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Patient Safety and Health Information Technology E-Newsletter

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January 10, 2006, Issue No. 16

Quote of the Month

"Medication safety is often overlooked in physician office-based practices. Our medication self-assessment tool provides a first step for providers in these settings to make improvements in medication use process."

—Kimberly A. Galt, Pharm.D., Associate Dean of Research and Professor of Pharmacy Practice, Creighton University

Select for more information on on Dr. Galt's medication safety guide.

Today's Headlines:

  1. AHRQ issues third annual national reports on health care quality and disparities
  2. Use of new medication safety guide can help improve care in outpatient practices
  3. Adverse drug events increase health care costs for elderly patients in ambulatory care settings
  4. Georgia PSIC's surgery tool kit helps hospitals prevent wrong-site surgeries
  5. New video from AHRQ on Tips for Taking Medicines Safely
  6. January issue of AHRQ WebM&M is available online
  7. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ Issues Third Annual National Reports on Health Care Quality and Disparities

AHRQ Director Carolyn M. Clancy, M.D., announced on Monday the findings of the third annual reports on the quality of and disparities in health care in America in a speech at the National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health, sponsored by the HHS Office of Minority Health. According to the new reports—the 2005 National Healthcare Quality Report and the 2005 National Healthcare Disparities Report—disparities have widened in both quality of care and access to care for Hispanics. The reports measure and track trends in quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness. Select to read our press release; read the reports; view a Webcast of the summit, produced by The Henry J. Kaiser Family Foundation; or listen to an audio newscast about the reports with commentary from Dr. Clancy and other experts. Print copies of the reports can be obtained by calling (800) 358-9295 or by sending an E-mail to

2.  Use of New Medication Safety Guide Can Help Improve Care in Outpatient Practices

AHRQ researchers have developed an easy-to-use medication safety guide that helps outpatient physician practices incorporate safer systems for medication sample prescribing and dispensing. The guide was developed as a result of an AHRQ study that found that standards for medication safety among 31 physician practices were suboptimal and unacceptable. With this assessment tool, health care providers can now closely examine and take inventory of their current practices of medication use, error management, and safety education. Designed in a checklist format, the guide helps users rate their current medication use processes—prescribing, dispensing, administering, counseling, and monitoring—so plans for improvements can be prioritized and implemented. The guide also addresses processes in technology and safety, office environment, error management, workplace conditions, safety education, and safety perceptions. AHRQ researchers, led by Kimberly A. Galt, Pharm.D., Associate Dean of Research and Professor of Pharmacy Practice at Creighton University in Omaha, NE, plan to develop new components for the guide to address electronic prescribing and other innovations in health information technology. Select to access a free, downloadable self-assessment guide, Medication Safety Best Practices Guide for Ambulatory Care Use, in PDF format [PDF Help].

3.  Adverse Drug Events Increase Health Care Costs for Elderly Patients in Ambulatory Care Settings

Complications due to preventable adverse drug events increased treatment costs by nearly $2,000 for elderly patients in a group practice setting in the 6 weeks after the event occurred, according to a study co-funded by AHRQ and the National Institute on Aging. For preventable adverse drug events, hospital stays accounted for 62 percent of the increase, emergency department visits accounted for 6 percent, outpatient care and physician fees accounted for 29 percent, and prescribed medications accounted for 4 percent. Researchers studied 1,210 Medicare enrollees who had experienced an adverse drug event; 323 of the events were preventable. The increase in costs across all adverse drug event categories was more than $1,300, and their associated hospital stays accounted for 71 percent of the increase, emergency department visits accounted for 5 percent, outpatient care and physician fees accounted for 22 percent, and prescription medications accounted for 3 percent. The researchers, Terry S. Field, D.Sc., and Jerry H. Gurwitz, M.D., of the University of Massachusetts Medical School, conclude that even with conservative estimates, reducing the rate of preventable adverse drug events will result in savings that could offset sums required to implement effective patient safety efforts. Results of the study appear in "The Costs Associated with Adverse Drug Events Among Older Adults in the Ambulatory Setting," published in the December 2005 issue of Medical Care. Select to read an abstract of the study in PubMed®.

