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Patient Safety E-Newsletter

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April 6, 2007, Issue No. 30

Patient Safety Quote of the Month

"I hope that you will find the purpose and rationale for the new Advances as exciting as I do and that you will be interested in sharing your unique patient safety efforts with the broader health care community."

—Carolyn Clancy, M.D., Director, AHRQ, on the Agency's new Call For Papers for the second Advances in Patient Safety publication.

For more information on Advances in Patient Safety, select Item No. 2.

Today's Headlines

1. AHRQ Partnerships in Implementing Patient Safety Grantees To Be Featured at NPSF Meeting in May
2. AHRQ Issues a Call for Papers for the Second Advances in Patient Safety Publication
3. Latest Issue of AHRQ WebM&M Available Online
4. New Podcast Features Research About Reducing Catheter-Related Bloodstream Infections
5. New Study Finds Outpatient Medication Errors Common but Difficult to Detect Among Organ Transplant Patients
6. Calling All AHRQ Researchers! "Help Us To Help You"
7. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1. AHRQ Partnerships in Implementing Patient Safety Grantees To Be Featured at NPSF Meeting in May

Agency for Healthcare Research and Quality (AHRQ) grantees who are completing toolkits as part of the Agency's Partnerships in Implementing Patient Safety (PIPS) projects will be showcasing the contents of those toolkits—which feature tools for medication reconciliation, hospital discharge, and much more—during special "Meet the Experts" sessions at the National Patient Safety Foundation's (NPSF) annual Patient Safety Congress on May 2-4 in Washington, DC. Fourteen of AHRQ's 17 PIPS grantees will be present at the "Meet the Experts" sessions in Exhibit Hall A during the following times:

Wednesday, May 2, 5:30 to 7:30 p.m.:

  • "Improving Patient Safety through Enhancements in Provider Communication Strategies," Kay Daugherty, Ph.D., R.N., Denver Health and Hospital Authority, CO.
  • "Implementing Reduced Work Hours for All ICU House Staff to Improve Patient Safety," Christopher Landrigan, M.D., Brigham and Women's Hospital, Boston, MA.
  • "Medication Reconciliation: Bridging Communications Across the Continuum of Care," Principal Investigator Melinda J. Muller, M.D., Legacy Health System, Portland, OR.
  • "Medications at Transitions and Clinical Handoffs," Gary Noskin, M.D., Northwestern University, Chicago, IL.

Thursday, May 3, 12:15 to 1:30 p.m.:

  • "Implementing a Program of Patient Safety in Small Rural Hospitals," Katherine Jones, Ph.D., University of Nebraska Medical Center, Omaha, NE.
  • "Safe Critical Care: Testing Improvement Strategies," Theodore Speroff , Ph.D., Vanderbilt University, Nashville, TN.
  • "Improving Warfarin Management in Competitive Healthcare Using ISO 9001 Principles," James Levett, M.D., Kirkwood Community College, Cedar Rapids, IA.

Thursday, May 3, 5:00 to 7:00 p.m.:

  • "The ED Pharmacist as a Safety Measure in Emergency Medicine," Rollin Fairbanks, M.D., University of Rochester, NY.
  • "Implementing a Simulation-Based Safety Curriculum in a Pediatric Emergency Site," Mary Patterson, M.D., Cincinnati Children's Hospital Medical Center, OH.
  • "Venous Thromboembolism Safety Toolkit: A Systems Approach to Safe Practice Interventions," Brenda Zierler, Ph.D., R.N., University of Washington, Seattle, WA.
  • "Patient Partnerships to Improve Safety in the Clinic Setting," Kathryn K. Leonhardt, M.D., Aurora Health Care, Milwaukee, WI.

2. AHRQ Issues a Call for Papers for the Second Advances in Patient Safety Publication

AHRQ seeks submissions for its second Advances in Patient Safety publication. The new peer-reviewed compendium, titled Advances in Patient Safety: New Directions and Alternative Approaches, will highlight new paradigms, directions, technologies, and findings that have potential for addressing patient safety concerns. AHRQ grantees, Federal agencies, professional associations, international partners, and other health care stakeholder groups are invited to submit abstracts and papers.

