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Patient Safety and Health Information Technology E-Newsletter

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November 6, 2006, Issue No. 25

Quote of the Month

"AHRQ and the Department of Defense have joined forces to bring a much-needed product into the public domain. We want to see TeamSTEPPS used in both military and community health settings".

—David Tornberg, M.D., Assistant Secretary of Defense for Health Affairs (for more information, select Item No. 1).

Today's Headlines:

  1. AHRQ and Department of Defense Release New Patient Safety Team Training Toolkit
  2. AHRQ's Recent Healthcare 411 Newscasts Highlight Research on Surgery and Health IT
  3. Change in Standing Receipt Dates for AHRQ Grant Applications Beginning in January 2007
  4. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ and Department of Defense Release New Patient Safety Team Training Toolkit

AHRQ has joined with the Department of Defense in releasing TeamSTEPPSTeam Strategies and Tools to Enhance Performance and Patient Safety—a new evidence-based team training toolkit for clinicians that demonstrates techniques of effective communication and other teamwork skills to prevent medical errors. Designed for high-stress situations such as hospital emergency departments, critical care units, operating rooms, and obstetrical suites, this multimedia curriculum can be tailored to any health care setting, including physicians' offices and ambulatory clinics. Components of the toolkit include:

  • An Instructor Guide that explains how to conduct a pre-training assessment of an organization's training needs, how to present the information effectively, and how to manage organizational change.
  • PowerPoint® presentations that convey basic TeamSTEPPS principles.
  • A DVD that contains nine video vignettes that show how failures in teamwork and communication can place patients in jeopardy, and how successful teams can work to improve patient safety.
  • A spiral-bound pocket guide that summarizes TeamSTEPPS principles in a portable, easy-to-use format.
  • A CD-ROM that contains files of all print materials so that users of TeamSTEPPS can adapt the presentations to reflect their institutions' particular situations.
  • A 17" X 22" poster to announce TeamSTEPPS activities in a heath care organization.

Single copies of the CD-ROM and DVD, the poster, and the pocket guide can be obtained free of charge from the AHRQ Publications Clearinghouse by calling 800-358-9295, sending an E-mail to E-mail to, or using the order form on the AHRQ Web site. For more information on TeamSTEPPS, see AHRQ's press release.

2.  AHRQ's Recent Healthcare 411 Newscasts Highlight Research on Surgery and Health IT

Below are summaries of recent AHRQ audio newscasts that relate to patient safety:

  • Making Surgery Safer. This 6-minute newscast discusses a new effort called the Surgical Care Improvement Project (SCIP). With input from consumer groups, SCIP includes Federal government agencies, hospital, physician and nursing organizations, and private groups dedicated to improving health care safety. SCIP has set a goal of reducing surgical complications nationwide by 25 percent by 2010. Select to access this newscast.
  • Health IT is Used to Reduce Pressure Ulcers. This 12-minute newscast features an interview with AHRQ health IT grantee Susan Horn, Ph.D., senior scientist for the Institute for Clinical Outcomes Research, Salt Lake City, UT, discussing her study that used health IT to reduce the prevalence of pressure ulcers in nursing homes. Dr. Horn worked with the nursing home staff to help them design new forms to better track the health of the residents and reduced pressure ulcers by one-third. The newscast also highlights some findings from a recent Kaiser/AHRQ survey on the public's view of medical errors. Select to access this newscast.
  • Weighing the Benefits and Risks of a Medication or Treatment. AHRQ's latest Healthcare 411 "Quality Insider" is about understanding the risks and benefits of medical treatments and procedures. AHRQ Director Carolyn M. Clancy, M.D., explains the terms and discusses how risks and benefits help patients to make decisions about their health care treatment. Select to access this 9-minute audio program.

You can listen to these audio newscasts directly through your computer—if it has a sound card and speakers and can play MP3 audio files—or you can download it to a portable audio device. In any case, you will be able to listen at your convenience. To access any of AHRQ's newscasts and special reports or to sign up for a free subscription to the series to receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.

3.  Change in Standing Receipt Dates for AHRQ Grant Applications Beginning in January 2007

AHRQ published an October 5 notice informing the extramural research community of a change in standard receipt dates for grant applications submitted to AHRQ. The new receipt dates will be effective as of January 2007 and will apply to both paper and electronic applications. New dates are announced for a variety of new, renewal, resubmission, and revision applications. Select for details on specific changes by funding mechanism.

4.  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, ask your technical support staff for possible remedies.

Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006 Oct 3;145(7):488-96. Select to access the abstract in PubMed®.

Ridley DB, Kramer JM, Tilson HH, et al. Spending on postapproval drug safety. Health Aff 2006 Mar-Apr;25(2):429-36. Select to access the abstract in PubMed®.

Smith DH, Perrin N, Feldstein A, et al. The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation. Arch Intern Med 2006 May 22;166(10):1098-104. Select to access the abstract in PubMed®.

Walsh KE, Adams WG, Bauchner H, et al. Medication errors related to computerized order entry for children. Pediatrics 2006 Nov;118(5):1872-9. Select to access the abstract in PubMed®.

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

Please address comments and questions regarding the newsletter to Salina Prasad at or (301) 427-1864.

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Current as of November 2006


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