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Patient Safety and Health Information Technology E-Newsletter

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July 18, 2008, Issue No. 46

Quote of the Month

"We are making great strides in transforming the health care system. We have new tools, a greater focus on the evidence base, an increasing shift in priorities toward patient-focused activities, and a host of additional initiatives that are designed to turn the U.S. health care system into a real system. Yet, always looming in the background is the issue of addressing the needs of priority populations. We must ensure that these populations experience the benefits of health IT."

—Carolyn M. Clancy, M.D., Director, AHRQ, in June 12 remarks at National Health IT Collaborative for the Underserved (For more information, go to item no. 2.)

Today's Headlines:

  1. Barcoded technology promising for reducing medication administration errors but needs refinement, according to AHRQ researchers
  2. AHRQ Director speaks at National Health IT Collaborative for the Underserved
  3. Upcoming Web conference on teambuilding strategies set for July 30
  4. AHRQ to publish funding opportunity announcements for health IT
  5. Free Web conference series on clinical decision support starts September 19
  6. Nominations sought for Chair of CERTs National Steering Committee
  7. AHRQ's 2008 annual conference: Promoting Quality.Partnering for Change
  8. Latest issue of WebM&M is available online
  9. New feature on AHRQ PSNet: Patient Safety Primers
  10. AHRQ in the patient safety and health IT professional literature—some useful citations

1.  Barcoded Technology Promising for Reducing Medication Administration Errors But Needs Refinement, According to AHRQ Researchers

A recent study of how hospital nurses use bar-coded technology to match the right patient with the correct dose of the proper medication found that the design and implementation of bar coding technology, while helpful for identifying medication administration errors, needs refinement and may increase the probabilities of certain errors. AHRQ-funded researchers, led by Ross Koppel, Ph.D., of the University of Pennsylvania School of Medicine in Philadelphia, conducted a study of five hospitals in the Midwest and on the East Coast equipped with barcoded medication administration systems (BCMA) and examined nearly 500,000 instances in which nurses and other staff scanned patients and medications. They found that nurses scanning the barcode on the medication or the patient's ID bracelet overrode BCMA alerts for 4.2 percent of patients charted and for 10.3 percent of medications charted. The study also illustrates how adjustments to workflow and the technology can dramatically reduce the risk of consequential errors. The findings of the study appear in the July/August issue of the Journal of the American Medical Informatics Association. Select to read an abstract of the study.

2.  AHRQ Director Speaks at National Health IT Collaborative for the Underserved

AHRQ Director Carolyn Clancy, M.D., spoke to health care leaders, stakeholders, and other professionals at the inaugural meeting of the National Health IT Collaborative for the Underserved on June 12 in Washington, D.C. Dr. Clancy discussed the importance of addressing the needs of priority populations and ensuring that these populations experience the benefits of health IT. She also provided an overview of AHRQ's health IT activities relevant to this population, including AHRQ's newly funded Ambulatory Safety and Quality Initiative and Transforming Healthcare Quality through Health IT Program. Select to read Dr. Clancy's speech.

3. Upcoming Web Conference on Teambuilding Strategies Set for July 30

AHRQ and the Department of Defense are hosting a series of free, 90-minute Web conferences on various topics related to patient safety culture and team training as part of a project to implement the TeamSTEPPS™ training program nationwide. The next Web conference, "Determining Readiness and Developing a Strategy to Build Administrative Buy-In" is scheduled for July 30 from 12:00p.m.—1:30p.m., EDT. The Web conference, which features Rebecca Beard of the Group for Organizational Effectiveness and David Baker of the American Institutes for Research, will provide an overview of criteria that can be used to determine an organization's readiness to implement TeamSTEPPS and strategies for building buy-in from administrators and quality improvement staff. Select to learn more about TeamSTEPPS National Implementation Project.

To register for the Web conference, send an E-mail to You will be contacted with further instructions on how to register. Stay tuned for announcements of future Web conferences.

4.  AHRQ To Publish Funding Opportunity Announcements for Health IT

AHRQ has announced intent to publish three types of funding opportunity announcements (FOAs) by the end of August to fund health IT research. The FOAs will include research demonstration projects, exploratory developmental research projects, and small research grants. The research demonstration projects will study the leveraging of health IT implementation to improve the quality, safety, effectiveness and efficiency of health care in ambulatory settings and to support transitions in care between ambulatory settings or ambulatory and non-ambulatory settings. The exploratory developmental research projects will support pilot or feasibility studies that are needed to inform future health IT implementation efforts that may include but are not limited to health IT research demonstration grants. The small research grants will support small, self-contained health IT research projects, economic analyses of health IT implementation, and secondary data analyses of health IT research. Select for additional information on the notice of intent.

