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AHRQ Tools Support Teamwork and Patient Safety Awareness Week

Patient Safety and Health IT Newsletter, Issue #58

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

Quote of the Month

"During Patient Safety Awareness Week, we're all reminded that building strong communication channels between patients, families, and health care providers can help lead to higher quality care. We encourage patients and their families to participate in their health care and we remind health care leaders to create and sustain a culture of patient safety."

—William B. Munier, M.D., Director of AHRQ's Center for Quality Improvement and Patient Safety

Today's Headlines:

AHRQ Patient Safety News:

  1. AHRQ tools support teamwork and patient safety awareness week
  2. Michigan intensive care units maintain low rates of catheter-related bloodstream infections over three years
  3. New AHRQ study finds over a third of patients experienced a medication error upon hospital admission
  4. AHRQ announces interest in research of prevention and management of health care-associated infections—Applications due March 29
  5. Register now for free technical assistance call on AHRQ Nursing Home Survey on Patient Safety Culture on March 31
  6. Meet the AHRQ Pharmacy Health Center
  7. Latest issue of Web M&M is available online
  8. AHRQ in the patient safety professional literature—some useful citations

AHRQ Health IT News:

  1. National Coordinator for Health IT issues statement on certification programs
  2. CMS and ONC issue regulations proposing a definition of 'meaningful use' and setting standards for electronic health record incentive program
  3. AHRQ and the Office of the National Coordinator's Health IT Research Center
  4. Materials now available from February 24 Web conference on transitions in care
  5. AHRQ releases Web page on consumer health IT applications
  6. AHRQ podcasts on clinical decision support
  7. AHRQ in the health IT professional literature—some useful citations


AHRQ Patient Safety News: 

1. AHRQ Tools Support Teamwork and Patient Safety Awareness Week

This is Patient Safety Awareness Week, and this year's theme is "Let's Talk: Healthy Conversations for Safer Healthcare." Patient Safety Awareness Week is a national education and awareness-building campaign for improving patient safety at the local level. AHRQ has a wide array of patient safety tools and materials designed for health systems, providers and consumers. For example, TeamSTEPPS® is an evidence-based teamwork system to improve communication and teamwork skills among health care professionals. Select to access the TeamSTEPPS® and information about team training program eligibility. Select for other AHRQ patient safety tools and resources. 

2. Michigan Intensive Care Units Maintain Low Rates of Catheter-Related Bloodstream Infections Over Three Years

Over 100 participating intensive care units in Michigan have been able to keep the rates of central line-associated bloodstream infections to near zero—even three years after first adopting standardized procedures. The project, known as the Michigan Health and Hospital Association Keystone ICU project, involved the use of a comprehensive unit-based safety program to reduce these common, costly and potentially lethal infections. This project used a model to translate evidence into practice with the comprehensive patient safety intervention to improve culture, educate staff, learn from mistakes, and involve senior leaders. Last year, AHRQ announced new funding that has expanded the project to all 50 States, Puerto Rico and the District of Columbia. In addition, more hospitals will be involved in each State, other settings in addition to ICUs will be able to participate, and other types of infections will be addressed. The study, "Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study," was published in the February 4 issue of the British Medical Journal. Select to access the abstract.


3. New AHRQ Study Finds Over a Third of Patients Experienced a Medication Error Upon Hospital Admission

AHRQ-funded researchers found that nearly 35 percent of hospital patients experienced a medication error at the time of admission. Of those errors, 85 percent originated in the patients' medication histories. Researchers, led by Kristine Gleason, R.Ph., Clinical Quality Leader at Northwestern Memorial Hospital, Chicago, recommend that attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists. Findings from the study, "Results of the Medications at Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission," appear in the Feb 24 issue of the Journal of General Internal Medicine. Select to access an abstract of the article or to learn more about the MATCH project. 

4. AHRQ Announces Interest in Research of Prevention and Management of Health Care-Associated Infections—Applications due March 29

AHRQ has issued a funding opportunity announcement (FOA) for extramural health services research, demonstration, dissemination, and evaluation grants aimed at preventing and more effectively managing health care associated infections (HAIs). The FOA sets a multi-year research framework, based on the distillation of existing, peer-reviewed research, case studies, HHS' 2009 National Action Plan on Healthcare-associated Infections, and qualitative information resulting from a series of listening sessions that occurred in selected cities across the United States in 2009. Select to access the announcement. Deadline to submit an application to be considered for funding during fiscal year 2010 is March 29. Additional receipt dates for funding consideration in future years are indicated within the FOA. AHRQ also has issued two Special Emphasis Notices in the area of health-care associated infections in ambulatory settings (see NOT-HS-10-007 and NOT-HS-10-009). These notices reinforce HAIs as a research priority for AHRQ and call for submission of large research (R01) as well as career development (K01, K02, K08) applications in this area. 

