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Patient Safety and Health Information Technology E-Newsletter

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October 3, 2008, Issue No. 48

Quote of the Month

"This is an exciting opportunity to provide health care professionals with valuable tools that support patient safety by eliminating health care-associated infections in ICUs. Application of these research findings will help us reach our goals of improving patient care and ensuring that Americans receive high-quality, safe health care." (For more information on AHRQ's new award for reducing central line-associated bloodstream infections, go to item no.1 .)

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

Today's Headlines:

  1. AHRQ awards $3 million to help reduce central line-associated bloodstream infections in hospital ICUs
  2. AHRQ issues new health IT funding opportunities
  3. Common Formats Version 0.1 beta now available for Patient Safety Organizations
  4. Free Web conference on clinical decision support on October 27
  5. New AHRQ resources help consumers and clinicians prevent dangerous blood clots
  6. New Nursing Home Survey on Patient Safety Culture now available
  7. New report on lessons from AHRQ-funded bar-coded medication administration projects
  8. New Advances in Patient Safety compendium is available
  9. Meeting for users of AHRQ CAHPS® and patient safety culture surveys on December 3-5—register now
  10. 2008 John M. Eisenberg Patient Safety and Quality Award recipients announced
  11. Latest issue of WebM&M is available online
  12. Medical errors & patient safety E-mail updates now available
  13. AHRQ in the patient safety and health IT professional literature—some useful citations

1.  AHRQ Awards $3 Million to Help Reduce Central Line-Associated Bloodstream Infections in Hospital ICUs

AHRQ has awarded a contract for nearly $3 million to help reduce central line-associated bloodstream infections in hospital intensive care units (ICUs) by spreading the knowledge gained from a previous AHRQ-funded project. The Health Research & Educational Trust, an affiliate of the American Hospital Association, has been selected to coordinate the new 3-year project, part of the U.S. Department of Health and Human Services' initiative to reduce health care-associated infections. The project will continue work started by the Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association to implement a comprehensive unit-based patient safety program to help prevent infections related to the use of central line catheters. The comprehensive program, designed to survey and improve an intensive care unit's patient safety culture, was developed by researchers at the Johns Hopkins University and has been used in more than 100 ICUs in Michigan.The program includes tools to help health care professionals identify opportunities to reduce potential health care-associated infections and implement policies to make care safer. Within 3 months of implementation in Michigan, the program helped reduce infection rates to zero in more than 50 percent of participating hospitals. Under the new contract, the safety program will be implemented by statewide consortia in at least 10 different states. The consortia, which will be established as part of this project, will include members of state hospital associations, quality improvement organizations and public health agencies. Select to read our press release.

2.  AHRQ Issues New Health IT Funding Opportunities

AHRQ recently announced new health IT funding opportunities that will help achieve improvements in quality and safety in ambulatory settings and transitions of care. The types of funding opportunities include:

  • Career Development and Dissertation Research Grants (K01, K02, K08, R36) Special Emphasis Notice: Supports development and enhancement of expertise in health IT and related disciplines, including research and evaluation methods. It will also enhance the capacity of grantees to participate in multi-disciplinary research teams that apply trans-disciplinary perspectives in health IT research.
  • Small Research Grant to Improve Healthcare Quality through Health IT (RO3) FOA: Supports different types of small research studies including (1) small pilot and feasibility or self-contained health IT research projects, (2) secondary data analysis of health IT research, and (3) economic (prospective or retrospective) analyses of health IT implementation. This grant is limited to $100,000 for up to two years of funding.
  • Exploratory and Developmental Grant to Improve Health Care Quality through Health IT (R21) FOA: Supports the conduct of short-term preparatory, pilot, or feasibility studies that are needed to inform future health IT implementations such as the conduct of a health IT research demonstration grant. These projects are limited to $300,000 over two years with no more than $200,000 total costs in a given year.
  • Utilizing Health IT to Improve Health Care Quality Grant (R18) FOA: Supports demonstration research grants that rigorously study health IT implementation and use to improve the quality, safety, effectiveness and efficiency of health care in ambulatory settings and in the transitions between care settings. Costs are limited to $1.2 million over three years with no more than $500,000 in total costs in a given year.

