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Patient Safety E-Newsletter

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December 10, 2007, Issue No. 39

Patient Safety Quote of the Month

"At some point... we have to acknowledge the fact that a human being can work only so long without sleep deprivation becoming a factor. Research shows that we do not do well in transitions of care... but limiting these transitions by having work hours that are not compatible with human physiology is not the answer."

—Carolyn M. Clancy, M.D., Director, AHRQ, in remarks from December 3 opening address at the Institute of Medicine workshop on resident work hours and patient safety (For more information, go to Item No. 1).

Today's Headlines:

1. AHRQ director delivers opening remarks at Institute of Medicine workshop on resident work hours and patient safety
2. AHRQ releases new toolkits for reducing medical errors
3. AHRQ releases new DVD about designing hospitals for safety and quality
4. AHRQ-sponsored tools help improve health care delivery efficiency
5. AHRQ grantee delivers presentations on patient safety culture
6. AHRQ patient safety grantee receives honor from Institute for Safe Medication Practices
7. AHRQ director helps consumers navigate the health care system in a new advice column on the Web
8. AHRQ Annual Conference presentations now available
9. AHRQ-sponsored DVD addresses questions after diagnosis, safe medication practices
10. AHRQ to participate in International Conference on Ergonomics and Patient Safety in June 2008
11. AHRQ in the patient safety professional literature—some useful citations

1. AHRQ Director Delivers Opening Remarks at Institute of Medicine Workshop on Resident Work Hours and Patient Safety

AHRQ Director Carolyn M. Clancy, M.D., discussed the need for incentives to promote safe work schedules in graduate medical education settings as a part of her opening remarks at a public meeting of the Institute of Medicine's new committee on December 3. Dr. Clancy told members of the IOM Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules that AHRQ research has shown a correlation between extended work hours and quality of care. Although the maximum number of hours that medical residents should work was capped at 80 hours a week in 2003 by the Accreditation Council for Graduate Medical Education, the culture and traditions in training remain strong and, as a result, the problem continues to exist throughout health care. Dr. Clancy also identified four primary areas of focus for the IOM committee—developing a current evidence base on resident work hours and schedules and their impact on safety; identifying and developing strategies for implementing reasonable work hours; analyzing the benefits and harms of updating work hours and schedules; and developing recommendations for action by various stakeholders. AHRQ is sponsoring an IOM study that is expected to produce recommendations on resident work hours in late 2008. Select to view Dr. Clancy's remarks; objectives of the IOM committee; and a list of future IOM meetings on the topic.

2. AHRQ Releases New Toolkits for Reducing Medical Errors

AHRQ recently released 17 Partnerships in Implementing Patient Safety (PIPS) toolkits, developed by AHRQ-funded experts who specialize in patient safety research. Inspired by the Institute of Medicine report To Err is Human: Building a Safer Health System, the toolkits are designed to help doctors, nurses, hospital managers, patients, and others reduce medical errors. The toolkits include checklists to help reconcile medications when patients are discharged from the hospital, processes to enhance effective communication among caregivers and with patients, and toolkits to help patients taking medications. Select for a complete listing of the 17 interventions and to view AHRQ's press release.

3. AHRQ Releases New DVD about Designing Hospitals for Safety and Quality

AHRQ released a new DVD that provides evidence to help hospital officials and architects design safer, high-quality hospitals. This new two-part DVD illustrates the value of evidence-based hospital design—a phrase used to describe how the physical design of health care environments affects patients and staff. The first part, entitled Transforming Hospitals: Designing for Safety and Quality, gives a brief 13-minute overview and provides current examples of how evidence-based hospital design increases patient safety, satisfaction, and quality of care that results in higher staff satisfaction, recruitment, and retention. The second part, Transforming Hospitals: Three Case Studies, is 36 minutes and features the experiences of three hospitals that incorporated principles of evidence-based hospital design into new construction and renovation projects. With an estimated $250 billion construction boom in the hospital industry over the next 10 years, the DVD is expected to be of significant interest to hospital executives and architects planning or implementing construction and renovation projects. Select for more information on Transforming Hospitals: Designing for Safety and Quality or AHRQ's research in evidence-based hospital design. Copies of the DVD can be obtained by sending an E-mail to

4. AHRQ-Sponsored Tools Help Improve Health Care Delivery Efficiency

With support from AHRQ, Denver Health, the safety net system for Denver, Colorado, has applied Lean techniques to redesign processes throughout its delivery system. According to Denver Health, it has saved at least $2.7 million to date by implementing the transformation. Lean is a business system for organizing and managing product development, operations, suppliers, and customer relations. The objectives of the 18-month project included developing structures and processes capable of coordinating and aligning approximately 50 rapid-cycle process improvement projects, developing evaluation methods, providing timely feedback to participants, and assessing the overall contribution of the projects to hospital improvement, as well as drawing lessons for future efforts at Denver Health and elsewhere. Select to read the summary for further details.

