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HHS Awards $17 Million in a New National Initiative To Fight Health Care-associated Infections

Patient Safety and Health IT Newsletter, Issue #56

AHRQ's Patient Safety and Health Information Technology E-Newsletter summarizes patient safety news and information from the Agency.

Quote of the Month

"When patients go to the hospital, they expect to get better, not worse. Eliminating infections is critical to making care safer for patients and to improving the overall quality and safety of the health care system. We know that it can be done, and this new initiative will help us reach our goal." (For more details, go to item no. 1.)

—HHS Secretary Kathleen Sebelius

Today's Headlines:

AHRQ Patient Safety News:

  1. HHS awards $17 million in a new national initiative to fight health care-associated infections
  2. AHRQ announces new video to help patients use blood thinner pills safely
  3. New AHRQ study finds failure to order necessary tests a leading cause of diagnostic errors
  4. Latest issue of WebM&M is available online
  5. AHRQ radiocast on new national initiative to fight health care-associated infections
  6. AHRQ in the patient safety professional literature—some useful citations

AHRQ Health IT News:

  1. National coordinator for Health IT issues statement on "meaningful use" of electronic health records
  2. AHRQ releases new resources for health IT system adoption
  3. New resource reports consumers' perceptions of electronic health information systems
  4. AHRQ releases key findings for health IT researchers and implementers
  5. New evidence report shows consumer health informatics applications can improve health care processes
  6. AHRQ in the health IT professional literature—some useful citations

 

AHRQ Patient Safety News: 

1. HHS awards $17 million in a new national initiative to fight health care-associated infections

HHS Secretary Kathleen Sebelius on October 23 announced the award of $17 million to fund projects to fight costly and dangerous health care-associated infections (HAIs). Nearly 2 million patients develop HAIs, which contribute to 99,000 deaths each year and $28 billion to $33 billion in health care costs each year. Of the $17 million in new awards, $8 million will fund a national expansion of the Keystone Project, which within 18 months successfully reduced the rate of central-line blood stream infections in more than 100 Michigan intensive care units and saved 1,500 lives and $200 million. The project was originally started by researchers at the Johns Hopkins University in Baltimore and the Michigan Health and Hospital Association to implement a comprehensive unit-based safety program. The program involves using a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses, and hospital leaders. Earlier this year, AHRQ funded an expansion of this project to 10 states. With additional funding from AHRQ and a private foundation, the Keystone Project is now operating in all 50 states, Puerto Rico, and the District of Columbia. The new funding will expand the effort to more hospitals, extend it to other settings in addition to ICUs, and broaden the focus to address other types of infections. In addition, AHRQ, in collaboration with the CDC, also identified several high-priority areas to apply the remaining $9 million toward reducing MRSA and other types of HAIs. Select for a complete list of projects funded by the $17 million in resources and select for the HHS press release. 

2. AHRQ announces new video to help patients use blood thinner pills safely

AHRQ released "Staying Active and Healthy with Blood Thinners," a 10-minute video in English and Spanish that helps educate patients about how to use anticoagulant drugs safely. Nearly 2 million Americans are prescribed a blood thinner each year to reduce their risk of forming dangerous blood clots. Designed to complement education that patients receive in their doctor's office, clinic, pharmacy, or hospital, the new video helps patients better understand blood thinners and how to manage them effectively. The video is available as a DVD and can be obtained free of charge by sending an E-mail to ahrqpubs@ahrq.hhs.gov. A companion print brochure, Blood Thinner Pills: Your Guide to Using Them Safety / Pastillas que diluyen la sangre: Guía para su uso seguro, is also available. Select to access the video and brochure on the AHRQ Web site. 