5. Register Now for Free Technical Assistance Call on AHRQ Nursing Home Survey on Patient Safety Culture on March 31

Registration is now open for a free 60-minute national technical assistance conference call on the AHRQ Nursing Home Survey on Patient Safety Culture, which will take place on March 31 from 3:00 to 4:00 pm ET. Participants will hear from the developers of the survey as well as professionals who administered the survey from both a regional perspective and an individual nursing home. Learn about their successes and challenges in survey administration and how they maximized their survey response. Also, learn how nursing homes used their survey results to develop action plans to target their safety culture improvement initiatives. Select to register. 

6. Meet the AHRQ Pharmacy Health Literacy Center

AHRQ is pleased to announce its Pharmacy Health Literacy Center to help retail pharmacists meet the needs of customers with low or limited health literacy. Research shows that many people misread or misunderstand instructions on how to take medications as prescribed. But effective communication can reduce medication errors and the adverse outcomes they may cause. The AHRQ Pharmacy Health Literacy Center features four tools for retail pharmacies: Is Our Pharmacy Meeting Patients' Needs: a Pharmacy Health Literacy Assessment Tool User's Guide; Strategies to Improve Communication between Staff and Patients: Training Program for Pharmacy Staff;How to Create a Pill Card; and Telephone Reminders: A Tool to Help Refill Medications on Time. The Web site also features additional assistance for pharmacies interested in using the assessment tool; a list of resources to learn more about health literacy; and a discussion board for visitors to post comments and questions to learn from other pharmacists. 

7. Latest Issue of Web M&M is Available Online

The February issue of AHRQ Web M&M is now available online. The Perspectives on Safety section addresses the topic of medical education and patient safety and features Thomas Nasca, M.D., the executive director and CEO of the Accreditation Council for Graduate Medical Education, which accredits all U.S. residency and fellowship training programs. In an accompanying perspective piece, Arpana Vidyarthi, M.D., and Robert Baron, M.D., both educational leaders at University of California, San Francisco, discuss the role of graduate medical education in improving patient safety. The Spotlight Case features a commentary by Gail B. Slap, M.D., Professor of Pediatrics and Medicine, University of Pennsylvania School of Medicine, and Chief, Division of Adolescent Medicine, the Children's Hospital of Philadelphia, discussing issues pertinent to diabetes, obesity, sexual history, and pregnancy in adolescents. The second case features a commentary by Robert Weber, Pharm.D., of University of Pittsburgh School of Pharmacy, Pittsburgh, discussing how to enhance the safe usage of patients' home medications when they are in the hospital. The third case, features a commentary by Manish Sethi, M.D., of Harvard Medical School, Boston, discussing how defensive medicine can endanger patient safety. Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ Web M&M cases by using the "e-mail a colleague" feature. 

8. AHRQ in the Patient Safety 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.

Farley DO, Haviland A, Champagne S, Jain AK, Battles JB, Munier WB, et al. Adverse-event-reporting practices by U.S. hospitals: results of a national survey. Qual Saf Health Care 2008 Dec; 17(6):416-23. Select to access the abstract.

Chrischilles EA, Pendergast JF, Kahn KL, Wallace RB,et al. Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer. J Clin Oncol 2010 Feb 1; 28(4):620-7. Select to access the abstract.

Hyzy RC, Flanders SA, Pronovost PJ, et al. Characteristics of intensive care units in Michigan: not an open and closed case. J Hosp Med 2010 Jan; 5(1):4-9. Select to access the abstract.


AHRQ Health IT News: 

9. National Coordinator for Health IT Issues Statement on Certification Programs

The National Coordinator for Health Information Technology, David Blumenthal, M.D., M.P.P., issued a message on March 2 on the notice of proposed rulemaking that outlines the proposed approach for establishing a certification program to test and certify electronic health records (EHRs). Dr. Blumenthal states that while we are making significant strides toward modernizing our health care system, these efforts will only succeed if providers and patients are confident that their health information systems are safe and functional. The proposed rule incorporates two phases of development for the certification program to ensure that eligible professionals and eligible hospitals are able to adopt and implement Certified EHR Technology in time to qualify for meaningful use incentive payments. The programs will help support end users of certified products and ultimately serve the interests of each patient by ensuring that their information is securely managed and available where and when it is needed. Participation in the open public comment period is encouraged. Select to access Dr. Blumenthal's entire message on the Office of the National Coordinator for Health Information's Web site.


