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AHRQ Report Finds Most Staff Not Reporting Medical Errors in Hospitals

Electronic Newsletter, Issue 276

Electronic Newsletter

June 9, 2009

AHRQ News and Numbers

Hospital admissions for asthma and diabetes of Americans from the poorest communities were 87 percent and 77 percent higher, respectively, than admissions for patients from wealthier areas for the same diseases. [Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Statistical Brief #73: Hospital Stays among People Living in the Poorest Communities, 2006.]

Today's Headlines

  1. AHRQ report finds most staff not reporting medical errors in hospitals
  2. AHRQ director selected as 2009 William B. Graham Prize for Health Services Research recipient
  3. AHRQ and DoD release new team training tool for hospital rapid response systems
  4. Living with adult children doesn't help elders preventive health
  5. Call for papers for AHRQ-sponsored Health Services Research theme issue
  6. Register for a Webcast update on the CAHPS® Clinician & Group Survey
  7. Task Force recommendation on screening for syphilis infection in pregnancy
  8. New evidence report on erectile dysfunction drugs is available
  9. New evidence report on maternal and neonatal outcomes of elective induction of labor is available
  10. Reports on the use of systematic reviews in nutritional research are available
  11. New evidence report on accuracy of family history cancer risk assessment is available
  12. Audio newscasts available when you have time to listen
  13. What's new at AHRQ Health Care Innovations Exchange
  14. AHRQ in the professional literature

1.  AHRQ Report Finds Most Staff Not Reporting Medical Errors in Hospitals

On average, over half (52 percent) of hospital staff surveyed did not report any medical errors in their hospital over a 12-month period, according to a report based on data from nearly 200,000 hospital staff from 622 hospitals nationwide. The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report is an update that summarizes the latest results from hospitals that have administered the AHRQ Hospital Survey on Patient Safety Culture. Teamwork within hospital units and supervisor and manager support for patient safety are areas of strength for most hospitals, but non-punitive response to error and handoffs continue to be main areas for improvement in patient safety culture. Trend analyses found that hospitals with improvements over time in non-punitive response to error had slight increases in event reporting. Select to access the report and hospital survey. Print copies of both are available by sending an E-mail to Hospitals using the survey are encouraged to submit data to the database between May 1 and June 30; select for details.

2. AHRQ Director Selected as 2009 William B. Graham Prize for Health Services Research Recipient

AHRQ Director Carolyn M. Clancy, M.D., will be awarded the 2009 William B. Graham Prize for Health Services Research on June 29, at the Association of University Programs in Health Administration (AUPHA) Annual Meeting in Chicago, IL, in recognition of her contributions to the field of health services research and her lifelong achievements. The Prize is funded by The Baxter International Foundation and managed by the AUPHA. Select to read The Baxter International Foundation May 28 press release

3. AHRQ and DoD Release New Team Training Tool for Hospital Rapid Response Systems

AHRQ and the Department of Defense released a new team training tool on Rapid Response Systems designed for use by hospital teams. The new training module complements the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™) published in 2006. Research suggests that after implementing a Rapid Response System, hospitals experience a decrease in the number of cardiac arrests, deaths from cardiac arrest, the number of days in the intensive care unit and the hospital overall post arrest, and inpatient death rates. This new module provides an overview of the Rapid Response System and the role of the Rapid Response Team, which is composed of clinicians who bring critical care expertise to patients requiring immediate treatment while under hospital care. The Rapid Response System module, available in CD format, features simple, ready-to-use, structured communication tools and teamwork strategies. Free copies of the new Rapid Response System module CD are available by sending an E-mail to

4.  Living with Adult Children Doesn't Help Elders Preventive Health

Living with an adult child does not mean that an elderly parent is more likely to avail himself or herself of recommended preventive services, such as influenza immunization or colorectal cancer screening compared to living alone, according to a new study by researchers with Northwestern University and AHRQ. The finding held true even when the elderly person also lived with a spouse. In contrast, living just with the spouse does seem to increase an older person's use of preventive services compared to living alone. For example, older people living with a spouse had 33 percent greater odds of being vaccinated against influenza than when living alone. In contrast, elders who lived only with an adult child and no spouse had 35 percent lower odds of being immunized against the disease, even when the spouse was in the same household. Older people living with an adult child and a spouse were not significantly more likely to get influenza vaccination than they would if they were living alone. Currently, about one in three Americans age 65 and older, and one in two aged 80 and older and not in a nursing home lives alone. The study, "The Relationship Between Living Arrangement and Preventive Care Use Among Community-Dwelling Elderly Persons," was published in the May issue of the American Journal of Public Health. Select to access the abstract in PubMed®.