3. New AHRQ study finds failure to order necessary tests a leading cause of diagnostic errors

AHRQ researchers found that failure to order tests, report results to patients, or follow up with abnormal test findings are leading types of diagnostic errors. Results were based on a survey issued to nearly 300 primary care and specialist physicians who reported 583 cases of diagnosis error, the largest-ever study of diagnostic errors in medicine. Researchers also found that tests were overlooked because clinicians often failed to consider the diagnosis, leading to delays in ordering the tests or making the correct diagnosis. The most common missed or delayed diagnoses include pulmonary embolism, drug reactions or overdose, lung cancer, colorectal cancer, acute coronary syndrome, including heart attack, breast cancer and stroke. The study, led by Gordon Schiff, M.D., associate director of Brigham and Women's Hospital Center for Patient Safety Research and Practice, Boston, which is part of the Cook County Hospital/Rush University AHRQ-supported Developmental Center for Research in Patient Safety. According to Dr. Schiff, the survey found that other major categories of errors involved failure to consider a diagnosis or overweighing a competing diagnosis, failures in history taking, physical examination, and referral or consultation delays. Findings from the study, "Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors," are published in the November 9 issue of the Archives of Internal Medicine. 

4. Latest issue of WebM&M is available online

The October issue of AHRQ WebM&M is now available online. The Perspectives on Safety section highlights the role of the media in patient safety and features Charles Ornstein, a journalist who co-authored a series of articles in the Los Angeles Times about medical errors at Martin Luther King Jr./Drew Medical Center. In an accompanying perspective piece, Robert M. Wachter, M.D., professor of medicine at the University of California, San Francisco, and editor of AHRQ WebM&M, discusses how the media covers medical errors and promotes patient safety. The Spotlight Case features a commentary by Ernest J. Ring, M.D., former chief medical officer and Jane E. Hirsch, R.N., former chief nursing officer, from University of California San Francisco Medical Center, discussing issues surrounding disruptive physician behavior and how medical center leadership should handle such situations. The second case features a commentary by Dorrie K. Fontaine, R.N., Ph.D., University of Virginia, Charlottesville, discussing how physicians and nurses can work together to create a positive work environment. The third case features a commentary by Christopher R. Lee, M.D., of University of Washington, Seattle, discussing key issues in airway management and prevention of retained foreign objects during surgical procedures. Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using the "E-mail a colleague" feature. 

5. AHRQ radiocast on new national initiative to fight health care-associated infections

In a recent Healthcare 411 radiocast, William Munier, M.D., director, AHRQ's Center for Quality Improvement and Patient Safety, discusses the Agency's recent award of $17 million to fund projects to fight costly and dangerous health care-associated infections (HAIs), including central line-associated bloodstream infections and methicillin-resistant Staphylococcus aureus, or MRSA. Dr. Munier talks about AHRQ's collaboration with the Centers for Disease Control and Prevention and other federal agencies to identify these high-priority projects that are aimed at reducing the rate of HAIs. Select to access the Healthcare 411 program or transcript. 

6. AHRQ in the patient safety professional literature—some useful citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Bundy DG, Shore AD, Morlock LL, et al. Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database. Vaccine 2009 Jun 12; 27(29):3890-6. Select to access the abstract.

Gallagher TH, Bell SK, Smith KM, et al. Disclosing harmful medical errors to patients: tackling three tough cases. Chest 2009 Sep; 136(3):897-903. Select to access the abstract.

Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff 2009 Sep-Oct; 28(5):1475-84. Select to access the abstract.

 

AHRQ Health IT News: 

7. National coordinator for Health IT issues statement on "meaningful use" of electronic health records

National Coordinator for Health Information Technology, David Blumenthal, M.D., M.P.P., recently issued a message on progress toward electronic health information exchange. Dr. Blumenthal discussed the term "meaningful use" of electronic health records both as a concept that underlies the movement toward an electronic health care environment and as a practical set of standards that will be issued as a proposed regulation by the end of 2009, as well as next steps. Select to access his entire message on the Office of the National Coordinator for Health Information's Web site. 

