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Patient Safety and Health Information Technology E-Newsletter

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July 10, 2006, Issue No. 21

Quote of the Month

"According to data from the National Ambulatory Medical Care Survey, 1.4 million prescriptions for ACE inhibitors were written in physicians' offices for women ages 15 to 44 in 1995; the number of prescriptions increased to 2.7 million in 2002. Now researchers find that first trimester use of ACE inhibitors increases the risk of birth defects."

—William O. Cooper, M.D., M.P.H., of Vanderbilt Children's Hospital, in the June 8 issue of the New England Journal of Medicine.

For more information on Dr. Cooper's study, select Item No. 2.

Today's Headlines:

  1. AHRQ Annual Patient Safety/Health IT Conference Draws More Than 700 Researchers and Stakeholders
  2. New Study Finds Increased Risk of Birth Defects Related to First Trimester Use of ACE Inhibitors
  3. Institute of Medicine Releases Reports on the Future of Emergency Care
  4. AHRQ Director Testifies on Accelerating the Adoption of Health IT
  5. FDA and ISMP Work to Stop Use of Ambiguous Medical Abbreviations
  6. Signup Now for Short Course on Human Factors Engineering and Patient Safety—August 14-18
  7. NQF Issues Call for Steering Committee and Technical Panel Nominations
  8. Latest Issue of AHRQ WebM&M Available Online
  9. Updated Fact Sheet Showcases Additional Research from AHRQ's Patient Safety Portfolio
  10. New AHRQ Publication—AHRQ Patient Safety Tools and Resources
  11. AHRQ Patient Safety Researcher Receives this Year's Excellence in Research Award from the Society of Hospital Medicine
  12. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ Annual Patient Safety/Health IT Conference Draws More Than 700 Researchers and Stakeholders

More than 700 AHRQ patient safety and health IT researchers, policymakers, and other stakeholders attended AHRQ's 2006 Patient Safety and Health IT Annual Conference in Washington, DC, June 4-7. Attendees heard from a wide range of experts during plenary sessions on June 5 and 6. National Health Day—AHRQ's collaboration with the Healthcare Information and Management Systems Society—on June 7 featured presentations by AHRQ Director Carolyn M. Clancy, M.D.; Newt Gingrich, Ph.D., former Speaker, U.S. House of Representatives, and founder, Center for Health Transformation; Mark McClellan, M.D., Ph.D., Administrator, CMS; and, David Brailer, M.D., Ph.D., vice chair, American Health Information Community.

Select to access Dr. Clancy's June 5 remarks on patient safety; and select to access her June 7 remarks on health IT. Also, select to access the video of the National Health Day presentations and to access the conference presentations.

2.  New Study Finds Increased Risk of Birth Defects Related to First Trimester Use of ACE Inhibitors

Infants born to mothers who took angiotensin converting enzyme (ACE) inhibitors during the first trimester of pregnancy had an increased risk of major congenital malformations compared with infants whose mothers didn't take these drugs, according to a new study jointly funded by AHRQ and the Food and Drug Administration (FDA). This study is the first to find an adverse impact of ACE inhibitors on a fetus when taken only during the first trimester of pregnancy.

The researchers found that major congenital malformations identified by vital records and hospital claims were diagnosed in 856, or 2.9 percent, of infants and that 203 infants had more than one malformation. Among infants exposed to ACE inhibitors in the first trimester, the proportion born with major congenital malformations was 7.1 percent, compared with 1.7 percent among infants exposed to other antihypertensive medications. The rate of major congenital malformations in the general populations is about 3 percent—or 3 infants out of every 100 pregnancies.

According to data from the National Ambulatory Medical Care Survey, in 1995 there were 1,426,220 prescriptions for ACE inhibitors written in physicians' offices for women ages 15 to 44. That number increased to 2,712,510 in 2002 for women in the same age group. The study, led by William O. Cooper, M.D., M.P.H., of Vanderbilt Children's Hospital, was published in the June 8 issue of the New England Journal of Medicine, and was conducted by researchers at the AHRQ-sponsored Vanderbilt University Center for Education and Research on Therapeutics (CERTs) in Nashville. Select to access our press release and to access an abstract of the study.

