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Patient Safety E-Newsletter

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September 11, 2007, Issue No. 35

Patient Safety Quote of the Month

"Adverse events and errors take a very heavy emotional toll on health care workers, and currently few hospitals or health care organizations have effective programs for supporting their staff after these events." (For more information on this AHRQ-sponsored research, go to item no.2.)

—Thomas H. Gallagher, M.D., Associate Professor of Medicine, Departments of Medicine and Medical History and Ethics, University of Washington School of Medicine, Seattle

Today's Headlines:

1. AHRQ WebM&M to provide content for largest health care Web portal in China
2. New study examines emotional impact of medical errors on physicians
3. New mentoring program for emergency department pharmacists featured in AHRQ's Healthcare 411 Series
4. AHRQ begins fourth class of Patient Safety Improvement Corps
5. HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study
6. Latest issue of AHRQ WebM&M available online
7. AHRQ-sponsored DVD demonstrates safe techniques for chest tube insertion
8. Check out what's new on AHRQ Patient Safety Network Web site
9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1. AHRQ WebM&M to Provide Content for Largest Health Care Web Portal in China

AHRQ WebM&M, an online journal that uses a case-based approach to educate health care providers and trainees about patient safety, is providing content to Bridgetech Holdings International, Inc., as part of a new project to create the largest health care Web portal in China. Bridgetech, which is focused on maximizing the potential of emerging health care products and services in the U.S. and Asian markets, will translate the AHRQ WebM&M content into Chinese. "AHRQ is pleased to be part of an initiative that is helping to provide evidence-based information about patient safety to an international audience," said Carolyn M. Clancy, M.D., Director of AHRQ. Robert M. Wachter, M.D., Professor of Medicine at the University of California, San Francisco and Editor of AHRQ WebM&M, added, "Over the past decade, we have learned a tremendous amount about how to keep patients safe in hospitals and clinics. We are thrilled to be working with Bridgetech to help make this information accessible to even more health care providers and leaders around the world." To learn more about the latest AHRQ WebM&M content, go to item no. 6.

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2. New Study Examines Emotional Impact of Medical Errors on Physicians

Many physicians experience significant emotional distress and job-related stress following serious medical errors and near misses, according to a new AHRQ study. Of the 3,100 internists, pediatricians, family physicians, and surgeons in the United States and Canada that were surveyed, 61 percent experienced increased anxiety about future errors; 44 percent experienced a loss of confidence; 42 percent had difficulty sleeping; 42 percent experienced reduced job satisfaction; and 13 percent felt their reputation had been damaged. Researchers also found that 82 percent of physicians expressed interest in counseling after a serious error, but 90 percent felt that hospitals and health care organizations offered inadequate support in coping with stress associated with medical errors. Results of the study, led by Amy D. Waterman, Ph.D., Assistant Professor of Medicine at the Washington University School of Medicine, St. Louis, and Thomas H. Gallagher, M.D., Associate Professor of Medicine, Departments of Medicine and Medical History and Ethics, University of Washington School of Medicine, Seattle, are published in the August issue of the Joint Commission Journal on Quality and Patient Safety. Selet to read an abstract of the study, "The emotional impact of medical errors on practicing physicians in the United States and Canada."

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3. New Mentoring Program for Emergency Department Pharmacists Featured in AHRQ's Healthcare 411 Series

AHRQ's latest Healthcare 411 audio newscast features an interview with AHRQ researcher Rollin J. (Terry) Fairbanks, M.D., of the University of Rochester, New York, as he discusses his new mentoring program for emergency department pharmacists that is based on AHRQ research. The program is designed to connect teams of ED pharmacists with pharmacists who wish to develop these practices in their own hospitals. Select to listen to the 12-minute program. Another recent Healthcare 411 newscast features stories on AHRQ's Healthcare Cost and Utilization Project statistics about adverse drug events in hospitals. Select to listen to the 10-minute program and to access any of AHRQ's audio podcasts, visit our Healthcare 411 series main page.

