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Patient Safety and Health Information Technology E-Newsletter

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May 5, 2006, Issue No. 19

Quote of the Month

"Wrong-site surgery is extremely rare and major injury from it even rarer."

—Mary R. Kwaan, M.D., M.P.H., of Brigham and Women's Hospital and Harvard School of Public Health

More information on findings from Dr. Kwann's study can be found in items No. 1 and No. 7.

Today's Headlines:

  1. AHRQ study finds wrong-site surgery rare and preventable
  2. AHRQ director addresses hill briefing on patient safety organizations
  3. AHRQ requests proposals for medical simulation projects
  4. AHRQ releases new report to help providers adopt health IT
  5. AHRQ expands therapeutic education and research network to focus on critical issues facing the health care system
  6. Common oral medications are often misidentified by health care practitioners
  7. AHRQ's latest Healthcare 411 audio series features stories on wrong-site surgery, diabetes, eating disorders, and more
  8. Tools for medication reconciliation help promote safe practices
  9. National Guideline Clearinghouse™ features patient safety-related guidelines
  10. Visit the AHRQ patient safety network Web site
  11. Deadline extended for submitting data to populate AHRQ's new Hospital Survey on Patient Safety Culture Database
  12. Register now for AHRQ's 2006 annual patient safety and health IT conference, June 4-7
  13. AHRQ in the patient safety professional literature—some useful citations

1.  AHRQ Study Finds Wrong-site Surgery Rare and Preventable

Wrong-site surgery is extremely rare and major injury from it even rarer, according to an AHRQ-funded study published in the April 2006 Archives of Surgery. The term "wrong-site surgery" includes surgery on the wrong organ or limb, at the wrong site on the spine, or on the wrong person. Researchers led by Mary R. Kwaan, M.D., M.P.H., of Brigham and Women's Hospital and Harvard School of Public Health in Boston, estimate that a wrong-site surgery serious enough to result in a report to insurance risk managers or in a lawsuit would occur approximately once every 5 to 10 years at a single large hospital.

The study assessed all wrong-site surgeries reported to a large medical malpractice insurer between 1985 and 2004 and found that the number of wrong-site surgeries conducted on limbs or organs other than the spine occurred once in every 112,994 operations. Forty cases of wrong-site surgery were identified among 1,153 malpractice claims and 259 instances of insurance loss related to surgical care were reported. Twenty-five of the cases were non-spine wrong-site surgeries, with the remainder involving surgery of the spine. Select to read our press release and to read an abstract of the article, "Incidence, patterns, and prevention of wrong-site surgery" in PubMed®.

2.  AHRQ Director Addresses Hill Briefing on Patient Safety Organizations

AHRQ Director Carolyn M. Clancy, M.D., keynoted at an April 7 Alliance for Health Reform briefing on Capitol Hill to discuss last year's enactment of the Patient Safety and Quality Improvement Act. AHRQ is currently drafting proposed regulations to implement the legislation, which requires providers to report medical errors to designated entities known as Patient Safety Organizations (PSOs).

Questions addressed at the briefing included: How will these PSOs operate? What information will be reported to them and how will policymakers use the data to make additional improvements in health care facilities across the country? Select to view a video Webcast or to listen to an audio podcast of the event. Select for more information on AHRQ's efforts to implement the legislation.

3.  AHRQ Requests Proposals for Medical Simulation Projects

AHRQ is interested in funding research and evaluation of simulation and the roles it can play in improving the safe delivery of health care, according to an April 12 announcement in the NIH Guide. Simulation is described as a strategy—not a technology—to mirror, anticipate, or amplify real situations with guided experiences in a fully interactive way. Simulation can complement other organizational change methods to facilitate adoption and implementation of best practices and new technologies.

In these projects, AHRQ is interested in the use of and/or adaptation of simulation tools in diverse health care settings and the evaluation of their impact on improving patient safety. AHRQ intends to fund 8 to 10 new grants for a total of $2.4 million. Applications are due May 22. Select for details.

4.  AHRQ Releases New Report To Help Providers Adopt Health IT

AHRQ Director Carolyn M. Clancy, M.D., released a new health information technology (IT) report during the eHealth Initiative's Connecting Communities Learning Forum on April 11. The report acknowledges that while health IT has been shown to improve quality of care for patients, most health care providers need more information about how to implement these technologies successfully. The report, Costs and Benefits of Health Information Technology, is a synthesis of studies that have examined the quality impact of health IT as well as the costs and organizational changes needed to implement health IT systems.

This report reviews scientific data about the implementation of health IT to date, as documented in studies published through 2003. It does not project future health care benefits or savings, in contrast to other reports. The report was prepared by AHRQ's Southern California Evidence-based Practice Center-RAND Corporation. Select to read our press release to and to read the report.

In addition, Dr. Clancy said in her April 11 speech to the eHealth group that health IT has left behind a period of "rational exuberance" and entered the more important phase of "hard work." Implementation of health IT involves one part technology, and two parts work flow and culture change, she noted.