5. Call for Papers for AHRQ-Sponsored Health Services Research Theme Issue

AHRQ is sponsoring the second theme issue for Health Services Research on "Impacting Health Practice and Policy Through State-of-the-Art Research and Thinking. HSR is seeking abstracts on research results, evaluations, or policy analyses on payment reform. The deadline for submission is June 23. Select to read the announcement

6. Register for a Webcast Update on the CAHPS® Clinician & Group Survey

The CAHPS User Network is presenting a free Webcast for anyone interested in the CAHPS® Clinician & Group Survey on June 23, from 2:00-3:30 p.m. ET. Webcast attendees will learn about:

  • Ongoing enhancements to the design of the Clinician & Group Survey.
  • A major health system's experience with the visit-specific version of the survey.
  • The new Clinician & Group component of the CAHPS® Database.

7. Task Force Recommendation on Screening for Syphilis Infection in Pregnancy

The U.S. Preventive Services Task Force has reaffirmed its 2004 recommendation that clinicians screen all pregnant women for syphilis infection. The Task Force did a targeted literature search for evidence on the benefits of screening, the harms of screening, and the harms of treatment of syphilis with penicillin during pregnancy. The recommendation reaffirmation was published in the May 19 issue of Annals of Internal Medicine and is available on the AHRQ Web site.

8. New Evidence Report on Erectile Dysfunction Drugs Is Available

AHRQ released a new evidence report that found insufficient evidence to determine which drugs work best to treat erectile dysfunction and which cause the least harm. More studies are needed to clarify the best treatment management options for different groups of patients as well as more clinical trials to compare phosphodiesterase type 5 inhibitors (also known as PDE-5 inhibitors) to hormonal, injection, and creams or other topical treatments for erectile dysfunction. The report, Diagnosis and Treatment of Erectile Dysfunction, was conducted by AHRQ's University of Ottawa Evidence-based Practice Center. Select to access the report.

9. New Evidence Report on Maternal and Neonatal Outcomes of Elective Induction of Labor Is Available

AHRQ released a new evidence report that found that inducing labor in women at 41 weeks of pregnancy and beyond may be associated with a decreased in the risk of cesarean delivery. Induction of labor on an elective basis in the United States increased from 9.5 percent of pregnancies in 1990 to 22 percent in 2004. According to the report, there are a number of complications of pregnancy that confer significant ongoing risk to the mother or fetus, such as preeclampsia or intrauterine growth restriction. Pregnant women may also wish to end their pregnancy because of physical discomfort or ongoing concerns that they or their baby may be at risk for complications. For these conditions, induction of labor is often the principal medical intervention used to decrease both maternal and neonatal morbidity and mortality. In addition to the rise in the rate of induction of labor for medical reasons, it seems that there has also been an increase in the rate of induction of labor that is not indicated for a medical reason. Clinicians may be given incentives to use elective induction for their own financial benefit and scheduling preferences, such as ending their patients' physical discomfort or concerns about the risk of developing either complications of pregnancy or intrauterine fetal death. The authors recommend careful examination of the impact of clinical policies to manage labor induction in a wide variety of settings before elective induction of labor is routinely adopted as a potential clinical policy to prevent complications of term pregnancies. The report, Maternal and Neonatal Outcomes of Elective Induction of Labor: A Systematic Review and Cost-Effectiveness Analysis, was produced by AHRQ's Stanford-University of California, San Francisco Evidence-based Practice Center. Select to access the report. A print copy is available by sending an E-mail to

10. Reports on the Use of Systematic Reviews in Nutritional Research Are Available

AHRQ produced three volumes of research on the use of systematic reviews in nutritional research. The reports were produced by the AHRQ's Tufts Evidence-based Practice Center in Boston, MA. The titles of the reports are:

  • Volume 1: Application of Systematic Review Methodology to the Field of Nutrition.
  • Volume 2: Issues and Challenges in Conducting Systematic Reviews to Support Development of Nutrient Reference Values.
  • Volume 3: Reporting of Systematic Reviews of Micronutrients and Health.

