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November 1, 2004, Issue No. 2
Quote of the Month
AHRQ Patient Safety Researchers in the News
"While sleep experts advocate 8 hours of sleep per 24-hour period, it has historically been difficult to achieve in medicine as patient care is an around-the-clock effort. These are the first studies to demonstrate clinically that reducing work shifts and tackling sleep deprivation will help increase attentiveness and reduce medical errors."
—Charles Czeisler, M.D., Ph.D.
Select for more information on new studies by Dr. Czeisler and his colleagues at Brigham and Women's Hospital.
- Limiting medical interns' work hours can reduce serious medical errors in ICUs
- HHS awards $139 million to drive adoption of health information technology
- More tools and findings from AHRQ's recent patient safety conference
- AHRQ participating in development of Surgical Care Improvement Partnership
- AHRQ begins second class of Patient Safety Improvement Corps
- Latest issue of AHRQ WebM&M is available online
- Recent findings from important AHRQ patient safety research
- AHRQ in the patient safety professional literature—some useful citations
- Featured items coming up in our next issue
1. Limiting Medical Interns' Work Hours Can Reduce Serious Medical Errors in ICUs
The rate of serious medical errors committed by first-year doctors in training (interns) in two intensive care units (ICUs) at a Boston hospital fell significantly when traditional 30-hour-in-a-row extended work shifts were eliminated, and when interns' continuous work schedules were limited to 16 hours, according to two new studies funded by AHRQ and the Centers for Disease Control & Prevention's (CDC) National Institute for Occupational Safety and Health. In the first study, "Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units," led by Christopher P. Landrigan, M.D., M.P.H., and his colleagues, 24 interns were randomly assigned to work either the traditional schedule in the cardiac care unit and the intervention schedule in the medical intensive care unit or the converse from July 2002 to June 2003. The second study, " Effect of Reducing Interns' Weekly Work Hours on Sleep and Attentional Failures," led by Steven W. Lockley, Ph.D., and his colleagues, examined the impact of the new work schedule on interns' sleep patterns and "attentional failures," characterized by nodding off while on duty, even while providing care to patients. These two complementary studies, published in the October 28 issue of the New England Journal of Medicine, result from a project led by Charles Czeisler, M.D., Ph.D., Chief of Brigham and Women's Hospital's Sleep Medicine Division. Select to access our press release, an abstract of Dr. Landrigan's study on PubMed®, and an abstract of Dr. Lockley's study on PubMed®.
2. HHS Awards $139 Million to Drive Adoption of Health Information Technology
HHS announced $139 million in grants and contracts to promote the use of health information technology (HIT). Awarded through AHRQ, this multi-year program builds on President Bush's initiative to use HIT to improve the nation's health care system. These awards will provide insight into how best to use health information technologies to improve patient safety by reducing medication errors; increasing the use of shared health information between providers, laboratories, pharmacies and patients; helping to ensure safer patient transitions between health care settings, including hospitals, doctors' offices, and nursing homes; and reducing duplicative and unnecessary testing. Select to access the HHS press release and the fact sheet for more information about each grant.
3. More Tools and Findings from AHRQ's Recent Patient Safety Conference
Presentations from AHRQ's conference, "Making the Health Care System Safer: Third Annual Patient Safety Conference," are now posted on AHRQ's Patient Safety Research Coordinating Center (PSRCC) Web site. Select the conference button on the right-hand side of the home page. If you are not a regular AHRQ-PSRCC Web site user, please use the following information to gain access: User ID: conference; Password: AHRQ3rd. Below are highlights of tools that were featured among the 75 displays at the conference. Stay tuned for more updates on tools and products in upcoming issues.
Hand-held Technologies Reduce Medication Errors
AHRQ researchers have developed a training curriculum to help physicians use personal digital assistants (PDAs) for electronic prescribing through case-based simulation. Researchers, led by Kimberly Galt, Pharm.D., Associate Dean of Research and Professor of Pharmacy Practice, Creighton University, Omaha, NE, describe a prospective, randomized, controlled trial of 80 physicians in primary care office-based practices to determine the impact of using PDAs for drug information sources and prescription printing on potential medication errors generated during prescribing. These tools bring electronic drug information and prescription printing technology to the point of care in primary care physicians' offices and will improve clinical decision making, reduce prescribing errors, and advance patient safety. The curriculum will be offered at Creighton University in the spring of 2005 as part of the Foundations in Patient Safety Course. The course itself is being offered to medical, pharmacy, nursing, dental, physical therapy, occupational therapy, law, social work and business students at the university. Select to access the Creighton University Web site for more details.
New Patient Safety Education Modules Available for CME/CEU Credit
AHRQ researchers have developed three interactive Web-based modules for physicians, nurses, and patients on a range of patient safety topics. Under the direction of the National Patient Safety Foundation (NPSF), researchers worked with physicians, nurses, patient representatives, and educators throughout the United States to develop a standard method of patient safety education. The modules provide fundamental information to achieve safe patient care and have active links to other educational sites as well as to additional information about the concepts presented in the educational units within each module. Instructions for obtaining continuing medical education (CME) and continuing education unit (CEU) credits for completing the online patient safety units are available on the NPSF Web site.
