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Patient Safety E-Newsletter

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April 15, 2008, Issue No. 43

Patient Safety Quote of the Month

"Sharing information about important new developments in methods of delivering effective health care is typically a hit-or-miss process. Such information exchanges often occur only within organizations, through conferences, and by chance over the Internet. AHRQ's updated innovations exchange will encourage information sharing, reduce duplication and save time and money." (For more information on AHRQ's new Health Care Innovations Exchange, go to item no.3.)

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

Today's Headlines:

  1. AHRQ data report shows upward trend for hospital patient safety culture, highlights areas to focus improvement
  2. AHRQ awards $5 million to help integrate clinical decision support technologies into health care delivery
  3. AHRQ Web resource features 100 examples of health care innovations and tools
  4. AHRQ issues report about transforming hospitals into high reliability organizations
  5. AHRQ unveils new tool to help reduce unnecessary hospitalizations
  6. AHRQ helps patients take medications safely
  7. National Conference on Reducing Diagnostic Error in Medicine set for May 31-June 1
  8. Health IT Survey Compendium is available
  9. AHRQ's 2008 annual conference set for September 7-10
  10. Latest issue of WebM&M is available online
  11. AHRQ in the patient safety professional literature—some useful citations

1.  AHRQ 2008 Comparative Database Report Shows Upward Trend for Hospital Patient Safety Culture, Highlights Areas to Focus Improvement

AHRQ released the 2008 Comparative Database Report which shows that one of the most important things a hospital can do to improve its culture of patient safety is to focus on how it responds to medical errors made by staff. The new report analyzes data provided by 519 hospitals that administered the Hospital Survey on Patient Safety Culture to more than 160,000 staff nationwide. Hospitals that have administered the hospital survey can use the comparative database report to compare survey data with similar hospitals; identify and target areas for improvement; and track changes over time. Trend data from 98 hospitals, available for the first time, show that overall staff perceptions of their organization's patient safety culture improved by 2 percent.

The hospital survey and comparative database report are available on the AHRQ Web site. A print copy is available by sending an E-mail

Hospitals can submit survey data to the hospital database between May 1 and June 30. Select for more information on data submission. AHRQ plans to release two new patient safety culture surveys later this year specifically for use in the medical office and nursing home settings.

2.  AHRQ Awards $5 Million to Help Integrate Clinical Decision Support Technologies Into Health Care Delivery

AHRQ recently awarded $5 million to two new health information technology (IT) contracts that focus on the development, adoption, implementation, and evaluation of best practices using clinical decision support. The Brigham and Women's Hospital, Boston, and Yale University School of Medicine, New Haven, CT, have been selected to incorporate clinical decision support into widely used health IT products, demonstrate cross-platform utility, and establish lessons learned for clinical decision support implementation across the health IT vendor community. Select to read AHRQ's press release.

3.  AHRQ Web Resource Features 100 Examples of Health Care Innovations and Tools

Yesterday, AHRQ launched its Health Care Innovations Exchange a new resource that allows users to learn, share, and adopt innovations in the delivery of health services. The resource is the Federal government's repository for successful health care innovations. It also includes useful descriptions of attempts at innovations that were unsuccessful. The Web site is a tool for health care leaders, physicians, nurses, and other health professionals who seek to reduce health care disparities and improve health care overall. It is being launched with 100 examples of innovations in the delivery of health care services and attempts at innovation; that number will increase as the site is updated every two weeks. Profile examples include an intensive care unit's successful efforts to shorten patient stays by setting and adhering to daily care goals; a home care initiative by geriatricians, nurse practitioners, and social workers to help seniors avoid hospital or nursing home stays; and a patient/physician E-mail communication system that overcomes the inconvenience of automated phone systems and accommodates the difficult schedules of both the physician and the patient.

To learn more about the tool, register for AHRQ's upcoming Web conference, Using AHRQ's Health Care Innovations Exchange to Take on the Challenges of Care Delivery, on May 12 at 2pm, E.D.T., by sending an E-mail to Select to read AHRQ's press release for more information on the new resource.

