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March 11, 2005, Issue No. 161

AHRQ News and Numbers

Nearly one-third of the U.S. population under age 65 was uninsured for at least 1 month during the 2-year period 2001-2002. Of the 240 million people under age 65, approximately 10 percent, or nearly 25 million people, were uninsured for the entire 2-year period. [Source: Agency for Healthcare Research and Quality, MEPS Statistical Brief #67: The Long-term Uninsured in America, 2001 to 2002, Estimates for the U.S. Population under Age 65. (PDF File, 153 KB; PDF Help).]

Today's Headlines:

  1. New study on computerized order entry finds flaws that could lead to errors, points to opportunities for improvement
  2. Study finds high rates of adverse drug events in long-term care facilities
  3. New study shows how health plans communicate with non-English-speaking patients
  4. Latest issue of AHRQ WebM&M is available online
  5. New AHRQ CERTs program brief on child health available
  6. Second telephone briefing on hospital patient safety culture survey set for March 24
  7. Quality report/disparities report summit set for April 4
  8. Free AHRQ Webcast on using CAHPS® to improve patient care set for April 6
  9. HCUP seminar set for June 29
  10. New AHRQ publication available
  11. AHRQ in the professional literature

1.  New Study on Computerized Order Entry Finds Flaws that Could Lead to Errors, Points to Opportunities for Improvement

While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors, according to a new AHRQ-funded study. The study, "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," led by Ross Koppel, Ph.D., of the University of Pennsylvania, identified 22 situations in which the CPOE system increased the probability of medication errors. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals' many information systems and interface problems between humans and machines, where the computer's requirements are different than the way clinical work is organized. The study looked at clinicians' experience in using one CPOE system at a major urban teaching hospital. "New health care information technology products usually go through an ongoing process of refinement and improvement as health care workers identify problems," according to AHRQ Director Carolyn M. Clancy, M.D. The study was published in the March 9 issue of JAMA. Select to read our press release.

2.  Study Finds High Rates of Adverse Drug Events in Long-term Care Facilities

There were over 800 adverse drug events, of which more than 40 percent were judged preventable, in two large long-term care facilities during a 9-month period in 2000-2001, according to a new AHRQ-funded study. Of the 225 adverse drug events considered to be serious, life-threatening, or fatal, over 60 percent were preventable. The study, led by Jerry H. Gurwitz, M.D., of the University of Massachusetts Medical School, found that preventable adverse drug events occurred most often during the ordering and monitoring stages of care and that the two drugs most commonly involved in preventable adverse drug events were warfarin and atypical antipsychotic agents (olanzapine, risperidone, quetiapine, and clozapine). The study, "The Incidence of Adverse Drug Events in Two Large Academic Long-term Care Facilities," was published in the March 2005 issue of the American Journal of Medicine. Select to read the abstract in PubMed®.

3.  New Study Shows How Health Plans Communicate with Non-English-Speaking Patients

A new study published in the March/April issue of Health Affairs is about language assistance strategies that work in communicating with non-English-speaking patients and how 14 health plans have responded to the problem. Currently, more than 10 million people in the United States speak English poorly or not at all, impeding their access to care and the quality of health care they receive. The researchers found evidence that use of language assistance in the form of bilingual physicians and interpreter services improves health care and patient satisfaction. In addition, they concluded that health plans can take the following steps to cross the language chasm: develop formal language assistance programs, collect and use data on languages that their members speak, educate physicians about language assistance, integrate language assistance with their quality improvement efforts, and negotiate with purchasers. By developing cost estimates, plans can demonstrate to purchasers that the short-run costs of interpreter services are not exorbitant. Select to read the abstract in PubMed®. A reprint copy of the article, "Crossing the Language Chasm," is available by sending an E-mail to

4.  Latest Issue of AHRQ WebM&M Is Available Online

The latest issue of the AHRQ WebM&M online patient safety journal is now available. The March cases include a patient whose screening test for syphilis is positive, but he is not notified and later develops a classic syphilitic rash; a patient who is transferred from one hospital to another with a CD containing her radiographs, with her older x-rays displayed first, and the receiving hospital overlooks the abnormalities on the newest studies; a patient who, because of a miscommunication, is taken to the operating room after the surgery has been cancelled; and a case involving the administration of low-molecular-weight heparin to a patient undergoing epidural anesthesia-despite a precautionary note on the order sheet about this very combination-who tragically develops an epidural hematoma that leads to lower extremity paralysis. The March Spotlight case highlights the safety challenges that providers and systems face in managing morbidly obese patients. As always, the Spotlight case includes a downloadable set of slides. By completing the Spotlight quiz, physicians can receive CME credit, nurses can obtain CEUs, and trainees can receive certification in patient safety. Cases and CME/CE from previous issues are still available under "Archives" and "Past Issues" on the site. You can also submit a case for consideration for future editions of the online journal. Next month will be the premiere of the new and improved AHRQ WebM&M, which has been redesigned with three case-commentaries and many new features, including Perspectives on Safety, interviews with newsmakers, point-counterpoints, and more.

