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Patient Safety E-Newsletter

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February 13, 2008, Issue No. 41

Patient Safety Quote of the Month

"Patient Safety Organizations will help make health care safer for all Americans. By making it easier for patient safety events to be reported and the lessons learned from them to be shared more broadly, patients will ultimately receive safer health care."

— HHS Secretary Mike Leavitt

(For more information on the proposed patient safety regulation, go to item no.1.)

Today's Headlines:

  1. New patient safety proposed regulation aims to improve health care quality and patient safety
  2. AHRQ patient safety grantees reduce patient risk in hospital emergency departments
  3. AHRQ patient safety grantees use simulation to improve communications and patient safety within post-anesthesia care units
  4. AHRQ launches new consumer-oriented video on personal health records
  5. AHRQ Director helps consumers navigate the health care system in a new advice column on the Web
  6. AHRQ podcast on health screenings and medication safety
  7. AHRQ's 2008 annual conference set for September 7-10
  8. IOM to host West coast meeting on resident work hours set for March 4-5
  9. National conference on reducing diagnostic errors in medicine set for May 31-June 1
  10. Latest issue of WebM&M is available online

1. New Patient Safety Proposed Regulation Aims To Improve Health Care Quality and Patient Safety

A proposed regulation to improve the quality and safety of health care for all Americans by fostering the establishment of Patient Safety Organizations (PSOs) was announced yesterday by the U.S. Department of Health and Human Services (HHS). PSOs are private entities recognized by the Secretary to collect and analyze patient safety events reported by health care providers. They are new and separate from all currently existing entities that are addressing health care quality. PSOs would allow for the voluntary reporting of patient safety events without fear of new tort liability. In addition, they would encourage clinicians and health care organizations to voluntarily share data on patient safety events more freely and consistently. Under the proposal, PSOs can collect, aggregate and analyze data and provide feedback to help clinicians and health care organizations improve health care quality. "Patient Safety Organizations will help make health care safer for all Americans," HHS Secretary Mike Leavitt said. "By making it easier for patient safety events to be reported and the lessons learned from them to be shared more broadly, patients will ultimately receive safer health care." AHRQ will administer the rules for listing qualified PSOs, and the Office for Civil Rights (OCR) is responsible for enforcing the confidentiality provisions of the act. "We know that clinicians and health care organizations want to participate in efforts to improve patient care, but they often are inhibited by fears of liability and sanctions," said AHRQ Director Carolyn M. Clancy, M.D. "The proposed regulation provides a framework for Patient Safety Organizations to facilitate a shared-learning approach that supports effective interventions that reduce risk of harm to patients. We want to make the right thing to do the easy thing to do." After collecting and analyzing sufficient non-identifiable data, AHRQ will publish information on national and regional statistics, including trends and patterns of patient safety events. This information will be published in AHRQ's annual National Healthcare Quality Report. Members of the public are invited to comment on the proposed regulation until April 14, and their feedback will be used to shape the final regulation. In addition, AHRQ and OCR are planning to host an audio conference on Feb. 29 from 2:00 p.m. to 3:00 p.m., EST, to provide additional details and answer questions about the proposed regulation. The notice of proposed rulemaking was published in yesterday's Federal Register. Select to view the proposed regulation on the Federal eRulemaking Portal. More information can be found on AHRQ's PSO Web site.

2. AHRQ Patient Safety Grantees Reduce Patient Risk in Hospital Emergency Departments

AHRQ patient safety researcher Twila Burdick, M.B.A., Vice President, Banner Health-Arizona State University Partnership for Emergency Department Patient Safety in Phoenix, and a team of investigators recently completed work to reduce waiting time, inefficiencies, and patient risk in eight Banner Health hospital emergency departments using a patient flow process called "Door-to-Doc." As a result of their work, they developed a toolkit that includes resources to assist others in implementing similar programs. The "Door-to-Doc" process improves patient care by reducing the time patients wait to see an ED physician, which results in lower rates of patients who leave the ED without treatment. The process reorganizes patient flow in the emergency department and improves the response time between patient arrival and the initiation of care for treat-and-release patients as well as for those who need to be admitted as inpatients. Select to learn more about, view, or download the patient safety toolkit.

3. AHRQ Patient Safety Grantees Use Simulation to Improve Communications and Patient Safety Within Post-Anesthesia Care Units

AHRQ patient safety researcher Matthew Weinger, M.D., Professor of Anesthesiology, Biomedical Informatics and Medical Education at Vanderbilt University School of Medicine, Nashville, TN, and his team of researchers have been using simulation learning to evaluate and improve communication between anesthesia providers and nurses as care is transitioned from the operating room to the post-anesthesia care unit. As a result of this project, a 2-hour simulation-based training session, called Simulation Training for Rapid Assessment and Improved Teamwork, has been developed to improve the quality of handoffs and enhance the culture of communication within the post-anesthesia care unit. In addition, researchers have taken a unique approach at evaluating the effect of this tool on the communication culture and outcomes. Dr. Weinger, one of AHRQ's 19 medical simulation grantees, and his team also examine specific elements of a good handoff, essential information to a post-anesthesia care unit handoff, and more general issues in effective interpersonal communication. Select to learn more about Dr. Weinger's research and tools.

