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Patient Safety E-Newsletter

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May 7, 2007, Issue No. 31

Patient Safety Quotes of the Month

"We need to set a target date by which we can say that all health care professionals—at the undergraduate and graduate levels—are trained in patient safety."
    —Carolyn M. Clancy, M.D.

"I welcome patient safety as a wedge to address many of the quality problems that exist in our health care system."
    —Donald M. Berwick, M.D.

"First we have to recognize that we have a problem, and then we have to figure out how to come together as a community to solve the problem."
    —James B. Conway.

"With hand washing, it's inconceivable that a surgeon would go into an operating room without scrubbing and putting on a gown and gloves, but it's okay to not wash your hands between rounds of patients on hospital wards. Why are we so rigorous in one area but not in another?"
    —Sir Liam Donaldson, M.D.

"We know that patient safety is a team sport, but all of health care delivery is in fact a team sport."
    —David M. Lawrence, M.D.

"We won't get where we need to go in health care until the consequences (of providing less-than-optimal care) are much more consequential. That will probably happen through reimbursement mechanisms.""
    —Lucian L. Leape, M.D.

Highlights from Distinguished Advisors Panel at National Patient Safety Foundation Annual Congress (Item No. 1).

Today's Headlines

1. AHRQ Activities at National Patient Safety Foundation Annual Meeting
2. New Survey Results Show Strong Teamwork but Room for Improvement with Handoffs and Transitions in Hospitals
3. AHRQ Seeks Participants for Fourth Class of Patient Safety Improvement Corps
4. AHRQ's New Resource Offers Suggestions for Improving the Safety in Health Care Environments
5. AHRQ Vacancy Announcements Posted
6. HHS Issues Report to Congress on E-Prescribing
7. Technology, Alert Systems, and High Workload Increase Risk of Dispensing of Potentially Harmful Drugs
8. AHRQ Produces Two New Audio Podcasts about Care Coordination and Transitions
9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1. AHRQ Activities at National Patient Safety Foundation Annual Meeting

AHRQ Director Carolyn M. Clancy, M.D., and several AHRQ researchers were key participants at the NPSF's Annual Patient Safety Congress held in Washington, D.C., last week. The meeting drew more than 1,200 attendees and provided participants with an interactive opportunity to learn about the latest in patient safety from the nation's most notable experts.

For example, Dr. Clancy participated in a distinguished advisors town hall meeting on May 3, along with Donald M. Berwick, M.D., President and CEO, Institute for Healthcare Improvement; James B. Conway, Senior Fellow, IHI; Sir Liam Donaldson, M.D., Chair, World Alliance for Patient Safety; David M. Lawrence, M.D., retired Chairman and CEO, Kaiser Foundation Health Plan and Hospitals; Lucian L. Leape, M.D., Adjunct Professor of Health Policy, Harvard School of Public Health; and Dennis S. O'Leary, M.D., President, the Joint Commission. Dr. Clancy also participated in a World Alliance for Patient Safety Event, cosponsored by the World Health Organization.

In addition, grantees from AHRQ's Partnerships in Implementing Patient Safety projects previewed their upcoming toolkits, which are scheduled for release this summer, during a special "Meet the Experts" session in the exhibit hall at the Congress. A video clip from AHRQ's new public service campaign—"Questions Are the Answer: Get More Involved With Your Health Care"—generated a lot of interest at the AHRQ exhibit booth. AHRQ and the Ad Council launched the national public service campaign to encourage patients and caregivers to take a more proactive role in their health care by asking questions.

The campaign includes television, radio, print, and Web advertising that directs audiences to AHRQ resources for obtaining tips on how to help prevent medical mistakes and become involved in their health care. Select for more information about "Questions are the Answer," including links to AHRQ's customizable Question Builder.

