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The Agency for Healthcare Research and Quality (AHRQ), is committed to helping the Nation improve our health care system. To fulfill its mission, AHRQ conducts and supports a wide range of health services research. This report presents key findings from AHRQ's research portfolio during 2006.
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Improving the Safety and Quality of Health Care
Health Information Technology to Improve Patient Safety and Quality
Promoting the Use of Evidence
Eliminating Disparities in Health Care
Ensuring the Value in Health Care
Developing Tools and Data for Research and Policymaking
Preparing for Public Health Emergencies
Looking to the Future
Americans spend nearly $2 trillion on health care each year. U.S. hospitals, physicians, nurses, and other health care providers offer some of the best care in the world, but far too many people still do not receive the quality of care that they expect, deserve, and purchase. The health care system in the United States is working to improve the quality of care. These changes require that health care providers, policymakers, and consumers get accurate,
unbiased information in order to make the best decisions along with tools and practices they can use to improve the Nation's health care system.
The Agency for Healthcare Research and Quality (AHRQ), 1 of 12 agencies within the Department of Health and Human Services (HHS), is committed to helping the nation improve our health care system. AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To fulfill this mission, AHRQ conducts and supports health services research that:
- Reduces the risk of harm from health care services by using evidence-based research and technology to promote the delivery of the best possible care.
- Transforms research into practice to achieve wider access to effective health care services and reduce unnecessary health care costs.
- Improves health care outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment choices/decisions.
The Agency's mission and goals help HHS achieve the objectives set forth in the Secretary's 2006 priority initiatives, especially those of health care transparency, health care technology, value-based health care, Medicaid modernization, personalized health care, prevention, and public health preparedness.
AHRQ customers include clinicians and other health care providers, such as:
- Hospitals and hospital systems.
- Consumers and patients.
- Health care policymakers at the Federal, State, and local levels.
- Purchasers and payers, such as employers and public and private insurers.
- Medical school faculty.
The evidence developed through AHRQ-sponsored research and analysis helps clinicians, consumers, patients, and health care providers make informed choices about what treatments work, for whom, when, and at what cost.
Clinicians who provide direct care and services to patients use AHRQ's evidence-based research to deliver high-quality health care and to work with their patients as partners. AHRQ also provides clinicians with clinical decision-support tools as well as access to guidelines and quality measures.
Policymakers, purchasers, and other health officials use AHRQ research to make better informed decisions on health care services, insurance, costs, access, and quality. Public policymakers use the information produced by AHRQ to expand their capability to monitor and evaluate changes in the health care system and to devise policies designed to improve its performance. Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services. Health plan and delivery system administrators use the findings and tools developed through AHRQ-sponsored research to make choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.
AHRQ research helps consumers and patients get and use objective, evidence-based information on how to choose health plans, doctors, or hospitals. In addition, AHRQ can help patients and their families play an active role in their health care and reduce the likelihood that they will be subject to a medical error. Personal health guides developed by
AHRQ help individuals keep track of their preventive care and other health services they receive. AHRQ's goal is to help people become better informed consumers and to be partners in their own care.
In 2005, AHRQ created Healthcare 411 to help
Americans become informed about the Agency's
latest health care research findings, news, and
information. This audio newscast features
synopses of AHRQ's latest findings and
information on current health care topics. The
newscasts are distributed through Apple®
iTunes®, Yahoo® PodCasts, and other Web sites
that provide health information to their
customers, patients, students, employees, or
health care personnel. They can be heard
through a computer or downloaded to a
portable digital player such as an iPod®.
Examples of newscasts released in 2006 include:
- Medical intern fatigue and errors.
- Making surgery safer.
- Weighing the benefits and risks of a medication or treatment.
- Health care for minority women.
- Obesity surgery.
For more information on Healthcare 411 and to
listen to the newscasts, go to
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Improving the Safety and Quality of Health Care
AHRQ supports research that helps to improve
patient safety and the quality of health care.
Since 2001, AHRQ has supported research that is
focused on reducing medical error and, in turn,
improving patient safety. Research projects
funded by the Agency identify, develop, test,
and implement patient quality and safety
measures. Key to reducing medical errors and
improving quality is the dissemination and
translation of these research findings and
methods into practice, as well as the
development of strategies to implement
promising research and evaluate its impact.