4. AHRQ Launches New Consumer-Oriented Video on Personal Health Records

AHRQ has launched a new consumer-oriented video on keeping a personal health record. "The Importance of Keeping a Personal Medical Record," features AHRQ Director Carolyn M. Clancy, M.D.; Ronald Stock, M.D., Medical Director of Geriatrics and Care Coordination Services, PeaceHealth Oregon Region; and David Lansky, Ph.D., Senior Director of the Health Program and Executive Director of the Personal Health Technology Initiative, Markle Foundation. Experts discuss what information you need; how to gather the information; what works best-a notebook, a computer program, or a Web-based health record; and how patients can become more engaged in their health care by maintaining a personal health record. The videos are being distributed to a network of over 4,500 Web sites. These include media sites, such as CNN and ABC News, as well as health care provider and consumer sites.

5. 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. Recent topics include questions consumers should ask about medical tests, what to ask before having surgery, and tips for taking medicines safely. Select to read Dr. Clancy's advice columns.

6. AHRQ Podcast on Health Screenings and Medication Safety

A recent Healthcare 411 podcast features AHRQ Director Carolyn M. Clancy, M.D., offering consumers tips on medication safety. The podcast was distributed to AHRQ's 221 partnership organizations, including the American Health Quality Association and the Chicago Patient Safety Forum. Shorter versions of these stories will also air on 125 radio stations nationwide. Select to listen to the podcast or select to read the transcript. 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.

7. AHRQ's 2008 Annual Conference Set for September 7-10

Save the date! AHRQ's 2008 Annual Conference will be held September 7-10 in Bethesda, MD, at the North Bethesda Marriott. The conference will feature exciting opportunities to learn about AHRQ's latest research aimed at improving quality, safety, efficiency, and effectiveness of care. Conference sessions will feature leading experts involved in AHRQ-sponsored research and implementation projects. Information regarding registration and hotel accommodations will be available soon.

8. IOM to Host West Coast Meeting on Resident Work Hours Set for March 4-5

The Institute of Medicine's (IOM) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety will meet March 4-5 at the Beckman Center at the University of California, Irvine, CA. The first afternoon of the meeting willl include a workshop which will be open to the public and include several panels and speakers. The rest of the meeting will be closed. This meeting follows a similar meeting held December 3 in Washington, D.C., and will be used to gather input for a report IOM will issue later this year. Select for meeting information and registration.

9. National Conference on Reducing Diagnostic Error in Medicine Set for May 31-June 1

AHRQ and the American Medical Informatics Association are co-sponsoring the first national meeting dedicated to diagnostic errors in medicine May 31-June 1 in Phoenix. The goals of the meeting are to summarize the current state of the field and approaches to reducing diagnostic errors, examine the role of clinical decision support systems in addressing diagnostic errors, identify and discuss ongoing research on diagnostic errors, stimulate creative thought directed at reducing harm from diagnostic errors, and establish a community of stakeholders interested in reducing diagnostic errors. In addition, experts plan to explore both system-related contributions to errors and cognitive origins. Select for conference details and further information.

10. Latest Issue of WebM&M Is Available Online

The January issue of AHRQ WebM&M is now available online. The Perspectives on Safety section features Jennifer Daley, M.D., Chief Medical Officer of Partners Community Healthcare, Boston about improving safety in complex systems. The accompanying perspective piece features Loran Hauck, M.D., Senior Vice President and Chief Medical Officer and Jan Jacob, M.B.A., R.N., Corporate Patient Safety Officer, both of Adventist Health System in Winter Park, FL, discussing the implementation of a patient safety program in Adventist Health System. Commentaries discuss how providers react to significant medical errors that cause harm, errors in the interpretation of blood culture results, and leakages related to chemotherapy. There are three Spotlight Cases this month. The first, "How do Providers Recover from Errors?," includes an accompanying commentary by Colin West, M.D., of Mayo Clinic College of Medicine in Rochester, MN. The second case, "Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures," includes an accompanying commentary by Melvin Weinstein, M.D., of Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey. The third case, "Chemotherapy Extravasation," includes an accompanying commentary by Lisa Schulmeister R.N., an oncology nursing consultant in New Orleans. Physicians and nurses can receive free continuing medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using our "Email a colleague" feature.

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Current as of February 2008


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