studied practices for environmental cleaning and decontamination were associated with significant decreases in facility-level CDI rates in most of the reviewed studies; however, study quality was low.
AHRQ-funded; 233201500013I.
Citation: Schoyer E, Hall K .
Environmental cleaning and decontamination to prevent clostridioides difficile infection in health care settings: a systematic review.
J Patient Saf 2020 Sep;16(3S Suppl 1):S12-s15. doi: 10.1097/pts.0000000000000749..
Keywords: Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Infectious Diseases, Prevention, Patient Safety
Shoemaker-Hunt SJ, Wyant BE
The effect of opioid stewardship interventions on key outcomes: a systematic review.
In this study, the investigators sought to identify potential patient safety practices to reduce high-risk opioid prescribing. They conducted a systematic review of the literature to identify opioid stewardship (OS) strategies implemented in primary care and other settings. The investigators concluded that the strength of the evidence was low to moderate that OS efforts decreased numbers of opioid prescriptions, proportion of patients on long-term opioids, or days' supply. The strength of the evidence for OS initiatives producing significant reductions in opioid dosages was moderate.
AHRQ-funded; 233201500013I.
Citation: Shoemaker-Hunt SJ, Wyant BE .
The effect of opioid stewardship interventions on key outcomes: a systematic review.
J Patient Saf 2020 Sep;16(3S Suppl 1):S36-s41. doi: 10.1097/pts.0000000000000710..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Evidence-Based Practice, Patient-Centered Outcomes Research, Substance Abuse, Prevention
De Roo AC, Hendren S, Ameling JM
Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use.
Researchers applied Michigan Appropriate Perioperative criteria to statewide registry data to identify improvement targets for urinary catheter use. They found that perioperative urinary catheter use was appropriate for most simple abdominal procedures, but duration of use varied in all categories.
AHRQ-funded; HS019767; HS024385; HS018334; HS000053.
Citation: De Roo AC, Hendren S, Ameling JM .
Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use.
Am J Surg 2020 Sep;220(3):706-13. doi: 10.1016/j.amjsurg.2020.01.008..
Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Urinary Tract Infection (UTI), Healthcare-Associated Infections (HAIs), Patient Safety, Surgery, Prevention, Adverse Events
Earl TR, Katapodis ND, Schneiderman SR
Using deprescribing practices and the screening tool of older persons' potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults.
This paper is a systematic review of the literature published between 2008 to 2018 that studies the effect of interventions to reduce preventable adverse drug effects (ADEs) for adults who are prescribed multiple medications. Two safety practices were examined: 1) deprescribing interventions to reduce polypharmacy; and 2) use of the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) to reduce potentially inappropriate medications (PIMS). A total of 26 studies and 1 systematic review were included (14 for deprescribing and 12 for STOPP). Deprescribing interventions included decision support tools, educational interventions, and medication reviews. The STOPP tool most reported changes in PIMS, as well as some economic outcomes. Both methods were found to be effective.
AHRQ-funded; HHSP233201500013I.
Citation: Earl TR, Katapodis ND, Schneiderman SR .
Using deprescribing practices and the screening tool of older persons' potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults.
J Patient Saf 2020 Sep;16(3S Suppl 1):S23-s35. doi: 10.1097/pts.0000000000000747..
Keywords: Elderly, Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Screening, Prevention
Chatterjee P, Williams MD, Coppin JD
Effectiveness of copper-impregnated solid surfaces on lowering microbial bio-burden levels in an acute care hospital.
This study examined whether using novel coper-impregnated solid materials on high-touch surfaces in patient rooms lowered bacterial contamination which may lead to health care-associated infections in acute care hospitals. Sixteen rooms were installed with copper-impregnated surfaces and were compared to standard noncopper laminate surfaces in 16 rooms over a 3-day period. Samples were taken 3 times per day. A lower level of microbial contamination was found in copper-impregnated solid surfaces as compared to standard surfaces.
AHRQ-funded; HS025598.
Citation: Chatterjee P, Williams MD, Coppin JD .
Effectiveness of copper-impregnated solid surfaces on lowering microbial bio-burden levels in an acute care hospital.
Open Forum Infect Dis 2020 Aug;7(8). doi: 10.1093/ofid/ofaa238..
Keywords: Patient Safety, Healthcare-Associated Infections (HAIs), Infectious Diseases, Hospitals, Comparative Effectiveness, Prevention, Evidence-Based Practice
Dowding D, Russell D, Trifilio M
Home care nurses' identification of patients at risk of infection and their risk mitigation strategies: a qualitative interview study.
Investigators sought to understand if and how home care nurses identify patients at high risk of infection and which strategies they use to mitigate that risk. Interviews with fifty nurses were audio recorded and transcribed. Factors identified by the nurses as putting a patient at higher risk of infection included being older, having diabetes, and inadequate nutrition as well as inadequate clinical information available at start of care. The main strategy for infection prevention was patient and caregiver education. Nurses also discussed the importance of their own infection prevention behaviors and the ability to adjust a patient's plan of care according to their infection risk.