5.  Free Web Conference Series on Clinical Decision Support Starts September 19

The AHRQ National Resource Center for Health Information Technology is hosting a series of four, free 90-minute Web conferences over the next few months that will focus on how clinical decision support—a clinical system, application, or process that helps health professionals make good patient care decisions—can be used to inform and improve health care delivery. The first conference, "Using Clinical Decision Support To Make Informed Patient Care Decisions," will be on September 19, from 3:30 p.m. to 5:00 p.m., EDT, and features AHRQ Health IT Director Jon White, M.D.; Blackford Middleton, M.D., of The Brigham and Women's Hospital in Boston, MA; and, Richard N. Shiffman, M.D., M.C.I.S., of Yale University School of Medicine in New Haven, CT. They will discuss the development, adoption, implementation, and evaluation of best practices using clinical decision support as well as methods of creating, storing, and replicating clinical decision support elements across multiple clinical sites and ambulatory practices. Detailed registration information for upcoming events will be announced in future issues of this E-newsletter.

6.  Nominations Sought for Chair of CERTs National Steering Committee

The Centers for Education and Research on Therapeutics (CERTs) Program is seeking highly qualified individuals for consideration to take on the role of chair and chair- elect of the CERTs National Steering Committee. The deadline for receipt of nominations is August 31. AHRQ is asking for help in finding and recruiting qualified candidates for this high-visibility position. The CERTs Program has expanded in size, scope, and visibility in the past few years. It is poised to assume increasing roles in therapeutics safety surveillance and assessment, comparative effectiveness, and the use and development of Medicare Part D prescription drug coverage data. Please review AHRQ's request for nominations and notify others of the search for the new CERTs National Steering Committee Chair.

7.  AHRQ's 2008 Annual Conference: Promoting Quality.Partnering for Change

Register now for AHRQ's 2008 Annual Conference, which will be held September 7-10 in Bethesda, MD. Leading national experts will hold sessions on patient safety, health IT, comparative effectiveness research, disease prevention and care management, and innovations in health care.

8. Latest Issue of WebM&M Is Available Online

The July issue of AHRQ WebM&M is now available online. The Perspectives on Safety section focuses on root cause analysis and features Albert Wu, M.D., of Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, and the WHO's World Alliance for Patient Safety. Dr Wu, an expert in patient safety, disclosure, and evaluation, was lead author of a recent JAMA article that examined the value of root cause analyses. Patrice Spath, of Brown-Spath & Associates in Forest Grove, OR, and William Minogue, M.D., of the Maryland Patient Safety Center in Elkridge, MD, support the value of root cause analyses, although they call for some changes in how they are carried out. Adam J. Gordon, M.D., of the University of Pittsburgh School of Medicine in Pittsburgh, PA, discusses issues surrounding treating acute illnesses in patients with opioid dependence. Jill R. Scott-Cawiezell, R.N., Ph.D., of University of Missouri-Columbia, Sinclair School of Nursing in Columbia, MO, addresses medication safety for IV therapy in long-term care settings. Roslyn Yomtovian, M.D., of Case Western Reserve University School of Medicine in Cleveland, OH, discusses safety issues in platelet transfusion. As always, a Spotlight slide presentation is available for download.

Physicians and nurses can receive free continuing medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. You can share AHRQ WebM&M cases by using the "Email a colleague& feature.

9.  New Feature on AHRQ PSNet: Patient Safety Primers

AHRQ PSNet, a national Web-based resource featuring the latest news and essential resources on patient safety, introduces Patient Safety Primers designed to guide users through key concepts in patient safety. Each Primer provides background and context, highlights relevant content from AHRQ PSNet and AHRQ WebM&M, a Web-based patient safety resource and journal that showcases patient safety lessons drawn from actual cases of medical errors, and is continually updated with items newly added to AHRQ PSNet. More topics will be added in the future. Select to view the Patient Safety Primers.

10.  AHRQ in the Patient Safety and Health IT 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.

Hoff TJ. How work context shapes physician approach to safety and error. Qual Manag Health Care 2008; 17(2):140-53. Select to access the abstract.

Jha AK, Orav EJ, Ridgway AB, Zheng J, Epstein AM. Does the Leapfrog program help identify high-quality hospitals? Jt Comm J Qual Patient Saf 2008 Jun; 34(6):318-25. Select to access the abstract.

Olson MK. The risk we bear: the effects of review speed and industry fees on new drug safety. J Health Econ 2008 Mar; 27(2):175-200. Select to access the abstract.

Rivera AJ, Karsh BT. Human factors and systems engineering approach to patient safety for radiotherapy. Int J Radiat Oncol Biol Phys 2008; 7191 Suppl):S174-S177. Select to access the abstract.

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Current as of July 2008


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