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November 4, 2005, Issue No. 14
Quote of the Month
As many as 60 percent of the 150,000 catheter-related, blood-stream infections that occur in the U.S. annually are thought to be preventable.
—Marta Render, M.D., Director of the Cincinnati Department of Veterans Affairs' "Getting At Patient Safety" Center
(Select for more information on the JCAHO award presented to Dr. Render and her colleagues.)
- AHRQ-funded patient safety ICU collaborative earns JCAHO's 2005 Codman award
- AHRQ launches first audio newscast
- AHRQ Director Carolyn M. Clancy speaks to AMIA
- AHRQ's Patient Safety Improvement Corps team receives honor
- Summary materials from AHRQ Quality Indicators users' meeting now available
- Personal health records conference Webcast is available
- AHRQ releases new guide to help consumers understand quality health care
- Attention AHRQ patient safety grantees—new electronic grant application process and forms to be available soon
- Latest issue of AHRQ WebM&M is available online
- Visit the AHRQ Patient Safety Network Web site
- AHRQ in the Patient Safety Professional Literature—Some Useful Citations
1. AHRQ-Funded Patient Safety ICU Collaborative Earns JCAHO's 2005 Codman Award
On November 1, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) named the Greater Cincinnati Patient Safety ICU Collaborative a 2005 recipient of the ninth annual Ernest Amory Codman Award for using evidence-based practices to improve patient safety. Led by Marta Render, M.D., Director of the Cincinnati Department of Veterans Affairs' "Getting At Patient Safety" Center, the AHRQ-funded ICU Collaborative helped reduce nosocomial infections for patients in the operating room and intensive care units. This resulted in a 50 percent decrease in central-line infections and increased adherence to evidence-based practices to 95 percent from 30 percent. Select to read JCAHO's
news release. Select to read details on the award presented to the Collaborative.
2. AHRQ Launches First Audio Newscast
On November 1, AHRQ launched its first audio newscast, a new innovative tool that will provide AHRQ researchers with an opportunity to be heard beyond the research community. The weekly newscasts will be distributed through Apple iTunes®, Yahoo PodCasts, and other Web sites that provide health information to their customers, including patients, students, employees, and health care personnel. The first newscast features an interview with AHRQ patient safety researcher Ann E. Rogers, Ph.D., R.N., Associate Professor, University of Pennsylvania, who talks about her research on the effect of nurse fatigue on the incidence of medical errors. Select to listen to the audio
newscast. You can hear it from your computer's speakers, or from any portable digital player. This page also will include some general information as well as links to all newscasts and other podcasts as they are being produced. Stay tuned for upcoming audio newscasts on patient safety research.
3. AHRQ Director Carolyn M. Clancy Speaks to AMIA
Health information technology, combined with quality-of-care initiatives and evidence-based medicine, form an interlinked triad that can transform health care delivery in America, AHRQ Director Carolyn M. Clancy, M.D., told the American Medical Informatics Association in remarks on October 25. She discussed important steps to take now in order to harness the power of health IT. Select to read Dr. Clancy's speech.
4. AHRQ's Patient Safety Improvement Corps Team Receives Honor
AHRQ's Patient Safety Improvement Corps (PSIC) team from the District of Columbia received the 2005 District of Columbia Hospital Association award for patient safety because of their recent assessment of the culture of safety conducted at the National Rehabilitation Hospital and Greater Southeast Community Hospital. The PSIC team administered AHRQ's Hospital Survey on Patient Safety Culture to employees of nursing units at each hospital and compared the survey results between both hospitals and the AHRQ benchmark. As a result, team members identified prevention of falls as the most common safety concern on all units. The PSIC team members who will be presented with the award are W. Eugene Egerton, M.D., Medical Director of the Delmarva Foundation of the District of Columbia; Sharon Williams Lewis, R.N., Acting Program Manager, Health Regulation Administration, D.C. Department of Health; Paul Rao, Ph.D., Vice President of Clinical Services, Corporate Compliance, and Quality Improvement at National Rehabilitation Hospital; and Vickie Sears, R.N., formerly Director of Medical Staff Services at Greater Southeast Community Hospital. Select to read more information on the PSIC training program.