2. New Survey Results Show Strong Teamwork but Room for Improvement with Handoffs and Transitions in Hospitals

More than three-fourths (78 percent) of hospital staff believe there is a positive environment of teamwork within their units, but nearly half (45 percent) indicate there is room for improvement in the area of handoffs and transitions across units, according to the results of the 2007 Hospital Survey on Patient Safety Culture Comparative Database Report released by AHRQ. The report presents results from the first compilation of aggregated national data from AHRQ's Hospital Survey on Patient Safety Culture and is based on data from 382 U.S. hospitals and survey responses from 108,621 hospital staff.

The report found a number of strengths among hospitals as well as areas for patient safety culture improvement. The report provides the first national benchmarks for hospital staff assessments about patient safety issues, medical errors, and event reporting from a wide range of hospitals that participated in AHRQ's Hospital Survey on Patient Safety Culture. The report provides results by hospital characteristics such as bed size, teaching status, ownership, and geographic region. It also offers results by respondent characteristics such as respondent work area/unit, staff position and interaction with patients.

AHRQ recently issued an announcement for a second year of submissions to update the database with results from additional hospitals and evidence of change in the initial hospital set. The deadline for Year 2 submissions of all information and survey data files is June 30. Select for submission details and to access the report.

3. AHRQ Seeks Participants for Fourth Class of Patient Safety Improvement Corps

AHRQ, in partnership with the Department of Veterans Affairs' National Center for Patient Safety, is supporting a fourth year of the Patient Safety Improvement Corps (PSIC). This program provides training in a number of topics, tools, and methods designed to help participants reduce medical errors and improve patient safety.

Topics include patient safety science, human factors, root cause analysis, health care failure mode and effects analysis, probabilistic risk assessment, medical error reporting and analysis, measurement, and evaluation. Topics focused on organizational issues include communication, leading and sustaining organizational change, safety culture assessment, high reliability organization characteristics and operations, TeamSTEPPS™ team training, mistake-proofing in the delivery of health care, just culture, persuasion through storytelling, the Patient Safety and Quality Improvement Act of 2005, patient safety organizations, patient safety indicators, and AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report.

This year's PSIC program is open to teams of patient safety officers in large hospitals or health systems; critical access or rural hospitals or health care systems; long-term care facilities or systems; ambulatory centers and large clinics; those responsible for patient safety reporting and analysis as well as intervention initiatives in other relevant organizations such as quality improvement organizations; and, Federal government agencies. The program begins with a 1-week session in mid-September and will continue through the year with two additional 1-week sessions and project work. Select for application requirements and information on the PSIC training program.

4. AHRQ's New Resource Offers Suggestions for Improving the Safety in Health Care Environments

AHRQ recently released a new resource of mistake proofing tools, examples, and practical applications to help providers improve the delivery of care within their settings. Mistake-Proofing the Design of Health Care Processes includes tips for simple and inexpensive mistake proofing, leveraging the benefit of root causes analyses, and creative methods for using non-medical products in health care environments. Specific examples include marking floors to delineate quiet zones that reduce interruptions to nurses that could result in medication errors; using a pen, microchip, and wristband to minimize the chances of wrong-site surgery; and attaching chemical light sticks to intravenous tubes for fluid identification.

Written by AHRQ collaborator John Grout, Ph.D., dean of Campbell School of Business, Berry College, Mount Berry, GA, this resource is a helpful reference point for those responsible for delivering care and for those who instruct or coach others that deliver care. Mistake-Proofing the Design of Health Care Processes includes 150 examples, most with photographs, and is available online. Limited copies can be ordered free of charge by contacting the AHRQ Clearinghouse at or by phone at (800) 358-9295.

5. AHRQ Vacancy Announcements Posted

AHRQ is seeking applicants for the positions of Director, Center for Quality Improvement and Patient Safety (CQuIPS), and Director, Center for Primary Care, Prevention, and Clinical Partnerships (CP3).

CQuIPS works to improve the quality and safety of our health care system through evidence-based research, synthesis, and practical implementation of evidence-based tools, products, strategies, and interventions.

