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Clancy, C.M. (2005, September). "Training health care professionals for patient safety." American Journal of Medical Quality 20(5), pp. 277-279.
In this commentary, the Director of the Agency for Healthcare Research and Quality (AHRQ) discusses AHRQ's commitment to patient safety training and some of the results of the Agency's latest patient safety training projects. One project, the ICU Safety Reporting System, is a voluntary, anonymous, Web-based system that collects data about adverse events and "near misses" from all staff in ICUs around the country and provides feedback to participating ICUs so they can change procedures to improve safety. A component of AHRQ's larger Patient Safety Network Web site, the WebM&M (http://webmm.ahrq.gov) takes a similar approach.
AHRQ's Patient Safety Improvement Corps Program, conducted in collaboration with the Department of Veterans Affairs, is a nationwide "train the trainer" program by State officials and selected hospital staff members who have been trained in "root cause analysis" of medical errors. AHRQ also makes federal patient safety research findings, programs, and products available via a series of reports available at http://www.ahrq.gov/qual/advances, and the Patient Safety Network Web site.
Reprints (AHRQ Publication No. 06-R006) are available from the AHRQ Publications Clearinghouse.
Doshi, J.A., Shaffer, T., and Briesacher, B.A. (March 2005). "National estimates of medication use in nursing homes: Findings from the 1997 Medicare Current Beneficiary Survey and the 1996 Medical Expenditure Survey." Journal of the American Geriatric Society 53, pp. 438-443.
Researchers used nursing home medication files from two nationally representative data sets, the 1997 Medicare Current Beneficiary Survey (MCBS) and the 1996 Medical Expenditure Panel Survey-Nursing Home Component (MEPS-NHC) to examine characteristics of facilities and residents. About 8 percent of residents in the MCBS and 5 percent in the MEPS-NHC had simple medication regimens consisting of one to two drug therapies in the course of a month. Most residents took between three and eight different medicines every month (58 percent in MCBS and 61 percent in MEPS-NHC). About 32 percent of residents in both surveys had monthly drug regimens consisting of nine or more medicines, with an average of seven to eight prescriptions per month. The most commonly used medications were pain relievers and fever reducers (76-82 percent), followed by gastrointestinal agents (75-76 percent), electrolytic and caloric preparations (70-71 percent), central nervous system agents (65-66 percent), anti-infective agents (62-68 percent), and cardiovascular agents (55-59 percent).
Reprints (AHRQ Publication No. 05-R057) are available from the AHRQ Publications Clearinghouse.
Elliott, M.N., Farley, D., Hambarsoomians, K., and Hays, R.D. (2005, October). "Do Medicaid and commercial CAHPS scores correlate within plans?" (AHRQ grant HS00924). Medical Care 43(10), pp. 1027-1033.
The 3,939 Medicaid enrollees of 6 New Jersey managed care plans reported poorer care than 3,027 commercial enrollees in the same plans on 6 measures evaluated by the Consumer Assessment of Health Plans Study survey, but on none of the 4 global measures. After controlling for these main effects, variability in care evaluations between commercial and Medicaid enrollees within plans exceeded variability between plans for 4 out of the 10 measures. The researchers conclude that within-plan variability in care evaluations by these two groups is too great to permit meaningful inference about plan performance for one group from the other for many important outcomes. They recommend that separate surveys should still be fielded.
Miller, M.R., Gergen, P., Honour, M., and Zhan, C. (2005, September). "Burden of illness for children and where we stand in measuring the quality of this health care." Ambulatory Pediatrics 5(5), pp. 268-278.
Measures of health care quality for children are not as well developed as those for adults. This study identified high-prevalence conditions for children using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project State Inpatient Databases and Ambulatory Surgery Databases. The goal was to create lists of high-priority conditions for children, which the researchers then cross-tabulated with existing quality measures for pediatric health care.
They found numerous and large gaps in existing quality-of-care
measures for children relative to high-burden conditions in both the inpatient and outpatient setting. Efforts are needed to build a representative repertoire of quality measures for the high-burden conditions children experience, conclude the researchers.
Reprints (AHRQ Publication No. 06-R0004) are available from the AHRQ Publications Clearinghouse.
Miller, M.M., Pronovost, P., Donithan, M., and others (2005, September). "Relationship between performance measurement and accreditation: Implications for quality of care and patient safety." American Journal of Medical Quality 20(5), pp. 239-252.
This study concludes that all health care performance measurement tools need to be continuously reevaluated to ensure that they are providing the public with reliable, consistent information about health care quality and safety. The investigators examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores from 1997 to 1999 with the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs) from 24 States involved in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation. No significant relationship existed between JCAHO categorical accreditation decisions and IQI/PSI performance.
Reprints (AHRQ Publication No. 06-R005) are available from the AHRQ Publications Clearinghouse.
Pronovost, P., Weast, B., Rosenstein, B., and others (2005, March). "Implementing and validating a comprehensive unit-based safety program." (AHRQ grant HS11902). Journal of Patient Safety 1(1), pp. 33-40.
Researchers implemented a comprehensive unit-based safety program (CUSP) in the Weinberg oncology surgical intensive care unit (WICU) at Johns Hopkins Hospital, while a surgical ICU (SICU) served as a control. Six months later, they implemented the program at the SICU. Thus, they had two 6-month periods (pre and post) in the WICU and three 6-month periods in the SICU (pre, control, and post).
