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AHRQ Director's Commentary Provides Insight on Patient Safety and Medical Liability Reform

Patient Safety and Health IT Newsletter, Issue #63

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

Quote of the Month

"The U.S. medical liability system is designed both to compensate patients who suffer injury because of medical negligence and to reduce the likelihood of patients being harmed in the future. Yet the system has not performed adequately on these goals." (For more information on Dr. Clancy's recent commentary on patient safety and medical liability reform, go to item no.1.)

Today's Headlines:

AHRQ Patient Safety News:

  1. AHRQ director's commentary provides insight on patient safety and medical liability reform
  2. AHRQ announces interest in funding grants focused on healthcare-associated infections
  3. ACTION II partnership awards announced
  4. Latest Issue of AHRQ WebM&M is available online
  5. CDC spotlights global efforts to address antibiotic resistance
  6. AHRQ in the patient safety professional literature—some useful citations

AHRQ Health IT News:

  1. AHRQ's new report highlights successes in health IT
  2. New report examines impact of health IT on workflow in outpatient settings
  3. Second edition of Registries for Evaluating Patient Outcomes: A User's Guide is available
  4. New health IT fact sheet on State and regional demonstration projects is available
  5. AHRQ in the health IT professional literature—some useful citations

 

AHRQ Patient Safety News: 

1. AHRQ Director's Commentary Provides Insight on Patient Safety and Medical Liability Reform

In a recent commentary, AHRQ Director Carolyn M. Clancy, M.D., discussed the disconnect between patient safety and medical liability and how problems associated with injury and harm due to processes of care continue. Dr. Clancy highlighted the efforts that AHRQ is making to improve patient safety and lower medical liability claims, including the recent award of $23 million in projects that will support efforts by States and health systems to create, implement, and evaluate patient safety approaches and medical liability reforms. Select to access Dr. Clancy's commentary, "Patient Safety and Medical Liability Reform: Putting the Patient First," which appeared in the September-October issue of Patient Safety and Quality Healthcare. 

2. AHRQ Announces Interest in Funding Grants Focused on Healthcare-Associated Infections

AHRQ recently issued two Special Emphasis Notices announcing AHRQ's interest in funding grants focused on preventing and reducing healthcare-associated infections (HAIs). These notices re-emphasize HAIs as a research priority for AHRQ and call for submission of research grant applications (R01, R03, and R18) as well as career development grant applications (K01, K02, and K08) that address HAIs. Below are the priority areas of HAI research for applications for fiscal year 2011:

  • Determination of the clinical efficacy, effectiveness, and cost-effectiveness of interventions to prevent HAIs.
  • Development, demonstration, and implementation of strategies for prevention and management of HAIs.
  • Characterization and assessment of relevant epidemiological aspects of HAIs, such as patient risk factors, clinical presentation, and sources of antibiotic-resistant organisms involved in the development of HAIs.

A research focus that will receive additional emphasis in fiscal year 2011 is HAIs in ambulatory care. Additionally, AHRQ is interested in developing, evaluating, and demonstrating linkages between the various settings of care (hospitals, ambulatory settings, and long-term care facilities) to improve the prevention, management and tracking of HAIs. Select to learn more about the Special Emphasis Notice for research grants and for career development grants. 

3. ACTION II Partnership Awards Announced

AHRQ announced 17 new Accelerating Change and Transformation in Organizations and Networks II (ACTION II) partnership awards. ACTION II is a five-year task order contract model of practice-based implementation research. Collectively, the Action II Partnerships, which span all States, provide access and care to an estimated 50 percent of the U.S. population, representing a broad geographic, demographic, and payer mix. The goal of ACTION II is to promote and accelerate the development, implementation, dissemination and sustainability of evidence-based innovation in health care delivery and organization to measurably improve health care in the U.S. The 17 partnerships are composed of more than 350 diverse organizations involved in health care delivery, including inpatient, ambulatory and long-term care health care providers (including integrated delivery systems and Federally Qualified Health Centers/safety nets), health plans, health services research organizations/networks, consumer and patient safety groups, professional or trade associations/organizations, and Quality Improvement Organizations. Select to access the fact sheet. 