5. AHRQ Grantee Delivers Presentations on Patient Safety Culture

AHRQ Partnerships in Implementing Patient Safety grantee Katherine Jones, Ph.D., P.T., Assistant Professor, Department of Physical Therapy Education, University of Nebraska Medical Center, Omaha, recently delivered two WebEx presentations on patient safety culture. The first presentation, titled "Understanding Reassessment Results from the AHRQ Hospital Survey on Patient Safety Culture," defines safety culture, discusses AHRQ's Hospital Survey on Patient Safety Culture report, and explains how to use items within a dimension to engineer interactions between practices that produce a safe, informed culture. In a second presentation, "Understanding Assessment Results from the AHRQ Hospital Survey on Patient Safety Culture," Dr. Jones discusses similar topics, including creating an action plan to engineer a safe and informed culture. Select to view the first presentation and the second presentation (PDF Help).

6. AHRQ Patient Safety Grantee Receives Honor from Institute for Safe Medication Practices

The Walworth County Patient Safety Council, funded through AHRQ's Partnerships in Implementing Patient Safety project and Aurora Health Care, has been selected as a recipient of this year's 10th Annual Cheers Award from the Institute for Safe Medication Practices for its efforts at improving medication safety for local seniors. The Cheers Awards honor individuals and organizations that have set a superlative standard of excellence for others to follow in the prevention of medication errors and adverse drug events. The award was presented at the American Society of Health-System Pharmacists Midyear Clinical Meeting on December 4. Select to view ISMP's press release (PDF Help).

7. AHRQ Director Helps Consumers Navigate the Health Care System in a New Advice Column on the Web

AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in new, brief, easy-to-understand columns. The biweekly columns will help consumers better navigate the health care system. Select to read Dr. Clancy's new advice columns.

8. AHRQ Annual Conference Presentations Now Available

Nearly 1,200 researchers and others attended AHRQ's 2007 Annual Conference held September 26-28. The presentations are organized by date. Save the date! Next year's conference will be September 7-10, 2008. Watch for more information in a future newsletter.

9. AHRQ-Sponsored DVD Addresses Questions After Diagnosis, Safe Medication Practices

Two new videos from AHRQ help answer important questions patients are likely to have once they've been diagnosed with a condition or illness and provide simple steps on how to take medications safely. The videos, contained in a single DVD and produced in collaboration with Healthology, Inc., provide valuable, easy-to-understand advice for patients that can help guide further discussions with their health care provider. Next Steps After Your Diagnosis: Finding Information and Support helps patients find information and resources and addresses the various physical and emotional aspects of a new diagnosis. Check Your Medicines: Tips for Taking Medicines Safely provides simple steps for taking drugs safely and correctly, thus avoiding the risk of medication errors. The program encourages patients to ask questions about their prescriptions, to bring a list of all current medications to their doctor's appointment, and to make sure that the medication they receive is what their doctor ordered. AHRQ Director Carolyn M. Clancy, MD, and other experts are featured in each segment. Free single copies are available from the AHRQ Publications Clearinghouse at

10. AHRQ To Participate in International Conference on Ergonomics and Patient Safety in June 2008

The International Ergonomics Association is sponsoring the second International Conference on Healthcare Systems Ergonomics and Patient Safety from June 25-28, 2008, in Strasbourg, France. The conference is aimed at creating bridges among different disciplines—medicine and surgery, information technology, occupational psychology, clinical engineering and architecture, and human factors and ergonomics—in order to share a strong interest in the promotion of human factors and ergonomics in health care and patient safety. AHRQ's Kerm Henriksen, Ph.D., Human Factors Advisor for Patient Safety, will serve with other experts, including AHRQ grantees, on the conference steering committee. The deadline for abstracts is December 15. Visit for more information on the conference.

11. 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.

Culler SD, Hawley JN, Naylor V, Rask KJ. Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals. J Med Syst 2007 Oct;31(5):319-27. Select to read an abstract of the study.

Hansen LB, Saseen JJ, Westfall JM, Holcomb S, Nuzum DS, Pace WD. Evaluating sample medications in primary care: a practice-based research network study. Jt Comm J Qual Patient Saf 2006 Dec;32(12):688-92. Select to read an abstract of the study.

Singer S, Meterko M, Baker L, et al. Workforce perceptions of hospital safety culture: development and validation of the Patient Safety Climate in Healthcare Organizations survey. Health Serv Res 2007 Oct; 42(5):1999-2021. Select to read an abstract of the study.

Smith RB, Cheung R, Owens P, Wilson RM, Simpson L. Medicaid markets and pediatric patient safety in hospitals. Health Serv Res 2007 Oct; 42(5):1981-98. Select to read an abstract of the study.

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Current as of December 2007


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