10. CMS and ONC Issue Regulations Proposing a Definition of 'Meaningful Use' and Setting Standards for Electronic Health Record Incentive Program

CMS and the Office of the National Coordinator for Health Information Technology (ONC) encourage public comment on two regulations recently issued that lay a foundation for improving quality, efficiency and safety through meaningful use of certified electronic health record (EHR) technology. The regulations will help implement the EHR incentive programs enacted under the American Recovery and Reinvestment Act of 2009. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of "meaningful use" of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Both regulations are open to public comment. Select to view the CMS proposed rule and fact sheets and ONC's interim final rule. In early 2010 ONC intends to issue a notice of proposed rulemaking related to the certification of health information technology. Select to access the HHS press release announcing these regulations. 

11. AHRQ and the Office of the National Coordinator's Health IT Research Center

AHRQ, in collaboration with the Office of the National Coordinator (ONC) for Health Information Technology, is working to develop the Health Information Technology Research Center (HITRC), part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITRC will provide a forum for the exchange of knowledge and experience; accelerate the transfer of lessons learned from existing public and private sector initiatives, including those currently receiving Federal financial support; and assemble, analyze, and widely disseminate evidence and experience related to the adoption, implementation, and effective use of health IT that allows for the electronic exchange and the use of information including through the Regional Centers. HITRC, along with the Regional Extension Centers, together are referred to as the Health IT Extension Program and form the National Learning Consortium. A total of $50 million has been made available for this effort which will involve the award of nine task orders funded under the American Recovery and Reinvestment Act of 2009. Select for more information on other HITECH efforts on ONC's Web site. 

12. Materials Now Available from February 24 Web Conference on Transitions in Care

AHRQ has made available the materials from its February 24 Web conference titled "Managing Patient Care Transitions: How Health IT Can Reduce Unnecessary Rehospitalization." During the event, experts explored the latest research on leveraging health IT to reduce rehospitalizations and the potential impact of health IT systems to improve transitions in care and quality of care. The event began with an overview of the current state and challenges IT systems face in managing transitions in care and was followed by findings on how evidence-based health IT tools can enable systems integration across care settings and issues surrounding patient support and education. The role of health IT in improving quality of care and supporting patients transitioning from the hospital to the ambulatory settings was addressed. Finally, the role of health IT in supporting transitions in care in integrated delivery systems and other clinical settings also was discussed. The presentation concluded with a discussion on health IT implementation issues at an institutional level and how the presented research findings affect these implementation efforts. Select to access the presentation transcript, slides, and recording. 

13. AHRQ Releases Web Page on Consumer Health IT Applications

A new Web page on consumer health information technology (health IT) applications is now available on AHRQ's National Resource Center (NRC) on Health Information Technology. As patients become more involved in managing an increasing volume of health information, including their medical history, lab results, and medications, new consumer health IT applications are being developed that allow patients to manage, share, and control their health information electronically and to assume a more active role in the management of their health. AHRQ's new Web page discusses self-management systems, electronic personal health records and patient portals, and peer interaction systems. It also features information on relevant AHRQ-funded projects. Select to access the new Web page. 

14. AHRQ Podcasts on Clinical Decision Support

AHRQ recently held a series of three audio podcasts on clinical decision support (CDS) featuring P. Jon White, M.D., AHRQ's director for health information technology. In the first segment, Clinical Decision Support - Improving Health Care Quality, Dr. White explains CDS and how it can improve the quality of health care delivery. The second segment, Clinical Decision Support White Papers, focuses on tools, such as computerized alerts, that provide clinicians, patients or others with timely information to enhance their health care. The final segment, Clinical Decision Support and Improving Patient Outcomes, provides an in-depth look at the high-tech tools designed to help patients and providers get the information they need to make high-quality, evidence-based health care decisions. 

15. AHRQ in the 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.

Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J Am Med Inform Assoc 2010 Jan-Feb; 17(1):78-84. Select to access the abstract

Witry MJ, Doucette, WR, Daly JM, Levy BT, Chrischilles EA. Family physician perceptions of personal health records. Perspectives in Health Information Management (Winter 2010). Select to access the abstract.

Wright A, Soran C, Jenter CA, et al. Physician attitudes toward health information exchange: results of a statewide survey. J Am Med Inform Assoc 2010 Jan-Feb; 17(1):66-70. Select to access the abstract.

AHRQ's Patient Safety and Health Information Technology E-Newsletter Contact:

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Page last reviewed March 2010
Internet Citation: AHRQ Tools Support Teamwork and Patient Safety Awareness Week: Patient Safety and Health IT Newsletter, Issue #58. March 2010. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


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