CP3 expands the knowledge base for clinicians, health care organizations, and patients to assure the translation of new knowledge and systems improvement into primary care practices. CP3 also supports and conducts research to improve the access, effectiveness, and quality of primary and preventive health care services by working closely with clinician groups and other primary care-associated organizations to assure the implementation of that knowledge into practice, the use of health information technology to improve health care, and the evaluation/diffusion of effective health information technology tools into clinical practice.

Select for these and other AHRQ job announcements.

6. HHS Issues Report to Congress on E-Prescribing

Results of an electronic prescribing pilot project support the adoption of new electronic prescribing standards, according to a report to Congress released April 17 by Department of Health & Human Services (HHS) Secretary Michael Leavitt. These standards, required by the Medicare Modernization Act of 2003, would help cut both medication errors and health care costs. The pilot project demonstrated that three initial standards are already capable of supporting e-prescribing transactions in Medicare Part D. These are standard transactions that provide physicians with patients' formulary and benefit information, medication history, and the fill status of their medications.

The report also found that, with some adjustments, e-prescribing can work successfully in long-term care settings. Some of the initial e-prescribing standards tested by the pilot project were found to have potential but still need further development if they are to be adopted as e-prescribing standards. These include standards used to convey structured patient instructions, a terminology to describe clinical drugs, and messages that convey prior authorization information.

The pilot project was conducted through an interagency agreement between the Centers for Medicare & Medicaid Services (CMS) and AHRQ. Select to read the HHS press release. Copies of the report to Congress and the full evaluation contractor's report are available on AHRQ's Health IT site.

7. Technology, Alert Systems, and High Workload Increase Risk of Dispensing of Potentially Harmful Drugs

High workload and unexpected consequences from technologies that assist pharmacists in filling prescriptions and provide alerts about possible drug interactions increase the potential for medication errors, according to a new study published in the May issue of Medical Care and funded in part by AHRQ.

The study, which compared pharmacy characteristics to dispensing records, also found that telephone, Internet, and fax systems—which are intended to decrease pharmacist workload and increase the efficiency of prescription receipt and filling—were associated with an increase in the number of prescriptions dispensed for medications that could interact. Additional research is needed to confirm and clarify these findings, according to the study authors.

The study was conducted by a team of researchers led by Daniel C. Malone, Ph.D., at AHRQ's Arizona Center for Education and Research on Therapeutics at The Critical Path Institute and the University of Arizona College of Pharmacy. Select to review an abstract of the study.

8. AHRQ Produces Two New Audio Podcasts about Care Coordination and Transitions

AHRQ's Healthcare 411 series produced two audio podcasts on quality during health care transitions. Both are interviews with AHRQ Director Carolyn M. Clancy, M.D., discussing patient transitions in care from one setting to another or from one clinician to another, sometimes referred to as handoffs. Dr. Clancy stressed the importance of all people caring for a single patient to work from one common script.

The consumer program, dubbed the "Consumer Insider," is 10 minutes and provides some tips for patients and their families. The provider version, dubbed the "Provider Insider," is 14 minutes and gives providers some ways to improve the problems with handoffs, including sending care reports to the patient's primary care provider and using non-medical terms with patients. Select to access the consumer version or the provider version.

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.

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.

Elder NC, Graham D, Brandt E, et al. Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN). J Am Bd Fam Med 2007 Mar-Apr;20(2):115-23. Select to access the abstract in PubMed®.

Leonhardt KK, Bonin D, Pagel P. Partners in safety: implementing a community-based Patient Safety Advisory Council. WMJ 2006 Dec;105(8):54-9. Select to access the abstract in PubMed®.

Scott-Cawiezell J, Pepper GA, Madsen RW, et al. Nursing home error and level of staff credentials. Clin Nurs Res 2007 Feb;16(1):72-8. Select to access the abstract in PubMed®.

Wakefield DS, Ward MM, Wakefield BJ. A 10-Rights Framework for patient care quality and safety. Am J Med Qual 2007 Mar-Apr;22(2):103-11. Select to access the abstract in PubMed®.

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 May 2007


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


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