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Patient Safety E-Newsletter

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January 14, 2008, Issue No. 40

Patient Safety Quote of the Month

"Physicians are more likely to discuss serious errors, minor errors, and near misses with their colleagues than report them to a risk management or patient safety official." (For more information on this AHRQ-sponsored research, go to item No. 1.)

—Jane Garbutt, MBChB, FRCP, Assistant Professor, Department of Medicine, Washington University, St. Louis, MO


Today's Headlines:

1. Physicians want to learn from medical mistakes but say current error-reporting systems are inadequate
2. New study describes the effect of electronic prescribing on physician and staff workflow
3. AHRQ Podcasts spotlights health care quality, hospital design, and safety tips for patients and hospitals
4. AHRQ patient safety grantee receives 2007 Patient Care Award for Excellence in Patient Education Innovation
5. AHRQ director helps consumers navigate the health care system in a new advice column on the Web
6. Latest issue of WebM&M is available online
7. Visit the AHRQ Patient Safety Network Web site
8. AHRQ in the patient safety professional literature—some useful citations



1. Physicians Want To Learn From Medical Mistakes but Say Current Error-Reporting Systems Are Inadequate

The perception that U.S. doctors are unwilling to report medical errors and learn how to prevent them is untrue, according to a new AHRQ-funded study. Because most doctors think that current systems to report and share information about errors are inadequate, they rely instead on informal discussions with their colleagues. Consequently, important information about medical errors and how to prevent them often is not shared with the hospital or the health care organization. As a result, such information is not aggregated for analysis and systematic improvement. To assess physicians' attitudes about communicating errors with their colleagues and health care organizations, the study authors used a 68-question survey, conducted between July 2003 and March 2004, to poll a geographically diverse group of more than 1,000 physicians and surgeons currently practicing in rural and urban areas in Missouri and Washington State. Doctors were asked about their attitudes toward and experience with communicating about errors with both their health care organizations and their colleagues. Most physicians reported that they had been involved in an error—56 percent reported a prior involvement with a serious error, 74 percent with a minor error, and 66 percent with a near miss. Only 30 percent of physicians surveyed agreed that current systems to report patient safety errors were adequate.

The study, "Lost Opportunities: How Physicians Communicate About Medical Errors," was published in the January/February issue of Health Affairs. Select to read our press release and to read an abstract of the study.

2. New Study Describes the Effect of Electronic Prescribing on Physician and Staff Workflow

Implementing e-prescribing within ambulatory care clinics does not greatly disrupt the workflow of prescribers and should not be viewed as a barrier to the adoption of these systems, according to a new AHRQ-funded study. AHRQ researchers used time-motion techniques to compare prescribing times at three ambulatory care sites that used paper-based prescribing, desktop, or laptop e-prescribing. They found that prescribers at e-prescribing sites spent less time writing, but time-savings were offset by increased computer tasks. After adjusting for site, prescriber, and prescription type, e-prescribing tasks took marginally longer than hand-written prescriptions. Overall, researchers found that e-prescribing was not associated with an increase in combined computer and writing time for prescribers.

Results of the study, led by William Hollingworth, Ph.D., Research Assistant Professor, Department of Radiology, University of Washington, Seattle, WA, are published in the November/December 2007 issue of the Journal of the American Medical Informatics Association. Select to read an abstract of the study, "The impact of e-prescribing on prescriber and staff time in ambulatory care clinics: a time motion study."

3. Podcast Spotlights Health Care Quality, Hospital Design, and Safety Tips for Patients and Hospitals

A recent AHRQ Healthcare 411 audio podcast featured AHRQ Director Carolyn M. Clancy, M.D., giving consumers tips on how to spot high-quality health care. Also featured is a new AHRQ DVD that shows how to design hospitals for quality and safety. Select to listen to this audio podcast or select to read the transcript.

In another audio podcast, Dr. Clancy talks to consumers about AHRQ's Five Steps to Safer Health Care and talks to clinicians about 10 Patient Safety Tips for Hospitals. This podcast was distributed to members of AHRQ's partnership organizations, including the American Board of Medical Specialties and the Leapfrog Group. Shorter versions of these stories and others are airing on 125 radio stations nationwide. Select to listen to this podcast and select to read the transcript.