2006, AHRQ-funded patient safety research
projects emphasized teamwork, ways to reduce
medical errors, and creating a culture of patient
safety within the health care workplace. The use
of health information technology (health IT)
can accelerate the progress we have made in
patient safety and quality during the next
decade. AHRQ has also developed tools and
resources that measure the quality of health care
and disseminates this information to help our
stakeholders take action in areas that need
improvement. Descriptions of several current
TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety
AHRQ and the Department of Defense released
TeamSTEPPS™, a new evidence-based team
training and implementation toolkit that
demonstrates techniques of effective
communication and other teamwork skills. The
new toolkit is designed to optimize team
performance and outcomes across the health
care delivery system. TeamSTEPPS™ is presented
in a multimedia format, with tools to help a
health care organization plan, conduct, and
evaluate its own team training program. It
includes an instructor guide, PowerPoint™
presentations, a DVD, spiral-bound pocket
guide, a CD-ROM with printable materials, and a
poster to announce TeamSTEPPS™ activities in a
heath care organization.
More information on TeamSTEPPS™ can be found at
AHRQ Patient Safety Network (PSNet) Provides Resources for Improving Patient Safety and
Preventing Medical Errors
AHRQ's PSNet (http://psnet.ahrq.gov) is a national Web-based resource featuring the latest news and
essential resources on patient safety. The site offers weekly updates on patient safety literature, news,
tools, and meetings and a vast set of carefully annotated links to important research and other
information on patient safety. Supported by a robust patient safety taxonomy and Web architecture,
the AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse
users to customize the site around their interests.
Minnesota Used AHRQ Products to Inform Their Work on the Adverse Health Events Reporting Law
The State of Minnesota used the AHRQ Patient Safety Network (http://psnet.ahrq.gov) and the AHRQ
WebM&M (http://www.webmm.ahrq.gov) to assist in the development and implementation of Minnesota's
Adverse Health Events Reporting Law. Minnesota is the first State in the nation to institute a mandatory
adverse health event reporting system. The law requires hospitals and ambulatory surgical centers to
report 27 types of "never events"—events that are serious, largely preventable, and of concern to both
the public and health care providers—as well as the subsequent findings of root-cause analyses and
the corrective action plan.
The Minnesota Department of Health publishes an annual public report of
the adverse events and the corrective actions at each hospital and ambulatory surgical center in
Minnesota. The 2006 Annual Report detailed 106 adverse events and included AHRQ's Consumer Web
page as a resource to support consumers in making informed decisions about health care safety and quality. Minnesota's 2006 report is available at
Hospital Survey on Patient Safety
Released in 2005, the Hospital Survey on Patient
Safety Culture (Culture Survey) is a tool to help
hospitals and health systems evaluate employee
attitudes about patient safety within their
facilities. The survey can also be used to track
changes in patient safety over time and evaluate
the impact of specific patient safety
Because of increasing interest from hospitals and
other facilities that want to use the AHRQ
Culture Survey, in 2006 the Agency established
the Patient Safety Culture Survey Database as a
central repository for survey data. Facilities will
be able to compare their patient safety culture
survey results with those of other facilities in
support of patient safety culture improvement
efforts. The database will also produce average
scores and percentiles on the survey items and
composites to help users assess their own results
and identify strengths and opportunities for
Other examples of how the Culture Survey is
being used and adapted include:
- Employees of the Cincinnati Children's
Hospital Medical Center completed the
survey. The highest-scoring results were in
the categories called "teamwork within
hospital units" and "hospital management
support for patient safety." The lowest areas
were for "non-punitive response to error" and
"hospital handoffs and transitions."
Department heads selected areas to work on
with their staff for improvement.
- The University of Pittsburgh School of
Medicine adapted AHRQ's Culture Survey to
survey nursing home staff as part of ongoing
research on patient safety in nursing homes.
The effort yielded a 69 percent response rate.
Nursing home staff scored significantly worse
than hospital staff benchmarks on 5 of the
12 patient safety culture dimensions. These
significant differences were reported in
nonpunitive response to error, teamwork
within units, communication openness,
feedback and communication about errors,
and organizational learning.
- Northwestern Memorial Hospital in Chicago
administered AHRQ's Culture Survey and
received a 28 percent response rate among
clinicians—four times the rate of a shorter
paper survey administered in 2002. Staff
voiced concern about handoffs,
communication between workgroups, and
lack of feedback about reported issues. The
survey also highlighted that staff were more
uncomfortable with filing reports of adverse
events than was previously recognized. The
patient safety team focused on strategies to
address these concerns including new
processes and technical support to improve
team training and the institution of new
monthly patient safety morbidity and
mortality conferences. Northwestern plans to
repeat the survey approximately every 18
- The Multnomah County Health Department
in Portland, Oregon, used AHRQ's Culture
Survey in a project that covers the county's
27 patient care delivery sites, which include
primary care health centers, school-based
health centers, and the Department of
Corrections health program, in addition to
clinics serving HIV patients and those with
sexually transmitted diseases and
tuberculosis. The Corrections Health Quality
Improvement Committee has begun working
with its management team to identify,
prioritize, and initiate performance
improvement activities in response to the
Additional information on the Culture Survey
and Database can be accessed at
Recent Research Findings on Patient
Safety and the Quality of Health Care
- An AHRQ-supported study found that wrong-site
surgery is extremely rare, and major
injury related to it is even more rare. A
wrong-site surgery serious enough to result in
a report to insurance risk managers or a
lawsuit could be expected to occur
approximately once every 5 to 10 years at a
single large hospital. Between 1985 and 2004,
the number of wrong-site surgeries conducted
on limbs or organs other than the spine
occurred once in every 112,994 operations.
