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Patient Safety and Health Information Technology E-Newsletter

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December 2, 2005, Issue No. 15

Quote of the Month

"Doctors are responsible for ordering the removal of catheters, but research has shown that many of them forget which patients have catheters and how long they have them. Our reminder system helps doctors do the right thing."

—Sanjay Saint, M.D., Hospitalist, Ann Arbor VA Medical Center, and Associate Professor of Medicine, University of Michigan Health System.

Select for more information on Dr. Saint's urinary catheter reminder tool.

Today's Headlines:

  1. New AHRQ study finds mixed compliance with medication warning labels
  2. New international survey finds U.S. patients experience the most medical mistakes
  3. Updated fact sheet showcases additional research from AHRQ's patient safety portfolio
  4. AHRQ researchers find that simple written reminders can reduce catheter-related infections
  5. AHRQ awards nearly $6.6 million for 19 IDSRN projects
  6. AHRQ begins third and final class of Patient Safety Improvement Corps
  7. New AHRQ Web video helps patients who have just been diagnosed
  8. The 25th issue of AHRQ WebM&M Is available online
  9. Special audio report discusses personal and electronic health records
  10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  New AHRQ Study Finds Mixed Compliance with Medication Warning Labels

More than 40 percent of nearly 930,000 patients enrolled in 10 geographically diverse health plans received at least 1 medication for which the FDA had issued a black box warning. These warnings are the strongest labels issued by the FDA and indicate that the medication carries the risk of potential injury or death. Researchers found that physicians' compliance with the black box warnings was highly variable, depending on the medication prescribed. Physicians were less likely to comply with the warning when patients did not receive needed lab tests before beginning a new prescription. Nearly 50 percent of all prescriptions that should have been accompanied by a lab test were not. However, medications prescribed to pregnant women were among those with the highest levels of physician compliance. Of 79,000 prescriptions prescribed to women of childbearing age who might have been pregnant, only 95 carried a black box warning against use during pregnancy. In addition, physicians did not prescribe medications that were likely to have negative interactions with QT-interval-prolonging medications that regulate heart rhythm. The study, "FDA Drug Prescribing Warnings: Is the Black Box Half Empty or Half Full?" was published in the November 18 issue of Pharmacoepidemiology and Drug Safety. Select to read the article by Anita K. Wagner, Pharm.D., M.P.H., D.P.H., and Richard Platt, M.D., M.S., of Harvard Medical School and Harvard Pilgrim Health Care.

2.  New International Survey Finds U.S. Patients Experience the Most Medical Mistakes

A new international survey reports that 34 percent of U.S. patients with health problems experienced medical mistakes, medication errors, inaccurate lab results, or delays in abnormal lab results. This is the highest rate of any of the six nations that were surveyed—Germany, Australia, Canada, New Zealand, the United Kingdom, and the United States. More specifically, U.S. patients stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs. No country was ranked best or worst overall; all countries experienced high rates of safety risks, failure to coordinate care during transitions, inadequate communication, and a lack of support for chronically ill patients. Results from the 2005 survey, supported by The Commonwealth Fund, are found in "Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries," published in the November 3 issue of Health Affairs. Select to read an abstract of the article in PubMed®.

3.  Updated Fact Sheet Showcases Additional Research from AHRQ's Patient Safety Portfolio

New summaries of important findings, tools, and products developed by AHRQ's patient safety researchers have been added to an AHRQ fact sheet titled Patient Safety Research Highlights. The descriptions of research showcase the significant advances made by the Agency's patient safety researchers, who work on various aspects of patient safety, ranging from system-wide event reporting methods to specific measures to minimize known medical errors in particular situations. Summaries that have been added to the revised fact sheet fall into the following categories: technology, event reporting, medication safety, clinical practice change, education and training, and safety in intensive care units. Updated versions of the fact sheet will be issued periodically. The fact sheet 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 health information technology, clinical practice change, safety in intensive care units, and much more. Select to read the updated fact sheet.

4.  AHRQ Researchers Find That Simple Written Reminders Can Reduce Catheter-Related Infections

AHRQ-funded researchers have developed a written reminder system to help reduce the duration of urinary catheterizations and the number of catheter-related urinary tract infections in hospitalized patients. As part of the study, researchers evaluated nearly 5,700 patients at the University of Michigan Medical Center and attached written reminders to the charts of all patients assigned to the intervention group whose catheters had been in place for 48 hours or more. The reminders were intended to prompt physicians to retain or remove catheters as soon as feasible. As a result, patients whose charts received the reminder averaged a reduction in catheterization of approximately 1 day. Researchers, led by Sanjay Saint, M.D., a hospitalist at the Ann Arbor VA Medical Center and an Associate Professor of Medicine at the University of Michigan, also estimated that use of the urinary catheter reminder can result in potential cost savings of $500 per patient when an infection is avoided. Select to read an abstract of the study by Dr. Saint, an AHRQ patient safety grantee, and to view the text of the urinary catheter reminder, published in the August 2005 issue of the Joint Commission Journal on Quality and Patient Safety, in PubMed®.

