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Patient Safety and Health Information Technology E-Newsletter

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September 8, 2006, Issue No. 23

Quote of the Month

"Current professional regulations allow doctors-in-training to work 24-30 hours in a row, a limit far beyond established safe limits for pilots and truckers, and far beyond the legally-enforced 13-hour limit for physicians in Europe… Yet even this limit is routinely exceeded. To address the epidemic of medical errors in this country, we must start by establishing evidence-based, safe work hour limits for young physicians, and we must enforce them."

—Christopher P. Landrigan, M.D., M.P.H., Director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, from an article in the September 6 issue of the Journal of the American Medical Association.

For more information on two studies by Dr. Landrigan and his colleagues, select Item No. 1.

Today's Headlines:

  1. New National Study of Medical Interns Finds Majority Exceed Work Hour Limits—A Second Study Finds a Link Between Needle Stick Injuries and Long Shifts
  2. Majority of Physicians Would Disclose Medical Errors to Patients, But Struggle with What to Say
  3. Health Department Uses AHRQ Data to Develop Its Own Patient Safety Culture Project
  4. President Bush issues Executive Order on Health Care Transparency
  5. Latest issue of AHRQ WebM&M Available Online
  6. Special AHRQ-Funded Journal Issue Highlights Lessons From High-Reliability Organizations
  7. AHRQ Audio Newscast Highlights Study on Medication Errors in Hospitalized Children and Complication Rates for Bariatric Surgery
  8. AAP's Upcoming Webinar on Pediatric Patient Safety, September 14
  9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  New National Study of Medical Interns Finds Majority Exceed Work Hour Limits—A Second Study Finds a Link Between Needle Stick Injuries and Long Shifts

A majority of medical interns are continuing to work hours that exceeded the limits of a 2003 national standard implemented by the medical profession, according to one of two AHRQ studies published in the September 6 issue of the Journal of the American Medical Association.

In the first study, "Interns' Compliance with Accreditation Council for Graduate Medication Education Work-Hour Limits," Christopher P. Landrigan, M.D., M.P.H., Director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, Boston, and his colleagues, collected data on interns' work and sleep hours in the year before and after the Accreditation Council for Graduate Medical Education (ACGME) issued standards that limited work-hours for all first-year residents training in U.S. hospitals. They found that nearly 84 percent of interns reported work hours that did not comply with the ACGME standards during at least one month in the year following implementation.

The second study, "Extended Duration Work and the Risk of Self-Reported Percutaneous Injuries in Interns," led by Najib T. Ayas, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and his colleagues, examined the contributing factors for percutaneous (through the skin) injuries in interns and assessed their relationship to extended-duration work. They found that interns working during the day following an overnight shift suffered 61 percent more needlesticks and other sharp injuries than they experienced during a day that was preceded by a night at home.

The studies were co-funded by the National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention (CDC). Select to access AHRQ's press release.

2.  Majority of Physicians Would Disclose Medical Errors to Patients, But Struggle with What to Say

Sixty-five percent of physicians would "definitely" disclose a harmful medical error to patients, and 29 percent would "probably" do so, according to one of two articles supported, in part, by AHRQ and published in the August 14 issue of the Archives of Internal Medicine.

Four percent of doctors would disclose only if the patient asked, and 1 percent would definitely not disclose, according to the article, "Choosing Your Words Carefully: How Physicians Would Disclose Harmful Medical Errors to Patients," which surveyed nearly 3,000 American and Canadian physicians. Researchers found that Canadian physicians and those who had positive attitudes or good prior experiences would be more likely to disclose more information to patients.

The other article, "U.S. and Canadian Physicians' Attitudes and Experiences Regarding Disclosing Errors to Patients," based on the same survey, found that despite different malpractice climates, physicians in both the U.S. and Canada have similar attitudes toward and experiences with error disclosure. Select to access the abstract of the former journal article; and to access the abstract of the latter article.

3.  Health Department Uses AHRQ Data to Develop Its Own Patient Safety Culture Project

The Multnomah County Health Department in Portland, OR, initiated its own patient safety culture project in 2005 using AHRQ's Hospital Survey on Patient Safety Culture. The project includes the County's 27 patient care delivery sites, among which are primary care health centers, school-based health centers, and the corrections health program, in addition to clinics serving patients with HIV, sexually transmitted infections, and tuberculosis. According to Mary Loos, B.S.N., M.P.H., Director of Quality, Support, and Public Health Programs for Multnomah County's Integrated Clinical Services division, "We will use the results to develop process and system improvement plans for each service area and site. Improvement and sustainability are our objectives."

Select to access the Health Department's Clinical Survey on Patient Safety Culture (PDF Help) and for more information on AHRQ's Hospital Survey on Patient Safety Culture and upcoming database.

4.  President Bush issues Executive Order on Health Care Transparency

On August 22, President Bush signed an Executive Order to promote federally led efforts to implement more transparent and high-quality health care. The purpose of this Executive Order is to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers.

The Executive Order will make relevant information available to beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Measures of quality at the provider and health plan level will be developed from private and government sources and will not involve developing or releasing data at the individual patient level. Consumers will be able to access information from a variety of potential sources, including insurance companies, employers, and Medicare-sponsored Web sites. Select to access the Executive Order.

