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Patient Safety and Health Information Technology E-Newsletter

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December 1, 2006, Issue No. 26

Quote of the Month

Chest tube insertion is a life-saving procedure—if performed incorrectly, patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury or infection.

—From a new AHRQ-published DVD, "Problems and Prevention: Chest Tube Insertion," developed by Colin F. Mackenzie, M.D. and the University of Maryland's National Study Center for Trauma and Emergency Medical Services, in Baltimore.

For more information on the DVD and related work being undertaken by Dr. Mackenzie and his colleagues, select Item No. 1.

Today's Headlines:

  1. AHRQ-Sponsored DVD Demonstrates Safe Techniques for Chest Tube Insertion
  2. AHRQ Director Calls for Achieving Enhanced Quality and Care Through Health IT
  3. AHRQ Awards More Than $5 Million to Study the Safe Delivery of Health Care Through Medical Simulation
  4. AHRQ Announces ACTION Project Awards
  5. Register Now to Learn More about AHRQ-Sponsored Keystone ICU Project in January
  6. Latest issue of AHRQ WebM&M Available Online
  7. AHRQ Transitioning To Electronic Grant Applications
  8. Calling All AHRQ Researchers! "Help Us To Help You"
  9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ-Sponsored DVD Demonstrates Safe Techniques for Chest Tube Insertion

AHRQ has published a new 11-minute DVD, "Problems and Prevention: Chest Tube Insertion," that uses excerpts from videotapes of 50 actual chest tube insertions to illustrate problems that can occur if this life-saving procedure is not done correctly. The DVD includes a demonstration of a series of preventive measures, using an easy-to-remember mnemonic, UWET, which stands for Universal Precautions (achieved by using sterile cap, mask, gown, and gloves); Wider skin prep; Extensive draping; and Tray positioning.

The DVD was developed under an AHRQ grant to Colin F. Mackenzie, M.D., and his colleagues at the University of Maryland's National Study Center for Trauma and Emergency Medical Services in Baltimore. Free single copies are available from the AHRQ Publications Clearinghouse at Select for additional information on the DVD.

2.  AHRQ Director Calls for Achieving Enhanced Quality and Care Through Health IT

AHRQ Director Carolyn M. Clancy, M.D., gave the keynote address at the 2006 World Healthcare Innovation and Technology (WHIT) Congress on November 1 in Washington, DC. Dr. Clancy focused on patient safety and health information technology, including overcoming barriers and opportunities for advancement.

"As the wiring of America's health care system continues, we need to find ways to integrate the principles and practice of evidence-based medicine across the full spectrum of care, particularly in areas including clinical decision support systems, payment systems, care coordination systems, and patient-provider communication systems," Dr. Clancy told the meeting participants.

The WHIT Congress was co-sponsored by The Wall Street Journal. Select to access Dr. Clancy's speech.

3.  AHRQ Awards More Than $5 Million to Study the Safe Delivery of Health Care Through Medical Simulation

AHRQ has awarded more than $5 million for 19 new grants under its "Improving Patient Safety Through Simulation Research" request for applications. The projects focus on assessing and evaluating the roles that simulation can play to improve the safe delivery of quality health care. These projects will inform providers, health educators, payers, policymakers, patients, and the public about the effective use of simulation in preventing medical errors and improving patient safety.

The projects span a wide spectrum of settings and populations in 16 States throughout the United States, including Children's Hospital of Philadelphia, Louisiana State University Health Sciences Center in New Orleans, and Scott and White Hospital in Temple, TX. Select to access our press release and select for a complete listing of the 19 projects.

4.  AHRQ Announces ACTION Project Awards

AHRQ has recently made awards for 13 new projects under its Accelerating Change and Transformation in Organizations and Networks (ACTION) program. ACTION, which is the successor to the Integrated Delivery System Research Network (IDSRN), fosters public-private collaboration in rapid-cycle, applied studies with a goal of turning research into practice.

ACTION includes 15 large partnerships that link many of the nation's largest health care systems with top health researchers and span all 50 states. For example, some of the ACTION projects funded in FY 2006 will help develop data and measurement capacity in the AQA Alliance pilot projects sponsored by HHS' Centers for Medicare & Medicaid Services and develop and test a rapid response team training module within the TeamSTEPPS curriculum recently unveiled by AHRQ and the Department of Defense. Select for a complete listing of project descriptions.

