National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
Topics
- Adverse Events (3)
- Ambulatory Care and Surgery (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Children/Adolescents (1)
- Communication (1)
- Comprehensive Unit-based Safety Program (CUSP) (2)
- Dental and Oral Health (1)
- Diagnostic Safety and Quality (1)
- Dialysis (1)
- Falls (1)
- Healthcare-Associated Infections (HAIs) (2)
- Health Information Technology (HIT) (1)
- Hospitals (3)
- Injuries and Wounds (1)
- Kidney Disease and Health (1)
- Labor and Delivery (1)
- Long-Term Care (2)
- Maternal Care (1)
- Medical Errors (1)
- Newborns/Infants (1)
- Nursing Homes (2)
- Organizational Change (3)
- Outcomes (2)
- Patient-Centered Healthcare (1)
- Patient Safety (11)
- Pregnancy (1)
- Provider (3)
- Provider: Nurse (1)
- Provider Performance (1)
- Quality Improvement (1)
- Quality Indicators (QIs) (1)
- Quality Measures (1)
- Quality of Care (2)
- Simulation (1)
- Surgery (2)
- (-) Surveys on Patient Safety Culture (13)
- Teams (2)
- TeamSTEPPS (2)
- Training (1)
- Women (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 13 of 13 Research Studies DisplayedSorra J, Zebrak K, Yount N
Development and pilot testing of survey items to assess the culture of value and efficiency in hospitals and medical offices.
Given rising costs and changing payment models, healthcare organisations are increasingly focused on value and efficiency. The goal of this study was to develop survey items to assess clinician and staff perspectives about the extent to which the organizational culture in hospitals and medical offices supports value and efficiency. The investigators concluded when added to the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture, the item sets they developed extended those surveys by assessing additional dimensions of organizational culture that affect care delivery.
AHRQ-funded; 290201000025I.
Citation: Sorra J, Zebrak K, Yount N .
Development and pilot testing of survey items to assess the culture of value and efficiency in hospitals and medical offices.
BMJ Qual Saf 2022 Jul;31(7):493-502. doi: 10.1136/bmjqs-2020-012407..
Keywords: Surveys on Patient Safety Culture, Organizational Change
Zebrak K, Yount N, Sorra J
Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture™ (SOPS(®)) workplace safety supplemental items for hospitals.
The purpose of this AHRQ-funded study was to develop and test survey items that can be utilized together with the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture™ (SOPS(®)) Hospital Survey to evaluate how hospitals’ organizational cultures support workplace safety for both providers and staff. Based on a literature review and qualitative interviews with experts in workplace safety, the researchers identified prime areas of workplace safety culture (workplace hazards, moving patients, workplace aggression, management support for workplace safety, workplace safety reporting, and work stress or burnout) and drafted survey items to evaluate these areas. The survey items were then pilot tested on providers and staff in 28 U.S. hospitals using the SOPS Hospital Survey 2.0. Data from 6,684 respondents was analyzed and demonstrated conceptual convergence among the survey measures. The researchers concluded that both researchers and hospitals can utilize the Workplace Safety Supplemental items to evaluate the dimensions of organizational culture that support provider and staff safety and to pinpoint organizational strengths and areas for improvement.
AHRQ-funded; 233201500026I.
Citation: Zebrak K, Yount N, Sorra J .
Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture™ (SOPS(®)) workplace safety supplemental items for hospitals.
Int J Environ Res Public Health 2022 Jun 2;19(11). doi: 10.3390/ijerph19116815..
Keywords: Surveys on Patient Safety Culture, Patient Safety, Hospitals, Organizational Change
Dy SM, Acton RM, Yuan CT
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
This cross-case analysis study's objective was to explore which patient-centered medical home (PCMH) and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture using 25 diverse US PCMHs. Findings suggested that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists.
AHRQ-funded; HS024859.
Citation: Dy SM, Acton RM, Yuan CT .
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.
J Patient Saf 2022 Jan;18(1):e249-e56. doi: 10.1097/pts.0000000000000752..
Keywords: Patient-Centered Healthcare, Surveys on Patient Safety Culture, Patient Safety
Yansane A, Lee JH, Hebballi N
Assessing the patient safety culture in dentistry.
