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AHRQ Partnerships in Implementing Patient Safety


In 2005, the Agency for Healthcare Research and Quality (AHRQ) awarded over $9 million for Partnerships in Implementing Patient Safety (PIPS) grants. These 2-year cooperative agreements will assist health care institutions in implementing safe practice interventions that show evidence of eliminating or reducing risks, hazards, and harms associated with the process of care. The goals of these projects are to:

  • Identify the medical errors, risks, hazards, or harms.
  • Develop an intervention implementation plan.
  • Demonstrate the impact of the intervention on the process of care.
  • Determine the efficacy of the intervention for adoption.

The 17 PIPS projects focus on safe practice interventions that can be generalized to other settings of care and for use by those who wish to adapt and/or adopt the safe practices interventions to improve patient safety. At the end of the grant period, the PIPS projects will have developed tools, including a comprehensive implementation tool kit that will focus on documenting the impact of the safe practice intervention and the manner in which barriers to implementation and adoption were overcome. AHRQ will widely disseminate the tools from the grants, including the implementation toolkits, for adaptation and/or adoption by other institutions. These implementation projects will inform AHRQ, providers, patients, payers, policymakers, and the public about how safe practice interventions can be successfully implemented in diverse health care settings and lead to safer and better health care for all Americans.


Introduction

In its November 1999 report To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. The IOM report quickly elevated awareness of patient safety. In January 2000, within weeks of the IOM report's release, the Senate Committee on Appropriations began hearings on medical errors and patient safety issues. As a result of those hearings, the Committee directed AHRQ to lead the national effort to combat medical errors and improve patient safety. In FY 2001, AHRQ received a $50 million appropriation, which enabled the Agency to implement a broad and diversified patient safety initiative. Through a portfolio of grants and contracts, the initiative stimulates research and demonstrations in patient safety and medical error reduction. AHRQ received continued appropriations of $55 million in FY 2002 and $60 million in FY 2003 to carry out its patient safety initiative. The current effort continues the Agency's activities to reduce errors and improve the delivery of safe health care in a purposeful and coordinated manner.

In December 2003, AHRQ submitted an interim report Building Foundations, Reducing Risk that presented an update of AHRQ's Patient Safety Initiative. The goal of AHRQ's Patient Safety Initiative is to identify, understand, and reduce the medical errors, risks, hazards, and harms associated with health care system-related problems. To support this initiative, AHRQ developed a long-term plan that includes four distinct elements. The plan requires sustained effort, and many projects underway span more than one element of activity. The four elements are:

  • Identifying threats to patient safety.
  • Identifying and evaluating effective patient safety practices.
  • Teaching, disseminating, and implementing effective patient safety practices.
  • Maintaining vigilance.

The overall goal of the PIPS projects is for institutions to work in collaboration with AHRQ to implement safe practice interventions to improve patient safety. Through collaboration, AHRQ and the institutions will be able to improve patient safety through the reduction of medical errors, risks, hazards, and harms in the health care system.

Projects Descriptions

Banner Health/ASU Partnership for ED Patient Safety
Principal Investigator: Twila Burdick, MBA
Description: This intervention reduces patient risk and harm through implementation of a patient flow process called "Door-to-Doc" which reduces the time patients wait to see an emergency department (ED) physician and by speeding the process of moving ED patients who need to be admitted to the most appropriate inpatient nursing unit.
Applicant Institution: Banner Health; Phoenix, AZ
Year 1 Funding: $299,822
Grant No.: HS015921-01

Improving Patient Safety Through Enhancements in Provider Communication Strategies
Principal Investigator: Kay Daugherty, PhD, RN
Description: By focusing on improving the effectiveness of communication among caregivers, this intervention will decrease errors related to team communication failures in the hospital setting.
Applicant Institution: Denver Health & Hospital Authority; Denver, CO
Year 1 Funding: $299,162
Grant No.: HS015846-01

The ED Pharmacist as a Safety Measure in Emergency Medicine
Principal Investigator: Rollin J. Fairbanks, MD, MS
Description: Through focusing on the working conditions in the emergency department (ED), the intervention improves medication safety by implementing an ED Pharmacist program.
Applicant Institution: University of Rochester; Rochester, NY
Year 1 Funding: $299,934
Grant No.: HS015921-01

Using Military and Aviation Simulation Experience to Improve Rural Obstetric Safety
Principal Investigator: Jeanne-Marie Guise, MD, MPH
Description: This intervention implements aviation crew resource management and medical simulation training to improve the the safety of obstetric care in rural communities statewide in Oregon.
Applicant Institution: Oregon Health and Science University, Portland, OR
Grant No.: HS015800-01

Testing the Re-engineered Hospital Discharge*
Principal Investigator: Brian Jack, MD
Description: This intervention re-engineers the workflow process and improves patient safety for patients from a network of Community Health Centers discharged from a general medical service at an urban hospital.
Applicant Institution: Boston Medical Center; Boston, MA
Year 1 Funding: $291,075
Grant No.: HS015905-01

