The Division has decades of experience conducting research to better understand and reduce threats to patient safety among medical patients in inpatient and outpatient settings and during care transitions. Areas of focus include medication safety, diagnostic errors, and hospital-acquired conditions.
The Division also conducts research to improve the quality of health care delivery more broadly, making it more effective, patient-centered, equitable, timely, and efficient. Interventions to achieve these goals are often multi-faceted, involving high-tech and high-touch components, process redesign, systems engineering, and implementation science methods. Many of these interventions have made an impact locally, nationally, and internationally. The Division also explores the effects of different payment and organizational structures on healthcare cost and quality.
Faculty
- David Bates
- Evan Benjamin
- Asaf Bitton
- Bonnie Blanchfield
- Issac Chua
- Anuj Dalal
- Patricia Dykes
- Shira Fischer
- Dinah Foer
- Ishani Ganguli
- David Levine
- Stephanie Mueller
- Larissa Nekhlyudov
- Ronen Rozenblum
- Alejandra Salazar
- Hojjat Salmasian
- Gordon Schiff
- Jeffrey Schnipper
- Shela Sridhar
- Emani Srinivas
References:
- Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015. JAMA Intern Med. 2019;179(4):506-514. 1001/jamainternmed.2018.7624
- Basu S, Phillips RS, Berkowitz SA, Landon BE, Bitton A, Phillips RL. Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States. Ann Intern Med. 2021 07; 174(7):920-926. https://doi.org/10.7326/M20-7381
- Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, Vander Vliet M, Nemeskal R, Leape Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA 1995;274(1):29-34. PMID: 771255
- Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, Spurr C, Khorasani R, Tanasijevic M, Middleton Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003;10(6):523-530. DOI: 10.1197/jamia.M1370
- Blanchfield BB, Demehin AA, Cummings CT, Ferris TG, Meyer GS. The Cost of Quality: An Academic Health Center's Annual Costs for its Quality and Patient Safety Infrastructure. Joint Comm J Qual Patient Safety. Jt Comm J Qual Patient Safety. 2018; 44(10):583–9. https://doi.org/10.1016/j.jcjq.2018.03.012
- Collins SA, Rozenblum R, Leung WY, Morrison CR, Stade DL, McNally K, Bourie PQ, Massaro A, Bokser S, Dwyer C, Greysen RS, Agarwal P, Thornton K, Dalal AK. Acute care patient portals: a qualitative study of stakeholder perspectives on current practices. J Am Med Inform Assoc. 2017 Apr 1;24(e1):e9-e17. PubMed PMID: 27357830.
- Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, Meltzer S, Tsurikova R, Zuyov L, Middleton B. Fall prevention in acute care hospitals: a randomized trial. Journal of the American Medical Association 2010;304:1912-8. DOI: 1093/jamia/ocw081
- Dykes PC, Rozenblum R, Dalal AK, Massaro A, Chang F, Clements M, Collins S, Donze J, Fagan M, Gazarian P, Hanna J, Lehmann L, Leone K, Lipsitz S, McNally K, Morrison C, Samal L, Mlaver E, Schnock K, Stade D, Williams D, Yoon C, Bates DW. Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Crit Care Med. 2017 Aug;45(8):e806-e813. PubMed PMID: 28471886. DOI: 1097/ccm.0000000000002449
- Dykes PC, Burns Z, Adelman J, Benneyan J, Bogaisky M, Carter E, Ergai A, Lindros ME, Lipsitz SR, Scanlan M, Shaykevich S, Bates DW. Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries: A Nonrandomized Controlled Trial. JAMA Netw Open. 2020 11 02; 3(11):e2025889. PMID: 33201236. DOI: 10.1001/jamanetworkopen.2020.25889
- Edwards ST, Neri PM, Volk LA, Schiff GD, Bates DW. Association of note quality and quality of care: a cross-sectional BMJ Qual Saf. 2014 May;23(5):406-13. Doi: 10.1136/bmjqs-20
- Emani S, Sequist TD, Lacson R, Khorasani R, Jajoo K, Holtz L, Desai S. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer. The Joint Commission Journal on Quality and Patient Safety. 2019;45(8):552-7. DOI: 1016/j.jcjq.2019.05.010