- A nationwide study found that 83.6 percent
of interns reported work hours that did not
comply with the Accreditation Council for
Graduate Medical Education standards during
at least 1 month in the year (July 2003
through May 2004) following
implementation. About 67 percent of interns
reported working shifts in excess of 30
consecutive hours. Averaged over 4 weeks, 43
percent of interns reported working more
than 80 hours a week, and 43.7 percent
reported not having 1 day in 7 free from
- More than one-fourth (27 percent) of 502
critical care nurses reported making at least 1
error, and more than one-third (38 percent)
reported making at least 1 near-error over the
course of 28-days. The risk for making an
error almost doubled when the nurses
worked 12.5 or more consecutive hours.
Working more than 40 hours per week
increased both errors and near-errors. Almost
two-thirds of the critical care nurses struggled
to stay awake at least once during the study
period, and 20 percent fell asleep at least
once during their work shift. The risk of
falling asleep at work almost doubled when
shifts exceeded 8 hours and more than
doubled when shifts were longer than 12
Close Call Reporting System Reports Medical Errors That Are Corrected Before Reaching the
The Close Call Reporting System (CCRS), a patient safety and quality assurance mechanism developed
by the University of Texas Center of Excellence for Patient Safety Research and Practice, is currently
being used by nine hospitals in Texas and one hospital in New York. Developed through an AHRQ
grant, CCRS is a voluntary and anonymous tool designed to gather information about "close calls,"
which are situations that could have resulted in an accident, injury, or illness, but did not either because
of timely intervention or by chance. The system is based on an error reporting system used in
commercial aviation, the Aviation Safety Action Program.
Through April 2006, 2,750 close calls have
been reported via CCRS, and 5 close call alerts have been sent to participating hospitals, the Food and
Drug Administration, and the United States Pharmacopeia regarding close calls related to labeling and
packaging of medications. Participating hospitals are using the data to inform and guide their own
quality improvement efforts.
AHRQ WebM&M Features Cases of Medical
Errors and Perspectives on Patient Safety
AHRQ WebM&M (Morbidity and Mortality
Rounds on the Web) is a popular online journal
and forum on patient safety and health care
quality. This site features expert analysis of
medical errors reported anonymously by our
readers, interactive learning modules on patient
safety, perspectives on safety, and forums for
online discussion. Continuing medical education (CME) and continuing education units (CEU) credit are
WebM&M can be accessed at
AHRQ-supported Research Influences Revisions to Health Canada's Process for Approving
Names for Drugs
Research conducted by Bruce Lambert, Ph.D., Department of Pharmacy Administration at the University
of Illinois at Chicago, focused on how auditory perception of sound-alike names can lead to medication
errors. Dr. Lambert showed how similarity increases the risk of drug confusion errors and how errors
occur in visual perception, auditory perception, and short-term memory. The information and
discussions significantly contributed to Health Canada's policy recommendations. Under the new
premarketing policy, Canadian drug manufacturers will now be required to submit a name analysis for
new products to demonstrate that the proposed name is not similar to other product names. The new
process is expected to avoid confusion between products, reduce the likelihood of medication mix-ups,
and improve patient safety in the context of day-to-day use of products.
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Health Information Technology to Improve Patient Safety and Quality
AHRQ's $166 million health IT initiative funds
more than 100 projects throughout the nation,
in settings ranging from large health plans and
hospitals to small practices, including rural and
inner city communities. As leaders of these
projects plan and implement various health IT
products, they provide a clinic-level window on
the pitfalls and opportunities that others will
face. AHRQ will synthesize these experiences to
create useful findings and tools. The projects
also will measure actual benefits from AHRQ's
health IT projects, providing evidence for the
business case for health IT adoption.
National Resource Center for Health
As part of the health IT initiative, AHRQ created
the AHRQ National Resource Center for Health
Information Technology (the National Resource
Center) to help the health care community
make the leap into the Information Age. In
addition to providing technical assistance, the
National Resource Center shares new knowledge
and findings that have the potential to
transform everyday clinical practice. AHRQ's
National Resource Center is committed to
advancing our national goal of modernizing
health care through the best and most effective
use of health IT.