Medical errors are among the leading causes of death within the United States. Studies have shown that patients can be harmed while receiving care, sometimes resulting in permanent injury or, in extreme cases, death. To reduce the risk of patient safety incidents, it is imperative that a robust culture of safety be established. The primary objective of this study was to evaluate the patient safety culture among providers at 4 US dental institutions, comparing the results with their medical counterparts in 2016.
AHRQ-funded; HS024406.
Citation: Yansane A, Lee JH, Hebballi N .
Assessing the patient safety culture in dentistry.
JDR Clin Trans Res 2020 Oct;5(4):399-408. doi: 10.1177/2380084419897614..
Keywords: Surveys on Patient Safety Culture, Patient Safety, Dental and Oral Health, Provider, Medical Errors, Adverse Events
Temkin-Greener H, Cen X, Li Y
Nursing home staff turnover and perceived patient safety culture: results from a national survey.
In this study, the investigators examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs). The investigators suggest that the effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.
AHRQ-funded; HS024923.
Citation: Temkin-Greener H, Cen X, Li Y .
Nursing home staff turnover and perceived patient safety culture: results from a national survey.
Gerontologist 2020 Sep 15;60(7):1303-11. doi: 10.1093/geront/gnaa015..
Keywords: Nursing Homes, Long-Term Care, Surveys on Patient Safety Culture, Patient Safety, Provider: Nurse, Provider
Hessels AJ, Murray M, Cohen B
Patient Safety Culture Survey in pediatric complex care settings: a factor analysis.
The objective of this study was to evaluate the psychometric properties of the Nursing Home Survey on Patient Safety Culture tool slightly modified for use in the pediatric long-term care facilities (pLTC) setting. Factor analyses were performed on data collected from 239 staff at 3 pLTCs. Findings showed that this study demonstrated that the Nursing Home Survey on Patient Safety Culture, with minimal modification, may be an appropriate instrument to measure patient safety culture in pLTC settings. Recommendations included additional psychometric testing to validate further the use of this instrument in this setting, including examining the relationship to safety outcomes.
AHRQ-funded; HS021470.
Citation: Hessels AJ, Murray M, Cohen B .
Patient Safety Culture Survey in pediatric complex care settings: a factor analysis.
J Patient Saf 2020 Sep;16(3):223-31. doi: 10.1097/pts.0000000000000279..
Keywords: Children/Adolescents, Surveys on Patient Safety Culture, Patient Safety, Long-Term Care
Campione JR, Mardon RE, McDonald KM
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
Researchers investigated the relationship between patient safety culture, health information technology (IT) implementation, and the frequency of problems that could lead to diagnostic errors in the medical office setting. Using survey data from the 2012 Agency for Healthcare Research and Quality Medical Office Surveys on Patient Safety Culture database, they found that the most frequent problem was "results from a lab or imaging test were not available when needed," with 15% of respondents reporting that it happened daily or weekly. Higher overall culture scores were significantly associated with fewer occurrences of each problem assessed, and offices in the process of health IT implementation had higher frequency of problems.
AHRQ-funded; 290201200003I.
Citation: Campione JR, Mardon RE, McDonald KM .
Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.
J Patient Saf 2019 Dec;15(4):267-73. doi: 10.1097/pts.0000000000000531..
Keywords: Surveys on Patient Safety Culture, Health Information Technology (HIT), Diagnostic Safety and Quality, Patient Safety, Ambulatory Care and Surgery
Jones KJ, Crowe J, Allen JA
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
The purpose of this study was to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture. The investigators concluded that post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles were likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Crowe J, Allen JA .
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
BMC Health Serv Res 2019 Sep 9;19(1):650. doi: 10.1186/s12913-019-4453-y..
Keywords: TeamSTEPPS, Falls, Adverse Events, Surveys on Patient Safety Culture, Patient Safety, Hospitals, Teams
Odell DD, Quinn CM, Matulewicz RS
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.
The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. In this study, the investigators examined the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes. The authors found, among other results that operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive).
AHRQ-funded; HS024516.
Citation: Odell DD, Quinn CM, Matulewicz RS .
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.
J Am Coll Surg 2019 Aug;229(2):175-83. doi: 10.1016/j.jamcollsurg.2019.02.046..