- Engelman D, Benjamin E. Physician Engagement: The “Secret Sauce” to Success in Bundled Healthcare. Am J Med Qual. 2018;33(1):100-102. DOI: 2147/JHL.S214765
- Fischer SH, Tjia J, Reed G, Peterson D, Gurwitz JH, Field TS. (2014) Factors associated with ordering laboratory monitoring of high-risk medications. Journal of General Internal Medicine. 29(12),1589-98. PMCID: PMC4242891. doi: 1007/s11606-014-2907-9
- Foer D, Ornstein K, Soriano TA, Kathuria N, Dunn A. Nonmedical factors associated with prolonged hospital length of stay in an urban homebound population. J Hosp Med. 2012 Feb;7(2):73-8. PMID: 21391944 DOI: 1002/jhm.992
- Ganguli I, Wasfy JH, Ferris TG. What is the Right Number of Clinical Appointments? Visit Frequency and the Accountable Care JAMA. 2015;313(19):1905-6 DOI:10.1001/jama.2015.3356
- Ganguli I, Thompson RW, Ferris What can five high-cost patients teach us about healthcare spending? Healthcare. 2016;5(4):204-13. DOI: 10.1016/j.hjdsi.2016.12.004
- Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico F, Leape LL, Bates DW. Patient safety - adverse drug events in ambulatory N Engl J Med 2003;348:1556-1564. DOI: 10.1056/NEJMsa020703
- Ganguli I, Souza J, McWilliams, JM, Mehrotra A. Association of Medicare’s Annual Wellness Visit with Cancer Screening, Referrals, Utilization, and 2019, Nov Health Aff. (Millwood). DOI: 10.1377/hlthaff.2019.00304
- Ganguli I, Lupo C, Mainor AJ, Raymond S, Wang Q, Orav EJ, Chang CH, Morden NE, Rosenthal MB, Colla CH, Sequist TD. Cascades Following Low-value Care: Pre-operative Electrocardiogram for Cataract JAMA Internal Medicine. 2019 Jun 3;179(9):1211-1219.
- Ganguli I, Shi Z, Orav EJ, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care among Commercially Insured Adults in the US, 2008-2016. Ann Intern 2020 Feb 18;172(4):240-7 doi: 10.1001/jamanetworkopen.2019.1514
- Ganguli I, Simpkin AL, Colla CH, Weissman A, Mainor AJ, Rosenthal MB, Sequist TD. Why Do Physicians Pursue Cascades of Care After Incidental Findings? A National J Gen Intern Med. 2020;35(4):1352‐1354. DOI: 10.1007/s11606-019-05213-1
- Garabedian, P. M., Wright, A., Newbury, I., Volk, L. A., Salazar, A., Amato, M. G., Nathan, A. W., Forsythe, K. J., Galanter, W. L., Kron, K., Myers, S., Abraham, J., McCord, S. K., Eguale, T., Bates, D. W., & Schiff, G. D. (2019). Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems. JAMA network open, 2(3), e191514. https://doi.org/10.1001/jamanetworkopen.2019.1514
- Kachalia A, Sands K, Niel MV, Dodson S, Roche S, Novack V, Yitshak-Sade M, Folcarelli P, Benjamin EM, Woodward AC, Mello MM. Effects of a communication-and-resolution program on hospitals’ malpractice claims and costs. Health Affairs. 2018 Nov 1;37(11):1836-44. DOI: 1377/hlthaff.2018.0720
- Levine DM, Linder JA, Landon BE. The Quality of Outpatient Care Delivered to Adults in the United States, 2002 – 2013. JAMA Intern Med. 2016;176(12):1778-1790. DOI: 1001/jamainternmed.2016.6217
- Levine DM, Healey MJ, Wright A, Bates DW, Linder JA, Samal L. Changes in the quality of care during progress from stage 1 to stage 2 of Meaningful Use. J Am Med Inform Assoc. 2016 Aug 26. DOI: 1093/jamia/ocw127
- Levine DM, Landon BE, Linder JA. Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care. JAMA Intern Med. 2019;179(3):363-372. DOI: 1001/jamainternmed.2018.6716
- Mueller SK, Cunningham Sponsler K, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172 (14):1057-1069. DOI: 1001/archinternmed.2012.2246
- Mueller SK, Yoon C, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical Errors. JAMA Intern Med. Aug 1 2016. DOI: 1001/jamainternmed.2016.4258
- Hickman, T. T., Quist, A., Salazar, A., Amato, M. G., Wright, A., Volk, L. A., Bates, D. W., & Schiff, G. (2018). Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. BMJ quality & safety, 27(4), 293–298. https://doi.org/10.1136/bmjqs-2017-006597
