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Patient Safety and Health Information Technology E-Newsletter

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July 25, 2005, Issue No. 11

Quote of the Month

"We've learned that doctors and health care workers do want to talk about and report on medical errors but they face barriers within the existing infrastructure where there is a lack of an efficient and effective reporting system."

—Victoria Fraser, M.D., Associate Professor and Medical Director, Washington University School of Medicine.

Select for more information on research about health care provider attitudes toward reporting medical errors by Dr. Fraser and her colleagues.

Today's Headlines:

  1. Publication highlights findings from AHRQ's patient safety research
  2. New study recommends teamwork training for physicians to improve patient safety
  3. Presentations from AHRQ's annual conference on patient safety and health information technology now available online
  4. Video of 5 Steps to Safer Health Care PSA now available
  5. AHRQ patient safety grantee Dr. Victoria Fraser and her colleagues are working to improve error reporting
  6. Do you know how AHRQ's hospital survey on patient safety culture is being used to improve patient safety?
  7. Visit the AHRQ Patient Safety Network Web site
  8. Latest issue of AHRQ WebM&M is available online
  9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  Publication Highlights Findings From AHRQ's Patient Safety Research Portfolio

AHRQ has produced a new program brief that highlights key findings from the Agency's patient safety research portfolio. The publication, Patient Safety Research in Progress, features tools, products, and findings from dozens of AHRQ patient safety projects that have been under way since 2001. The program brief includes Web links to tools as well as journal article citations for readers who want to find out more about these important resources. Topic areas covered include medication safety, the impact of provider fatigue on patient safety, event reporting, education and training, communication and patient support, and much more. Select to read the program brief. A print copy is available by sending an E-mail to If you are an AHRQ researcher whose work should be featured in the program brief, please let us know by sending an E-mail to Salina Prasad at with details of your tools, products, or findings.

2.  New Study Recommends Teamwork Training for Physicians To Improve Patient Safety

A new AHRQ-funded study has examined the role of teamwork in the professional education of physicians and made recommendations for measuring specific knowledge, skill, and attitude (KSA) competencies throughout a physician's career. Researchers identified eight KSA requirements for physicians to function effectively in health care teams and also stressed the importance of measuring and assessing process as well as outcomes. In addition to the type of training necessary at various stages of a physician's career, such as during their medical education, board certification, licensure, and continuing practice, researchers also suggested the professional groups most appropriate for assessing the training. The study, "The Role of Teamwork in the Professional Education of Physicians: Current Status and Assessment Recommendations," led by David P. Baker, Ph.D., of the American Institutes for Research, was prepared for AHRQ and the Department of Defense TRICARE Management Activity. Select to read the abstract of the article on PubMed®, published in the April edition of the Joint Commission Journal on Quality and Patient Safety.

3.  Presentations From AHRQ's Annual Conference on Patient Safety and Health Information Technology Now Available Online

Conference presentations and materials from AHRQ's recent annual conference on patient safety and health information technology are now available online. Topics include avoiding adverse drug events, challenges of implementing an electronic health record, and using HIT to improve care. Also available are profiles of key speakers from the conference and a calendar of upcoming events.

4.  Video of 5 Steps to Safer Health Care PSA Now Available

AHRQ, the American Medical Association, and the American Hospital Association have been working to distribute valuable information about improving patient safety to health care providers and patients across the country. The campaign, called 5 Steps to Safer Health Care, includes posters and fact sheets that offer evidence-based, practical tips on the role patients can play to help avoid errors related to prescription medicines, laboratory tests, procedures, and surgery. In addition, the groups recently worked with actress Laura Innes, who plays Dr. Kerry Weaver on the hit NBC show ER, to further promote the 5 Steps messages by recording a 30-second public service announcement that is airing on TV stations nationwide. Copies of 5 Steps to Safer Health Care are available on AHRQ's Web site in English and in Spanish. Print copies of the fact sheet also are available by calling AHRQ's Publications Clearinghouse at 1-800-358-9295 or by sending an E-mail to

5.  AHRQ Patient Safety Grantee Dr. Victoria Fraser and Her Colleagues Are Working To Improve Error Reporting

AHRQ patient safety researcher Victoria Fraser, M.D., of the Washington University School of Medicine in St. Louis, and a team of multidisciplinary investigators have been examining ways to improve the reporting of medical errors. With AHRQ's support, Dr. Fraser's research has been used to evaluate methods for analyzing medical error and safety event data, investigate optimal dissemination strategies for patient safety, and determine the best methods for informing patients about medical errors. Dr. Fraser and her colleagues have examined the attitudes of health care providers toward reporting medical errors and the cultural and technical barriers that make reporting difficult in hospitals. In a recent interview, she explained that although doctors and health care workers want to discuss and report medical errors, there are no resources in hospitals to fund these projects and collect, manage, and analyze the data in a timely fashion. Dr. Fraser and her colleagues are working on a survey expected to be released later this year that compares U.S. physician attitudes about reporting with those of their Canadian counterparts. To learn more about Dr. Fraser's research, go to the following recent article about safe medication prescribing; and an article about medical errors in emergency departments.

6.  Do You Know How AHRQ's Hospital Survey on Patient Safety Culture Is Being Used To Improve Patient Safety?

As you may know, AHRQ worked with Premier, Inc., the Department of Defense, and the American Hospital Association on its Hospital Survey on Patient Safety Culture. The survey, now available in Spanish, was designed to assess the safety culture of a hospital as a whole and specific units within hospitals, as well as to track changes in patient safety over time and evaluate the impact of patient safety interventions. At AHRQ, we are always looking for ways in which AHRQ-funded research, products, and tools have changed people's lives, influenced clinical practice, improved policies, and affected patient outcomes. These examples are used by AHRQ in testimony, budget documents, and speeches. Therefore, if you are actively using this survey instrument, we would like to hear from you. Please contact Nate Robinson at with your examples. Select for more information on AHRQ's Hospital Survey on Patient Safety Culture.

7.  Visit the AHRQ Patient Safety Network Web Site

AHRQ's new national Web site—the AHRQ Patient Safety Network, or AHRQ PSNet—continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The Web site includes summaries on tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature. Select to visit the AHRQ PSNet Web site.

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

The July-August issue of the AHRQ WebM&M online patient safety journal is now available. The Perspectives on Safety section highlights nursing and patient safety. This month's user-submitted cases include one in which a woman who receives morphine via a patient-controlled analgesia pump is found barely breathing a few hours after arriving at the unit. In another case, a nurse who is preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement a week earlier was still in the patient's leg vein. In the Spotlight Case, an intern increases a patient's warfarin dosage nightly based on subtherapeutic international normalized ratio (INR) levels drawn each morning. After several days, the patient develops potentially life-threatening bleeding. 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. Please submit cases to AHRQ WebM&M via the "Submit Case" button. All previously published cases and commentaries are available under "Case Archive."

9.  AHRQ in the Patient Safety Professional Literature—Some Useful Citations

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.

Branas CC, MacKenzie EJ, Williams JC, Schwab CW, Teter HM, Flanigan MC, Blatt AJ, ReVelle CS. Access to trauma centers in the United States. JAMA 2005 Jun 1;293(21):2626-33. Select to access the abstract on PubMed®.

Galt KA, Rule AM, Houghton B, Young DO, Remington G. Personal digital assistant-based drug information sources: potential to improve medication safety. J Med Libr Assoc 2005 Apr;93(2):229-36. Select to access the abstract on PubMed®.

Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units. BMC Health Serv Res 2005 Apr 11;5(1):28. Select to access the abstract on PubMed®.

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Current as of July 2005


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