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New Report Recommends Strategies to Reduce Medical Resident Fatigue-Related Errors and Improve Training

Patient Safety and Health IT Newsletter, Issue # 50

AHRQ's Patient Safety and Health Information Technology E-Newsletter summarizes patient safety news and information from the Agency.

Commemorating E-Newsletter's 50th Issue: Messages from AHRQ

"For more than 4 years, AHRQ has documented progress toward improving the safety of health care in "real time' via this e-newsletter. As this 50th issue is released, AHRQ and the Patient Safety Team continue to support research and projects aimed at understanding and enhancing patient safety through increased teamwork, prevention of healthcare-associated infections, use of medical simulation, expansion of a culture of patient safety, and many other important initiatives. We look forward to future issues of the newsletter and to the opportunity to share an increasingly wide array of ongoing efforts and new advances that strive to ensure patients receive the safest care possible."

Jeff Brady, M.D., M.P.H., Commander, U. S. Public Health Service, AHRQ's Patient Safety Portfolio Lead

"The Health IT Team at AHRQ is grateful for the outstanding work of our grantees, contractors and Federal colleagues regularly featured in the Patient Safety and Health IT E-Newsletter. It has provided readers with the latest advancements being brought to light through the health IT and patient safety portfolios. We look forward to keeping you informed of new developments on how AHRQ has funded the use of health IT to improve medication management, deliver patient-centered care, and enhance health care decision making with future issues of the newsletter."

P. Jon White, M.D., AHRQ's Health IT Director

Today's Headlines:

  1. New report recommends strategies to reduce medical resident fatigue-related errors and improve training
  2. Study finds doctors' use of e-prescribing systems linked to formulary data can boost drug cost savings
  3. New Spanish-language consumer guide explains safe and effective use of blood thinners
  4. New report on using telehealth to improve quality and safety from AHRQ-funded implementation projects
  5. Nearly all hospitals have adverse event reporting systems, according to new AHRQ study
  6. AHRQ to hold technical assistance conference call on January 13 for health IT funding opportunity announcements
  7. Crowding and staffing shortages imperil safety in hospital emergency departments
  8. Free Web conference on measuring success using clinical decision support on January 21
  9. TeamSTEPPS™ featured in Pentagon Web radio podcast
  10. AHRQ in the patient safety and health IT professional literature—some useful citations

1. New Report Recommends Strategies to Reduce Medical Resident Fatigue-Related Errors and Improve Training

Fatigued medical residents need protected sleep periods and increased supervision of work hour limits to improve patient safety and the training environment, according to a new Institute of Medicine (IOM) report funded by AHRQ. The report is the result of a 15-month study by an IOM committee that reviewed the relationship between residents' work schedules, their performance and the quality of care they provide. The study summarizes what scientific evidence has shown—that acute and chronically fatigued residents are more likely to make mistakes. As potential solutions, the report recommends several changes to the existing Accreditation Council for Graduate Medical Education's 80-hour-per-week limit on work hours, including protected sleep periods for residents. Other recommendations in the report include ensuring adequate supervision of resident work in general and compliance with work hour limits, guaranteed days off to permit adequate recovery after working long shifts, reasonable on-call periods, stronger moonlighting restrictions, and safe transportation provided by hospitals to residents who are too fatigued to drive home. The IOM committee also calls for increased resident training on better communication during handovers and more involvement of residents in patient safety activities and adverse event reporting. Select to read our press release.

2. Study Finds Doctors' Use of E-Prescribing Systems Linked to Formulary Data Can Boost Drug Cost Savings

Electronic prescribing (e-prescribing) systems that allow doctors to select lower cost or generic medications can save $845,000 per 100,000 patients per year and possibly more system-wide, according to findings from a new AHRQ-funded study. The study, entitled "Effect of Electronic Prescribing With Formulary Decision Support on Medication Use and Cost," was published in the December 8 issue of the Archives of Internal Medicine. The finding may have important financial implications, the study authors concluded. As e-prescribing systems become more widely available and easier to use, their greater use among doctors is likely. Complete use of e-prescribing systems with formulary decision support could reduce prescription drug spending by up to $3.9 million per 100,000 patients per year, according to the study's authors. Select to read our press release and select to read the abstract.