- Paladino J, Koritsanszky L, Neal BJ, Lakin JR, Kavanagh J, Lipsitz S, Fromme EK, Sanders J, Benjamin E, Block S, Bernacki R. Effect of the Serious Illness Care Program on Health Care Utilization at the End of Life for Patients with Cancer. J Palliat Med. 2020 Jan 3. DOI: 10.1089/jpm.2019.0437
- Panda N, Benjamin E, et al. Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers. World Journal of Surgery. 2020 April 19. https://doi.org/10.1007/s00268-020-05518-x
- Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, Carty MG, Karson AS, Bhan I, Coley CM, Liang CL, Turchin A, McCarthy PC, Schnipper JL. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-1422. DOI: 1007/s11606-008-0687-9
- Ratcliffe HL, Schwarz D, Hirschhorn LR, Cejas C, Diallo A, Elorrio EG, Fifield J, Gashumba D, Hartshorn L, Leydon N, Mohamed M, Nakamura Y, Ndiaye Y, Novignon J, Ofosu A, Roder-DeWan S, Rwiyereka A, Secci F, Veillard JH, Bitton A. PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity. BMJ Global Health 2019;4(5):e001822. DOI: 1136/bmjgh-2019-001822
- Salmasian H, Blanchfield B, Joyce K, Centeio K, Schiff G, Wright A, Baugh CW, Schuur J, Bates DW, Adelman JS, Landman AB. Association of Display of Patient Photographs in the Electronic Health Record with Wrong-Patient Order Entry Errors. JAMA Netw Open.2020;3(11):e2019652. DOI: 10.1001/jamanetworkopen.2020.19652
- Samal L, Wright A, Healey MJ, Linder JA, Bates DW. Meaningful Use and Quality of Care. JAMA Intern Med. 2014 Jun;174(6):997-8. DOI: 1001/jamainternmed.2014.662
- Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, Kachalia A, Horng M, Roy CL, McKean SC, Bates DW. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-71. DOI: 1001/archinte.166.5.565
- Schnipper JL, Hamann C, Ndumele CD, Liang CL, Carty MG, Karson AS, Bhan I, Coley CM, Poon E, Turchin A, Labonville SA, Diedrichsen EK, Lipsitz S, Broverman C, McCarthy P, Gandhi TK. Effects of a medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med 2009; 169(8):771-780. DOI: 1001/archinternmed.2009.51
- Schnipper JL, Mixon AS, Stein J, Wetterneck TB, Kaboli P, Mueller S, Labonville S, Minahan JA, Burdick E, Orav EJ, Goldstein J, Nolido NV, Kripalani S. The effects of a multi-faceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf DOI: 10.1136/bmjqs-2018-008233
- Schnipper JL, Nolido N, Dalal AK, et al. The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial. J Hosp Med. 2021 Jan;16(1):15-22. doi: 10.12788/jhm.3513. PMID: 33357325
- Schnipper JL, Reyes Nieva H, Mallouk M, et al. Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ Qual Saf. 2021. Epub ahead of print: DOI: 10.1136/bmjqs-2020-012709.
- Schiff, G. D., Klinger, E., Salazar, A., Medoff, J., Amato, M. G., John Orav, E., Shaykevich, S., Seoane, E. V., Walsh, L., Fuller, T. E., Dykes, P. C., Bates, D. W., & Haas, J. S. (2019). Screening for Adverse Drug Events: a Randomized Trial of Automated Calls Coupled with Phone-Based Pharmacist Counseling. Journal of general internal medicine, 34(2), 285–292. https://doi.org/10.1007/s11606-018-4672-7
- Sridhar S, Schmid A, Biziyaremye F, Hodge S, Patient N, Wilson K. “Implementation of a Pediatric Early Warning Score as a Tool for Improving Communication and Nursing Empowerment in Rural District Hospital in Rwanda” Global Health: Science & Practice. Oct 2020 DOI: 9745/GHSP-D-20-00075
- Chua I, Petrides AK, Schiff GD, Ransohoff JR, Kantartjis M, Streid J, Demetriou CA, Melanson SEF. Provider Misinterpretation, Documentation, and Follow-Up of Definitive Urine Drug Testing Results. J Gen Intern Med. 2020 Jan;35(1):283-290. DOI: 10.1007/s11606-019-05514-5
- Chua IS, Ransohoff JR, Ehrlich O, Katznelson E, Virk ZM, Demetriou CA, Petrides AK, Orav EJ, Schiff GD, Melanson SEF. Laboratory-Generated Urine Toxicology Interpretations: A Mixed Methods Study. Pain Physician. 2021 Mar;24(2):E191-E201