Contributions are invited from a broad array of topic areas and disciplines. The publication follows the first Advances in Patient Safety: From Research to Implementation publication released by AHRQ and the Department of Defense in May 2005. The deadline for abstract submission is Tuesday, May 8, 2007.

3. Latest Issue of AHRQ WebM&M Available Online

The March issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section examines the patient's role in improving safety. Rosemary Gibson, M.Sc., program officer of the Robert Wood Johnson Foundation, discusses how patients can help ensure their own safety. There is an interview with Sorrel King, whose daughter Josie King died due to a medical error at Johns Hopkins Hospital in Baltimore, and who has become an advocate for safety and patient-centered care.

In the first Spotlight Case, an infant received an overdose of the wrong antibiotic, but the error was not reported. Patient safety consultant Patrice Spath discusses common barriers to reporting adverse events and near misses, along with strategies to increase reporting. In the second case, a woman with insulin-dependent diabetes was placed on an insulin sliding scale. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the third case, a patient's preliminary post-surgical wound cultures grew Staphylococcus aureus. Although the final sensitivity profile showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis. Commentary authors are Richard Hellman, M.D., of the University of Missouri-Kansas City, and B. Joseph Guglielmo, Pharm.D., of the University of California, San Francisco. A Spotlight slide presentation is available for download.

As always, you can receive continuing medical education (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.

4. New Podcast Features Research About Reducing Catheter-Related Bloodstream Infections

A recent AHRQ Healthcare 411 audio program features an interview with Peter Pronovost, M.D., Ph.D., of The Johns Hopkins University School of Medicine in Baltimore, discussing his research about interventions to reduce bloodstream infections in hospital ICUs caused by central venous catheters. The study showed that the vast majority of the infections are preventable with simple and inexpensive measures. The 9-minute podcast also includes stories about surgeries performed at outpatient centers and about AHRQ's new "Questions are the Answer" public service campaign. Select to access the audio podcast.

You can listen to the audio program 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 either case, you will be able to listen at your convenience. To access any of AHRQ's podcasts and special reports or to sign up for a free subscription to the series and receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.

5. New Study Finds Outpatient Medication Errors Common but Difficult to Detect Among Organ Transplant Patients

Outpatient medication errors are abundant, often hard to detect, and associated with significant adverse events in a complex organ transplant population, according to a new AHRQ-funded study. In order to better understand the causal factors linked to medication errors and to define opportunities for systematic changes to improve the safety of prescription medication use, researchers documented medication errors that occurred among all recipients of liver, kidney, and pancreas transplants who were tracked by the Yale New Haven Organ Transplantation Center.

During a 1-year period, they identified 149 medication errors in 93 patients who were taking an average of 11 medications each. The most common type of error was patient error (56 percent of all errors), in which patients took medicines incorrectly. An additional 13 percent of the total errors were prescriptions errors; 13 percent were delivery errors; 10 percent were medication availability errors, and 8 percent were reporting errors. Researchers also examined the root causes of the errors, the majority of which were identified as the patient in 68 percent of errors; health care providers in 27 percent (including 10 percent caused by the transplant team); and, financial issues in 5 percent.

The study, "Medication errors in the outpatient setting: classification and root cause analysis," led by Amy L. Friedman, M.D.,of Yale University School of Medicine, New Haven, CT, was published in the March 2007 issue of the Archives of Surgery. Select to review an abstract of the study.

6. 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.

7. 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.

Clement JP, Lindrooth RC, Chukmaitov AS, et al. Does the patient's payer matter in hospital patient safety? Med Care 2007 Feb;45(2):131-8. Select to access the abstract in PubMed®.

Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care 2007 Feb;16(1):12-6. Select to access the abstract in PubMed®.

Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med 2007 Feb 12;167(3):302-8. Select to access the abstract in PubMed®.

Weingart SN, Price J, Duncombe D, et al. Patient-reported safety and quality of care in outpatient oncology. Jt Comm J Qual Patient Saf 2007 Feb;33(2);83-94. Select to access the abstract in PubMed®.

The Patient Safety E-newsletter is archived online at

Contact Information

Please address comments and questions to Salina Prasad at

Current as of April 2007


The information on this page is archived and provided for reference purposes only.


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