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Patient Safety and Health Information Technology E-Newsletter

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February 22, 2005, Issue No. 5

Quote of the Month

"This research underscores the need for providers to exercise caution when prescribing medication to the elderly, who often live with illness or chronic conditions, take multiple drugs, and are more susceptible to adverse drug reactions."

—Chunliu Zhan, M.D., Ph.D., AHRQ.

Today's Headlines:

  1. Second national reports on quality and disparities find improvements in health care quality, although disparities remain
  2. New study finds harmful drug-drug and drug-disease interactions among the elderly
  3. Save the date—June 6-10 for AHRQ's 2005 conference on patient safety and health information technology
  4. Recent findings from important AHRQ patient safety research
  5. New item coming soon
  6. National Quality Measures Clearinghouse™ features patient safety-related measures
  7. Calling all AHRQ researchers! "Help us to help you"
  8. AHRQ in the patient safety professional literature—some useful citations

1.  Second National Reports on Quality and Disparities Find Improvements in Health Care Quality, Although Disparities Remain

AHRQ today released its second annual reports on the quality of and disparities in health care in America. The 2004 National Healthcare Quality Report finds both evidence of improving quality and specific areas in which major improvements can be made. The 2004 National Healthcare Disparities Report indicates that there are pervasive disparities related to race, ethnicity, and socioeconomic status in the American health care system. Both reports extend the baseline data on quality and disparities within the health care system that were provided in AHRQ's 2003 reports. The reports measure quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness. Improvements have been made in specific measures related to health care delivery since the 2003 Quality Report. For example, there was a decrease of 34 percent from 1996 to 2000 in the percentage of elderly patients who were given potentially inappropriate medications. Select to read our press release and select to view the reports. Print copies of the reports also can be obtained by calling (800) 358-9295 or by sending an E-mail to

2.  New Study Finds Harmful Drug-drug and Drug-disease Interactions Among the Elderly

A new AHRQ study found that elderly patients were prescribed at least one medication that could have caused a harmful drug-disease interaction in more than 2.5 percent of outpatient visits. The likelihood that a patient was prescribed a medication that had the potential for a harmful drug-drug interaction was slightly less than 1 percent in visits that involved two or more prescriptions. Using data from 1995 to 2000, researchers assessed the likelihood that a patient would receive a prescription for a medication that could have a harmful drug-drug or drug-disease interaction. They studied six drug-drug and 50 drug-disease combinations considered to be harmful to the elderly. For example, when patients were prescribed the anticoagulant drug warfarin, 6.6 percent of the patients also were prescribed another drug that could cause a potentially harmful interaction. Researchers also found that patients with an enlarged prostate ran the highest risk (4.1 percent) of being prescribed at least one of six drugs that should be avoided for patients with this condition. Led by AHRQ's Chunliu Zhan, M.D., Ph.D., the study, "Suboptimal Prescribing in Elderly Outpatients: Potentially Harmful Drug-Drug and Drug-Disease Combinations," was published in the February issue of the Journal of the American Geriatrics Society. Select to read an abstract of the study on PubMed®. A reprint of the article is available by sending an E-mail to

3.  Save the Date—June 6-10 for AHRQ's 2005 Conference on Patient Safety and Health Information Technology

AHRQ's 2005 conference, "Patient Safety and Health Information Technology: Making the Health Care System Safer Through Implementation and Innovation," will facilitate collaboration and knowledge sharing across its patient safety grantees, health IT grantees, and state and regional health IT demonstration projects. Providers, researchers, and practitioners will be able to share information about their work in patient safety and health IT. In addition to discussions on best practices, lessons learned, and strategies for meeting common challenges, the conference also will feature presentations from innovative leaders who understand the importance of health IT as a critical element of improving the safety and quality of the health care system. The conference will be held June 6-10 at the Washington Convention Center in Washington, DC. For more information, send an E-mail to

4.  Recent Findings from Important AHRQ Patient Safety Research

Most Airway Events in ICUs Are Preventable, According to Findings from AHRQ-Sponsored ICU Safety Reporting System

