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Patient Safety and Health Information Technology E-Newsletter

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April 7, 2006, Issue No. 18

Quote of the Month

"Health IT systems make it possible to measure performance quickly and comprehensively. Health care providers and facilities can see in real time how they measure up. And, consumers can have access to the quality information they should have when they're making decisions about their care."

—Carolyn M. Clancy, M.D., Director, AHRQ, in remarks on March 23 at the eHealth Connecticut Inaugural Summit

Today's Headlines:

  1. AHRQ launches new Web-based tool for States to measure quality performance
  2. AHRQ establishes new database to host information from Hospital Survey on Patient Safety Culture
  3. AHRQ director speaks at eHealth Connecticut Inaugural Summit
  4. AHRQ patient safety researchers receive honors from National Sleep Foundation
  5. JCAHO issues alert on dangerous tubing misconnections
  6. JCAHO clarifies its position on alcohol hand sanitizers
  7. April issue of AHRQ WebM&M is available online
  8. AHRQ's Healthcare 411 audio series features special reports on quality
  9. Register now for AHRQ's 2006 annual patient safety and health IT conference, June 4-7
  10. Calling all AHRQ researchers! "Help us to help you"
  11. AHRQ in the patient safety professional literature—some useful citations

1.  AHRQ Launches New Web-based Tool for States to Measure Quality Performance

AHRQ recently released a new interactive Web-based tool for States to use in measuring health care quality at a press conference at the Association of Health Care Journalists meeting in Houston, TX. The new State Snapshot Web tool is based on the 2005 National Healthcare Quality Report (NHQR) and 2005 National Healthcare Disparities Report (NHDR), released January 9, and provides quick and easy access to the many measures and tables of the quality report from each State's perspective.

The 2005 NHQR and the 2005 NHDR are available online at AHRQ's Measuring Healthcare Quality. Print copies of the reports are available by sending an E-mail to In addition, we have posted an audio newscast about the State Snapshot Tool. The newscast features an interview with AHRQ Director Carolyn M. Clancy, M.D., discussing the importance of the tool and its key elements. In addition, AHRQ's Dr. Dwight McNeill explains how to use some of the tool's features. Select to listen to the program.

2.  AHRQ Establishes New Database to Host Information from Hospital Survey on Patient Safety Culture

AHRQ is establishing the new Survey on Patient Safety Culture Database to serve as a national repository for data collected using AHRQ's Hospital Survey on Patient Safety Culture. This database will be an important resource for hospitals wishing to compare their patient safety culture survey results with those of similar hospitals. Hospitals will not be publicly identified in the database. Participation is open to hospitals in the United States or one of its territories that have completed administration of the AHRQ survey by May 31.

To learn more about eligibility requirements, registration procedures, and the benefits of participation, select to access the AHRQ Web site or send an E-mail to with your complete contact information and "Database" in the subject line of the E-mail message.

3.  AHRQ Director Speaks at eHealth Connecticut Inaugural Summit

AHRQ Director Carolyn Clancy, M.D., spoke to health care leaders, stakeholders, and other professionals at the eHealth Connecticut Inaugural Summit on March 23. The subject of her talk was the pivotal role of health information technology (HIT) in advancing health care research and quality. According to Dr. Clancy, HIT should be embedded and integrated into the practice of medicine. Select to read Dr. Clancy's speech, which also addresses the need for measuring and reporting on health care quality.

4.  AHRQ Patient Safety Researchers Receive Honors from National Sleep Foundation

On March 28, the Harvard Work Hours, Health, and Safety Group received the National Sleep Foundation's 2006 Healthy Sleep Community Award for its AHRQ-funded work on sleep deprivation and safety among medical interns. The group was also honored for their work with law enforcement, sponsored by the National Institute of Justice and the Centers for Disease Control and Prevention. The group, led by AHRQ researchers Charles A. Czeisler, Ph.D., M.D., Christopher P. Landrigan, M.D., M.P.H., Steven W. Lockley, Ph.D., Laura K. Barger, Ph.D., Najib T. Ayas, M.D., M.P.H., and Shantha W. Rajaratnam, Ph.D., is part of the Division of Sleep Medicine at Brigham and Women's Hospital, Boston. Select to read NSF's press release.

