Highlights, 2009 (continued 1)

AHRQ Annual Highlights, 2009

Patient Safety Portfolio

In support of its mission to improve the quality, safety, efficiency, and effectiveness of health care, AHRQ funds research and develops successful partnerships that help generate and implement the knowledge and tools required for long-term improvements in health care. Finding ways to eliminate medical errors and improve patient safety are an integral part of the Agency's research agenda. AHRQ-funded research projects and partnerships identify, develop, test, and implement patient safety and quality measures and solutions.

During FY09, AHRQ funded and developed several tools to help improve the quality and safety of health care. The Agency launched more than a dozen projects to help prevent health care-associated infections and created Patient Safety Organizations (PSOs) and Common Formats for the PSOs to report data. Common Formats are common definitions and reporting formats that health care providers can use to collect and track patient safety information. This information can then be used to learn more about trends and patterns in patient safety, to identify risks and hazards to patients, and improve health care quality and safety. AHRQ provided new patient education videos and consumer guides in English and Spanish on the safe use of blood thinner pills to help prevent and treat blood clots. New products also released in FY09 include a module on Rapid Response Systems for the TeamSTEPPS™ training module as well as two new patient safety culture surveys for nursing homes and medical offices. Additionally, the Institute of Medicine released an AHRQ-funded report on strategies to reduce fatigue-related errors among medical residents.

Projects To Prevent Health Care-Associated Infections

AHRQ received $17 million in FY09 to fund projects to help reduce and eliminate health care-associated infections (HAIs), the most common complications of hospital care. HAIs are both virulent and widespread in the United States. For example, there are an estimated 95,000 cases annually of methicillin-resistant Staphylococcus aureus (MRSA), 85 percent of which are health care-associated. Nineteen percent of these 95,000 infections result in death. Another HAI, Clostridium difficile, has been associated with an estimated 15,000 to 30,000 attributable deaths annually, based on recent mortality data from the Centers for Disease Control and Prevention (CDC).

Of the $17 million, $8 million funds a national expansion of the Keystone Project, which within 18 months successfully reduced the rate of central-line blood stream infections in more than 100 Michigan intensive care units (ICUs) and saved 1,500 lives and $200 million. The project was originally started by the Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association to implement a comprehensive unit-based safety program. The program involves using a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses, and hospital leaders.

In February 2009, AHRQ funded an expansion of the Keystone Project to 10 States. With additional funding from AHRQ and a private foundation, the project is now operating in all 50 States, Puerto Rico, and the District of Columbia. The FY09 funding will expand the effort to more hospitals, extend it to other settings in addition to ICUs, and broaden the focus to address other types of infections. Specifically, the new $8 million in funding will provide:

  • $6 million to the Health Research & Educational Trust (HRET) for national efforts to expand the Comprehensive Unit-Based Patient Safety Program to Reduce Central Line-Associated Blood Stream Infections. The funding will allow more hospitals in all 50 States to participate in the program and expand the program's reach into hospital settings outside of the ICU. HRET also will use $1 million to support a demonstration project that will help fight catheter-associated urinary tract infections.
  • $1 million to Yale University to support a comprehensive plan to prevent bloodstream infections in hemodialysis patients.

AHRQ, in collaboration with the CDC, also identified several high-priority areas to apply the remaining $9 million toward reducing MRSA and other types of HAIs. These projects will focus on:

  • Reducing Clostridium difficile infections through a regional hospital collaborative.
  • Reducing the overuse of antibiotics by primary care clinicians treating patients in ambulatory and long-term care settings.
  • Evaluating two ways to eliminate MRSA in ICUs.
  • Improving the measurement of the risk of infections after surgery.
  • Identifying national-, regional- and State-level rates of HAIs that are acquired in the acute care setting.
  • Reducing infections caused by Klebsiella pneumoniae carbapenemase-producing organisms by applying recently developed recommendations from CDC's Healthcare Infection Control Practices Advisory Committee.
  • Standardizing antibiotic use in long-term care settings (two projects).
  • Implementing teamwork principles for frontline health care providers.

For more information on AHRQ's projects to prevent HAIs, see https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/hais/.

Patient Safety Organizations (PSOs)

Established by the Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act), PSOs collect and analyze patient safety events that health care providers report and can provide feedback to help clinicians and health care organizations improve health care quality. Under the Patient Safety Act, information that PSOs collect, create, or use for patient safety and quality improvement activities is protected from legal discovery. Thus, PSOs allow clinicians and health care organizations to voluntarily share data on patient safety events more freely and consistently within a protected environment. Strong confidentiality provisions are also key to voluntary reporting.