5.  AHRQ Expands Therapeutic Education and Research Network To Focus on Critical Issues Facing the Health Care System

AHRQ announced the award of $16 million over the next 5 years to establish four new Centers for Education and Research on Therapeutics (CERTs) to increase awareness of the benefits and risks of therapeutic products, including prescription medicines, biological products and medical devices, and to translate research findings into improved health care. The four new AHRQ-funded CERTs are located at Rutgers, the State University of New Jersey in New Brunswick; the University of Iowa in Iowa City; Baylor College of Medicine in Houston; and Weill Medical College of Cornell University in New York City.

The cooperative agreement grants expand the existing CERTs network from 7 to 11 AHRQ-funded centers and one coordinating center. Each center will work collaboratively with AHRQ and the FDA to conduct research and provide education that advances the optimal use of medications, medical devices, and biologic products. Select to read our press release and for more information on CERTs activities.

6.  Common Oral Medications Are Often Misidentified by Health Care Practitioners

Physicians and pharmacists fail to correctly identify the tablets of three common, everyday medications—Zocor (a cholesterol-lowering drug), lorazepam (a sedative), and naproxen (a pain reliever)—more than a third of the time, possibly because a standardized system for marking prescription tablets with identifying codes and symbols is lacking. This could cause confusion and medication errors, according to researchers led by Gordon Schiff, M.D., Director, Clinical Quality Research and Improvement, and Senior Attending Physician, Department of Medicine, John H. Stroger Jr. Hospital of Cook County.

An abstract of the study, jointly funded by the Agency for Healthcare Research and Quality, the United States Pharmacopeia, Inc., and the American Society for Health Systems Pharmacists Research and Education Foundation, was published in the May 1 issue of the American Journal of Health-System Pharmacy.

7.  AHRQ's Latest Healthcare 411 Audio Series Features Stories on Wrong-site Surgery, Diabetes, Eating Disorders, and More

AHRQ's latest audio newscast features an interview with Dr. Mary Kwaan, who discusses her research on wrong-site surgery. Other highlights from the newscast are:

  • Fewer than half of Americans with diabetes get the necessary annual tests to manage their disease properly.
  • Behavioral therapy may be effective in treating eating disorders, but few medications work.
  • Researchers examine the impact of health IT on health care quality, and discuss the costs and organizational changes needed to implement health IT systems.
  • Plus, the newscast includes a new public service announcement on 20 Tips to Help Prevent Medical Errors in Children.

Select to listen to AHRQ's 15-minute newscast. To access any of AHRQ's newscasts and special reports, or to learn about subscribing to receive all AHRQ podcasts automatically, go to the Healthcare 411 home page.

8.  Tools for Medication Reconciliation Help Promote Safe Practices

A toolkit to support hospitals' adoption of safe practices for reducing medication errors—including recommendations for medication reconciliation and strategies for putting the recommendations into practice—has been created by AHRQ researchers, led by grantee Nancy Ridley, M.S. Hospitals nationwide are using these tools to comply with JCAHO's National Patient Safety Goals and the Institute for Healthcare Improvement's 100,000 Lives Campaign.

The safe practice recommendations, many of the implementation strategies, and sample tools are available from the Massachusetts Coalition for the Prevention of Medical Errors. Select to access an abstract of the article "Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies," published in the January 2006 issue of the Joint Commission Journal on Quality and Patient Safety.

9.  National Guideline Clearinghouse™ Features Patient Safety-related Guidelines

Did you know that approximately 240 of more than 1,800 guidelines included in the National Guideline Clearinghouse™ have been categorized in the Institute of Medicine's domain of "safety"? To learn more about these guidelines, and for a selection of preset patient safety topic searches, go to the "Frequently Requested Searches." Then scroll down to "Patient Safety" and select from the eight specific areas of interest, which include fall prevention, medication safety, and the prevention and surveillance of nosocomial infections.

10.  Visit the AHRQ Patient Safety Network Web site

AHRQ's 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. It 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 of 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 particular interests and needs through the Web site's unique "My PSNet" feature.

11.  Deadline Extended for Submitting Data to Populate AHRQ's New Hospital Survey on Patient Safety Culture Database

Register now to submit data for AHRQ's new Survey on Patient Safety Culture Database, which will serve as a national repository for data collected using AHRQ's Hospital Survey on Patient Safety Culture. The database will be an important resource for hospitals wishing to compare their patient safety culture survey results with those of similar hospitals. Participation is open to hospitals in the United States and any of its territories that have completed administration of the AHRQ survey by June 30.

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

12.  Register Now for AHRQ's 2006 Annual 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 in 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 improve health care quality. Get a "first look" at the evidence base for widespread health IT adoption.

13.  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.

Cimiotti JP, Quinlan PM, Larson EL, et al. The magnet process and the perceived work environment of nurses. Nurs Res 2005 Nov-Dec;54(6):384-90. Select to access the abstract in PubMed®.

Duclos CW, Eichler M, Taylor L, et al. Patient perspectives of patient-provider communication after adverse events. Int J Qual Health Care 2005 Dec;17(6):479-86. Epub 2005 Jul 21. Select to access the abstract in PubMed®.

Schneider EC, Zaslavsky AM, Epstein AM. Quality of care in for-profit and not-for-profit health plans enrolling Medicare beneficiaries. Am J Med 2005 Dec;118(12):1392-400. Select to access the abstract in PubMed®.

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Current as of May 2006


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