5.  JCAHO Issues Alert on Dangerous Tubing Misconnections

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert warning that tubing and catheter misconnections are under-reported in health care organizations. Nine cases of tubing misconnections resulting in eight deaths, and one resulting in permanent disability, have been reported to JCAHO's Sentinel Event Database. The alert recommends strategies to reduce tubing misconnections. Select to read JCAHO's Sentinel Event Alert.

6.  JCAHO Clarifies its Position on Alcohol Hand Sanitizers

Gel and foam alcohol-based hand sanitizer dispensers are now permitted in corridors of health care facilities despite previous fire safety concerns, according to JCAHO, due to recent changes in national and international fire codes. The location of these dispensers is key to improving hand hygiene. JCAHO reserves the right to modify its position, should safety concerns arise following additional testing. Select for more information on JCAHO's 2006 National Patient Safety Goals.

7.  April Issue of AHRQ WebM&M is Available Online

The April 2006 issue of the AHRQ WebM&M online patient safety journal is now available. The issue features perspectives on the role of clinical pharmacists in patient safety and commentaries on surgical complications, implantation of an intrauterine contraceptive during pregnancy, and an overdose of medication given to an infant by her parents. This issue also includes downloadable slides and a quiz for CME, CEU, or trainee certification. All commentaries published previously are available via the "Case Archive" link. Please submit cases to AHRQ WebM&M via the "Submit Case" link.

8.  AHRQ's Healthcare 411 Audio Series Features Special Reports on Quality

AHRQ has posted two new audio special reports as part of the Healthcare 411 series, called "Quality 101." These are interviews with AHRQ Director Carolyn M. Clancy, M.D., on such topics as "Understanding Health Care Quality," "Questions to Ask Before Surgery," and "How to Get the Most out of a Visit with Your Health Care Professional." The latest reports are "Next Steps After Diagnosis," based on the consumer booklet on this topic, and "Patient Safety" produced for Patient Safety Awareness Week, held early in March. If your computer has a sound card and speakers and can play MP3 audio files, you will be able to listen to the audio on your computer whenever you have 10 or 15 minutes. Select to listen to "Next Steps After Diagnosis" and to listen to "Patient Safety". Transcripts of the reports also are available from the site. If you want to receive all AHRQ newscasts automatically, you will need subscription software. The AHRQ subscription is free. Select for more details.

9.  Register Now for AHRQ's 2006 Patient Safety and Health IT Conference, June 4-7

Visit AHRQ's National Resource Center for HIT to register and participate in the most important meeting of the year on new and emerging research on patient safety and health IT implementation. Research funded by AHRQ in patient safety and health IT is helping to revolutionize everyday clinical practice. Discover how these new findings are being used to support health information exchange, reduce medical errors, and to improve health care quality. Get a "first look" at the evidence base for widespread health IT adoption. Space is limited, so register now.

10.  Calling All AHRQ Researchers! "Help Us To Help You"

AHRQ can help you to promote your research findings, but we can't do it without you. AHRQ has been successful in working with our grantees and contractors to promote findings to the media and to transfer knowledge based on the research to appropriate audiences in the health care community. However, we know that we can do better. We need you to notify us when you have an article accepted for publication. Please send a copy of the manuscript, anticipated publication date, and contact information for the journal and your institution's PR office to your AHRQ project officer and to AHRQ Public Affairs at Your manuscript will be reviewed to determine what level of marketing we will pursue. Please be assured that AHRQ will always honor the journal publication embargo. Thank you for your cooperation.

11.  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.

Raab SS, Gryzbicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Cancer 2005 Nov 15;104(10):2205-13. Select to read the abstract in PubMed®.

Thomas EJ, Sexton JB, Lasky RE, et al. Teamwork and quality during neonatal care in the delivery room. J Perinatol. 2006 Mar;26(3):163-9. Select to read the abstract in PubMed®.

Ursprung R, Gray JE, Edwards WH, et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care. 2005 Aug;14(4):284-9. Select to read the abstract in PubMed®.

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

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Current as of April 2006


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