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Patient Safety and Health Information Technology E-Newsletter

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August 20, 2008, Issue No. 47

Quote of the Month

"Like the physical and emotional harm caused by medical errors, the financial consequences don't stop at the hospital door. Eliminating medical errors and their after effects must continue to be top priority for our health care system." (For more information on a new AHRQ study on costs of surgical errors, go to item no. 1.)

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

Today's Headlines:

  1. New AHRQ study finds surgical errors cost nearly $1.5 billion annually
  2. AHRQ researchers develop "Smart Form" to facilitate clinical decision support
  3. AHRQ helps to improve pediatric safety and quality with health IT rules and reminders
  4. World Health Organization issues checklist for making surgery safer
  5. Project to improve care transitions launched
  6. Free Web conference series on clinical decision support starts September 19
  7. Joint Commission releases 2009 National Patient Safety Goals
  8. Save the date: meeting for users of AHRQ CAHPS® and Patient Safety Culture Surveys on December 3-5
  9. Free TeamSTEPPS™ training opportunities available through August 2009
  10. AHRQ requests proposals for developing criteria to assess patient safety practices
  11. AHRQ Director helps consumers navigate the health care system in a new advice column on the Web
  12. Request for planning ideas for AHRQ's new innovations portfolio
  13. AHRQ in the patient safety and health IT professional literature—some useful citations

1.  New AHRQ Study Finds Surgical Errors Cost Nearly $1.5 Billion Annually

Potentially preventable medical errors that occur during or after surgery may cost employers nearly $1.5 billion a year, according to a new AHRQ-funded study published in the July 28 issue Health Services Research. The study, "The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients," also found that 1 of every 10 patients who died within 90 days of surgery did so because of a preventable error and that one-third of the deaths occurred after the initial hospital discharge. Select to read our press release and select to access the abstract.

2.  AHRQ Researchers Develop "Smart Form" to Facilitate Clinical Decision Support

AHRQ researchers have developed a specialized health IT tool, called the "Smart Form," to facilitate documentation-based clinical decision support (CDS). The form, which is tied to electronic medical records, organizes clinical data in a disease-focused manner to help in decision making. It also highlights and requests coded information, such as height, weight, and smoking status. The form also is designed to fit into workflow before, after, and during the clinical visit where CDS systems should have the biggest impact on provider behavior. Researchers, led by Jeffrey L. Schnipper, M.D., of Brigham and Women's Hospital in Boston, MA, suggest that integrating decision support into the workflow has the potential to improve the quality of decision making and improve the management of patients with acute and chronic medical conditions. Findings from the study, "Smart Forms" in an Electronic Medical Record: Documentation-Based Clinical Decision Support to Improve Disease Management," are published in the July/August issue of the Journal of the American Medical Informatics Association. Select to access the abstract.

3.  AHRQ Helps to Improve Pediatric Safety and Quality with Health IT Rules and Reminders

AHRQ has released two new tools to help pediatricians, family physicians, and other clinicians integrate clinical decision support applications into their electronic health record (EHR) systems. Both tools, developed under a grant to Partners HealthCare in Boston, help simplify the process of implementing clinical decision support rules, reminders, and templates to improve the quality of care delivered to children in particular but could be applied to other patient populations as well.

A rules and reminders tool provides the information needed to develop and implement specific rules and reminders into an EHR system. This tool is designed to help improve adherence to clinical guidelines.

A second tool, a documentation templates tool, includes a series of templates for acute and chronic pediatric conditions that can be implemented into an EHR system. These templates are based on national guidelines and can be used to electronically document visits. The templates are models that can be tailored for a particular practice's needs.

4.  World Health Organization Issues Checklist for Making Surgery Safer

The World Health Organization (WHO) recently issued guidelines aimed at reducing complications and deaths from the rising numbers of operations now being performed. Several studies have shown that in industrial countries major complications occur in 3 percent to 16 percent of inpatient surgical procedures, and permanent disability or death rates are about 0.4 percent to 0.8 percent. The guidelines are a list of simple safety checks that WHO says could reduce the rate of surgical complications by 50 percent. The list offers simple checks to improve anesthetic safety practices, avoid infections and improve communication among members of surgical teams.

AHRQ Director Carolyn Clancy, M.D., spoke at a WHO meeting on June 25 to discuss the history of the National Surgical Quality Improvement Program (NSQIP)—the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. In her speech, Dr. Clancy explained that NSQIP served as the basis for Surgical Care Improvement Project (SCIP), an initiative of Federal government agencies, hospitals, physicians, nurses, and private groups dedicated to improving the safety of surgical care by reducing postoperative complications. SCIP has set a goal of reducing surgical complications nationwide by 25 percent by 2010. Select to read WHO's press release and to view checklist.

