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Patient Safety E-Newsletter

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March 11, 2008, Issue No. 42

Patient Safety Quote of the Month

"Health care quality is improving only modestly, at best. Given that health care spending is rising much faster, these findings about quality underscore the urgency to improve the value Americans are getting for their health care dollars." (For more information on AHRQ's new annual national reports on health care quality and disparities, go to item no.1.)

—Carolyn M. Clancy, M.D., Director, AHRQ

Today's Headlines:

  1. Modest health care quality gains outpaced by spending, according to new AHRQ reports
  2. Save the date for April 8 AHRQ audio conference on establishing a patient safety advisory council
  3. Voluntary medication error reports reveal substantial variation in warfarin errors
  4. AHRQ director helps consumers navigate the health care system in advice column on the Web
  5. Call for nominations for 2008 John M. Eisenberg patient safety and quality awards
  6. Latest issue of WebM&M is available online
  7. Calling all AHRQ researchers! "help us to help you"
  8. AHRQ in the patient safety professional literature-some useful citations

1. Modest Health Care Quality Gains Outpaced By Spending, According to New AHRQ Reports

The quality of health care improved by an average 2.3 percent a year between 1994 and 2005, a rate that reflects some important advances but points to an overall slowing in quality gains, according to AHRQ's 2007 National Healthcare Quality Report and National Healthcare Disparities Report. The improvement rate is lower than the 3.1 percent overall average annual improvement rate reported in the 2006 reports. The Centers for Medicare & Medicaid Services estimate health care expenditures rose by a 6.7 percent average annual rate between 1994 and 2005. While the 2007 reports show some notable gains, such as improvements in the care of heart disease patients, the disparities report shows that many major disparities remain. The reports measure and track trends in quality and disparities in four key areas of health care: effectiveness of care, patient safety, timeliness of care, and patient centeredness.

This year's National Healthcare Quality Report synthesizes more than 200 quality measures, which range from how many pregnant women received prenatal care to what portion of nursing home residents were controlled by physical restraints. The National Healthcare Disparities Report, meanwhile, summarizes which racial, ethnic or income groups are benefiting from improvements in care.

Select to read our press release, to access the quality and disparities reports, and to listen to a radiocast on the reports.

A print copy of the reports is available by sending an E-mail to

2. Save the Date for April 8 AHRQ Audio Conference on Establishing a Patient Safety Advisory Council

Hospital leaders and others who want to learn how to get patients and families to partner with health care providers on community-based patient safety advisory councils should mark their calendars for a free audio conference on April 8 from 2:00 to 3:00 pm, E.D.T. AHRQ grantee Kathy Leonhardt, M.D., M.P.H., of Aurora Health Care in Wisconsin, will present the latest evidence in "How to Develop a Community-Based Patient Safety Advisory Council." The audio conference will feature highlights from a how-to guide developed through AHRQ's Partnerships in Implementing Patient Safety (PIPS) grants program. The PIPS projects focus on implementing safe practice interventions that can be used by those who wish to adapt and/or adopt interventions to improve patient safety in diverse settings.

For conference registration information, send an E-mail to and select to learn more about the PIPS projects.

3. Voluntary Medication Error Reports Systems Reveal Substantial Variation in Warfarin Errors

The frequencies and patterns of errors in warfarin medication use reported by hospitals and clinics participating in a voluntary medication errors reporting system varied substantially, according to a new AHRQ study. Researchers analyzed over 8,800 inpatient warfarin errors reported by 445 hospitals from 2002 to 2004 and discovered a variation of errors ranging from 1 to 289 errors per hospital. Most errors occurred during transcribing/documenting (35 percent) and administering (30 percent) in hospitals. In addition, researchers also examined over 800 outpatient warfarin errors reported by 192 outpatient facilities and found a variation of errors ranging from 1 to 112 errors per facility. Most errors within this setting occurred during dispensing (39 percent) and prescribing (31 percent). This study demonstrates that voluntary reports can help providers to identify problems and develop safety improvement programs. However, it also suggests that voluntary reporting systems, although useful in identifying and correcting safety lapses, have serious limitations.