5.  AHRQ Awards Nearly $6.6 Million for 19 IDSRN Projects

AHRQ has awarded nearly $6.6 million for 19 projects that are funded as part of the FY 2005 Integrated Delivery System Research Network (IDSRN). Seven of the projects are dedicated to patient safety and quality of care and include topics on the development of training curriculum modules to analyze medical error reports and data; addressing how cancer care within complex managed care networks can be designed/redesigned to improve the quality of care; and developing and deploying a prospective triggers system for highly prevalent adverse events. The other categories covered under the award are chronic care and patient centeredness; data and methods; emergency preparedness; organization and design of health care; and, prevention. The IDSRN was developed to capitalize on the research capacity of, and research opportunities occurring within, integrated delivery systems. The network creates, supports, and disseminates scientific evidence about the effectiveness of data and measurement systems and organizational "best practices" related to care delivery and research diffusion. It also provides a cadre of delivery-affiliated researchers and sites to test ways to adapt and apply existing knowledge. Select to read the list of IDSRN projects that have been funded.

6.  AHRQ Begins Third and Final Class of Patient Safety Improvement Corps

AHRQ, in partnership with the Department of Veterans Affairs, is supporting the third and final year of a training program to create a Patient Safety Improvement Corps (PSIC). The Corps is comprised of teams of State health officials and their selected hospital partners; quality improvement organizations and their selected hospital partners; and hospital teams. Team members are trained in analyzing reported medical errors, identifying root causes, and developing and implementing patient safety improvement processes. The VA's National Center for Patient Safety is conducting the training, which began with a 1-week session in mid-September and will continue through the year with two additional 1-week sessions and project work. Teams from 17 States will be participating in the 2005-06 PSIC class, joining teams from 15 States that participated in the inaugural 2003-04 class and 20 States and the District of Columbia that participated in the 2004-05 class. "AHRQ's PSIC training program provided Georgia with valuable information that has helped us identify strategies and develop tools for building a safer health care system," said Anne Grabois-Davis, a patient safety specialist at the Georgia Hospital Association's Partnership for Health and Accountability. Select to for more information on the PSIC training program.

7.  New AHRQ Web Video Helps Patients Who Have Just Been Diagnosed

AHRQ recently released a new video that helps patients deal with the various physical and emotional aspects that can result from a medical diagnosis. The video informs patients and their families of what they need to know before making treatment decisions and suggests important followup questions that should be asked. Recommendations for treatment options and helpful resources to understand a disease or condition also are proposed. The video can be a useful tool for improving patients' quality of care, increasing safety, and preventing medical errors. The video is being distributed to over 4,500 Web sites in the Healthology® network, including those for ABC News, Chicago Sun-Times, iVillage®, the American Diabetes Association, and many others. The video features AHRQ's Director, Carolyn M. Clancy, M.D.; Gregg S. Meyer, M.D., Medical Director, Massachusetts General Physicians Organization; and Robert Muscalus, D.O., Medical Director for Clinical Client Relationships, Highmark Blue Shield, PA.

8.  The 25th Issue of AHRQ WebM&M Is Available Online

The December issue of the AHRQ WebM&M online patient safety journal marks its 25th edition and is now available. This month's Perspectives on Safety section explores legal aspects of patient safety and includes an interview with Troyen Brennan, M.D., J.D., M.P.H., of Harvard University and a perspective by Paul Barach, M.D., M.P.H., of the University of Miami regarding the impact of Florida's recent patient safety legislation. In this month's Spotlight Case, a medical student notices a urinary catheter is inserted into a child in an unsterile manner, but says nothing until a few days later on rounds when the patient shows signs of infection. A second case deals with clinicians who did not notice that a patient was blind and discharged him with written instructions on administering his medications. In the third case, a resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor. Commentary authors are Robert Wachter, M.D., of the University of California, San Francisco, Lisa Iezzoni, M.D., M.Sc., of Harvard University, and Louis Halamek, M.D., of Stanford University. 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 commentaries are available under "Case Archive."

9.  Special Audio Report Discusses Personal and Electronic Health Records

This week's program is the second of a two-part Newscast Special Report with AHRQ Director Carolyn M. Clancy, M.D., discussing personal and electronic health records. In the first part, released November 22, Dr. Clancy explains what personal health records include, how they differ from electronic health records, and how those records can help you in an emergency. In the second part, released November 29, she discusses the technology and how electronic health records can, and will, impact the quality of our health care. Select to listen to Part 1 and Part 2 of the audio newscast on your computer. You can hear them from your computer's speakers, or you can download them to any portable digital player.

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

We are providing the following hyperlinks to journal abstracts through 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.

France DJ, Stiles R, Gaffney EA, Seddon MR, Grogan EL, Nixon WR Jr, Speroff T. Crew resource management training—clinicians' reactions and attitudes. AORN J 2005 Aug;82(2):214-24; quiz 225-8. Select to read the abstract in PubMed®.

Mello MM, Kelly CN, Brennan TA. Fostering rational regulation of patient safety. J Health Polit Policy Law 2005 Jun;30(3):375-426. Select to read the abstract in PubMed®.

Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf 2005 Aug;31(8):438-46. Select to read the abstract in PubMed®.

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Current as of December 2005


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