At the end of FY09, there were 68 listed PSOs. As outlined in the Patient Safety Act, AHRQ administers provisions governing PSO operations. To allow health care providers to collect and submit standardized information regarding patient safety events, AHRQ coordinates the development of Common Formats (i.e., common definitions and reporting formats) for reporting events to the PSOs. Common Formats optimize the opportunity for the public and private sectors to learn more about trends and patterns in patient safety, with the purpose of improving health care quality. AHRQ released the initial set of Common Formats for hospitals, and subsequent sets will be developed for nursing homes, ambulatory surgery centers, and physician offices. For more information on the PSOs and Common Formats, go to http://www.pso.ahrq.gov.

Helping Patients Use Blood Thinners Safely

In FY09, AHRQ released a video and publication in both English and Spanish to help consumers take blood thinners safely. The Agency also combined the English and Spanish guides on preventing blood clots that were published in FY08. The video and both guides were developed based on research originally funded through AHRQ's Partnerships in Implementing Patient Safety grant program.

  • Staying Active and Healthy with Blood Thinners (http://www.healthcare411.ahrq.gov/videocast.aspx?id=555) is a new video that helps educate patients about how to safely use anticoagulant drugs, commonly called blood thinners. Designed to complement education that patients receive in their doctor's offices, clinics, pharmacies, or hospitals, the video helps patients better understand why they need a blood thinner, how they work, and how to manage them effectively. The video introduces a mnemonic called B-E-S-T to help patients remember four key actions they should take to safely use blood thinner pills. B-E-S-T stands for Be careful, Eat right, Stick to a routine, and Test regularly. The video, in DVD format, also features
    • The experiences of a patient on blood thinners to show how he manages his medication regimen safely at home and work.
    • Simplified medical terminology and easy-to-understand language.
    • Animated graphics showing how dangerous blood clots form and their consequences.
    • Menu selections that allow patients to replay and review specific segments.
  • Blood Thinner Pills: Your Guide to Using Them Safely (https://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills.html) and Pastillas que diluyen la sangre: Guía para su uso seguro (https://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills-esp/btpillssp2.html) is the companion bilingual print brochure to the video Staying Active and Healthy with Blood Thinners that helps consumers understand the lifestyle changes that they may need to make when they take blood thinner pills. The publication includes information on medications and foods to avoid when taking blood thinner pills, tips for lifestyle modifications, information on potentially dangerous side effects, advice on when to call the doctor or go to the hospital, and tips on preventing injuries. The brochure also lists the common medical conditions that may cause a person to be at higher risk for developing blood clots.
  • Your Guide to Preventing and Treating Blood Clots and Su guía para evitar y tratar la formación de coágulos (https://www.ahrq.gov/patients-consumers/prevention/disease/bloodclots.html) were first published separately in FY08, and in FY09 AHRQ combined them to create one easy-to-read guide that helps English- and Spanish-speaking consumers identify the causes and risk factors for blood clots. It lists the symptoms of blood clots and offers ways to prevent blood clots. The treatment section tells consumers what they can expect and the possible side effects of blood thinners. Finally, the guide offers a list of commonly used terms and their definitions.

Patient Safety Is a Team Sport


TeamSTEPPS™ is an evidence-based teamwork system designed for improving communication and other teamwork skills among health care professionals. In FY09, AHRQ released the TeamSTEPPS™ module on Rapid Response Systems designed for use by hospital teams. This new module applies TeamSTEPPS™ skills to 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 in the hospital. After implementing Rapid Response Systems, hospitals have experienced 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 following heart attacks, and inpatient death rates. Featuring video vignettes and presentation slides, the Rapid Response System module can help hospitals implement team training principles to improve care delivery and patient safety. The module is available in CD format, and the curriculum slides can be customized to meet an institution's unique needs.

TeamSTEPPS™ was developed by the Department of Defense in collaboration with AHRQ. TeamSTEPPS™ includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into a health care system. TeamSTEPPS™ is now a part of the Centers for Medicare & Medicaid Services (CMS) 9th Scope of Work for all Quality Improvement Organizations.

More information on TeamSTEPPS™ can be found at http://teamstepps.ahrq.gov.