4. AHRQ Participating in Development of Surgical Care Improvement Partnership
The Surgical Care Improvement Project (SCIP) is a national partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications. In summer 2005, the SCIP partnership will launch a multi-year national campaign to substantially reduce surgical mortality and morbidity in four target areas through collaborative efforts. The goal is to reduce the national incidence of surgical complications by 25 percent by the year 2010. The project is led by Centers for Medicare and Medicaid Services (CMS) and CDC. AHRQ is a member of the SCIP Partnership's steering committee. Select to access the SCIP Web site for more information.
5. AHRQ Begins Second Class of Patient Safety Improvement Corps
AHRQ, in partnership with the Department of Veterans Affairs, is supporting the second year of a training program to create a Patient Safety Improvement Corps (PSIC), comprised of teams of State health officials and their selected hospital partners as well as quality improvement organizations and their selected hospital partners. 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 20 States and the District of Columbia are participating in the 2004-2005 PSIC class, joining teams from 15 States that participated in the inaugural 2003-2004 class. Select to access the fact sheet for more information on the PSIC training program and the class lists for 2004-05 and 2003-04.
How the PSIC is Helping to Advance Excellence in Health Care
The New York State Department of Health participated in the first year of the PSIC training program and, as a result, is now holding nine regional educational sessions throughout the state. These sessions focus on the culture of safety, human factors engineering, quality assurance practices, and improving the quality of root cause analysis through hospital associations.
6. Latest Issue of AHRQ WebM&M Is Available Online
The latest issue of AHRQ WebM&M, an online patient safety journal, is now available. In light of health information technology's growing momentum, two of October's cases focus on health IT's potential risks. In the first case, a patient's planned move from one hospital room to another is documented in the electronic record before it actually occurs, nearly leading to a wrong-patient medication error. In the second case, an electronic health record fails to prevent (and may even have contributed to) an overdose of medications to prevent angina. Other cases in the October issue include a patient who is burned by the tip of a laparoscope when the instrument is laid on top of her surgical drape and a physician who fails to notice a speech therapist's recommendation that a neurologically impaired patient not be fed by mouth. The patient continues to eat, aspirates, and dies. The October Spotlight case involves a patient having difficulty breathing who fails to improve because she was mistakenly placed on compressed air instead of oxygen. 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. Cases and CME/CE from previous issues are still available under "Archives" and "Past Issues" on the site. You can also submit a case for consideration for future editions of the online journal.
7. Recent Findings from Important AHRQ Patient Safety Research
Many Chronically Ill Patients Don't Tell Their Doctors That They Limit Use of Prescription Drugs Because of Cost
A recent AHRQ-funded study shows that about two-thirds of chronically ill adults who cut back on their medications because of the cost don't tell their doctors in advance. The researchers found that most patients who failed to talk with their clinicians about medication costs said that none of their providers asked them about possible problems paying for their treatments. Patients also reported that they didn't think their clinicians would be able to help them with this problem or that they were too embarrassed to discuss issues related to cost. Most patients who did discuss the cost of prescription drugs with their clinicians found their clinicians to be helpful, and they received a variety of forms of assistance such as free samples or a change in their regimen to a less-expensive or generic alternative. The study, led by John D. Piette, Ph.D., and his colleagues from the Center for Practice Management and Outcomes Research at the VA Ann Arbor Healthcare System, was published in the September 13 issue of the Archives of Internal Medicine. Select to access our press release and Select to access the abstract on PubMed®.
Positive Attitudes Toward Electronic Healthcare Records and Web-based Communication
According to a recent AHRQ-funded study, patients are becoming increasingly satisfied through Web-based communication with their health care providers and online access to their electronic health care records (EHR). Researchers conducted an online survey of 4,282 Geisinger Health System members who are registered users of an application that allows patients to communicate electronically with their providers and view selected portions of their EHR. They also conducted focus groups with 25 patients who were using the system and conducted one-on-one interviews with 10 primary care clinicians. The study, led by Andrea Hassol, M.S.P.H., of Abt Associates Inc., Cambridge, MA, was published in the August 6 issue of the Journal of the American Medical Informatics Association. Select to access the abstract on PubMed®.
8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations
We are providing the following hyperlinks to abstracts of AHRQ-funded journal articles. These abstracts are available 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.
Feinstein KW, Grunden N, Harrison EI. A region addresses patient safety. Am J Infect Control 2002 Jun;30(4):248-51. Select to access the abstract on PubMed®.
Lilford RJ, Mohammed MA, Braunholtz D, Hofer TP. The measurement of active errors: methodological issues. Qual Saf Health Care 2003 Dec;12 Suppl 2:ii8-12. Select to access the abstract on PubMed®.
Saint S, Chenoweth CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003 Jun;17(2)411-32. Select to access the abstract on PubMed®.
Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med 2003 Nov;18(11):893-902. Select to access the abstract on PubMed®.
9. Featured Items Coming Up in Our Next Issue
Hospital Survey on Patient Safety Culture
AHRQ and the Medical Errors Workgroup of the Quality Interagency Coordination Task Force (QuIC) developed the Hospital Survey on Patient Safety Culture. This new tool will help hospitals and large health systems assess the current culture of patient safety within their organizations so they can improve the safety of services that patients receive.
Medical Errors Survey
AHRQ, the Kaiser Family Foundation, and the Harvard School of Public Health will announce the results of a public opinion survey to assess consumers' attitudes about medical errors, patient safety, and the use of information on health care quality. This survey builds on similar versions conducted in 1996 and 2000. The announcement will be held on November 17 at the Kaiser Family Foundation's Washington, DC, office.
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Current as of November 2004