4. Latest Issue of AHRQ WebM&M is Available Online

The November issue of AHRQ WebM&M is now available online. The Perspectives on Safety section looks at measuring patient safety and features Patrick S. Romano, M.D., of the University of California, Davis, School of Medicine, Sacramento, CA, whose work helped develop AHRQ's Patient Safety Indicators. In the accompanying perspective piece, Amy K. Rosen, Ph.D., of Boston University School of Public Health, addresses whether we are getting better at measuring patient safety. The Spotlight Case, "Treatment Challenges after Discharge," features a commentary by Chase Coffey, M.D., of Henry Ford Health System, Detroit, MI, on patient safety issues surrounding hospital discharge and the challenges surrounding tests pending at discharge. The second case, "Mother's Milk, but Whose Mother?" features a commentary by Dorothy Dougherty, RN, of Sunnybrook Health Sciences Centre, Toronto, CA, discussing methods to prevent and address breast-milk errors. The third case, "Reconciling Records," features a commentary by Hardeep Singh, M.D., of Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX; Dean F. Sittig, Ph.D., of University of Texas School of Biomedical Informatics, Houston; and Maureen Layden, M.D., of the Veterans Health Administration, Cleveland, OH, discussing how to prevent errors in reconciling medication records. 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. CDC Spotlights Global Efforts to Address Antibiotic Resistance

Antibiotic resistance is one of the world's most pressing public health threats. To bring attention to this increasing problem, CDC and other government partners observed the third annual "Get Smart About Antibiotics Week" on November 15-21. The national campaign highlighted the coordinated efforts of CDC, State and local health departments, and non-profit and for-profit partners to educate the public about antibiotic resistance and the importance of appropriate antibiotic use in both community and health care settings. CDC also unveiled its new "Get Smart for Healthcare" program to complement the existing "Get Smart: Know When Antibiotics Work" program. The goal of the program is to ensure that hospitals and nursing homes are using antibiotics wisely by implementing proven strategies. Select to access CDC's press release. CDC's activities are a part of an HHS-wide effort to address strategies outlined within the HHS Action Plan to Prevent HAIs. Partners across HHS, including AHRQ, CMS, and NIH, have been working together to achieve the prevention goals in the Action Plan. 

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.

Karsh BT, Brown R. Macroergonomics and patient safety: the impact of levels on theory, measurement, analysis and intervention in patient safety research. Appl Ergon 2010 Sep; 41(5):674-81. Select to access the abstract.

Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med 2010 Aug; 38(8 Suppl):S292-S298. Select to access the abstract. 

AHRQ Health IT News: 

7. AHRQ's New Report Highlights Successes in Health IT

AHRQ released a new report, Using Health IT: Eight Quality Improvement Stories, highlighting the successes of eight projects funded under the Transforming Healthcare Quality through Information Technology (THQIT) program. These projects demonstrate how health IT applications can be used to improve care for vulnerable populations, improve health care delivery, improve the quality of care, and increase access to health care. Select to access the report (PDF File, Plugin Software Help). 

8. New Report Examines Impact of Health IT on Workflow in Outpatient Settings

AHRQ released a new summary report, Incorporating Health IT into Workflow Redesign,prepared by the University of Wisconsin-Madison's Center for Quality and Productivity Improvement. The report summarizes existing research and evidence related to the impact of health IT on workflow in outpatient settings. Key information obtained from the research will be incorporated into a toolkit to assist small and medium-sized practices in workflow analysis and redesign before, during, and after health IT implementation. The toolkit, Workflow Assessment for Health IT, is expected to be available in January 2011. Select to access the summary report (PDF File, Plugin Software Help) and the associated appendix, Incorporating Health IT Into Workflow Redesign Summary Report Appendix F: Tool Compendium (PDF File, Plugin Software Help). 

9. Second Edition of Registries for Evaluating Patient Outcomes: A User's Guide Is Available

AHRQ's Effective Health Care Program has released a handbook, Registries for Evaluating Patient Outcomes: A User's Guide 2nd Edition. Originally published in 2007, the handbook has been completely updated with four new sections addressing emerging topics in registry science:

  • When To Stop a Registry; Use of Registries in Product Safety Assessment
  • Linking Registry Data
  • Technical and Legal Considerations
  • Interfacing Registries and Electronic Health Records

Select to access the handbook. Printed copies of the handbook are available by sending an E-mail to ahrqpubs@ahrq.hhs.gov. 

10. New Health IT Fact Sheet on State and Regional Demonstration Projects is Available

A new AHRQ factsheet, "Health Information Technology: State and Regional Demonstration Projects," highlights the work of six states in improving health information exchange at a state or regional level. Select to access the fact sheet. 

11. 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.

Co JP, Johnson SA, Poon EG, et al. Electronic health record decision support and quality of care for children with ADHD. Pediatrics 2010 Aug; 126(2):239-46. Select to access the abstract.

Johnson KB, Ho YX, Cala CM, et al. Showing your work: impact of annotating electronic prescriptions with decision support results. J Biomed Inform 2010 Apr; 43(2):321-5. Select to access the abstract.

Current as of December 2010
Internet Citation: AHRQ Director's Commentary Provides Insight on Patient Safety and Medical Liability Reform: Patient Safety and Health IT Newsletter, Issue #63. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/newsletters/patient-safety/63.html

 

The information on this page is archived and provided for reference purposes only.

 

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