8. AHRQ releases new resources for health IT system adoption

New information for health care providers adopting health information technology systems is now available from AHRQ's National Resource Center (NRC) for Health Information Technology. The new topic areas, found on the NRC's health IT bibliography Web page, include disease registries, personal health records, usability testing, education and training, privacy and security, quality measurement and improvement, and transitions in care. The health IT bibliography represents both peer-reviewed articles from professional journals and Web-based resources from highly respected health care and IT organizations. The bibliography's articles and resources provide knowledge and insight that may help clinicians and organizations implement systems and models related to the American Recovery and Reinvestment Act and the Health Information Technology for Economic and Clinical Health Act. For example, these resources can be used to:

  • Track and manage patients with chronic conditions and engage them in better self-management and care coordination.
  • Support nursing practice and long-term care of older adults.
  • Establish medical homes for patients.
  • Improve transitions in care.

9. New resource reports consumers' perceptions of electronic health information systems

AHRQ's National Resource Center for Health Information Technology has released a new resource on consumers' opinions of electronic health information systems. The report, titled Consumer Engagement in Developing Electronic Health Information Systems, provides an in-depth understanding of consumers' health care awareness, beliefs, perceptions, and fears concerning health IT. Results of focus groups suggest that participants are optimistic that health information technology (IT) will benefit health care quality. Privacy and security are the main concern of a large majority of participants. Participants also think that computers may add efficiency to health care and reduce medical errors, such as those associated with illegible handwriting. However, some participants are concerned that health IT might make providers more impersonal, devoting more attention to the computer screen and less to the patient. Select to view the new resource (PDF File, Plugin Software Help). 

10. AHRQ releases key findings for health IT researchers and implementers

AHRQ has developed a new report, Summary of Health IT Portfolio 2008, that highlights key findings from its health IT projects. The report presents an overview of nearly 150 summaries by strategic and business goals, project milestones, and other characteristics. It is a valuable tool for health IT researchers and individuals interested in synthesizing health IT research and identifying gaps. Researchers and implementers of health IT now have access to practical examples for planning and conducting their research and implementing projects. Select to view the new report. 

11. New evidence report shows consumer health informatics applications can improve health care processes

AHRQ released a new evidence report, Impact of Consumer Health Informatics Applications, that found that consumer health informatics applications can help improve health care processes such as medication adherence. These applications are defined as patient-focused electronic tools to support health improvement, process outcomes, and patient-centered care. The benefits of using such applications apply to a variety of clinical conditions, including cancer, smoking, diabetes, physical activity, and mental health disorders. The report also identified important knowledge gaps in the new and emerging field of consumer health informatics. Researchers, led by M. Christopher Gibbons, M.D., M.P.H., at AHRQ's Johns Hopkins University Evidence-based Practice Center, concluded that while the applications offer significant promise and potential to positively impact select clinical outcomes, more research is needed to determine conclusions on impact in many areas. Select to access the report. A print copy is available by sending an E-mail to ahrqpubs@ahrq.hhs.gov. 

12. AHRQ in the health IT professional literature—some useful citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Kilbridge PM, Noirot LA, Reichley RM, et al. Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc 2009 Sep-Oct; 16(5):607-12. Select to access the abstract.

Pace WD, Cifuentes M, Valuck RJ, et al. An electronic practice-based network for observational comparative effectiveness research. Ann Intern Med 2009 Sep 1; 151(5):338-40. Select to access the abstract.

Poon EG, Cusack CM, McGowan JJ. Evaluating healthcare information technology outside of academia: observations from the National Resource Center for Healthcare Information Technology at the Agency for Healthcare Research and Quality. J Am Med Inform Assoc 2009 Sep-Oct; 16(5):631-6. Select to access the abstract.

Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. Arch Intern Med 2009 Sep 14; 169(16):1465-73. Select to access the abstract.

AHRQ's Patient Safety and Health Information Technology E-Newsletter Contact:

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Current as of November 2009
Internet Citation: HHS Awards $17 Million in a New National Initiative To Fight Health Care-associated Infections: Patient Safety and Health IT Newsletter, Issue #56. November 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/newsletters/patient-safety/56.html

 

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