3. New Spanish-Language Consumer Guide Explains Safe and Effective Use of Blood Thinners

AHRQ released a new pamphlet, Su guía para el tratamiento con Coumadin/warfarina (Your Guide to Coumadin®Warfarin Therapy), to help Spanish-speaking patients know what to expect and watch out for while using the blood thinner Coumadin® / warfarin. This 13-page, easy-to-read brochure educates patients about their medication therapy and potentially dangerous side effects, explains how to communicate effectively with their health care providers and provides tips for lifestyle modifications. It also provides information on remembering when to take the medicine, learning how to stay safe while taking the medicine, maintaining a consistent diet and alerting health care providers to concurrent drugs and/or supplements to avoid any potential adverse interactions. An English-language Your Guide to Coumadin®/Warfarin Therapy also is available. Printed copies are available by sending an e-mail to

4. New Report on Using Telehealth to Improve Quality and Safety from AHRQ-Funded Implementation Projects

AHRQ's National Resource Center for Health Information Technology has released a new report on Using Telehealth to Improve Quality and Safety. The report provides an overview of technical and organizational challenges faced by AHRQ health IT grantees when developing, implementing, or evaluating telehealth interventions. The telehealth projects fall into the following four areas: provider-to-provider communication with patients present, provider-to-provider communication without patients present, telemonitoring, and health education. Select to access the report.

5. Nearly All Hospitals Have Adverse Event Reporting Systems, According to New AHRQ Study

More than 94 percent of U.S. hospitals have centralized systems for collecting reports of adverse events, but only 21 percent fully distribute adverse event summary reports. The AHRQ-funded study, "Adverse-Event-Reporting Practices by U.S. Hospitals: Results of a National Survey," is based on a national survey of more than 1,600 hospitals. Participating hospitals described how their adverse event reporting systems work, the status of reporting practices, and how they use reporting to improve care. Adverse events are unintended injuries that occur due to flaws in patient care rather than disease progression. According to the new study, successful reporting systems share common elements, including provisions that protect the privacy of staff who report adverse events, encourage reporting by a range of hospital staff, and distribute timely summary reports that are reviewed by senior-level staff and used to develop event reduction strategies. The survey found only 32 percent of hospitals have established "supportive environments" that allow anonymous reporting. Only 13 percent have broad staff involvement in reporting adverse events (96 percent of adverse events are submitted by nursing staff members). Select to view an abstract of the study published in the December 8 issue of Quality and Safety in Health Care.

6. AHRQ To Hold Technical Assistance Conference Call on January 13 for Health IT Funding Opportunity Announcements

AHRQ will host a technical assistance conference call January 13 from 1:00 p.m. to 3:00 p.m., EST, to provide an overview of AHRQ's new health information technology (health IT) funding opportunity announcements (FOAs) and information relevant to the health IT Special Emphasis Notice (SEN). During the call, AHRQ staff will highlight information found in the FOAs and respond to callers' requests for clarification. Persons considering submitting grant applications in response to these FOAs or SEN are welcome to attend this call. Participants are encouraged to register for the call by Friday, January 9, via email at: Participants may also submit questions in the body of the email. On January 13 use dial-in number 1-866-324-0236 and pass code 2362915 to participate in the call. Due to the anticipated high volume of calls, participants are encouraged to join the call at 12:45 p.m., EST. Those unable to attend are encouraged to view the transcript of the call, which will be posted January 23. AHRQ's health IT initiative is part of the Nation's strategy to put health IT to work in health care. Since 2004, AHRQ has invested more than $260 million in contracts and grants to more than 150 communities, hospitals, providers, and health care systems in 48 states to develop knowledge about and encourage adoption of health IT practices that improve quality. Select for more information on AHRQ's health IT projects and reports.