3.  Common Formats Version 0.1 Beta Now Available for Patient Safety Organizations

AHRQ has released Common Formats for collecting and reporting patient safety information, including adverse events, near misses, and unsafe conditions. The Common Formats provide common definitions and reporting formats that health care professionals can use to collect and track patient safety information. These Common Formats were authorized by the Patient Safety and Quality Improvement Act of 2005, and they facilitate Patient Safety Organizations' (PSOs) collection of patient safety work product from providers in a standardized manner. The formats will be used by both providers and PSOs to report a comprehensive range of patient safety concerns, capturing both structured and narrative information. AHRQ plans to issue updates and revisions to the Common Formats based upon feedback from users and other stakeholders. The Agency has contracted with the National Quality Forum to assist with gathering and analyzing feedback that will guide future versions of the Common Formats. Select to learn more and to view AHRQ's Common Formats Version 0.1 Beta.

4.  Free Web Conference on Clinical Decision Support on October 27

The AHRQ National Resource Center for Health Information Technology is hosting a series of free 90-minute Web conferences over the next few months that will focus on how clinical decision support (CDS)—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 next conference, "Use of Clinical Decision Support and Impact on Workflow," will be on October 27, 2:30 p.m. to 4:00 p.m., EDT, and features AHRQ Health IT Director Jon White, M.D.; Ben-Tzion Karsh, Ph.D., MSIE, University of Wisconsin Department of Industrial Engineering and Systems; Ross Koppel, Ph.D., University of Pennsylvania Department of Sociology, and Center for Clinical Epidemiology and Biostatistics, School of Medicine; and David F. Lobach, M.D., Ph.D., Division of Clinical Informatics, Department of Community and Family Medicine, Duke University. They will discuss existing evidence about the relationship between CDS and workflow, levels and stages, including findings regarding order sets and alerts, specific CDS implementations, their impact on workflow and share lessons learned from those implementations. Detailed registration information for upcoming events will be announced in future issues of this e-newsletter.

5.  New AHRQ Resources Help Consumers and Clinicians Prevent Dangerous Blood Clots

Two new AHRQ guides can help consumers and clinicians prevent and treat deep vein thrombosis. AHRQ's consumer booklet, Your Guide to Preventing and Treating Blood Clots is a 12-page easy-to-read resource that helps both patients and their families identify the causes and symptoms of dangerous blood clots, learn how to prevent them, and know what to expect during treatment. The guide, based on work by Brenda Zierler, Ph.D., R.N., at the University of Washington, Seattle, is available in both English and Spanish. The clinician guide, Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement , a comprehensive tool to help hospitals and clinicians implement processes to prevent blood clots, reflects the work of Gregory Maynard, M.D., at the University of California, San Diego, with contributions from Jason Stein, M.D., at Emory University in Atlanta. The 60-page guide details how to start, implement, evaluate, and sustain a quality improvement strategy. It includes case studies, as well as examples of forms for clinicians in the field to use. The guides were developed from toolkits originally created by experts funded through AHRQ's Partnerships in Implementing Patient Safety grant program. Select to read our press release. Free, single copies of the guides are available by sending an E-mail to

6.  New Nursing Home Survey on Patient Safety Culture Now Available

AHRQ's new Nursing Home Survey on Patient Safety Culture helps nursing homes assess nursing home staff opinions on 12 domains of patient safety culture in the nursing home. This information can help nursing homes evaluate the safety culture of their institution, track changes over time, and evaluate the impact of safety interventions. The evidence-based, easy-to-understand survey and user's guide are free. Select to view the survey. Technical assistance for survey administration and access to a user's group is also available for free by E-mailing

7.  New Report on Lessons from AHRQ-Funded Bar-Coded Medication Administration Projects

The AHRQ National Resource Center for Health Information Technology has released a new report in its health IT decision maker brief series. The report summarizes key findings from grantees implementing bar-coded medication administration (BCMA) technologies as part of AHRQ's health IT portfolio. The report focuses on lessons learned, emphasizing implementation challenges associated with BCMA as well as the promise that BCMA holds for improving patient safety.