To access any of AHRQ's podcasts and special reports or to sign up for a free subscription to the series and receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.

4. AHRQ Patient Safety Grantee Receives 2007 Patient Care Award for Excellence in Patient Education Innovation

AHRQ grantee Brain Jack, M.D., and his patient safety team at Boston University Medical Center were awarded the 2007 Patient Care Award for Excellence in Patient Education Innovation for his project, "Re-engineered Discharge: A Patient-Centered Transition from Hospital to Primary Care Provider," known as Project RED. The project, funded under AHRQ's Partnerships in Implementing Patient Safety program, helps hospitals institute a more formalized process for discharging patients that can help reduce inappropriate readmissions, produce more satisfied and informed patients, and promote better use of primary care services in the community after a hospital stay. The annual award is presented by the Society of Teachers of Family Medicine to a health professional or not-for-profit organization involved in developing patient education strategies for primary care. The award acknowledges creative, cutting-edge strategies developed to deliver patient education targeted to patients in an office setting. Select for more information on the award and for more information on Dr. Jack's research.

5. AHRQ Director Helps Consumers Navigate the Health Care System in a New Advice Column on the Web

AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in new, brief, easy-to-understand columns. The biweekly columns will help consumers better navigate the health care system. Select to read Dr. Clancy's advice columns.

6. Latest Issue of WebM&M Is Available Online

The December 2007 issue of AHRQ WebM&M is now available online. In the Perspectives on Safety section, Eric Coleman, M.D., Director of the University of Colorado's Care Transitions Program, speaks about improving transitions in care. The Care Transitions Program is an innovative program designed to improve the safety of patient handoffs. In the accompanying perspective piece, Sunil Kripalani, M.D., director of the hospitalist program at Vanderbilt University in Nashville, discusses initiatives aimed at systematically ensuring high quality discharges and transitions. The commentaries in this issue consider patients who leave the hospital before being discharged, safety indicators, and a care-associated burn.

This issue's Spotlight case, features a hospital patient missing from his room and found several hours later outside the emergency department (ED). Despite having arrived at the ED in a hospital gown with a patient ID bracelet, the patient is treated in the ED and discharged. The author, Debra Gerardi, R.N., of Creighton University School of Law in Omaha, N.B., discusses strategies for both preventing and responding to patient elopement. As always, a Spotlight slide presentation is available for download. Physicians and nurses can receive free continuing medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz.

In the second Spotlight case, an elderly woman undergoes surgery to repair a hip fracture. Even though formal preoperative assessment placed her at low risk, the patient suffers a pulseless electrical activity arrest during the operation and dies the next day. Kaveh Shojania, M.D., of the University of Ottawa, Canada, discusses whether unexpected deaths are useful patient safety signals.

In the third Spotlight case, after removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn. The commentary addresses the safe use of thermal therapy; authors are Heather Cleland, M.B.B.S., and Jason Wasiak, B.N., M.P.H., of The Alfred Hospital in Melbourne, Australia. You can easily share AHRQ WebM&M cases by using our "Email a colleague" feature.

7. 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 and 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. To visit the AHRQ PSNet Web site.

8. 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. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies..

Chi CL, Street WN, Ward MM. Building a hospital referral expert system with a Prediction and Optimization-Based Decision Support System algorithm. J Biomed Inform 2007 Oct 22. Select to read an abstract of the study.

Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM Jr. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 2007 Dec;205(6):778-84. Epub 2007 Oct 18. Select to read an abstract of the study.

Hall BL, Hirbe M, Waterman B, Boslaugh S, Dunagan WC. Comparison of mortality risk adjustment using a clinical data algorithm (American College of Surgeons National Surgical Quality Improvement Program) and an administrative data algorithm (Solucient) at the case level within a single institution. J Am Coll Surg 2007 Dec;205(6):767-77. Select to read an abstract of the study.

Menachemi N, Saunders C, Chukmaitov A, Matthews MC, Brooks RG. Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida. J Healthc Manag 2007 Nov-Dec;52(6):398-409; discussion 410. Select to read an abstract of the study.

Ralston JD, Carrell D, Reid R, Anderson M, Moran M, Hereford J. Patient web services integrated with a shared medical record: patient use and satisfaction. J Am Med Inform Assoc 2007 Nov-Dec;14(6):798-806. Select to read an abstract of the study.

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