The study, led by AHRQ's Chunliu Zhan, M.D., Ph.D., Scott R. Smith, Ph.D., Margaret A. Keyes, M.A., and AHRQ Director Carolyn M. Clancy, M.D., was published in the January issue of The Joint Commission Journal on Quality and Patient Safety. To read an abstract of the study, "How Useful Are Voluntary Medication Error Reports? The Case of Warfarin-Related Medication Errors."

4. AHRQ Director Helps Consumers Navigate the Health Care System in Advice Column on the Web

AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in brief, easy-to-understand columns. The biweekly columns 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 how to take medicines safely. Select to read Dr. Clancy's advice columns.

5. Call for Nominations for 2008 John M. Eisenberg Patient Safety and Quality Awards

The Joint Commission and the National Quality Forum are now accepting nominations for the 2008 John M. Eisenberg Patient Safety and Quality Awards, which recognize individuals and health care organizations that are making significant contributions to improving health care quality and patient safety. The deadline for nominations is April 14. Nomination forms are available on the Joint Commission Web site.

6. Latest Issue of WebM&M Is Available Online

The March issue of AHRQ WebM&M is now available online. The Perspectives on Safety section focuses on the value of medical procedure services for hospital patients and outpatients. It features an interview with Bradley T. Rosen, M.D., Medical Director of the Inpatient Specialty Program at Cedars-Sinai Medical Center, Los Angeles. In an accompanying perspective piece, C. Christopher Smith, M.D., and Grace C. Huang, M.D., both of Beth Israel Deaconess Medical Center, Boston, discuss creating a medical procedure service to improve patient safety at their hospital. There are three cases this month.

In the Spotlight Case, a man went to the emergency department several times in one week for back pain that became progressively worse. Providers assumed the pain did not represent a serious illness; however, on his final visit, the patient was admitted and died of complications from an infection that was the source of his pain. The author, Jon D. Lurie, M.D., of Dartmouth Medical School, Hanover, NH, discusses red flags and important concerns in evaluating patients with low back pain.

In the second case, a woman with history of a pituitary tumor and diabetes was admitted for management of a high sodium level. Once the level was stable, the physician ordered that a sodium-lowering medicine be held, not knowing that this would re-elevate the patient's sodium level. The author, Matthew Grissinger, R.Ph., of the Institute for Safe Medication Practices, Huntingdon Valley, PA, addresses safety issues involved with hold orders.

In the third case, an elderly woman with chronic obstructive pulmonary disease on home oxygen was admitted for pneumonia. The next morning the patient was not alert and physicians discovered that her carbon dioxide level was abnormally high, likely from being placed on too much oxygen. The author, B. Ronan O'Driscoll, M.D., of Salford Royal University Hospital in England, addresses safety issues in treating COPD exacerbations.

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 the "Email a colleague" feature.

7. Calling All AHRQ Researchers! "Help Us to Help You."

As you may know, we can help you promote the findings of your AHRQ-supported research, but we can't do it without you. AHRQ has been successful in working with our grantees and contractors to promote findings to the media and to transfer knowledge based on the research to appropriate audiences in the health care community.

Please notify us when you have an article accepted for publication and send a copy of the manuscript, anticipated publication date, and contact information for the journal and your institution's public relations office to your AHRQ project officer and to AHRQ's Office of Communications and Knowledge Transfer at AHRQ always honors the journal embargo.

8. 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.

Linkin DR, Fishman NO, Landis JR, Barton TD, Gluckman S, Kostman J, Metlay JP. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol 2007 Dec;28(12):1374-81. Select to read an abstract of the study.

Oken A, Rasmussen MD, Slagle JM, Jain S, Kuykendall T, Ordonez N, Weinger MB. A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. Anesthesiology 2007 Dec;107(6):909-22. Select to read an abstract of the study.

Rivard PE, Luther SL, Christiansen CL, Shibei Zhao , Loveland S, Elixhauser A, Romano PS, Rosen AK. Using patient safety indicators to estimate the impact of potential adverse events on outcomes. Med Care Res Rev 2008 Feb;65(1):67-87. Select to read an abstract of the study.

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Current as of March 2008


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