Implementing Reduced Work Hours for All ICU Staff to Improve Patient Safety*
Principal Investigator: Christopher P. Landrigan, MD, MPH
Description: This project will implement two new house staff work schedules in a medical intensive care unit and a critical care unit in order to improve house staff sleep and serious medical error rates.
Applicant Institution: Brigham & Women's Hospital; Boston, MA
Year 1 Funding: $299,875
Grant No.: HS015906-01

Patient Safety Partnerships to Improve Safety in the Clinic Setting
Principal Investigator: Kathryn Kraft Leonhardt, MD, MPH
Description: Focusing on patient-centered care for older Americans, this intervention improves medication list accuracy in the outpatient setting through a partnership model involving patients, health care providers, and the community.
Applicant Institution: Aurora Health Care; Milwaukee, WI
Year 1 Funding: $243,667
Grant No.: HS015915-01

Improving Warfarin Management in Competitive Healthcare Using ISO 9001 Principles
Principal Investigator: James M. Levett, MD
Description: Through the use of ISO 9001 quality principles, the intervention improves patient safety for warfarin administration through the establishment of a virtual anticoagulation clinic, for two hospitals and two physician practices.
Applicant Institution: Kirkwood Community College, Cedar Rapids, IA
Year 1 Funding: $300,000
Grant No.: HS015830-01

Optimal Prevention of Hospital Acquired Venous Thromboembolism
Principal Investigator: Greg Maynard, MD, MS
Description: This intervention focuses on eliminating preventable hospital-acquired venous thromboembolism (VTE) at an academic health care facility that has a large population of Hispanic patients.
Applicant Institution: University of California; San Diego, CA
Grant No.: HS015826-01

Implementing a Program of Patient Safety in Small Rural Hospitals
Principal Investigator: Katherine Jones, PhD
Description: Through regional collaboration for small rural hospitals, this intervention implements voluntary medication error reporting and organizational learning to improve the safety of medication use.
Applicant Institution: University of Nebraska Medical Center; Omaha, NE
Year 1 Funding: 294,027
Grant No.: HS015822-01

Medication Reconciliation: Bridging Communications Across the Continuum of Care
Principal Investigator: Melinda Muller, MD
Description: Focusing on medication safety, this intervention implements a single, shared, updated and reconciled medication and allergy list for each patient across the continuum of inpatient and outpatient care.
Applicant Institution: Legacy Health System; Portland, OR
Year 1 Funding: $294,248
Grant No.: HS015904-01

Medications At Transitions and Clinical Handoffs (MATCH)
Principal Investigator: Gary A. Noskin, MD
Description: Through effective medication reconciliation, MATCH will decrease the number of discrepant medication orders by training nursing and medical staff in medication history interviewing skills while implementing a single medication history list within the medical record, utilized by all clinicians.
Applicant Institution: Northwestern University; Chicago, IL
Year 1 Funding: $292,529
Grant No.: HS015886-01

Implementing a Simulation-Based Safety Curriculum in a Pediatric Emergency Site
Principal Investigator: Mary Patterson, MD
Description: In order to improve patient safety in a children's hospital, the intervention implements a multidisciplinary, simulation-based safety curriculum that emphasizes team behaviors for all care providers, including residents.
Applicant Institution: Cincinnati Children's Hospital Medical Center; Cincinnati, OH
Year 1 Funding: $243,219
Grant No.: HS015841-01

Enhanced Patient Safety Intervention to Optimize Medical Education "EPITOME"*
Principal Investigator: Carl A. Sirio, MD
Description: This intervention implements a multi-modal patient medication education system "EPITOME" to improve safety through involving clinicians and patients.
Applicant Institution: University of Pittsburgh; Pittsburgh, PA
Year 1 Funding: $299,988
Grant No.: HS015851-01

Safe Critical Care: Testing Improvement Strategies*
Principal Investigator: Theodore Speroff, PhD
Description: This project bundles two interventions to improve critical care—reduction of catheter-related blood stream infections and ventilator-associated pneumonia—across 147 of the medical/surgical and children's hospitals of the Hospital Corporation of America.
Applicant Institution: Vanderbilt University School of Medicine; Nashville, TN
Year 1 Funding: $288,955
Grant No.: HS015934-01

Hospital Patient Safe-D(ischarge): A Discharge Bundle for Patients*
Principal Investigator: Mark Vincent Williams, MD
Description: This intervention implements a "discharge bundle" of patient safety interventions such as, medication reconciliation and patient-centered education, to improve patient safety transition out of the hospital setting.
Applicant Institution: Emory University; Atlanta, GA
Year 1 Funding: $231,764
Grant No.: HS015882-01

VTE Safety Toolkit: A Systems Approach to Safe Practice Interventions
Principal Investigator: Brenda K. Zierler, PhD, RN
Description: To improve safety for patients at risk for, or who are diagnosed with, venous thromboembolism (VTE), the intervention implements a system-supported interactive VTE Safety Toolkit for providers, patients, and external referring providers in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI Region).
Applicant Institution: University of Washington; Seattle, WA
Year 1 Funding: $299,731
Grant No.: HS015898-01

* Builds on previous AHRQ funding

Current as of September 2005


Internet Citation:

AHRQ Partnerships in Implementing Patient Safety. September 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pips.htm


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