3.  Institute of Medicine Releases Reports on the Future of Emergency Care

The Nation's emergency medical system is overburdened, underfunded, and highly fragmented, according to a new series of three reports released June 14 by the Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point explores the changing role of the hospital emergency department and describes the national epidemic of overcrowded emergency departments and trauma centers; Emergency Medical Services at the Crossroads describes the development of EMS systems over the last 40 years and the fragmented system that exists today; and Emergency Care for Children: Growing Pains describes the unique challenges of emergency care for children.

As the reports note, there is more that can be done to improve everyday emergency services and to plan for potential public health emergencies. HHS Secretary Mike Leavitt has made disaster preparedness one of his top priorities, and ensuring the safety and availability of emergency medical services is central to that effort. The study was supported by AHRQ, HRSA, CDC, the Josiah Macy, Jr., Foundation, and the U.S. Department of Transportation's National Highway Traffic Safety Administration. Select to access the press release and to order the reports.

4.  AHRQ Director Testifies on Accelerating the Adoption of Health IT

AHRQ Director Carolyn M. Clancy, M.D., testified on June 21 before the Senate Committee on Commerce, Science, and Transportation's Subcommittee on Technology, Innovation, and Competitiveness on accelerating the adoption of health information technology. Dr. Clancy highlighted the progress that HHS is making in the area of health IT. HHS, under Secretary Mike Leavitt's leadership, is giving the highest priority to fulfilling President Bush's commitment to promote widespread adoption of interoperable electronic health records, she noted. Select to access Dr. Clancy's statement, or to view the Web cast.

5.  FDA and ISMP Work to Stop Use of Ambiguous Medical Abbreviations

FDA and the Institute for Safe Medication Practices (ISMP) have launched a national education campaign to help eliminate one of the most common but preventable sources of medication errors—the use of ambiguous medical abbreviations. FDA and ISMP's educational campaign focuses on eliminating the use of potentially harmful abbreviations by healthcare professionals, medical students, medical writers, the pharmaceutical industry, and FDA staff. The campaign includes:

  1. A brochure to be distributed to medical professionals, the pharmaceutical industry and medical publishing professionals.
  2. A print public service ad that will be sent to professional trade publications.
  3. A poster for health care facilities.
  4. An online toolkit of materials, including PowerPoint slides, for presentations at conferences and meetings.
  5. A patient safety video.

Select to access these campaign materials.

6.  Signup Now for Short Course on Human Factors Engineering and Patient Safety—August 14-18

The Systems Engineering Initiative for Patient Safety (SEIPS) is sponsoring a 5-day course at the University of Wisconsin that will feature discussions on human factors engineering, sociotechnical systems and macroergonomics, health care-related case studies, usability testing, and health care information technology. The course is designed for physicians, nurses, physician assistants, pharmacists, engineers, patient safety officers, and other professionals.

SEIPS, funded by AHRQ, is part of the Center for Quality and Productivity Improvement (CQPI) within the College of Engineering at the University of Wisconsin-Madison. Faculty for the course include SEIPS lead researcher Pascale Carayon, Ph.D., Director CQPI, University of Wisconsin; and, Kerm Henriksen, Ph.D., Human Factors Advisor for Patient Safety, Center for Quality Improvement and Patient Safety, AHRQ.

7.  NQF Issues Call for Steering Committee and Technical Panel Nominations

The National Quality Forum (NQF) recently issued a call for nominations for the project entitled "National Voluntary Consensus Standards for Hospital Care: Additional Priorities, 2006." Sponsored by AHRQ, the project examines selected AHRQ-developed quality indicators for hospital quality and similar measures in the following areas: morbidity and mortality related to failure of care; anesthesia and surgery-related events; utilization rates for risky or often unnecessary events; and selected mortality and volume for selected procedures. All nominations must be submitted by Tuesday, July 18, 2006, at 6:00 pm EDT.

8.  Latest Issue of AHRQ WebM&M Available Online

The July 2006 issue of AHRQ WebM&M is now available. This month, the Perspectives on Safety section focuses on patient safety programs and features an interview with Allan Frankel, M.D., director of patient safety for Partners HealthCare System, on his experiences in cultivating such programs. Also, John Whittington, M.D., patient safety officer at the OSF Healthcare System, offers his perspective on important issues in building successful hospital and health care system safety programs.