5. Summary Materials from AHRQ Quality Indicators Users' Meeting Now Available
AHRQ sponsored its first Quality Indicators (QI) users' meeting on September 26-27. This meeting provided an opportunity for users to share best practices in the areas of public and comparative reporting and pay for performance. Other discussion points included using the AHRQ QIs for quality improvement and future directions for QI development. Also, AHRQ's Patient Safety Indicators (PSIs) were highlighted in several presentations that prompted discussions on national trends of selected PSIs, case study presentations, and practical advice about reporting PSI rates to the public. Select to read a meeting
6. Personal Health Records Conference Webcast Is Available
On October 11, the Markle Foundation, the Robert Wood Johnson Foundation, and AHRQ co-sponsored a health IT forum on personal health records, "Connecting Americans to Their Health Care." The forum looked at the current status of personal health records, their potential for improving patient safety and health care quality, and challenges facing the personal health records market. In addition to remarks by AHRQ Director Carolyn M. Clancy, M.D., AHRQ senior staff and several AHRQ grantees participated in a Webcast. Select to view the Webcast.
7. AHRQ Releases New Guide to Help Consumers Understand Quality Health Care
AHRQ released its new consumer publication, Guide to Health Care Quality: How to Know It When You See It, which includes steps that consumers can take to receive safe, high-quality care. The publication explains the difference between clinical measures and consumer ratings. Clinical measures, such as those in AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report, are used to track and improve the quality of care provided by doctors, hospitals, and other providers. In addition, the Agency recently sponsored its first audio podcast, in which Agency Director Carolyn M. Clancy, M.D., discussed the importance of participating in your health care. Select to listen to the podcast.
8. Attention AHRQ Patient Safety Grantees—New Electronic Grant Application Process and Forms to Be Available Soon
AHRQ will replace the PHS 398 grant application form with the Standard Form (SF) 424 Research and Related Grant Application form over the next 2 years. At the same time, AHRQ will require full use of electronic submission through http://www.grants.gov. Transition to the new form and electronic submission will be phased in for different funding mechanisms, according to the October 7 NIH Guide. Applicants for the AHRQ conference grants (R13) will be the first required to use the SF 424, starting with the December 20 submission date. Select to read a detailed description of the electronic submission and receipt processes.
9. Latest Issue of AHRQ WebM&M Is Available Online
The November issue of the AHRQ WebM&M online patient safety journal is now available. This month's Perspectives on Safety section highlights the Institute for Healthcare Improvement's "100,000 Lives Campaign" and the concept of rapid response teams. The cases in this issue include one of a nurse mistakenly administering an oral contrast solution intravenously and another in which an intern incorrectly orders 50 pills for a patient, despite a pharmacist's attempt to clarify the order. In the Spotlight Case, an elderly man admitted to the hospital is given warfarin without verifying his current dose, which leads to internal bleeding and a neurologic complication.
10. Visit the AHRQ Patient Safety Network Web Site
AHRQ's national Web site—the AHRQ Patient Safety Network, or AHRQ PSNet—continues to be a valuable gateway to resources for improving patient safety and preventing medical errors. It is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature. Select to visit the AHRQ PSNet Web site.
11. 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. 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.
Carayon P, Gurses AP. A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. Intensive Crit Care Nurs 2005 Oct;21(5):284-301. Select to read the abstract in PubMed®.
Cook R, Rasmussen J. Going solid: a model of system dynamics and consequences for patient safety. Qual Saf Health Care 2005 Apr;14(2):130-4. Select to read the abstract in PubMed®.
Hanna D, Griswold P, Leape LL, Bates DW. Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf 2005 Feb;31(2):68-80. Select to read the abstract in PubMed®.
Steele AW, Eisert S, Witter J, Lyons P, Jones MA, Gabow P, Ortiz E. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med 2005 Sep;2(9):e255. Select to read the abstract in PubMed®.
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Current as of November 2005