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October 1, 2004, Issue No. 1
Quote of the Month
A Special Message from AHRQ Director Carolyn M. Clancy, M.D.
Welcome to the first issue of AHRQ's new Patient Safety E-Newsletter!
AHRQ will publish this E-Newsletter periodically to make important patient
safety news and information available to you in a timely fashion. I'm very
excited about being able to begin reporting the results of AHRQ's patient safety
portfolio to you here. This new E-Newsletter will feature concise descriptions
of findings, products, and tools from AHRQ's research as well as new Agency
activities, upcoming meetings, and grant award announcements. I am also excited
to announce that we are close to awarding new projects in the area of health
information technology. Please stay tuned in future issues for more details.
As you can see below, there will be Web links to more detailed material when
it's available. I hope you find this E-Newsletter to be an invaluable source
of information and look forward to your feedback.
- AHRQ's Making the Health Care System Safer: Third Annual Patient Safety Conference highlights new tools and findings
- Partnerships in Implementing Patient Safety RFA and technical assistance conference call
- Latest issue of AHRQ Web M&M Patient Safety Journal is available online
- AHRQ releases guide to using its quality and safety indicators
- Retrospective of important AHRQ patient safety findings
- AHRQ in the patient safety professional literature—some useful citations
1. AHRQ's Making the Health Care System Safer: Third Annual Patient
Safety Conference Highlights New Tools and Findings
AHRQ recently held its Making the Health Care System Safer: Third Annual Patient
Safety Conference, to provide our grantees with the opportunity to interact
and showcase their latest patient safety tools and products to more than 600
attendees, including clinicians, health care administrators, and purchasers.
Below is a highlight of a tool that was featured among the 75 displays at the
conference. Stay tuned for more updates on tools and products in upcoming issues.
Video Helps Providers Discuss Unanticipated Outcomes and Medical Errors
AHRQ researcher John Banja, M.D., an associate professor at Emory University's
Center for Ethics in Atlanta, wrote and directed an instructional video on
how best to inform patients and their families in the event of a medical error
that causes harm. The video features clinical scenarios involving medical errors
while experts—including a medical ethicist, a hospital risk manager, and two
health care attorneys—offer suggestions on how to effectively disclose adverse
events to patients and their families. The product, which is available at no
cost, is a result of an AHRQ-funded study by the Georgia Hospital Association
Research and Education Foundation. Select to download the instructions for
the video for additional information.
2. Partnerships in Implementing Patient Safety RFA and Technical
Assistance Conference Call
AHRQ announced a new Request for Applications (RFA) seeking grants for partnerships
in implementing patient safety. The objective of this RFA is to assist health
care institutions in implementing safe practice interventions that show evidence
of eliminating or reducing medical errors, risks, hazards, and harms associated
with the processes of care. The overall goal is for institutions to work in
collaboration with AHRQ to implement safe practice interventions to improve
patient safety. AHRQ intends to commit up to $3 million in total costs to fund
10 to 15 new grants. Letters of intent are due December 19, and the applications
are due January 19, 2005. Select the NIH Guide to read the RFA. AHRQ also encourages
applicants to take advantage of a technical assistance conference call. The
purpose of the conference call is to provide potential applicants with background
information and respond to questions about the preparation of an application
in response to this RFA. The conference call will take place on October 6, 2004,
at a time to be determined, and will last approximately 1-2 hrs.
3. Latest Issue of AHRQ Web M&M Patient Safety Journal Is Available
The latest issue of AHRQ WebM&M online patient safety journal is now
available. The cases include a radiologist who misinterprets his own x-ray;
an emergency department nurse who notices a potential error but is called away
before she can prevent it; a student who notices a computer security violation
and struggles with how to respond; and a patient who has an anaphylactic reaction
during a CT scan. The spotlight case discusses an elderly woman who is found
to have a mass in her neck and whose treating physician recommends palliative
care and withdrawal of mechanical ventilation before biopsy results are in.
As always, the spotlight case includes a downloadable set of slides. By completing
the spotlight quiz, physicians can receive CME credit, nurses can obtain CEUs,
and trainees can receive certification in patient safety. Cases and CME/CE
from previous issues are still available under "Archives" and "Past
Issues" on the site. You can also submit a case for consideration for
future editions of the online journal.
4. AHRQ Releases Guide to Using Its Quality and Safety Indicators
AHRQ announced the availability of a new guide for using the Agency's Inpatient
Quality Indicators or Patient Safety Indicators to report on hospital quality
or make payment decisions. AHRQ's Quality Indicators are measurement tools
that were originally developed by AHRQ and researchers at the University of
California at San Francisco and Stanford University to help individual hospitals
use their own discharge data to better understand and improve the care they
provide. Given the expanding use and interest in the Quality and Safety Indicators,
AHRQ created the guide to help answer questions about if, when, and how to
use them for these new purposes. Select to read our press release and select
to access the Quality Indicators Web site to download the Guidance for Using the AHRQ Quality Indicators
for Hospital-Level Public Reporting or Payment. In addition, AHRQ is sponsoring
a free, interactive Web conference, Using Quality Indicators for Hospital-Level
Public Reporting & Payment, to be held on October 27 from 1:00 p.m. to
2:30 p.m. EDT. It will provide guidance on the benefits and limitations of
using AHRQ's Quality Indicators for public reporting of quality or to inform
purchasing decisions. Select to access the AcademyHealth Web site for more information.