4.  Georgia PSIC's Surgery Tool Kit Helps Hospitals Prevent Wrong-Site Surgeries

Members of the Georgia Hospital Association's Patient Safety Improvement Corps class of 2004-05 have applied the lessons they learned from the PSIC program, sponsored by AHRQ and the Department of Veterans Affairs, to develop a Correct Site Surgery Tool Kit. The tool kit is designed to help hospitals prevent wrong-site surgeries and features a self-assessment form, examples of successful practices, and training materials to educate hospital staff on why and how to use the tools. It provides the 4 "C's" for ensuring correct-site surgeries—checking for the Correct Patient, Correct Procedure, Correct Site, and Compliance. GHA worked with the Georgia State Office of Regulatory Services and with all 150 of the State's acute-care hospitals to develop the kit, which is now available online for use by hospitals in other States. "The PSIC training and support received from faculty and PSIC members helped us to research and put together all of the components of this comprehensive and innovative tool kit," said Sandra Walczak, Vice President of the Partnership for Health and Accountability, the statewide patient safety organization sponsored by the GHA and the Georgia Hospital Association Research and Education Foundation. In addition, the GHA is scheduled to begin its own year-long GHA-PSIC program in February 2006, with many hospitals expected to participate. Select for more information on the PSIC training program.

5.  New Video from AHRQ on Tips for Taking Medicines Safely

AHRQ has just released a short Web video called Tips for Taking Medicines Safely, which features information to help consumers take medicines safely. Tips covered in the video include asking questions if you have doubts or concerns about your medicine, bringing a bag with all the medicines you take to your medical appointments, and asking about side effects and what to avoid while taking the medicine. The video is being distributed to more than 4,500 Web sites in the Healthology® network, including ABC News, the 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; David Bates, M.D., Chief, Division of General Internal Medicine, Brigham and Women's Hospital; and Christine Kovner, R.N., Ph.D., Professor at the College of Nursing, New York University.

6.  January Issue of AHRQ WebM&M Is Available Online

The January 2006 issue of AHRQ WebM&M online patient safety journal is now available. This month's Perspectives on Safety section covers aviation and patient safety and includes an article written by Eric J. Thomas, M.D., of the University of Texas Center of Excellence for Patient Safety Research and Practice, which discusses some of the lessons learned from aviation. In addition, Jack Barker, Ph.D., a commercial airline pilot, is interviewed about his views on how the aviation perspective applies to health care. In this month's Spotlight Case, a woman suffers a cardiopulmonary arrest following surgery. Closer review reveals that a pulmonary embolism caused the arrest and that the patient had received no prophylaxis to prevent it. A second case deals with a man with left foot pain and numbness who, over the course of several weeks, is evaluated by numerous doctors, each offering a different incorrect diagnosis until the patient's fourth visit. In the third case, parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill due to dangerously high acetaminophen levels. Commentary authors are Nils Kucher, M.D., of the University Hospital Zurich; Lee Berkowitz, M.D., of the University of North Carolina; and James Heubi, M.D., of the University of Cincinnati. 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."

7.  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.

Goldstein E, Farquhar M, Crofton C, Darby C, Garfinkel S. Measuring hospital care from the patients' perspective: an overview of the CAHPS® hospital survey development process. Health Serv Res 2005 Dec;40(6 Pt 2):1977-95. Select to read the abstract in PubMed®.

Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA 2005 Dec 14;294(22):2858-65. Select to read the abstract in PubMed®.

Raab SS, Grzybicki DM, Zarbo RJ, et al. Anatomic pathology databases and patient safety. Arch Pathol Lab Med 2005 Oct; 129(10):1246-51. Select to read the abstract in PubMed®.

Sofaer S, Crofton C, Goldstein E, Hoy E, Crabb J. What do consumers want to know about the quality of care in hospitals? Health Serv Res 2005 Dec;40(6 Pt 2):2018-36. Select to read the abstract in PubMed®.

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Current as of January 2006


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