Keywords: Hospitals, Patient Safety, Quality of Care, Quality Improvement, Outcomes, Surgery, Surveys on Patient Safety Culture
Li Y, Cen X, Cai X
Perceived patient safety culture in nursing homes associated with "Nursing Home Compare" performance indicators.
This study examined the association between the use of “Nursing Home Compare” performance indicators and improved patient safety culture in nursing homes. A survey was conducted in 2017 using AHRQ’s Survey on Patient Safety Culture for Nursing Homes which collects data on 12 core domains of safety culture scores. Out of 2254 nursing homes sampled, there was a response rate of 36%. It was found that for every 10 percentage points increase in overall positive response rate for safety culture, there was an association with 0.56 fewer health care deficiencies, 0.74 fewer substantiated complaints, reduced fines by $2285.20, and 20% increased odds of being designed as 4-star or 5-star.
AHRQ-funded; HS024923.
Citation: Li Y, Cen X, Cai X .
Perceived patient safety culture in nursing homes associated with "Nursing Home Compare" performance indicators.
Med Care 2019 Aug;57(8):641-47. doi: 10.1097/mlr.0000000000001142..
Keywords: Surveys on Patient Safety Culture, Patient Safety, Nursing Homes, Quality Indicators (QIs), Quality Measures, Quality of Care, Provider Performance
Kahwati LC, Sorensen AV, Teixeira-Poit S
AHRQ Author: Mistry KB
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
The purpose of this study was to describe the Safety Program for Perinatal Care (SPPC) implementation experience and evaluate the short-term impact on labor and delivery (L&D) unit patient safety culture, processes, and adverse events. SPPC implementation by L&D units were supported sing a program toolkit, trainings, and technical assistance. Researchers then evaluated the program using a pre-post, mixed-methods design. Changes in safety and quality were measured using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators. Findings showed that SPPC had a favorable impact on unit patient safety culture and processes, but mixed short-term impact on maternal and neonatal adverse events.
AHRQ-authored; AHRQ-funded; 2902010000241.
Citation: Kahwati LC, Sorensen AV, Teixeira-Poit S .
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Jt Comm J Qual Patient Saf 2019 Apr;45(4):231-40. doi: 10.1016/j.jcjq.2018.11.002..
Keywords: Adverse Events, Communication, Comprehensive Unit-based Safety Program (CUSP), Labor and Delivery, Maternal Care, Newborns/Infants, Outcomes, Patient Safety, Pregnancy, Simulation, Surveys on Patient Safety Culture, Teams, TeamSTEPPS, Training, Women
Lin DM, Carson KA, Lubomski LH
Statewide collaborative to reduce surgical site infections results of the Hawaii Surgical Unit-based Safety Program.
Surgical Site Infections (SSI) after colorectal surgery are common, lead to patient harm, and are costly to the healthcare system. This study's purpose was to evaluate the effectiveness of the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Surgery in Hawaii. Participation in the program was associated with a 61.7% decrease in colorectal SSI rate and an increase in patient safety culture.
AHRQ-funded.
Citation: Lin DM, Carson KA, Lubomski LH .
Statewide collaborative to reduce surgical site infections results of the Hawaii Surgical Unit-based Safety Program.
J Am Coll Surg 2018 Aug;227(2):189-97.e1. doi: 10.1016/j.jamcollsurg.2018.04.031..
Keywords: Comprehensive Unit-based Safety Program (CUSP), Healthcare-Associated Infections (HAIs), Surgery, Surveys on Patient Safety Culture, Injuries and Wounds
Davis KK, Harris KG, Mahishi V
Perceptions of culture of safety in hemodialysis centers.
Staff members, physicians, nurse practitioners, and physician assistants from a sample of hemodialysis facilities completed a 10-item assessment with modified questions from the Hospital Survey on Patient Safety Culture, with an emphasis on safety culture related to vascular access infections. Overall, scores were high, indicating a positive patient safety culture.
AHRQ-funded; 2902010000251.
Citation: Davis KK, Harris KG, Mahishi V .
Perceptions of culture of safety in hemodialysis centers.
Nephrol Nurs J 2016 Mar-Apr;43(2):119-26, 82; quiz 27.
.
.
Keywords: Surveys on Patient Safety Culture, Patient Safety, Dialysis, Kidney Disease and Health, Organizational Change, Catheter-Associated Urinary Tract Infection (CAUTI), Healthcare-Associated Infections (HAIs), Provider