4.  AHRQ Issues Report About Transforming Hospitals Into High Reliability Organizations

An AHRQ report about incorporating high-reliability organization concepts into health care environments in order to improve safety and quality of care is now available. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders is a guide for hospital executives, chief medical officers, patient safety officers, and others interested in improving safety, quality, and efficiency. The report captures lessons learned from an AHRQ-supported learning network comprised of patient safety representatives of 19 health systems and explains how these organizations applied high-reliability organization principles in their settings. Select to access the report.

5.  AHRQ Unveils New Tool to Help Reduce Unnecessary Hospitalizations

A free software program that maps AHRQ's Prevention Quality Indicators and Pediatric Quality Indicators for a State or county and estimates expected cost savings achieved by reducing potentially avoidable hospitalizations is now available. The Prevention Quality Indicators are designed to screen hospital data for conditions that require hospitalizations but could be prevented by receiving quality primary care. The Pediatric Quality Indicators screen for quality of care problems in hospitalized children. This tool was designed to help State and local health officials use hospital discharge data to assess problems with potentially preventable hospitalizations and medical errors and identify interventions. The program can also be useful to employers, employer coalitions, Medicaid programs, health departments, hospitals, health systems, health plans, and researchers interested in improving health care quality in the community. Select for more information on Preventable Hospitalization Costs.

6.  AHRQ Helps Patients Take Medications Safely

AHRQ's How to Create a Pill Card provides step-by-step instructions for making a pill card using a computer and printer. One in four Americans do not take prescription medicines as prescribed. Many people who fail to adhere to medication instructions do so because they do not understand how to take their medicines. Research has shown that using a pill card—which uses pictures and simple phrases to show each medicine, its purpose, how much to take, and when to take it—reduces misunderstandings. Select to download the instructions.

7.  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 on 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.

8.  Health IT Survey Compendium Is Available

AHRQ has released a new Health IT Survey Compendium. This new survey compendium contains a set of publicly available surveys to assist organizations in evaluating health information technology [IT]. The surveys cover a broad range of topics, including user satisfaction, usability, technology use, product functionality and the impact of health IT on safety, quality and efficiency.

9.  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.

10.  Latest Issue of WebM&M Is Available Online

The April 2008 issue of AHRQ WebM&M is now available online. The Perspectives on Safety section features Gary A. Noskin, M.D., of Northwestern University, Chicago, IL, discussing methicillin-resistant Staphylococcus aureus (MRSA) infections and patient safety. An accompanying video depicts a patient's experiences with numerous complications from MRSA. The Spotlight Case features author Sumant Ranji, M.D., of the University of California, San Francisco (USCF), discussing the indications for antibiotic usage in upper respiratory infections as well as potential harms of inappropriate antibiotic use. The second case features author S. Andrew Josephson, M.D., also of UCSF, discussing clinical issues in managing elevated intracerebral pressure. The third case, features Joan M. Teno, M.D., of Brown University, Providence, RI, discussing safety in advanced care planning. 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.

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.

Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. Intensive care unit nurses' perceptions of safety after a highly specific safety intervention. Qual Saf Health Care 2008 Feb;17(1):25-30. Select to read an abstract of the study.

Silver MP, Hougland P, Elder S, Haug J, Pritchett T, Donnelly S, Link CL, Xu W. Statewide identification of adverse events using retrospective nurse review: methods and outcomes. J Nurs Meas 2007;15(3):220-32. Select to read an abstract of the study.

Taylor BB, Marcantonio ER, Pagovich O, Carbo A, Bergmann M, Davis RB, Bates DW, Phillips RS, Weingart SN. Do medical inpatients who report poor service quality experience more adverse events and medical errors? Med Care 2008 Feb;46(2):224-8. Select to read an abstract of the study.

Wachter RM, Foster NE, Dudley RA. Medicare's decision to withhold payment for hospital errors: the devil is in the details. Jt Comm J Qual Patient Saf 2008 Feb;34(2):116-23. Select to read an abstract of the study.

AHRQ's Patient Safety E-Newsletter Contact:

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Current as of April 2008


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