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Patient Safety and Health Information Technology E-Newsletter

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May 6, 2005, Issue No. 9

Quote of the Month

"[Despite the challenges, implementation issues are] where it's at for patient safety. Only by putting into practice what we learn in our research will we make care safer."

—Lucian Leape, M.D., the Harvard School of Public Health.

Today's Headlines:

  1. AHRQ releases Advances in Patient Safety—a four-volume compendium
  2. Register now for AHRQ's annual patient safety and health IT conference, June 6-10
  3. Study finds high rates of adverse drug events in long-term care facilities
  4. Call for nominations for 2005 John M. Eisenberg patient safety and quality awards program
  5. Fact sheet "30 Safe Practices for Better Health Care" now available
  6. Latest issue of AHRQ WebM&M is available online
  7. Do you know how AHRQ's research findings are being used to improve patient safety?
  8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ Releases Advances in Patient Safety—A Four-Volume Compendium

AHRQ and the Department of Defense recently released the Federal government's first compendium of studies on the successes and challenges of efforts to improve patient safety and reduce medical errors. Advances in Patient Safety: From Research to Implementation—a four-volume set of 140 peer-reviewed articles—represents an overview of patient safety studies by AHRQ-funded researchers and other government-sponsored research over the past 5 years following the release of a 1999 report by the Institute of Medicine, To Err is Human. The volumes contain information on virtually every dimension of the patient safety field, including new research findings on medication safety, technology, investigative approaches to better treatment, process analyses, human factors, and practical tools for preventing medical errors and harm. The compendium features emerging lessons from clinical studies, presents cutting-edge technologies such as simulation tools for surgery training, the effects of change on dynamic systems of care, and national and regulatory issues. For additional information, view AHRQ's press release. A limited number of four-volume printed sets are available, as well as free single copies of a searchable CD-ROM. To place an order, contact the AHRQ Publications Clearinghouse at (800) 358-9295, or send an E-mail to Select for individual articles that comprise the four volumes.

2.  Register Now for AHRQ's Annual Patient Safety and Health IT Conference, June 6-10

Join the more than 400 expected attendees and register now for AHRQ's 2005 annual meeting, Patient Safety and Health Information Technology: Making the Health Care System Safer through Implementation and Innovation. The June 6-10 conference will highlight new findings, products, tools, best practices, and implementation methods to improve health care safety and quality, including IT, that can bridge the gap between research and practice to improve health care safety and quality. Discussions on lessons learned and strategies for meeting common challenges will be held, as well as 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. An Innovations Café will feature new products and publications where patient safety and health IT grantees can collaborate and share information gained through their work. The conference will be held at the Washington Convention Center in Washington, DC.

3.  Study Finds High Rates of Adverse Drug Events in Long-term Care Facilities

There were over 800 adverse drug events, of which more than 40 percent were judged preventable, in two large long-term care facilities during a 9-month period from late 2000 to early 2001, according to a recent AHRQ-funded study. Of the 225 adverse drug events considered to be serious, life-threatening, or fatal, over 60 percent were preventable. The study, led by Jerry H. Gurwitz, M.D., of the University of Massachusetts Medical School, found that preventable adverse drug events occurred most often during the ordering and monitoring stages of care and that the two drugs most commonly involved in preventable adverse drug events were warfarin and atypical antipsychotic agents (olanzapine, risperidone, quetiapine, and clozapine). The study, "The Incidence of Adverse Drug Events in Two Large Academic Long-term Care Facilities," was published in the March 2005 issue of the American Journal of Medicine. Select to read the abstract of the study in PubMed®.

4.  Call for Nominations for 2005 John M. Eisenberg Patient Safety and Quality Awards Program

The Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum are now accepting nominations for the 2005 John M. Eisenberg Patient Safety and Quality Awards, which recognize individuals and health care organizations that are making significant contributions to improving health care quality and patient safety. The deadline for submissions is May 27. Questions about the awards may be directed to or

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

AHRQ released a 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 AHRQ fact sheet and select to read the NQF executive summary of the full report. A print copy of the fact sheet is available by sending an E-mail to

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

The May issue of AHRQ WebM&M is now available online. In this issue, the "Perspectives on Safety" section highlights how two world-class institutions reacted to fatal errors that caught the media spotlight, turning the tragedies into catalysts for positive change. The user-submitted cases include one in which a man admitted with alcoholic dementia and a broken upper arm refused surgery and decided to leave the hospital in the middle of the night. The discussion explores how safety can best be assured when a patient leaves against medical advice. In another case, a woman who was 38 weeks pregnant came to the emergency department complaining of left leg pain. Ruled out for deep vein thrombosis, she was sent home, only to die the following morning of another cause. The discussion addresses safety issues in pregnant patients with acute complaints. In the "Spotlight Case," the authors discuss the challenges inherent in classifying diagnostic mistakes as medical errors by reanalyzing past WebM&M cases. Please continue to submit cases to AHRQ WebM&M and explore the site—all previously published commentaries are available under "Case Archive."

7.  Do You Know How AHRQ's Research Findings Are Being Used to Improve Patient Safety?

We are always looking for ways in which AHRQ-funded research, products, and tools have changed people's lives, influenced clinical practice, improved policies, and affected patient outcomes. These impact case studies describe AHRQ research findings in action. They are used in testimony, budget documents, and speeches. We would like to know if you are aware of any impact your AHRQ-funded research has had on health care policy, clinical practice, or patient outcomes. Contact AHRQ's Impact Case Studies Program at or (301) 427-1244 with your impact stories.

8.  AHRQ in the Patient Safety Professional Literature—Some Useful Citations

We are providing the following hyperlinks to journal abstracts 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.

Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005 Feb 15;142(4):260-73. Select to access the abstract on PubMed®.

Melton GB, Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc 2005 Mar 31. Select to access the abstract on PubMed®.

Reichley RM, Seaton TL, Resetar E, Micek S, Scott K, Fraser VJ, Dunagan WC, Bailey TC. Implementing a commercial rule base as a medication order safety net. J Am Med Inform Assoc 2005 Mar 31. Select to access the abstract on PubMed®.

AHRQ's Patient Safety and Health Information Technology E-Newsletter Contact:

Please address comments and questions regarding the newsletter to Salina Prasad at or (301) 427-1864.

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Current as of May 2005


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