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4. AHRQ Begins 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 year's Corps is comprised primarily of teams from hospitals, health care systems, and quality improvement organizations. Team members are trained in analyzing reported medical errors, identifying their root causes, and developing and implementing patient safety improvement processes such as TeamSTEPPS™ and a variety of other processes or tools. The program begins with a weeklong session in mid-September and will continue through the year with two additional weeklong sessions and project work. Teams from 22 States will be participating in the 2007-08 PSIC class, joining teams from 17 States in the 2005-06 PSIC class, 20 States and the District of Columbia in the 2004-05 class, and 15 States in the inaugural 2003-04 class. Select for information on the PSIC training program and a list of participants in the new class. "Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety," a DVD featuring modules based on content from the previous PSIC programs, will soon be available. Ordering information will be available in next month's AHRQ Patient Safety E-Newsletter.

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5. HANDS Care Plan Tool Seeks To Improve Nurse Communication at Handoff in AHRQ-Funded Study

An AHRQ-supported project is testing whether a standardized, computerized tool can help nurses better document patient care and communicate more effectively when they hand off a patient to another provider. So far, the new tool-called HANDS-has proved extremely useful for documenting care.

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6. Latest Issue of AHRQ WebM&M Available Online

The September issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section focuses on surgical errors. Atul Gawande, M.D., associate professor of surgery at Harvard Medical School in Boston, general and endocrine surgeon at Brigham and Women's Hospital and Dana Farber Cancer Institute, and a staff writer for The New Yorker, is interviewed on professionalism, training, patient safety, and the writing process. You can listen to an excerpt of the interview via an audio podcast. In the accompanying perspective, Leo Gordon, M.D., associate director of surgical education at Cedars-Sinai Medical Center in Los Angeles, discusses how he has reconfigured the surgical morbidity and mortality conference by developing a patient safety curriculum called the M+M Matrix. In the Spotlight Case, a woman hospitalized for surgery was given an overdose of the wrong medicine due to multiple errors, including an inaccurate pre-admission medication list, failure to verify medication history, and uncoordinated information systems. The author, Eric Poon, M.D., M.P.H., of Harvard Medical School in Boston, discusses medication discrepancies and best practices for reconciling medications. In the second case, an elderly man with a history of hospitalizations for congestive heart failure came to the emergency department complaining of shortness of breath and fatigue. The admitting physician discovered that the patient had never received clear education about caring for himself outside the hospital. The commentary, written by Gregg Fonarow, M.D., of UCLA David Geffen School of Medicine, discusses education for heart failure patients. In the third case, a man who underwent coronary angiography and stent placement developed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting his delayed bypass surgery, the patient had a cardiac arrest and died. Commentary authors Jose Baez-Escudero, M.D., and Glenn Levine, M.D., of Baylor College of Medicine in Houston, discuss complications of cardiac catheterization. Now you can easily share AHRQ WebM&M articles by using the "E-mail a colleague" feature. 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.

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

AHRQ has published an 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.

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8. Check Out What's New on AHRQ Patient Safety Network Web Site

New material is being added to the AHRQ Patient Safety Network, or AHRQ PSNet, every week. The Web site continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is a comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature. Select to visit the AHRQ PSNet Web site.

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9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies..

Harrison MI, Koppel R, Bar-Lev S. Unintended Consequences of Information Technologies in Health Care-An Interactive Sociotechnical Analysis. J Am Med Inform Assoc. 2007 September-October;14(5):542-549. Select to read an abstract of the study.

Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007 Jul 9;167(13):1400-5. Select to read an abstract of the study.

Longo DR, Hewett JE, Ge B, Schubert S. Rural hospital patient safety systems implementation in two States. J Rural Health. 2007 Summer;23(3):189-97. Select to read an abstract of the study.

Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007 Jun;25(2):225-36. Select to read an abstract of the study.

Raebel MA, Carroll NM, Kelleher JA, Chester EA, Berga S, Magid DJ. Randomized trial to improve prescribing safety during pregnancy. J Am Med Inform Assoc. 2007 Jul-Aug;14(4):440-50. Select to read an abstract of the study.

Tang Z, Weavind L, Mazabob J, Thomas EJ, Chu-Weininger MY, Johnson TR. Workflow in intensive care unit remote monitoring: A time-and-motion study. Crit Care Med. 2007 Jul 24. Select to read an abstract of the study.

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Contact Information

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


Current as of September 2007


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


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