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AHRQ Awards Six Grants in Systems-Related Best Practices to Improve Patient Safety

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Press Release Date: November 9, 2000

The Agency for Healthcare Research and Quality (AHRQ) today announced funding for six new research projects designed to improve patient safety by identifying and preventing avoidable system errors. Funding for these FY 2000 projects totals $2 million and builds on AHRQ's earlier investments in patient safety research. The AHRQ expects to award a larger amount for patient safety research in fiscal year 2001 and is in the process of releasing a series of patient safety related Requests for Applications (RFAs).

"This down-payment on our future investment in patient safety research will have a measurable impact on the quality of health care received by the American people," said AHRQ Director John M. Eisenberg, M.D. "These projects are a critical step in learning how to improve systems so that errors can be avoided, or if they occur, can be caught quickly before harm is done."

The newly funded grants are:

  • Characterizing Medical Error: A Primary Care Study. Principal investigator: Steven H. Woolf, M.D., Virginia Commonwealth University, Richmond, VA. Total projected funding: $350,362. Project period: 9/15/00-8/31/02.

    This study seeks a new perspective on the definition of medical error by gathering the input of primary care patients and their providers. In-depth interviews will be conducted with approximately 45 primary care patients from Virginia and Ohio from various demographic groups. Their perspective will be contrasted with that of 10-20 primary care physicians, who will participate in a telephone interview that explores their experience with errors and seeks their reaction to the patients' comments. The study seeks to find out what constitutes a medical error, and the experiences the victims of error consider most common and most serious.

  • TIPI Systems to Reduce Errors in Emergency Cardiac Care. Principal investigator: Harry P. Selker, M.D., New England Medical Center, Boston, MA. Total projected funding: $1,585,335. Project period: 9/15/00-8/31/03.

    This project addresses the prevention of medical errors in emergency department triage and treatment of acute cardiac ischemia (ACI) by computing the probability that a patient has ACI. It also will gauge the benefits of thrombolytic therapy using a time-insensitive predictive instrument that provides real-time decision support to prevent inappropriate discharges. The tool uses tested and statistically based information. The intervention will be introduced in a stepwise fashion, and a before-after time-series design will be used to measure its impact.

  • Brief Risky High Benefit Procedures: Best Practice Model. Principal investigator: Colin F. MacKenzie, M.D, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD. Total projected funding: $537,843. Project period: 9/30/00-8/31/03.

    This project will study and evaluate the procedure of chest tube thoracostomy insertion at the Maryland Shock Trauma Center using video and audio recordings to demonstrate how medical errors can occur through deviations in processes, and to prompt discussion among the clinical team about improving practice guidelines to encourage appropriate clinical actions. The goals are to create a best practice model for chest tube insertion; examine diagnostic procedures, indications, and techniques under elective versus emergency conditions; and develop a best practice training guideline to reduce complications from chest thoracostomy insertion and improve patient safety.

  • Developing Best Practices for Patient Safety. Principal investigator: Mark B. McClellan, M.D., Ph.D., Stanford University, Stanford, CA. Total projected funding: $1,259,823. Project period: 9/30/00-8/31/03.

    This project builds on previously completed work, and develops a public-private patient safety consortium between leading national organizations and 14 northern California hospitals serving diverse populations. The goals of this consortium will be to conduct a collaborative study to build a national evidence base for measuring and predicting patient safety performance and to develop cost-effective strategies for improving safety practices in hospitals. The study will analyze data from event reporting systems using internal hospital surveys, a new database on medication safety procedures, and a new patient safety culture survey.

  • Improving Safety by Computerizing Outpatient Prescribing. Principal investigator: David W. Bates, M.D., M.Sc., Brigham and Women's Hospital, Boston, MA. Total projected funding: $1,700,187. Project period: 9/30/00-8/31/03.

    This project will study the impact of electronic medical records and computerized medication prescribing on adverse drug events (ADE) in outpatient clinics associated with Partners HealthCare System and the Regenstrief Institute at Indiana University. The study has three primary goals. The first is to develop improved methods for ADE detection by the use of an automated ADE monitor. The second goal is to study the impact of electronic prescribing on preventable ADE rates in the outpatient setting by examining whether a basic electronic prescribing system can influence the prescribing process. Finally, the applicants plan to disseminate the knowledge gained in ADE monitoring and prevention and potential cost savings to encourage other institutions to implement these types of systems.

  • Teamwork and Error in Neonatal Intensive Care. Principal investigator: Eric J. Thomas, M.D., University of Texas Medical School, Houston, TX. Total projected funding: $677,795. Funding period: 9/30/00-8/31/02.

    This project will assess team-related, error-management behavior in the hospital neonatal intensive care unit (NICU). It will adapt the aviation model of teamwork and medical error management to NICU teams by conducting focus groups with NICU personnel and analyzing videotapes for a prospective cohort of preterm infants recorded during two critical periods: initial resuscitation and the first 90 minutes of admission to the NICU. The data derived from focus group sessions and videotape analysis, along with data from previous work, will aid in the design of an intervention to improve these behaviors and address elements of the organizational and professional culture that influences the frequency of error.

For more information on AHRQ's patient safety research programs, select for an October 26 press release announcing the first in a series of Fiscal Year 2001 RFAs on patient safety.

For additional information, please contact AHRQ Public Affairs, (301) 427-1364: Nancy Comfort, (301) 427-1866 (

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