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Patient Safety and Health Information Technology E-Newsletter

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January 14, 2005, Issue N0.4

Quote of the Month

"It is unsafe to get behind the wheel of a car after working for 24 consecutive hours. The health care profession has a duty to protect its young trainees from exposure to the well-known hazard of drowsy driving, which causes over 100,000 motor vehicle crashes on our nation's highways every year."

—Charles A. Czeisler, Ph.D., M.D., Director, Division of Sleep Medicine, Brigham and Women's Hospital.

Select for more information on the new study by Dr. Czeisler and his colleagues at Brigham and Women's Hospital.

Today's Headlines:

  1. Medical interns who work extended-duration shifts double their risk of car crashes when driving home from the hospital
  2. Telephone briefing on hospital patient safety culture survey set for February 15
  3. Recent findings from important AHRQ patient safety research
  4. Latest issue of AHRQ WebM&M is available online
  5. National Guideline Clearinghouse™ features patient safety-related guidelines
  6. Do you know how AHRQ's research findings are being used to improve patient safety?
  7. AHRQ in the patient safety professional literature—some useful citations

1.  Medical Interns Who Work Extended-Duration Shifts Double Their Risk of Car Crashes When Driving Home from the Hospital

First-year doctors in training, or medical interns, who work shifts of longer than 24 hours are more than twice as likely to have a car crash leaving the hospital and five times as likely to have a "near miss" incident on the road as medical interns who work shorter shifts, according to an article in the January 13 issue of the New England Journal of Medicine (NEJM). The article, "Extended Work Shifts and the Risk of Motor Vehicle Crashes Among Interns," is the third in a series of studies on the impact of extended work hours and fatigue on interns conducted by the Divisions of Sleep Medicine at the Brigham and Women's Hospital and the Harvard Medical School in Boston. All three studies were co-funded by AHRQ and the Centers for Disease Control & Prevention's (CDC) National Institute for Occupational Safety and Health and result from a project led by Charles A. Czeisler, Ph.D., M.D. Select to access our press release by primary author Laura K. Barger, Ph.D. For additional information on the two earlier related studies published in the October 28, 2004, issue of NEJM, Select to access the AHRQ press release.

2.  Telephone Briefing on Hospital Patient Safety Culture Survey Set for February 15

On February 15, from 2:00 p.m. to 3:30 p.m., EST, AHRQ, in partnership with Premier, Inc., the Department of Defense, the American Hospital Association, and Westat will host the first in a series of technical assistance telephone briefings on the Hospital Survey on Patient Safety Culture. The purpose of the briefing is to provide hospital leaders interested in adopting this tool with tips and techniques for administering the survey. This toll-free conference call will include the faculty responsible for the development of the survey and feature the experiences of users who have successfully adopted and implemented it. Please RSVP by sending an E-mail to by February 11. The survey is currently available online. Print copies may be ordered by calling (800) 358-9295 or by sending an E-mail to

3.  Recent Findings from Important AHRQ Patient Safety Research

Study of Hospital Staff Nurses Finds High Rate of Errors and Near Errors

Nearly 30 percent of the hospital staff nurses who participated in a study of errors and near errors reported making at least one error during a 28-day period, according to an AHRQ-funded study. The study, "The Prevalence and Nature of Errors and Near Errors Reported by Hospital Staff Nurses," was led by Ann E. Rogers, Ph.D., R.N., and Michele C. Balas from the University of Pennsylvania School of Medicine. Select to access an abstract of the study on PubMed®, published in the November 2004 issue of Applied Nursing Research. For information on patient safety and hospital nurse staffing and links to additional resources, visit AHRQ's redesigned nursing Web page.

Most Physicians are Dissatisfied with Current Test Result Management Systems

Many primary care physicians are dissatisfied with current test result management systems, according to a recent AHRQ-funded study. Physicians report that delays in reviewing test results for patients are not uncommon, and that managing these test results is becoming more difficult. Researchers at Brigham and Women's Hospital, Boston, led by Eric G. Poon, M.D., M.P.H., and David W. Bates, M.D., M.Sc., conducted a survey of 262 physicians working in 15 internal medicine practices affiliated with two large urban teaching hospitals. Just 41 percent of physicians reported being satisfied with how they were able to manage test results, despite reporting that they spent on average 74 minutes per clinical day managing test results. Researchers suggest implementing tools that would help physicians generate result letters to patients, prioritize their workflow, and track test orders to completion. The article, "I Wish I Had Seen This Test Result Earlier! Dissatisfaction with Test Result Management Systems in Primary Care," was published in the November 8, 2004, issue of Archives of Internal Medicine. Select to access the abstract on PubMed®.

4.  Latest Issue of AHRQ WebM&M Is Available Online

The latest issue of the AHRQ WebM&M online patient safety journal is now available. The cases include a patient who calls his doctor's office complaining of feeling "weak" and is patched through to a covering physician who misses the clues of a significant illness; a patient who receives genetic testing without consent; a physician who learns of a patient's seizure disorder and surprises the patient by informing him that he must report the disorder to the Department of Motor Vehicles; and a patient who nearly has surgery on the wrong limb—despite a "time out" and signing of the site by the surgeon. The Spotlight case discusses medication errors at the time of hospital discharge. As always, it includes a downloadable set of slides. By completing the Spotlight quiz, physicians can receive continuing medical education (CME) credit, nurses can obtain continuing education units (CEUs), and trainees can receive certification in patient safety. Cases and CME/CE from previous issues are still available under "Archives" and "Past Issues" on the site. You also can submit a case for consideration for future editions of the online journal.

5.  National Guideline Clearinghouse™ Features Patient Safety-Related Guidelines

Nearly 225 of approximately 1,400 guidelines included in the National Guideline Clearinghouse™ (NGC), have been categorized in the Institute of Medicine's (IOM) domain of "safety." The NGC team catalogues a guideline as patient safety-related when it provides recommendations on how care should be given. Traditionally, guideline recommendations assist in decisionmaking on what care should be given, when, to whom, where, and why. With the increasing emphasis on the need to reduce medical errors and improve patient safety, guideline developers may purposefully include statements about how that care should be given, such as checking patient identification before dispensing medication, and by whom. To find these safety-related evidence-based guidelines, use the detailed search feature (scroll approximately two-thirds down, select "safety" in the IOM Domain field box, scroll to the bottom of page, and select Search).

6.  Do You Know How AHRQ's Research Findings Are Being Used to Improve Patient Safety?

We are always looking for ways in which AHRQ-funded research, products, and tools have changed people's lives, influenced clinical practice, improved policies, and affected patient outcomes. These impact case studies describe AHRQ research findings in action. They are used in testimony, budget documents, and speeches. We would like to know if you are aware of any impact your AHRQ-funded research has had on health care policy, clinical practice, or patient outcomes. Contact AHRQ's Impact Case Studies Program at or (301) 427-1244 with your impact stories.

7.  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.

Zivin JG, Pfaff AS. To err on humans is not benign. Incentives for adoption of medical error-reporting systems. J Health Econ 2004 Sep;23(5):935-49. Select to access the abstract on PubMed®.

Solberg LI, Hurley JS, Roberts MH, Nelson WW, Frost FJ, Crain AL, Gunter MJ, Young LR. Measuring patient safety in ambulatory care: potential for identifying medical group drug-drug interaction rates using claims data. Am J Manag Care 2004 Nov;10(11 Pt 1):753-9. Select to access the abstract on PubMed®.

Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon Jr LF, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004 Dec 7;141(11):851-7. Select to access the abstract on PubMed®.

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

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Current as of January 2005


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