More than half of airway events (e.g., coughing, spasms of the larynx, excessive salivation and breath holding, and other complications involving endotracheal tubes) in intensive care units, were considered preventable, according to a recent study about an AHRQ-sponsored ICU safety reporting system. These events could lead to physical injury, increased hospital length of stay, and death. To help limit the impact of these events, researchers suggest that prevention efforts focus on critically ill infants and patients with complex medical conditions. Also, ICU managers should ensure appropriate staffing to limit the impact of airway events when they occur. Findings from this research result from the Intensive Care Unit Safety Reporting System, the first Web-based, multiple-center reporting system of its kind, which currently includes 23 adult and pediatric ICUs across the United States. Developed in partnership with the Society of Critical Care Medicine, the ICUSRS ( is used to report unsafe conditions and events in ICUs that could or did lead to patient harm, and it has provided detailed information for improved understanding and prevention of airway events in critically ill patients. The AHRQ-funded study, "A System Factors Analysis of Airway Events from the Intensive Care Unit Safety Reporting System (ICUSRS)," was led by Dale M. Needham, M.D., and Peter J. Pronovost, M.D., Ph.D., of Johns Hopkins University School of Medicine, Baltimore, and is published in the November 2004 issue of Critical Care Medicine. Select to read an abstract of the study on PubMed®.

Missing Health Records Can Pose Health Risks

Primary care clinicians report that missing clinical information is common, consumes time and other resources, and may adversely affect patients. In a survey conducted by researchers at the University of Colorado Health Sciences Center, Denver, led by Peter C. Smith, M.D., and Wilson D. Pace, M.D., 253 clinicians in 32 primary care clinics completed questionnaires on 1,614 patient visits. These clinicians indicated that certain clinical information-including laboratory and radiology results, letters/dictation, examination results, or medication lists-was missing for nearly one in seven visits. In 44% of the visits, the missing information was thought to be at least somewhat likely to adversely affect patients. Missing information was less likely in rural practices and when clinicians had full electronic records. The study, "Missing Clinical Information During Primary Care Visits", was published in the February 2 issue of the Journal of the American Medical Association. Select to read an abstract of the study on PubMed®.

5.  New Item Coming Soon

AHRQ and DoD's Compendium of Original Patient Safety Articles

AHRQ, in collaboration with the Department of Defense, will be publicly releasing in March Advances in Patient Safety: From Research to Implementation. This compendium of original, peer-reviewed articles covers a wide range of research paradigms, clinical settings, and patient populations. The compendium also reports research findings and highlights research in progress. Available in a four-volume book set, on CD-ROM, and on the AHRQ Web site, the articles represent the efforts of AHRQ-funded patient safety researchers as well as the patient safety initiatives of other components of the Federal Government. To be placed on a waiting list for these products, send an E-mail to specifying print or CD-ROM. Stay tuned for more information.

6.  National Quality Measures Clearinghouse™ Features Patient Safety-Related Measures

More than 30 of the approximately 575 quality measures included in the National Quality Measures Clearinghouse™ (NQMC) have been categorized in the Institute of Medicine's domain of "safety." The NQMC team classifies a measure as patient safety-related when safety applies to the measure's primary clinical component. In addition to the AHRQ Patient Safety Indicators, measures from the Veterans Health Administration, Institute for Clinical Systems Improvement, Physician Consortium for Performance Improvement, and the Accreditation Association for Ambulatory Health Care Institute for Quality Improvement are classified as safety in NQMC. To find these safety-related evidence-based measures, use the detailed search feature (scroll approximately two-thirds down, select "safety" in the IOM Domain field box, scroll to the bottom of page, and select Search).

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

As you may know, AHRQ can help you promote the findings of your 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 transfer knowledge based on the research to appropriate audiences in the health care community. However, we know that we can do better. We need you to notify us when you have an article accepted for publication. Please send a copy of the manuscript, anticipated publication date, and contact information for the journal and your institution's PR office to your AHRQ project officer and to AHRQ Public Affairs at Your manuscript will be reviewed to determine what level of marketing we will pursue. Please be assured that AHRQ always honors the journal embargo. Thank you for your cooperation.

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. Some of these articles were published a few years ago, but they remain informative. These abstracts are available through PubMedŽ for your convenience. Unfortunately, some of you may not be able to access the abstracts because of firewalls or specific settings on your individual computer systems. If you are having problems, you should ask your technical support staff for possible remedies.

Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004 Nov;44(5):439-50. Select to access the abstract on PubMed®.

Feldman PH, Kane RL. Strengthening research to improve the practice and management of long-term care. Milbank Q 2003;81(2):179-220, 171. Select to access the abstract on PubMed®.

Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care 2002 Aug;8(4):316-20. Select to access the abstract on PubMed®.

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Current as of February 2005


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