8.  New Advances in Patient Safety Compendium Is Available

AHRQ has published a new compendium of 115 original research papers by AHRQ grantees and other authors entitled Advances in Patient Safety: New Directions and Alternative Approaches. The four-volume set, which is also available as a searchable CD-ROM, highlights new knowledge and lessons learned in such critical areas as reporting systems, risk assessment, health IT, clinical process redesign, and medical simulation. The new compendium is a followup to an earlier version published in 2005. A single copy of the printed compendium or the CD-Rom is available by sending an E-mail to

9.  Meeting for Users of AHRQ CAHPS® and Patient Safety Culture Surveys on December 3-5—Register Now

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 develops standardized surveys of patients' experiences with health plans, medical groups, hospitals, nursing homes, individual clinicians, and other providers. The program also offers guidance on how to use the survey results to improve quality of care and report useful information to consumers. 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 the culture surveys; for meeting agenda highlights; and to register for the meeting. Exit Disclaimer

10.  2008 John M. Eisenberg Patient Safety and Quality Award Recipients Announced

The National Quality Forum (NQF) and the Joint Commission have announced the 2008 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards. The honorees, by award category, were for Individual Achievement: Michael R. Cohen, R.Ph., M.S., Sc.D. of the Institute for Safe Medication Practices, Huntington Valley, PA; Research: The RAND Corporation and University of California at Los Angeles School of Medicine, Los Angeles, CA; Innovation in Patient Safety and Quality at the National Level: National Coordinating Council for Medication Error Reporting and Prevention, Rockville, MD; and Innovation in Patient Safety and Quality at the Local Level: Anthem Blue Cross and Blue Shield of Virginia, subsidiary of WellPoint Inc., Richmond, VA, and New York City Health and Hospitals Corporation, New York, NY; Honorary Award for Individual Achievement: Dennis S. O'Leary, M.D., president emeritus of The Joint Commission. Select to read NQF's press release. Exit Disclaimer

11.  Latest Issue of WebM&M Is Available Online

The September issue of AHRQ WebM&M is now available online. The Perspectives on Safety section addresses bar coding for medication safety and features Eric Poon, M.D., of Harvard Medical School and the Brigham and Women's Hospital, Boston, MA. In an accompanying perspective piece, Jeffrey Rothschild, M.D., and Carol Keohane, R.N., also of Brigham and Women's Hospital, describe how both smart pumps and bar-coded medication administration can augment safety. The Spotlight Case features three examples that illustrate appropriate indications and contraindications for using glucocorticoids. The author, Edward Harris, Jr., M.D., of Stanford University, Stanford, CA, discusses how certain comorbidities should preclude the use of steroids to avoid exacerbating underlying disease processes. The second case features Mitch Rodriguez, M.D., of Mercer University Medical School, Macon, GA; Rebecca Mannel of Oklahoma University Medical Center, Oklahoma City, OK and Hospital Corporation of America, Inc., Nashville, TN; and Donna Frye, R.N., of Hospital Corporation of America, Inc., Nashville, TN., discussing appropriate lactation education of hospital staff as well as breastfeeding assessment. The third case features Norma Metheny, R.N., Ph.D., of Saint Louis University School of Nursing, St. Louis, MO, and Kathleen Meert, M.D., of Wayne State University School of Medicine, Detroit, MI, and Children's Hospital of Michigan, Detroit, MI, discussing safety issues with feeding tubes. As always, a Spotlight slide presentation is available for download. Physicians and nurses can receive free 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.

12.  Medical Errors & Patient Safety E-mail Updates Now Available

If you would like to receive regular updates on AHRQ's new releases and the latest on patient safety initiatives and efforts to reduce medical errors, subscribe to E-mail alerts on the AHRQ Web site under Patient Safety.

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.

Matheny ME, Gandhi TK, Orav EJ, et al. Impact of an automated test results management system on patients' satisfaction about test result communication. Arch Intern Med 2007 Nov 12; 167(20):2233-2239. Select to access the abstract.

Pronovost PJ, Rosenstein BJ, Paine L, Miller MR, Haller K, Davis R, Demski R, Garrett MR. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008 Jun;34(6):342-8. Select to access the abstract. Yu F, Housto TK, Ray MN, et al. Patterns of use of handheld clinical decision support tools in the clinical setting. Med Decis Making 2007 Nov-Dec; 27(6):744-753. Select to access the abstract.

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Current as of October 2008


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