Components of the online
National Resource Center include:
- Health Costs and Benefits Database Project, a
searchable database that contains hundreds
of studies and articles on the costs, benefits,
and barriers related to health IT
- Initiatives for Change, which highlights
innovative approaches to improving health
care quality and safety through health IT.
Current features include an overview on
health information exchange, details on the
Connecting for Health Common Framework
(a small set of nationally uniform technical
and policy guidelines for health care
organizations that share a big objective, that
of rapid attainment of widespread
information-sharing in support of modern
health care practice), and a profile of the
Indiana Network for Patient Care (an
executive summary that highlights the
findings from a pending white paper
describing in detail the architecture and
development of a successful regional health
- The Knowledge Library, with links to more
than 6,000 health IT tools, best practices, and
For more information on the National Resource
Center and AHRQ's health IT initiative, go to
Integrating Health IT Improves Communication and Reduces Costs in a Nursing Facility
Christian Home and Rehabilitation Center, a skilled nursing facility in rural Wisconsin, implemented
findings from an AHRQ-funded project. The project, "Real-time Optimal Care Plans for Nursing Home
Quality Improvement," demonstrated the value of integrating standardized documentation and timely
feedback reports in the facility by simplifying and reducing the number of forms used to document care
by at least half and, in some cases, by as much as 70 percent. Resident information related to activities
of daily living—such as bathing, eating, toileting, incontinence episodes, and dressing, as well as
behaviors and weight loss—is located in one place and used to generate reports that are provided to the
caregivers each week. The incontinence reports led to increased savings at the facility. By reviewing the
reports, urinary tract infections were caught before they became medical issues. A reduction in the
incidence of pressure ulcers translated to a savings of approximately $26,000 in the first year of full
Annual Patient Safety and Health
Information Technology Conference
AHRQ sponsored the 2006 Annual Patient Safety
and Health Information Technology Conference
which brought together the Nation's leading
innovators and implementers of on-the-ground
solutions for improving health care safety and
quality. Nearly 700 people attended.
conference focused on how AHRQ-funded
patient safety and health IT projects across the
- Implementing new interventions and technologies that improve care.
- Measuring and managing innovations in everyday clinical practice that reduce medical errors.
- Advancing community health through regional health information exchange.
- Creating a culture of safety across various health care settings.
Recent Research Findings on Health IT
- Computerized alerts can substantially reduce
inappropriate drug prescribing for the elderly
for two drug classes: long-acting
benzodiazepines and tertiary amine tricyclic
antidepressants (TCAs), which can cause
problems such as daytime sedation and falls.
Besides noting the inappropriate prescription,
the alerts also suggest alternatives, such as
shorter-acting and less-sedating
benzodazepines and secondary amine TCAs
or other medications such as buspirone. In
this study, the alerts led to a 22 percent
decline in inappropriate or nonpreferred
prescribing from these two drug classes
compared with the month prior to the drug-specific
alerts. This reduction was sustained
over a 2-year post-alert period and was driven
primarily by decreased dispensing of
- A handheld personal digital assistant (PDA)
that includes a software program to assess
gastrointestinal (GI) risk factors prior to
prescribing nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen (which
increase the risk of GI bleeding) can reduce
unsafe prescribing. Physicians whose PDA
software advised them to assess patient GI
risk factors before prescribing NSAIDs wrote
half as many unsafe prescriptions for NSAIDs
as physicians whose PDA software did not
include the GI risk assessment rule. The GI
rule prompted physicians to assess six
established risk factors for GI complications
from NSAIDs (age, self-assessed health status,
diagnosis of rheumatoid arthritis, steroid use,
a history of GI hemorrhage or hospitalization
for an ulcer, and symptoms with NSAIDs).
The program also provided real-time
treatment recommendations based on a
New Information Will Help Health Care Providers Adopt Health Information Technologies
AHRQ released the report, Costs and Benefits of Health Information Technology (AHRQ Publication No. 06-E006), a synthesis of studies that have examined the quality impact of health information technology
(health IT) as well as the costs and organizational changes needed to implement health IT systems.
Significant improvements in the quality of health care have occurred when utilizing health IT systems,
however, these successes have occurred primarily within large health care systems that created their
own health IT systems and devoted substantial commitment and resources to these efforts. Smaller
medical practices and hospitals that constitute the majority of the nation's health care providers have
limited technological expertise and must depend on the purchase of commercial systems. As a result, a
majority of health care providers in America have not had the information they need to calculate the
impact of health IT implementation on their organizations.
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