5.  Latest issue of AHRQ WebM&M Available Online

The August 2006 issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section offers reflections on the history of the patient safety movement from two of its pioneers: Lucian Leape, M.D., of Harvard University, and Jeff Cooper, Ph.D., an expert in biomedical engineering, anesthesia, and safety at Harvard.

In the first Spotlight Case, an admitting physician, a night float resident, and the daytime team all fail to provide a genitourinary exam on a patient with paraplegia. The attending physician later examines him and discovers that the patient has a life-threatening necrotizing fasciitis. The commentary discusses the decline in proficiency of and reliance on physical examination skills among health care providers. The authors are George Thompson III, M.D., and Abraham Verghese, M.D., from the University of Texas Health Sciences Center, San Antonio.

In the second case, an ambulatory patient with diabetes presents with high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she injected the insulin with a tuberculin rather than an insulin syringe, resulting in a 10-fold overdose. In the third case, in anticipation of discharge, a patient's opiate medication is changed—from an immediate-release to a long-acting form—but the dose is incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the intensive care unit (ICU).

Commentary authors are Saul Weingart, M.D., Ph.D., of Dana Farber Cancer Institute and Scott Strassels, Pharm.D., Ph.D., of University of Texas at Austin. A Spotlight slide presentation is available for download, as always, and you can receive continuing medical education (CME), continuing education units (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.

6.  Special AHRQ-Funded Journal Issue Highlights Lessons From High-Reliability Organizations

The August special issue of Health Services Research, funded by AHRQ, features 11 articles on lessons from high-reliability organizations (HROs)—those that experience fewer-than-expected medical errors. The special issue includes a foreword by AHRQ Director Carolyn M. Clancy, M.D., and five articles by AHRQ researchers.

"Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability," A Special Issue of Health Services Research, is the result of a February 2004 meeting that AHRQ co-sponsored with the American Hospital Association's Health, Research and Educational Trust, and the Hospital and Healthsystem Association of Pennsylvania. The meeting also resulted in the development and support of an AHRQ HRO Learning Network, which is comprised of 19 health care systems from across the United States.

The articles in the special issue address several important research and policy issues, including principles of reliability, patterns of behavior that constitute an organization's culture, and, the translation of reliability theory to practice. Following are links to abstracts of several key articles from the issue:

  • "Organizational Silence and Hidden Threats to Patient Safety," by Kerm Henriksen and Elizabeth Dayton. Select to access the abstract in PubMed®.
  • "Sensemaking of Patient Safety Risks and Hazards," by James B. Battles, Nancy M. Dixon, Robert J. Borotkanics, Barbara Rabin-Fastmen, and Harold S. Kaplan. Select to access the abstract in PubMed®.
  • "Struggling to Invent High-Reliability Organizations in Health Care Settings: Insights from the Field," by Nancy M. Dixon and Marjorie Shofer. Select to access the abstract in PubMed®.
  • "Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory," by Michal Tamuz and Michael I. Harrison. Select to access the abstract in PubMed®.

7.  AHRQ Audio Newscast Highlights Study on Medication Errors in Hospitalized Children and Complication Rates for Bariatric Surgery

Research on medication errors in hospitalized children is discussed by AHRQ-funded researcher Rodney W. Hicks, M.P.A., M.S.N., of the United States Pharmacopeia Center for the Advancement of Patient Safety, in a recent AHRQ audio newscast. The study found that medication errors that harm hospitalized children are common, and the drugs involved in many of these mistakes tend to be some of the oldest and most commonly used painkillers and antibiotics.

The 7-minute newscast also highlights statistics from a new AHRQ study about complication rates for bariatric surgery to treat obesity. Although many studies show that the health benefits of weight-loss surgery outweigh the risks for severely obese Americans who have tried and failed to lose weight through less radical means, the risk of complications can extend for at least 6 months after leaving the hospital. Select to access the audio newscast.

If your computer has a sound card and speakers and can play MP3 audio files, you will be able to listen to the latest newscast on your computer at your convenience—according to your schedule, whenever you have time to listen. Please visit the main page of our Healthcare 411 series to access any of AHRQ's newscasts and special reports. Sign up for a free subscription to the series to receive notice of all future AHRQ podcasts automatically.

8.  AAP's Upcoming Webinar on Pediatric Patient Safety, September 14

The American Academy of Pediatrics (AAP) has announced a one-hour Web-based seminar (Webinar) on pediatric patient safety entitled "Now What? How to Disclose a Medical Error." At this meeting, learn how to define "disclosure" and give at least one example of who should disclose a medical error and when disclosure should be performed; identify at least one example of "ideal" versus "non-ideal" disclosure; and apply two or more strategies to effectively handle the disclosure of medical errors in ambulatory settings.

The event, sponsored by AAP's Safer Healthcare for Kids program, is one in a series of 18 Webinars designed for pediatricians, family physicians, allied health professionals, medical directors, and others. CME credits will be offered.

9.  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.

Conway P, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics 2006;118:441-7. Select to access the abstract in PubMed®.

Landrigan CP, Conway P, Edwards S, et al. Pediatric hospitalists: a systematic review of the literature. Pediatrics 2006;117:1736-44. Select to access the abstract in PubMed®.

Meurer JR, Yang H, Guse CE, et al. Medical injuries among hospitalized children. Qual Saf Health Care 2006 Jun;15(3):202-7. Select to access the abstract in PubMed®.

Rogers SO Jr, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery 2006 Jul;140(1):25-33. Select to access the abstract in PubMed®.

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Current as of September 2006

 

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