5.  Project to Improve Care Transitions Launched

The Society of Hospital Medicine has launched Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to improve care of older patients as they transition from the hospital to home or another care facility. The project, led by AHRQ grantee Mark Williams, M.D., Chief of the Division of Hospital Medicine at Northwestern University in Chicago, resulted in part from AHRQ's Partnerships in Implementing Patient Safety program. It uses a team approach to assess patients' risk for re-hospitalization and plan and execute risk-specific discharge planning activities. The project is supported by a grant from the John A. Hartford Foundation and is led by a national advisory board of recognized leaders in hospital medicine, care transitions, payers, and regulatory agencies, which includes representatives from AHRQ; the Joint Commission; Centers for Medicare & Medicaid Services; the Blue Cross and Blue Shield Association; pharmacy, nursing, and patient advocates; and others. Select to learn more about Project BOOST.

6.  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.

7.  Joint Commission Releases 2009 National Patient Safety Goals

The Joint Commission recently released its 2009 National Patient Safety Goals and elements of performance. There are three new requirements that deal with healthcare-associated infections resulting from multiple drug-resistant organisms, central line-associated bloodstream infections, and surgical site infections. These requirements have a 1-year phase in period during which facilities will be expected to meet quarterly deadlines, with full implementation expected by January 1, 2010. Additional changes and new requirements can be found in the goals relating to improving patient identification, improving the safety of using medications, medication reconciliation, patients' involvement in their own care, responding to changes in a patient's condition, and the Universal Protocol. The Joint Commission also published a new system for numbering and referring to the goals to more easily sort electronic editions of the goals, as well as to better allow for future goals. Select to read more about the 2009 goals.

8.  Save the Date: Meeting for Users of AHRQ CAHPS® and Patient Safety Culture Surveys on December 3-5

AHRQ will hold a joint meeting for users of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) family of surveys and of the AHRQ patient safety culture surveys for hospitals, nursing homes, and medical offices on December 3-5. Registration is free, and the meeting will be held at the Doubletree Paradise Valley Resort in Scottsdale, AZ. The main meeting will be December 4-5 and the CAHPS® College will be on December 3. The CAHPS® program is a public/private initiative to develop standardized surveys of patients' experiences with ambulatory and facility-level care. The patient safety culture surveys are tools that staff in hospitals, nursing homes, and medical offices can use to assess their patient safety culture, track changes in patient safety culture over time, and evaluate the impact of patient safety interventions. AHRQ released the hospital patient safety culture survey in 2004 and plans to issue the surveys for nursing homes and medical offices this fall.

Select for more information about CAHPS® and the culture surveys. Select for meeting agenda highlights. Registration details will be posted online later this month and will be made available in the next issue of this E-newsletter.

9.  Free TeamSTEPPS™ Training Opportunities Available Through August 2009

AHRQ and the Department of Defense have created free TeamSTEPPS training opportunities for hospital and other health care provider systems through the National Implementation of TeamSTEPPS project at four project Training Resource Centers. The centers are located at Duke Medical Center, Durham, NC; Carilion Clinic, Roanoke, VA; University of Minnesota Fairview Medical Center, Minneapolis, MN; and Creighton University Medical Center, Omaha, NE. For information on eligibility for applying for these 2-½ day TeamSTEPPS training sessions, send an E-mail to or call 877-678-3777. Select to learn more about the TeamSTEPPS National Implementation Project, including training eligibility.

10.  AHRQ Requests Proposals for Developing Criteria to Assess Patient Safety Practices

AHRQ issued a new Request for Proposal (RFP) on August 15 called "Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria." AHRQ anticipates that the results of this work will benefit researchers and others seeking to evaluate the results of patient safety practice implementation, as well as to those who seek to synthesize the evidence on the effectiveness and safety of patient safety practices within specific organizational and systems contexts. Notice of intent letters are due on September 13, and the deadline for proposals is October 13. Select to access the RFP.

11.  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. Select to read Dr. Clancy's advice columns.

12.  Request for Planning Ideas for AHRQ's New Innovations Portfolio

AHRQ is establishing a new research portfolio, the Innovations Portfolio. The Portfolio goal is to identify and support research that has the potential to accelerate improvements in the organization, delivery, and management of health care. AHRQ has issued a Request for Information (RFI), "AHRQ Requests Input to Develop an Innovations Research Portfolio," to seek ideas on priority topics and activities, including those related to patient safety and health information technology or other topic areas, that should be addressed as components of the Innovations Portfolio. Select to access the Request for Information.

13.  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.

Mechanic D. Rethinking medical professionalism: the role of information technology and practice innovations. Milbank Q 2008 Jun;86(2):327-58. Select to access the abstract.

Werner RM, Goldman LE, Dudley RA. Comparison of change in quality of care between safety-net hospitals. JAMA 2008 May 14; 299(18):2180-7. Select to access the abstract.

Williams J. Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital? J Saf Res 2008; 39(3):287-94. Select to access the abstract.

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Current as of August 2008


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