In the first Spotlight Case, an elderly woman transported to CT with no medical escort and an inadequate oxygen supply dies later that day. In the commentary, Hildy Schell, R.N., M.S., of the University of California San Francisco (UCSF), and Robert Wachter, M.D., Editor of AHRQ WebM&M and Patient Safety Network, discuss the risks involved in intrahospital transport and how to improve it. In the second case, myocardial infarction is ruled out for a patient admitted to the emergency department with chest pain; he is prescribed an ACE inhibitor and discharged. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies. In the third case, despite full documentation and a wristband regarding her severe food allergy, an inpatient is inadvertently fed eggs and suffers an allergic reaction.

Commentary authors are David Juurlink, M.D., Ph.D., of the University of Toronto and Russ Cucina, M.D., M.S., of the University of California, San Francisco. A Spotlight slide presentation is available for download, as always, and you may receive CME, CEU, or trainee certification by taking the Spotlight Quiz. All previously published commentaries are available under "Case Archive." Please submit cases to AHRQ WebM&M via the "Submit Case" button.

9.  Updated Fact Sheet Showcases Additional Research from AHRQ's Patient Safety Portfolio

New summaries of important findings, tools, and products developed by AHRQ's patient safety researchers have been added to an AHRQ fact sheet entitled "Patient Safety Research Highlights." The descriptions of research showcase the significant advances made by the Agency's patient safety researchers, who work on various aspects of patient safety, ranging from system-wide event reporting methods to specific measures to minimize known medical errors in particular situations.

Summaries that have been added to the revised fact sheet fall into the following categories: technology, event reporting, medication safety, communications and patient support, clinical practice change, organizational change, education and training, and safety in intensive care units. Updated versions of the fact sheet will be issued periodically. The fact sheet includes Web links to tools as well as journal article citations for readers who want to find out more about these important resources. Topic areas covered include health information technology, clinical practice change, safety in intensive care units, and much more. Select to access the updated fact sheet.

10.  New AHRQ Publication—AHRQ Patient Safety Tools and Resources

This new brochure highlights important tools and resources for health care providers and policymakers from AHRQ's portfolio on patient safety. The brochure also features projects on team training and information sharing. Select to download the free bifold brochure (PDF file; PDF Help). Print copies also are available by sending an E-mail to AHRQPubs@ahrq.hhs.gov.

11.  AHRQ Patient Safety Researcher Receives this Year's Excellence in Research Award from the Society of Hospital Medicine

AHRQ researcher Christopher P. Landrigan, M.D., M.P.H., was recently presented with the 2006 national Award for Excellence in Research by the Society of Hospital Medicine (SHM). Dr. Landrigan has established himself as one of the nation's leading investigators in hospital medicine and patient safety and was recognized for his outstanding achievements in hospital medicine research. Dr. Landrigan is a pediatric hospitalist at Children's Hospital Boston; director of the Sleep and Patient Safety Program at Brigham and Women's Hospital; and a respected assistant professor at Harvard Medical School. Select to read SHM's press release (PDF Help).

12.  AHRQ in the Patient Safety Professional Literature—Some Useful Citations

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, ask your technical support staff for possible remedies.

Hansen LB, Fernald D, Araya-Guerra R, et al. Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative. J Am Board Fam Med 2006 Jan-Feb;19(1):24-30. Select to access the abstract in PubMed®.

Hellinger FJ, Encinosa WE. The Impact of State Laws Limiting Malpractice Damage Awards on Health Care Expenditures. Am J Public Health Epub 2006 Jun 29. Select to access the abstract in PubMed®.

Linder JA, Chan JC, Bates DW. Appropriateness of antiviral prescribing for influenza in primary care: a retrospective analysis. J Clin Pharm Ther 2006 Jun;31(3):245-52. Select to access the abstract in PubMed®.

Raab SS, Meier FA, Zarbo RJ, et al. The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer. J Clin Oncol 2006 Jun 20;24(18):2808-14. Select to access the abstract in PubMed®.

Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in thyroid gland fine-needle aspiration. Am J Clin Pathol 2006 Jun;125(6):873-82. Select to access the abstract in PubMed®.

Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care 2006 Jun;15(3):159-64. Select to access the abstract in PubMed®.

Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006 May 11;354(19):2024-33. Select to access the abstract in PubMed®.

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

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Current as of July 2006

 

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