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Patient Safety and Health Information Technology E-Newsletter

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March 25, 2005, Issue No. 6

Quote of the Month

"Hospital leaders in our sample were strongly supportive of policies that kept confidential the names of the hospitals and the practitioners involved."

—Joel S. Weissman, Ph.D., Associate Professor, Massachusetts General Hospital.

Select for more information on a new study about mandatory error reporting by Dr. Weissman and his colleagues.

Today's Headlines:

  1. Study finds hospital leaders have serious reservations about mandatory error reporting
  2. New study on computerized order entry finds flaws that could lead to errors, points to opportunities for improvement
  3. Last chance to register for April 4 AHRQ conference: "Improving Health Care for All Americans"
  4. Medical Care looks at lessons learned from AHRQ's 2003 national reports on quality and disparities
  5. New fact sheet on "30 Safe Practices for Better Health Care" now available
  6. Recent findings from important AHRQ patient safety research
  7. Connecticut Patient Safety Improvement Corps initiative
  8. Latest issue of AHRQ WebM&M is available online
  9. AHRQ soon to launch new national Patient Safety Network Web site
  10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  Study Finds Hospital Leaders Have Serious Reservations About Mandatory Error Reporting

A survey of hospital leaders found that nearly 70 percent believed that a non-confidential, mandatory system would discourage staff from reporting patient safety incidents to their hospital's own internal reporting system, and almost 80 percent thought it would encourage lawsuits. The AHRQ-funded study, led by Joel S. Weissman, Ph.D., of Massachusetts General Hospital in Boston, was published in the March 16 issue of JAMA. The researchers also found that more than 80 percent felt the names of both the hospital and involved staff members should be kept confidential, although respondents from States with mandatory, non-confidential systems already in place were more willing to have hospital names released. Over 90 percent said their hospital would report serious injuries to their State hospital licensing agencies, but far fewer would report moderate or minor injuries. However, the hospital leaders surveyed generally did favor disclosing patient safety incidents to patients who were involved. Select to read the abstract of the study, "Error Reporting and Disclosure Systems: Views from Hospital Leaders," on PubMed®.

2.  New Study on Computerized Order Entry Finds Flaws that Could Lead to Errors, Points to Opportunities for Improvement

While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors, according to a new AHRQ-funded study. The study, led by Ross Koppel, Ph.D., of the University of Pennsylvania, identified 22 situations in which the CPOE system increased the probability of medication errors. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals' many information systems and interface problems between humans and machines, where the computer's requirements are different than the way clinical work is organized. The study looked at clinicians' experience in using one CPOE system at a major urban teaching hospital. "New health care information technology products usually go through an ongoing process of refinement and improvement as health care workers identify problems," according to AHRQ Director Carolyn M. Clancy, M.D. The study was published in the March 9 issue of JAMA. Select to read our press release and select to read the abstract of the study, "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," on PubMed®.

3.  Last Chance to Register for April 4 AHRQ Conference: "Improving Health Care for All Americans"

Time is running out to register for AHRQ's first annual health care summit, "Improving Health Care for All Americans." This 1-day meeting, to be held on April 4 in Washington, DC, will highlight trends in health care quality improvement and disparities elimination and showcase the efforts of health systems, health plans, health care purchasing organizations, government programs, professional associations, and other organizations to bring about high-quality health care. AHRQ Director Carolyn M. Clancy, M.D., will deliver a speech on the "The Quality Challenge." Confirmed speakers include Governor Mike Huckabee of Arkansas; Don Berwick, M.D., President and CEO, Institute for Healthcare Improvement; John Nelson, M.D., President, American Medical Association; Randall Maxey, M.D., President, National Medical Association; David Schulke, Executive Vice President, American Health Quality Association; and Risa Lavizzo-Mourey, M.D., President and CEO of the Robert Wood Johnson Foundation, among others. Seating is limited and available on a first-come, first-served basis.

4.  Medical Care Looks at Lessons Learned from AHRQ's 2003 National Reports on Quality and Disparities

Highlights from AHRQ's two inaugural reports—2003 National Healthcare Quality Report (NHQR) and 2003 National Healthcare Disparities Report (NHDR)—have been published in a March 2005 supplement to Medical Care. The issue begins with an overview of key concepts, definitions, statistical methods, and findings from these reports. It also includes articles that examine methodological challenges in developing the reports and gaps in data that were encountered in producing the first NHDR. Additional articles focus on disparities in care among children, reproductive-age women, and men, and explore how the two reports can be used to improve quality and eliminate disparities. For a print copy of the Medical Care supplement, "Health Care Quality and Disparities: Lessons from the First National Reports," call (800) 358-9295 or send an E-mail to (supplies are limited). Both 2003 reports, along with the newly released 2004 reports, are available on AHRQ's QualityTools Web site.