5.  Register Now to Learn More about AHRQ-Sponsored Keystone ICU Project in January

Register Now! Join AHRQ-researcher Peter Pronovost, M.D., Ph.D., and other faculty as they share methods, tools, and lessons learned from the Keystone ICU Project at a January 22 seminar in Baltimore. Thus far, the results of the project have led to a reduction in nosocomial infections, intensive care unit (ICU) mortality, ICU length of stay, and health care costs.

The Keystone ICU Project, an AHRQ-sponsored quality improvement collaboration, was a partnership between the Johns Hopkins University School of Medicine, the Michigan Health & Hospital Association Keystone Center, and its member hospitals. Continuing medical/nursing education (CME/CNE) credits may be obtained upon completion of this course.

For more details and registration information, contact course director Lisa Lubomski, Ph.D., Assistant Professor at Johns Hopkins University, at

6.  Latest issue of AHRQ WebM&M Available Online

The November 2006 issue of AHRQ WebM&M is available online. This month, the Perspectives on Safety section examines the crucial linkage between human factors and patient safety. John Gosbee, M.D., M.S., a human factors engineering and health care specialist, offers his perspective on how viewing safety issues through a human factors lens can create the "surprises" needed to develop innovative, robust solutions. An interview about human-centered design features Don Norman, Ph.D., who is well known for his book The Design of Everyday Things.

In the Spotlight Case, a woman with end-stage renal disease and heart disease who is taking blood thinners receives a pneumonia vaccination that causes a large hematoma. The commentary, authored by Peter Lindenauer, M.D., M.Sc., of Baystate Health and Tufts University School of Medicine, discusses the potential unintended consequences of adhering to publicly reported quality standards. In the second case, a man with benign prostatic hypertrophy begins having trouble with urination following elective surgery. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics. In the third case, an elderly woman undergoes knee replacement, during which her airway is maintained with a laryngeal mask airway. Soon after, she develops a fever and fullness in her neck, which a computed tomography (CT) scan reveals to be retropharyngeal and mediastinal abscesses. Commentary authors are Angela Joseph, R.N., M.S.N., of the San Diego Veterans Administration Health Care System and Jonathan Jahr, M.D., and Puya Hosseini of the University of California, Los Angeles.

A Spotlight slide presentation is available for download, as always, and you can receive CME, continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. All previously published commentaries are available under "Case Archive." Please submit cases to AHRQ WebM&M via the "Submit Case" button.

7.  AHRQ Transitioning To Electronic Grant Applications

AHRQ continues its transition to electronic grant applications. All R01 research grant applications for the February 5 deadline must be submitted electronically using form set SF 424 (R&R). One-time registrations for both and the eRA Commons systems must be completed before application submission.

Applicants should submit applications early—ideally 4 weeks before the deadline. This transition continues through May 2007. Select for additional information.

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

As you may know, AHRQ can help you promote the findings of your research, 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 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 communications 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 always honors the journal embargo. Thank you for your cooperation.

9.  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.

Blake SC, Kohler S, Rask KJ, et al. Facilitators and Barriers to 10 NQF Safe Practices. Am J Med Qual 2006;21(5):323-34. Select to access the abstract in PubMed®.

MacPhee M, Ellis J, Sanchez McCutcheon A. Nurse staffing and patient safety. Can Nurs 2006 Oct;102(8):19-23. Select to access the abstract in PubMed®.

McLoughlin V, Millar J, Mattke S, et al. Selecting indicators for patient safety at the health system level in OECD countries. Int J Qual Health Care 2006 Sep;18(suppl_1):14-20. Select to access the abstract in PubMed®.

Meyers DS, Mishori R, McCann J, et al. Primary care physicians' perceptions of the effect of insurance status on clinical decision making. Ann Fam Med 2006 Sep-Oct;4(5):399-402. Select to access the abstract in PubMed®.

Rask KJ, Schuessler LD, Naylor D. A Statewide Voluntary Patient Safety Initiative: The Georgia Experience. Jt Comm J Qual Patient Saf 2006;32(10):564-72. Select to access the abstract in PubMed®.

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

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Current as of December 2006


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