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Patient Safety and Health Information Technology E-Newsletter

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November 23, 2004, Issue No. 3

Quote of the Month

"Many steps have been taken to improve patient safety, and the greater use of health information technology is one of the most promising developments in this area. However, these are largely 'system-related' improvements that aren't always apparent, even though consumers may recognize their importance. Our challenge is to show the connection between these kinds of changes and improving the care patients receive, while at the same time expanding and accelerating those efforts."

—Carolyn M. Clancy, M.D., Director, AHRQ, in remarks at a November 17 press event on the National Survey on Consumers' Experiences with Patient Safety and Quality Information.

Select for more information about the survey.

Today's Headlines:

  1. New national patient safety survey developed by the Henry J. Kaiser Family Foundation, AHRQ, and the Harvard School of Public Health
  2. New survey helps hospitals measure and improve patient safety culture
  3. Tools and findings from AHRQ's patient safety portfolio
  4. Calling all AHRQ researchers! "Help us to help you"
  5. AHRQ in the patient safety professional literature—some useful citations
  6. New item coming soon

1.  New National Patient Safety Survey Developed by the Henry J. Kaiser Family Foundation, AHRQ, and the Harvard School of Public Health

Five years after a groundbreaking Institute of Medicine report focused attention on medical errors in hospitals, Americans say that they do not believe that the nation's quality of care has improved. Four in 10 (40 percent) people say the quality of health care has gotten worse in the past 5 years, while one in six (17 percent) says the quality of care has gotten better, and nearly four in 10 (38 percent ) say it has stayed the same, according to the new survey. The survey was developed and analyzed by the Henry J. Kaiser Family Foundation, AHRQ, and the Harvard School of Public Health. The National Survey on Consumers' Experiences with Patient Safety and Quality Information also finds that one in three people (34 percent) says that they or a family member has experienced a medical error at some point in their life. In addition, people with chronic health conditions are considerably more likely than other consumers to express concerns about their quality of care and report having personal experience with medical errors. Select to access the joint press release and summary and chartpack.

2.  New Survey Helps Hospitals Measure and Improve Patient Safety Culture

AHRQ announced a new tool to help hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units. The Hospital Survey on Patient Safety Culture, released in partnership with Premier, Inc., the Department of Defense, and the American Hospital Association, addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm. To ensure widespread awareness and use of the survey, AHRQ and its partners will host a toll-free audioconference in January 2005 to help health professionals adopt and use the survey. Details on the audioconference will be made available on the AHRQ Web site and in this electronic newsletter in early January. Select to access our press release and the survey. A print copy of the survey may be ordered by sending an E-mail to

3.  Tools and Findings from AHRQ's Patient Safety Portfolio

As part of AHRQ's commitment to improve patient safety and reduce medical errors, the Agency has funded more than 100 projects on these topics since fiscal year 2001. This support has resulted in the development of new and innovative findings, tools, and products that can be used by the health care system, health care providers, and researchers to help improve patient safety. Below are examples of findings, tools, and products that have resulted from AHRQ-supported research:

New Sessions and CME Modules Offered to Reduce Medical Errors

AHRQ-supported researchers have developed train-the-trainer sessions and continuing medical education (CME) modules to address patient safety and ambulatory care. These courses result from an AHRQ-funded study led by Christel Mottur-Pilson, Ph.D., Director, Scientific Policy, American College of Physicians, Philadelphia. They are designed to raise physician awareness of patient safety issues, promote positive physician attitudes regarding the need to identify and analyze the practice environment to reduce medical errors, and facilitate physician behavior that is likely to diminish the occurrence of medical error. The 2-day train-the-trainer learning session is designed to train internists to teach the ACP's ambulatory care patient safety curriculum. Go to the ACP Web site for details.

New Web Site Now Available for Improving Medication Use

AHRQ researchers have developed a Web site that serves as a repository of studies on reducing medication errors called the Tools and Techniques of Improved Medication Use. The site, found on the Web page of America's Health Insurance Plans, was designed to translate research findings into practice by presenting detailed descriptions of intervention strategies, resources, and results that can be replicated in multiple settings. The project was led by Richard Platt, M.D., M.Sc., and Stephen B. Soumerai, Sc.D., of Harvard Pilgrim Health Care, Boston. Categorized by medical condition and intervention strategy, the Web site lists nearly 50 scientific studies focusing on improved medication use and patient compliance through varied intervention strategies. The project is carried out by AHRQ's Centers for Education and Research on Therapeutics program, a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. Select to access the new medication use site through the AHRQ-sponsored QualityTools Web site.

4.  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 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 always honors the journal embargo. Thank you for your cooperation.

5.  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.

Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003 Oct;29(10):503-11. Select to access the abstract on PubMed®.

Kovner C. The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations. Jt Comm J Qual Improv 2001 Sep;27(9):458-68. Select to access the abstract on PubMed®.

Myers SS, Lynn J. Patients with eventually fatal chronic illness: their importance within a national research agenda on improving patient safety and reducing medical errors. J Palliat Med 2001 Fall;4(3):325-32. Select to access the abstract on PubMed®.

Potter P, Boxerman S, Wolf L, Marshall J, Grayson D, Sledge J, Evanoff B. Mapping the nursing process: a new approach for understanding the work of nursing. J Nurs Adm 2004 Feb;34(2):101-9. Select to access the abstract on PubMed®.

6.  New Item Coming Soon

AHRQ's 2004 National Healthcare Quality and Disparities Reports

AHRQ will be publicly releasing the 2004 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). These reports provide baseline views of the quality of health care and differences in use of the services. Select for more information on the 2003 NHDR.

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

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Current as of November 2004


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