5.  New AHRQ CERTs Program Brief on Child Health Available

AHRQ released a new program brief on child health research conducted by AHRQ's University of North Carolina at Chapel Hill Centers for Education and Research on Therapeutics (CERTs), which devotes its research solely to studying therapies for children. The program brief summarizes child health research on evaluating drugs in children with HIV, blood glucose monitoring of children with type 1 diabetes, prenatal and early erythromycin exposure and pyloric stenosis, effect of tetracycline on bacterial resistance, and increased antibiotic-resistant pathogens in Hispanic children. Also, information to help patients and providers, including asthma improvement strategies and tools for diagnosing and managing ADHD, are provided. Select to read the program brief. A print copy is available by sending an E-mail to

6.  Second Telephone Briefing on Hospital Patient Safety Culture Survey Set for March 24

Save the date! On March 24, from 1:00 p.m. to 2:00 p.m., EST, AHRQ will host its second technical assistance telephone briefing on the Hospital Survey on Patient Safety Culture. This briefing, "Survey Administration Logistics," will help answer such questions as how to select a sample; deciding whether to use a Web, paper, or scannable survey; when and how to modify the survey; and how to analyze and interpret survey results. Speakers will include those responsible for the development of the survey and users who have administered the survey. Please register for this toll-free call by sending your first name and last name in the body of an E-mail to: In addition, you may submit questions about survey administration issues ahead of time by including them in the body of your E-mail. Having your questions in advance will help us make sure we address as many issues as possible during the call. The call-in number and passcode will be sent to you prior to the call. The Hospital Survey on Patient Safety Culture is currently available online. Printed copies may be obtained by sending an E-mail to

7.  Quality Report/Disparities Report Summit Set for April 4

You're invited to attend AHRQ's first annual health care summit, "Improving Health Care for All Americans." This 1-day meeting will be held on April 4 at the Renaissance Hotel in Washington, DC. This meeting will highlight trends in health care quality improvement and disparities elimination and showcase the efforts of health systems, health plans, health care purchasing organizations, government programs, professional associations, and other organizations to bring about high-quality health care. Confirmed speakers include Mark McClellan, M.D., Administrator, CMS; Governor Mike Huckabee of Arkansas; Don Berwick, M.D., President and CEO, Institute for Healthcare Improvement; John Nelson, M.D., President, American Medical Association; Randall Maxey, M.D., President, National Medical Association; David Schulke, Executive Vice President, American Health Quality Association; and, Risa Lavizzo-Mourey, M.D., President and CEO of the Robert Wood Johnson Foundation, among others.

8.  Free AHRQ Webcast on Using CAHPS® to Improve Patient Care Set for April 6

On April 6, from 1:30 p.m. to 3:00 p.m., EST, AHRQ, together with Westat, will host a live Webcast on "Improving Patient Care: How Medical Practices Are Using New CAHPS® Surveys for Ambulatory Settings." The Webcast is geared toward representatives of medical groups and other organizations interested in improving quality at the level of medical groups and individual clinicians. Speakers will include: Susan Edgman-Levitan, P.A., Massachusetts General Hospital, Boston, MA; Dana Gelb Safran, Sc.D., Tufts-New England Medical Center, Boston, MA; Richard Marshall, M.D., Harvard Vanguard Medical Associates, Boston, MA; Charles J. Hipp, M.D., and Lawrence E. Morrissey, M.D., Stillwater Medical Group, Stillwater, MN. These experts and practitioners will share what they have learned about successfully using surveys to improve patient care and overcoming the obstacles inherent in survey implementation. Select to register for the AHRQ Webcast.

9.  HCUP Seminar Set for June 29

AHRQ will hold a 1-day seminar on its Healthcare Cost and Utilization Project (HCUP) as part of the AcademyHealth Annual Research Meeting to be held in Boston, MA, on June 29. During this seminar, "The Healthcare Cost & Utilization Project: Data and Tools for Health Services & Policy Analyses," participants will learn about HCUP data products, how to obtain the data, how to access the tools and comprehensive, online technical assistance offered through AHRQ, and how to use the data, as well as information about the diversity of analyses that HCUP can support.

10.  New AHRQ Publication Available

Research on Child and Adolescent Health: New Starts FY 2004

11.  AHRQ in the Professional Literature

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, you should ask your technical support staff for possible remedies.

Sheth HS, Verrico MM, Skledar SJ, Towers AL. Promethazine adverse events after implementation of a medication shortage interchange. Ann Pharmacother 2005 Feb;39(2):255-61. Select to access the abstract on PubMed®.

Dusing SC, Skinner AC, Mayer ML. Unmet need for therapy services, assistive devices, and related services: data from the National Survey of Children with Special Health Care Needs. Ambul Pediar 2004 Sep-Oct;4(5):448-54. Select to access the abstract on PubMed®.

Ariza AJ, Binns HJ, Christoffel KK. Evaluating computer capabilities in a primary care practice-based research network. Ann Fam Med 2004 Sep-Oct;2(5):418-20. Select to access the abstract on PubMed®.

Ornstein S, Jenkins RG, Nietert PJ, et al. A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial. Ann Intern Med 2004 Oct 5;141(7):523-32. Select to access the abstract on PubMed®.

Herr K, Titler MG, Schillling ML, et al. Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers. Clin J Pain 2004 Sept-Oct;20(5):331-40. Select to access the abstract on PubMed®.

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Current as of March 2005


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