CUSPs work to engage and empower ICU staff to identify and eliminate patient safety hazards. The eight CUSP steps are: culture and safety assessment; science of safety education; staff identification of safety concerns; senior executives adopt a unit; improvements implemented from safety concerns; efforts documented/analyzed; results shared; and culture reassessment.
Prior to CUSP, 94 percent of WICU orders and 40 percent of SICU charts contained medication errors at patient transfer out of the ICU to another hospital unit, errors that were eliminated after CUSP implementation. Nursing turnover rates decreased from 9 percent (pre-CUSP) to 2 percent (post-CUSP) in the WICU and from 8 percent (pre-CUSP) and 9 percent (control) to 2 percent (post-CUSP) in the SICU. Mean WICU and SICU stays shortened from 2 days to 1 day and 3 days to 2.3 days, respectively.
Stukenborg, G.J., Kilbridge, K.L., Wagner, D.P., and others. "Present-at-admission diagnoses improve mortality risk adjustment and allow more accurate assessment of the relationship between volume and lung cancer operations and mortality risk." (AHRQ grants HS10134 and HS11419). Surgery 138, pp. 498-507.
Patient diagnoses made at the time of hospital admission can be used to improve mortality risk adjustment for lung cancer patients undergoing surgery. These present-at-admission diagnoses also may allow a more accurate assessment of the relationship between volume of lung cancer operations and mortality risk, concludes this study. The investigators used adjustments for conditions identified as present-at-admission to examine the relationship between the volume of lung cancer operations and mortality among 14,456 California hospital patients. Mortality risk adjustment using present-at-admission diagnoses yielded better discrimination and explained more of the variability in observed deaths than other methods of risk adjustment used in previous studies. Also large increases in hospital procedure volume were associated with much smaller decreases in mortality risk than those estimated using comparable risk-adjustment models.
Weissman, J.S., Annas, C.L., Epstein, A.M., and others (July 13, 2005.) "Error reporting and disclosure systems: Views from hospital leaders." (AHRQ grant HS11928). Journal of the American Medical Association 293(11), pp. 1359-1366.
In 2002 and 2003, researchers surveyed chief executive and chief operating officers (CEOs/COOs) from 203 randomly selected hospitals in 2 States with mandatory reporting and public disclosure, 2 States with mandatory reporting without public disclosure, and 2 States without mandatory systems. The survey asked the hospital executives about their perceptions of the effects that mandatory systems would have on error reporting, the likelihood of lawsuits, and patient safety.
Overall, 69 percent of CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital's own internal reporting system, and 79 percent thought it would encourage lawsuits. Less than one-third (28 percent) thought that it would have a positive effect on patient safety while 73 percent felt it would have no effect or a negative effect. More than 80 percent felt that the names of both the hospital and the involved professionals should be kept confidential. Hospital executives from States with mandatory public disclosure systems were more likely than those in other States to approve releasing the hospital name (22 vs. 4 percent). Based on vignettes of hypothetical errors, 89 to 98 percent of hospital leaders said their hospital would always or usually report incidents involving serious injury, but far fewer would report less severe injuries.
Wu, A.W., Holzmueller, C.G., Lubomski, L.H., and others (2005, March). "Development of the ICU safety reporting system." (AHRQ grant HS11902). Journal of Patient Safety 1(1), pp. 23-32.
The Intensive Care Unit Safety Reporting System (ICUSRS) is a voluntary, confidential, Web-based reporting system, with the goal of improving ICU patient safety. This article describes development of the system using 18 ICUs (2 pediatric and 16 adult units). Using a simple computer word processing program, patients or providers can anonymously report any adverse event, health care situation leading to patient harm, or near miss (an incident with potential for harm, but harm did not occur).
Individuals completing the form answer questions about factors that might have contributed to, minimized, or prevented similar incidents. They also report outcomes such as death, patient physical injury, discomfort, dissatisfaction, and economic consequences. After submission, reports are stripped of identifiers and analyzed by ICU safety experts. Monthly feedback reports are ICU site-specific and compare the ICU with data from all other participating ICUs. Occasional alerts are sent to all ICUs if an urgent situation is identified. The focus is not on naming and blaming (the system is anonymous and non-punitive), but on needed changes in care processes or systems.
Zarbo, R.J., Meier, F.A., and Raab, S.S. (2005, October). "Error detection in anatomic pathology." (AHRQ grant HS13321). Archives of Pathology and Laboratory Medicine 129, pp. 1237-1245.
Because of its complex nature, anatomic pathology is prone to error at many steps throughout the testing process. The authors reviewed the literature to examine the magnitude of error occurring in anatomic pathology. They conclude that there are currently no standardized tools for defining error in anatomic pathology; therefore, it cannot be reliably measured, nor can its clinical impact be assessed. The authors propose a standardized error classification that would permit measurement of error frequencies, clinical impact of errors, and the effect of error reduction and prevention errors. They note that the value of double-reading, case conferences, and consultations (the traditional triad of error control in anatomic pathology) awaits objective assessment.
AHRQ Publication No. 06-0022
Current as of January 2006