7. Crowding and Staffing Shortages Imperil Safety in Hospital Emergency Departments

Hospital emergency departments are not as safely designed and managed as they should be, according to the AHRQ-funded study, "The Safety of Emergency Care Systems: Results of a National Survey of Clinicians in 65 U.S. Emergency Departments," published online in the December 2008 issue of the Annals of Emergency Medicine. The study is the first to closely examine safety from the perspective of emergency department doctors and nurses. Select to read the abstract.

8. Crowding and Staffing Shortages Imperil Safety in Hospital Emergency Departments

The AHRQ National Resource Center for Health Information Technology is hosting the last in a series of four, free 90-minute Web conferences that focuses on how clinical decision support (CDS)—a clinical system, application, or process that helps health professionals make good patient care decisions—can be used to inform and improve health care delivery. This Web conference, "Evaluating Measures of Success Using Clinical Decision Support," will be held on January 21 from 2:30 p.m. to 4:00 p.m., EST, and features Charles P. Friedman, Ph.D., Office of the National Coordinator for Health IT, HHS; Jerry Osheroff, M.D., Thomson Reuters; Randall D. Cebul, M.D., Case Western Reserve University School of Medicine and MetroHealth System Center for Health Care Research and Policy; and Peter J. Greco, M.D., Case Western Reserve University School of Medicine. Presenters will discuss the necessity and appropriateness of matching evaluation methods to what key stakeholders in CDS projects want to know; expand on the features that should be evaluated in every CDS implementation, describing specific structure, process and outcome measures; outline obstacles to successful CDS evaluation and the means to overcome those obstacles; discuss evaluation methods of a large, randomized CDS clinical trial funded by AHRQ and the trial's findings regarding improvements in process measures and challenges that remain in effecting clinical outcomes; and share work examining alert fatigue and techniques to mitigate its occurrence. Select to register for the January 21 Web conference.

9. TeamSTEPPS™ Featured in Pentagon Web Radio Podcast

A recent Pentagon podcast features Army Col. Peter Napolitano, a physician champion for patient safety at Madigan Army Medical Center in Tacoma, WA, describing the importance of the "huddle," a TeamSTEPPS™ strategy to improve patient care, to medical corps personnel who were preparing to deploy last month. TeamSTEPPS™, an evidence-based training curriculum to improve communication and teamwork skills among health care professionals, was developed by AHRQ and the Department of Defense. Col. Napolitano's 30-minute podcast is part of a series that follows military doctors from training to deployment. Select to access the podcast. Look for Episode #35: MHS Patient Safety Program TeamSTEPPS™. Select to learn more about TeamSTEPPS™.

10. AHRQ in the Patient Safety and Health IT 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.

Eden KB, Messina R, Li H, Osterweil P, Henderson CR, Guise JM. Examining the value of electronic health records on labor and delivery. Am J Obstet Gynecol. 2008 Sep;199(3):307.e1-9. Select to access the abstract.

Hartzema AG, Winterstein AG, Johns TE, et al. Planning for pharmacy health information technology in critical access hospitals. Am J Health Syst Pharm 2007 Feb 1; 64(3):315-321. Select to access the abstract.

Porter SC, Kaushal R, Forbes PW, Goldmann D, Kalish LA. Impact of a patient-centered technology on medication errors during pediatric emergency care. Ambul Pediatr. 2008 Sep-Oct;8(5):329-35. Epub 2008 Jul 21. Select to access the abstract.

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Current as of January 2009
Internet Citation: New Report Recommends Strategies to Reduce Medical Resident Fatigue-Related Errors and Improve Training: Patient Safety and Health IT Newsletter, Issue # 50. January 2009. Agency for Healthcare Research and Quality, Rockville, MD.


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