AHRQ-funded; HS024723.
Citation: Dowding D, Russell D, Trifilio M .
Home care nurses' identification of patients at risk of infection and their risk mitigation strategies: a qualitative interview study.
Int J Nurs Stud 2020 Jul;107:103617. doi: 10.1016/j.ijnurstu.2020.103617..
Keywords: Home Healthcare, Community-Acquired Infections, Infectious Diseases, Patient Safety, Prevention, Nursing, Shared Decision Making
Zimmerman S, Sloane PD, Ward K
Effectiveness of a mouth care program provided by nursing home staff vs standard care on reducing pneumonia incidence: a cluster randomized trial.
Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia. The objective of this study was to evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents.
AHRQ-funded; HS022298.
Citation: Zimmerman S, Sloane PD, Ward K .
Effectiveness of a mouth care program provided by nursing home staff vs standard care on reducing pneumonia incidence: a cluster randomized trial.
JAMA Netw Open 2020 Jun;3(6):e204321. doi: 10.1001/jamanetworkopen.2020.4321..
Keywords: Pneumonia, Nursing Homes, Long-Term Care, Dental and Oral Health, Prevention, Patient Safety
Wolff C, Dowd WN, Ali MM
AHRQ Author: McClellan C
The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation.
The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. In this study, the investigators used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse.
AHRQ-authored.
Citation: Wolff C, Dowd WN, Ali MM .
The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation.
Addict Behav 2020 Jun;105:106268. doi: 10.1016/j.addbeh.2019.106268..
Keywords: Opioids, Medication, Medication: Safety, Patient Safety, Prevention, Pain, Substance Abuse
Bartsch SM, Wong KF, Stokes-Cawley OJ
Knowing more of the iceberg: how detecting a greater proportion of carbapenem-resistant Enterobacteriaceae carriers influences transmission.
This study examined the impact of detecting a greater proportion of carbapenem-resistant Enterobacteriaceae (CRE) carriers in the hospital inpatient population. The researchers used the Regional Healthcare Ecosystem Analyst-generated agent-based model of adult inpatient healthcare facilities in Orange County, California. They found that only if the detection level is increased to 1 in 5 carriers does it garner large reductions in the number of new CRE carriers. At the present time the detection level is 1 in 9 carriers.
AHRQ-funded; HS023317.
Citation: Bartsch SM, Wong KF, Stokes-Cawley OJ .
Knowing more of the iceberg: how detecting a greater proportion of carbapenem-resistant Enterobacteriaceae carriers influences transmission.
J Infect Dis 2020 May 11;221(11):1782-94. doi: 10.1093/infdis/jiz288..
Keywords: Healthcare-Associated Infections (HAIs), Infectious Diseases, Hospitals, Patient Safety, Prevention
Alfred M, Catchpole K, Huffer E
Work systems analysis of sterile processing: decontamination.
This study examined the work of sterile processing departments (SPDs) from a systems perspective. This paper reports the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation and identify potential improvement interactions. The analysis was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23,000 units each month. Mixed methods, including 56 hours of observations of work was done, as well as formal and informal interviews with relevant stakeholders and analysis of data collected about the system. The authors identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly with 1% of surgical cases having decontamination problems.
AHRQ-funded; HS025538.
Citation: Alfred M, Catchpole K, Huffer E .
Work systems analysis of sterile processing: decontamination.
BMJ Qual Saf 2020 Apr;29(4):320-28. doi: 10.1136/bmjqs-2019-009422..
Keywords: Patient Safety, Quality Improvement, Quality of Care, Prevention, Surgery, Healthcare-Associated Infections (HAIs)
Christiansen TL, Lipsitz S, Scanlan M
Patient activation related to fall prevention: a multisite study.
The purpose of this study was to examine the impact of the Fall TIPS (Tailoring Interventions for Patient Safety) program on patient activation related to fall prevention. Researchers used the short form Patient Activation Measure (PAM-13) adapted for fall prevention. Their findings showed that patient activation improved from preintervention to postintervention at all three studied sites. Patients with access to the Fall TIPS program are more activated and engaged in their fall prevention plan. Recommendations include engaging patients in the fall prevention plan to increase their knowledge, skill, and confidence.
AHRQ-funded; HS023535.
Citation: Christiansen TL, Lipsitz S, Scanlan M .
Patient activation related to fall prevention: a multisite study.
Jt Comm J Qual Patient Saf 2020 Mar;46(3):129-35. doi: 10.1016/j.jcjq.2019.11.010..
Keywords: Falls, Prevention, Patient Safety, Patient and Family Engagement, Education: Patient and Caregiver