Healthcare 411

Healthcare 411 (http://healthcare411.ahrq.gov) is a news series produced by AHRQ. Using the latest podcasting technology, these weekly audio and video programs feature AHRQ's latest research findings as news and informational stories on current health care topics such as cancer, heart disease, diabetes, patient safety, and quitting smoking. Healthcare 411 gives consumers information they can use to improve the quality of their health care and help them navigate the health care system. It also provides AHRQ researchers and grantees an opportunity to share their findings and be heard beyond the research community. In FY09, newscasts released included:

  • Rising Health Care Costs Related to Obesity - AHRQ data shows an 80 percent increase in health care spending among American adults with obesity.
  • Hospitalization of the Poor Much Higher for Asthma, Diabetes, Other Preventable Diseases—Low-income Americans are more likely than people in higher income groups to be hospitalized for chronic health conditions.
  • Basic Health Tips for Men—The U.S. Preventive Services Task Force recommends three basic things that men should do to stay healthy.
  • Making Hospital Discharges Safer for Seniors—Elderly patients just returning home from the hospital are prone to medication mishaps. Learn how information technology is making the transition from hospital to home easier.
  • Consumer Guide Compares Type 2 Diabetes Treatments—AHRQ summarizes the evidence comparing the effectiveness and safety of premixed insulin analogues with other insulin preparations and oral drugs for type 2 diabetes.
  • An EMR System that Helps Reduce Medication Errors—An Electronic Medical Record system can help prevent serious errors from happening when patients see multiple doctors in many different locations.
  • Having Surgery: What You Need to Know—Every year, more than 15 million Americans have surgery. If you're considering surgery, you need to make an informed decision.

Patient Safety Culture Surveys

In its 1999 landmark report, To Err Is Human, the Institute of Medicine cited studies that found that at least 44,000 people and potentially as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors with costs estimated to be between $17 billion and $29 billion. One of the main conclusions was that the majority of medical errors do not result from individual recklessness or the actions of a particular group but are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent adverse events. To improve safety, the culture within health care systems must be redesigned in a way that breaks down legal and cultural barriers. A culture of safety includes open communication between staff and management, with strong leadership and clearly defined safety policies that empower staff to both report and correct safety problems. As part of its goal to support a culture of patient safety and quality improvement in the Nation's health care system, AHRQ sponsors the development of patient safety culture assessment tools for hospitals, nursing homes, and medical offices. Health care organizations can use these survey assessment tools to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of specific patient safety interventions. In FY09, AHRQ released two new surveys, the Nursing Home Survey on Patient Safety Culture and the Medical Office Survey on Patient Safety Culture. In addition, the annual collection of data from hospitals led to the publication of Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.


AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is an online journal and forum on patient safety and health care quality. The site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety ("Spotlight Cases"), and Perspectives on Safety. Continuing medical education and continuing education unit credits are available. WebM&M can be accessed at http://www.webmm.ahrq.gov.

Nursing Home Survey on Patient Safety Culture

The Nursing Home Survey on Patient Safety Culture is designed specifically for nursing home providers and staff and asks for their opinions about the culture of patient safety in their nursing homes. Questions address respect and teamwork, training, communication, care plans for residents, and ways to keep residents safe from harm.

Medical Office Survey on Patient Safety Culture

The Medical Office Survey on Patient Safety Culture is an evidence-based tool for medical offices with at least three providers, such as physicians, physician assistants, or nurse practitioners, that can help organizations assess how their staff views different areas of patient safety. The survey captures opinions on important dimensions that relate to patient safety and quality issues, such as communication about errors, communication openness, information exchange among health care settings, office processes and standardization, organizational learning, staff training, teamwork, and work pressure and pace.

Both of the new surveys include survey forms and a user's guide that explains the survey process and discusses topics including overall project planning, data collection procedures and analysis, and report creation.

Hospital Patient Safety Culture Survey: 2009 Comparative Database Report

The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report summarizes the latest results from hospitals that have administered the AHRQ Hospital Survey on Patient Safety Culture. Based on data from more than 600 U.S. hospitals, the report provides initial results that hospitals can use as benchmarks in establishing a culture of safety. The 2009 report also presents results showing change over time for 204 hospitals that submitted data more than once. The report shows that one area of strength for most hospitals is teamwork within hospital units while non-punitive response to errors and handoffs continues to be a main area for improvement in patient safety. The report is available at https://www.ahrq.gov/qual/hospsurvey09/.

For more information on AHRQ's Patient Safety Culture Surveys, go to https://www.ahrq.gov/qual/patientsafetyculture/.

Report Recommends Ways To Reduce Errors Caused by Medical Residents

Medical residents need protected sleep periods and increased supervision of work-hour limits to improve patient safety and the training environment, according to Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, an Institute of Medicine (IOM) report funded by AHRQ. An IOM committee reviewed the relationship between residents' work schedules, their performance, and the quality of care they provide. The study confirms scientific evidence that shows 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 and guaranteed days off to permit adequate recovery after working long shifts.