5. Retrospective of Important AHRQ Patient Safety Findings
AHRQ-Funded Study Examines Risk Factors for Retained Instruments and Sponges
A surgical instrument or sponge is left in more than 1,500 patients during
surgery each year, according to an AHRQ-funded study. Researchers, led by Atul
Gawande, M.D., M.P.H., of Brigham and Women's Hospital and Harvard University
in Boston, studied 54 patients who had a total of 61 foreign bodies left inside
them after surgery. Of the 61 foreign bodies, 69 percent were sponges and 31
percent were surgical instruments. The study found that patients who had emergency
surgery were nine times as likely to have a sponge or surgical instrument left
in their body as patients undergoing the same procedure on a nonemergency basis.
The risk increased by four times for patients who had unplanned changes in
their procedure. Patients who had a higher body mass index were found to be
more likely to have a foreign body left after surgery. Researchers concluded
that a number of techniques are available to reduce the incidence of foreign
bodies left in patients after surgery, including counting instruments and sponges
before and after procedures and x-raying patients for instruments that may
have inadvertently been left behind. Select to read the abstract on PubMed® of
the study in the January 16, 2003, issue of the New England Journal of Medicine.
New Findings on Preventing Ventilator-Associated Pneumonia that You Can Use
Ventilator-assisted pneumonia is a common and frequently life-threatening
condition that affects between 10 percent and 25 percent of critically ill
patients. AHRQ researchers Henry Collard, M.D., Sanjay Saint, M.D., M.P.H.,
and Michael Matthay, M.D., have done a review and synthesis of the studies
on how to prevent ventilator-associated pneumonia, including an evaluation
of the benefits and risks of several specific interventions to reduce the incidence
of this condition. Based on their review, the study authors recommend a number
of steps that doctors, nurses, and other providers can take, such as putting
patients in a semi-recumbent position, aspiration of subglottic secretions,
and use of oscillating beds to increase mobility in select patient populations.
Select to access the abstract on PubMed®. The article, "Prevention
of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review," was
published in the March 18, 2003 issue of the Annals of Internal Medicine
and is in the process of being integrated into a curriculum for medical residents
Pittsburgh Blueprint for Health System Redesign—Check Out Previously Published
AHRQ researcher Carl Sirio, M.D., and his colleagues at the University of
Pittsburgh have looked at a design for changing the health system, outlined
progress to date, discussed lessons learned, and identified broader policy
considerations for replicating this model elsewhere. The Pittsburgh Regional
Healthcare Initiative is a model that includes 44 hospitals in 12 counties
in southwestern Pennsylvania, along with major insurers, health care purchasers,
and civic leaders. It is focused on linking patient outcomes data with processes
of care and then sharing that information among all of the initiatives' participants,
including patients and consumers. Select to access the abstract for Dr.
Sirio's article, "Pittsburgh Regional Healthcare Initiative: A Systems
Approach for Achieving Perfect Patient Care," which was published in the
September-October 2003 issue of Health Affairs.
6. AHRQ in the Patient Safety Literature
We are providing the following hyperlinks to journal abstracts through PubMed® for your convenience. Unfortunately, some of you may not be able to access the
abstracts because of firewalls or specific settings on your individual computer
systems. If you are having problems, you should ask your technical support
staff for possible remedies.
Gallagher TH. Medical errors in the outpatient setting: ethics in practice.
J Clin Ethics 2002;13(4):291-300. Select to access the abstract on PubMed®.
Dzik WH, Corwin H, Goodnough LT, Higgins M, Kaplan HS, et al. Patient safety
and blood transfusion: new solutions. Transfus Med Rev 2003 Jul;17(3):169-80.
Select to access the abstract on PubMed®.
Kaplan HS, Fastman BR. Organization of event reporting data for sense making
and system improvement. Qual Saf Health Care 2003;12 Suppl 2:i68-ii72. Select
to access the abstract on PubMed®.
O'Connor PJ, Desai JR, Solber LI, Rush WA, Bishop DB. Variation in diabetes
care by age: opportunities for customization of care. BMC Fam Pract 2003;4(1):16.
Select to access the article on PubMed®.
Pace WD, Staton EW, Higgins GS, et al. Database design to ensure anonymous
study of medical errors: a report from the ASIPS Collaborative. J Am Med Inform
Assoc 2003;Nov-Dec;10(6):531-40. Select to access the abstract on PubMed®.
AHRQ's Patient Safety and Health Information Technology E-Newsletter Contact:
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Current as of October 2004