5.  New Fact Sheet on "30 Safe Practices for Better Health Care" Now Available

AHRQ released a new fact sheet, "30 Safe Practices for Better Health Care," on safe practices that the National Quality Forum, with support from AHRQ, identified as having evidence showing they can work to reduce or prevent adverse events and medical errors. The safe practices were endorsed by the NQF member organizations, which strongly urge that these 30 safe practices be universally adopted in all applicable health care settings to reduce the risk of harm to patients. Select to read the fact sheet and the executive summary of the full report. A print copy of the fact sheet is available by sending an E-mail to

6.  Recent Findings from Important AHRQ Patient Safety Research

Surgical Simulation Web Site Now Available

AHRQ researchers have designed a Web site for information and results from a series of studies on an endoscopic sinus surgery simulator. The Web site, which also includes results of studies on other surgical simulators, serves as a valuable resource for simulation researchers, surgical training program directors, surgical residents, and others interested in surgical training and patient safety. The AHRQ-funded study was led by Marvin Fried, M.D., Professor and Chairman of the Department of Otolaryngology, Albert Einstein College of Medicine, Montefiore Medical Center, New York.

Improve Medication Safety by Detecting Errors Through the Use of Smart Infusion Pumps

Medication errors and adverse drug events are common among critically ill cardiac surgical patients who receive medications through intravenous infusion pumps, according to a new AHRQ-funded study. Researchers studied smart infusion pump data for 735 cardiac surgery patients and found 180 serious medication errors. Researchers at Brigham and Women's Hospital, Boston, led by Jeffrey M. Rothschild, M.D., M.P.H., and David W. Bates, M.D., M.Sc., concluded that although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety. The article, "A Controlled Trial of Smart Infusion Pumps to Improve Medication Safety in Critically Ill Patients" was published in the March 2005 issue of Critical Care Medicine. Select to read the abstract of the study on PubMed®.

7.  Connecticut Patient Safety Improvement Corps Initiative

Members of the Connecticut Hospital Association (CHA) gained valuable insights by participating in the Patient Safety Improvement Corps (PSIC) training program sponsored jointly by AHRQ and the Department of Veterans Affairs. PSIC team members are trained to analyze reported medical errors, identify root causes, and develop and implement patient safety improvement processes. As part of their PSIC project, CHA, along with team members from the Connecticut Department of Public Health, studied the State's adverse event reporting system. The Department of Public Health's Quality in Health Care Advisory Committee used this study to expedite efforts to incorporate into legislation the Committee's recommendations to enhance the effectiveness of the State's adverse event reporting system. This legislation was enacted by the Connecticut legislature in May 2004. One recommendation was to enable the creation of patient safety organizations (PSOs) so that providers can learn from each other's experiences by confidentially sharing detailed patient safety information. As a result, the PSIC training helped the Connecticut Healthcare Research and Education Foundation (CHREF), a CHA education and quality affiliate, obtain designation as a PSO under Connecticut's new law. "The formal PSIC training, as well as the informal interactions with faculty and other PSIC participants, were invaluable in assisting us in developing the patient safety organization and will continue to help us design effective PSO programs," said Jennifer Jackson, President and CEO of CHA and CHREF. Select for more information on the PSIC training program.

8.  Latest Issue of AHRQ WebM&M Is Available Online

The latest issue of the AHRQ WebM&M (, an online patient safety journal is now available. The March cases include a patient whose screening test for syphilis is positive, but he is not notified and later develops a classic syphilitic rash; a patient who is transferred from one hospital to another with a CD containing her radiographs, with her older x-rays displayed first, and the receiving hospital overlooks the abnormalities on the newest studies; a patient who, because of a miscommunication, is taken to the operating room after the surgery has been cancelled; and a case involving the administration of low-molecular-weight heparin to a patient undergoing epidural anesthesia—despite a precautionary note on the order sheet about this very combination—who tragically develops an epidural hematoma that leads to lower extremity paralysis. The March spotlight case highlights the safety challenges that providers and systems face in managing morbidly obese patients. As always, the spotlight case includes a downloadable set of slides. By completing the spotlight quiz, physicians can receive CME credit, nurses can obtain CEUs, and trainees can receive certification in patient safety. Cases and CME/CEU from previous issues are still available under Archives and Past Issues on the site. You can also submit a case for consideration for future editions of the online journal. Next month will be the premiere of the new and improved AHRQ WebM&M, which has been redesigned with three case-commentaries and many new features, including Perspectives on Safety, interviews with newsmakers, point-counterpoints, and more.

9.  AHRQ Soon to Launch New National Patient Safety Network Web Site

In early April, AHRQ will debut a new national Web site (the AHRQ Patient Safety Network, or PSNet) that will feature the latest news and essential resources on improving patient safety. Designed to be a valuable resource for clinicians, administrators, consumers, and policy makers, the Web site will include patient safety news, tools, alerts, upcoming meetings and conferences, classic literature, and an annotated bibliography. Stay tuned for more information.

10.  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 some time ago, but they remain informative. These abstracts are available through PubMed® 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.

Rosenberg AL, Hofer TP, Strachan C, Watts CM, Hayward RA. Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures. Ann Intern Med 2003 Jun 3;138(11):882-90. Select to access the abstract on PubMed®.

Sheth HS, Verrico MM, Skledar SJ, Towers AL. Promethazine adverse events after implementation of a medication shortage interchange. Ann Pharmacother 2005 Feb;39(2):255-61. Select to access the abstract on PubMed®.

Silber JH, Rosenbaum PR, Trudeau ME, Chen W, Zhang X, Kelz RR, Mosher RE, Even-Shoshan O. Changes in prognosis after the first postoperative complication. Med Care 2005 Feb;43(2):122-31. Select to access the abstract on PubMed®.

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Current as of March 2005


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