Ad Council Campaign Encourages Patients To Ask Questions

AHRQ joined with The Advertising Council in April FY09 to update the "Questions are the Answer" public service advertising campaign that was first launched in March 2007. Updates to the campaign, which encourages consumers to get more involved in their health care by knowing and asking appropriate questions when visiting their doctors or other clinicians, included new television, print, outdoor, and Web advertising, all of which were created pro bono by Grey New York. The ads feature people asking questions in everyday situations, such as ordering food at a restaurant and buying a cell phone, but clamming up when their doctor asks if they have questions. The ads direct audiences to visit a comprehensive Web site, , to learn the 10 questions every patient should think about asking during medical appointments.

Medical Liability Reform and Patient Safety Initiative

In FY09, President Obama announced as one of his health care reform proposals that AHRQ would establish a new demonstration initiative to evaluate existing medical liability reform models and to test future initiatives in patient safety and medical liability reform initiatives. The new demonstration initiative is intended to help States and health care systems test models that:

  • Put patient safety first and work to reduce preventable injuries.
  • Foster better communication between doctors and their patients.
  • Ensure that patients are compensated in a fair and timely manner for medical injuries while also reducing the incidence of frivolous lawsuits.
  • Reduce liability premiums.

The new initiative will also support planning grants to State and health systems for future initiatives in patient safety and medical liability reform. Funding for these grants is expected in May 2010. For more information, go to https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/liability/index.html.

Recent Research Findings on Quality and Patient Safety

  • Patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments, are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information. In an AHRQ-funded study, patients in one hospital received a personalized after-hospital care plan from a nurse discharge advocate, who also provided the plan and discharge summary to the patient's primary care provider on discharge day. A pharmacist followed up with a phone call to the patient within 4 days after discharge to ensure the patient understood how to take any new medications. Further, patients who underwent this reengineered discharge process were more likely to identify their diagnosis, understand their medication, and visit their primary care physicians within 30 days of discharge compared with patients who received the hospital's regular discharge plan. (Annals of Internal Medicine, February 2009)
  • Hospital stays that result in a patient safety event report are 17 percent more costly and 22 percent longer compared with stays with no events. The most expensive and most common events are medication and treatment errors, accounting for 77 percent of all event types and 77 percent of added costs. Over 2 years, patient safety events resulted in an estimated $8.3 million in additional costs with medication events accounting for an estimated $4 million and treatment events and falls accounting for $2.3 million of these extra costs. (American Journal of Medical Quality, January/February 2009)
  • Hospitals with a better safety climate—interpersonal, work unit, and organizational safety attitudes and safeguards—have a lower incidence of patient safety problems such as bed sores, postoperative hemorrhage, and HAIs. Researchers analyzed survey responses from hospital personnel at 91 hospitals in 37 States about the safety climate at their hospitals. Higher levels of safety climate were associated with higher safety performance, defined as a lower incidence of patient safety indicators developed by AHRQ. (HSR: Health Services Research, April 2009)
  • 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 national survey of over 1,600 hospitals found that 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). (Quality and Safety in Health Care, December 2008)

National Network of Libraries of Medicine uses Questions Are the Answer video in patient safety seminar

The National Network of Libraries of Medicine (NN/LM) has incorporated AHRQ's Questions Are the Answer video into its Patient Safety Resource Seminar, "Librarians on the Front Lines." The class has been taught in 15 States across the country and in Canada to more than 250 librarians, the majority of whom took the information back to their hospitals and health systems. The interactive seminar focuses on ways librarians can become more involved in patient safety processes and activities. This involvement can occur within their institutions and organizations, in addition to their role in providing patient safety resources for health professionals, administration, staff, patients, and families. Topics include: understanding the definitions and issues related to patient safety; locating where patient safety practices and contacts exist within an institution; identifying appropriate resources; and library advocacy in the area of patient safety. Four hours of lecture, discussion, and brainstorming help librarians in all fields become effective agents for improving patient safety. The course objectives include the ability to do the following:

  • Describe definitions related to patient safety and detect systems of potential error within institutions.
  • Identify patient safety issues and points of contact specific to individual institutions.
  • Locate resources available for administrators, health professionals, patients, and families.
  • Formulate methods for the library to participate effectively in improving patient safety.

This class has been approved by the Medical Library Association (MLA) for 2.5, 4, and 6 contact hours of MLA CE credit. The course is available online at: http://nnlm.gov/training/patientsafety/index.html.

Page last reviewed December 2012
Internet Citation: Highlights, 2009 (continued 1): AHRQ Annual Highlights, 2009. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/newsroom/highlights/highlt09b.html