Volume 1 focuses on the process of systematic reviews and the unique considerations that should be included for nutritional research, such as nutrient status, chemical forms of nutrients, biological functions with nutrients, and dose response relationships between nutrient intake or dietary patterns and health outcomes. Volume 2 focuses on results from a workgroup study, whose objective was to assess the use of systematic reviews to support the development of nutrient reference values using Vitamin A as an example. The workgroup concluded that the systematic review approach could be productively used to inform the development of reference values. The three reports appeared in the May 2009 issue of the American Journal of Nutrition. Volume 3 focuses on the reporting quality of published systematic reviews and identifying areas of improvements. The results of the study found that the reporting quality of systematic reviews has improved 3 years after publication of reporting standards for systematic reviews, but the reporting of nutrition variables has not. The study was published in the April 2009 issue of the American Journal of Nutrition. Select to access the report. Print copies of these reports are available by sending an E-mail to

11. New Evidence Report on Accuracy of Family History Cancer Risk Assessment Is Available

AHRQ released a new evidence report found no evidence to support the accuracy of the guidelines doctors use to determine a patient's individual risk for breast, ovarian, prostate, or colorectal cancer when he or she has a positive family history. The usefulness of family history risk-assessments depends in part on accurate reporting and capture of family history information, valid methods of risk estimation, and evidence that the use of family history provides incremental net benefit over and above non-family history based alternative approaches. The report, Cancer, Clinical Utility of Family History, was conducted AHRQ' McMaster University Evidence-based Practice Center in Hamilton, Ontario. Select to access the report. A print copy is available by sending an E-mail to

12.  Audio Newscasts Available When You Have Time to Listen

Are you looking for health-related news you can listen to at your convenience at home or on the go? AHRQ's Healthcare 411 is your reliable audio news program, based on the latest research and available when and where you need it! You can listen to 60-second radiocasts with tips for heath care consumers and 10-minute audio podcasts featuring longer, more in-depth interviews with experts who provide evidence-based information on today's critical health care topics. Log on and listen to Healthcare 411; or subscribe and we'll send stories directly to your computer or personal media player.

13.  What's New at AHRQ Health Care Innovations Exchange?

The AHRQ Health Care Innovations Exchange Web site features innovations and quality tools that focus on the implementation of evidence-based clinical practice guidelines. In the Spotlight features site overview, Webinar, expert commentary, and a human interest story. You can access past issues in "What's New." Has your organization adopted an innovation described on the Health Care Innovations Exchange Web site? We would appreciate hearing from you by sending an E-mail to

14.  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.

Hoover DR, Akincigil A, Prince JD, et al. Medicare inpatient treatment for elderly non-dementia psychiatric illnesses 1992-2002; length of stay and expenditures by facility type. Adm Policy Ment Health 2008 Jul; 35(4):452-6. Select to access the abstract in PubMed®.

Owens PL, Zodet MW, Berdahl T, Dougherty D, McCormick MC, Simpson LA. Annual report on health care for children and youth in the United States: focus on injury-related emergency department utilization and expenditures. Ambul Pediatr 2008 Jul-Aug; 8(4):219-40. Select to access the abstract in PubMed®.

Ellenbecker CH, Porell FW, Samia L, et al. Predictors of home healthcare nurse retention. J Nurs Scholarsh 2008; 40(2):151-60. Select to access the abstract in PubMed®.

Newsome BB, McClellan WM, Allison JJ, et al. Racial differences in competing risks of mortality and ESRD after acute myocardial infarction. Am J Kidney Dis 2008 Aug; 52(2):251-61. Select to access the abstract in PubMed®.

Liang H, Tomey K, Chen D, et al. Objective measures of neighborhood environment and self-reported physical activity in spinal cord injured men. Arch Phys Med Rehabil 2008 Aug; 89(8):1468-73. Select to access the abstract in PubMed®.

Horswell RL, Wascom CK, Cerise FP, et al. Diabetes mellitus medication assistance program: relationship of effectiveness to adherence. J Health Care Poor Underserved 2008 Aug; 19(3):677-86. Select to access the abstract in PubMed®.

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Page last reviewed June 2009
Internet Citation: AHRQ Report Finds Most Staff Not Reporting Medical Errors in Hospitals: Electronic Newsletter, Issue 276. June 2009. Agency for Healthcare Research and Quality, Rockville, MD.


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