February 9, 2007, Issue No. 28
Patient Safety Message of the Month
"We designed our simulated curriculum for teams to practice responding to rare obstetric emergencies and to teach crew resource management team training principles that the clinicians working on a case can apply to improve teamwork and responses to routine and emergent situations."
—Jeanne-Marie Guise, M.D., M.P.H., Director, State Obstetric and Pediatric Research Collaborative (STORC), Oregon Health and Science University National Center of Excellence in the journal Women's Health.
For more information on AHRQ-sponsored research by Dr. Guise and her colleagues, go to Item No.3.
Today's Headlines
1. AHRQ's FY 2008 Budget Request is $329.6 Million
2. New Evidence Report on Strategies to Prevent Health Care-Associated Infections Available
3. AHRQ Patient Safety Grantee Dr. Jeanne-Marie Guise and Her Colleagues Are Working To Improve Obstetric Care and Reduce Medical Errors
4. AHRQ's Recent Healthcare 411 Audio Podcast Programs Highlight Patient Safety Findings
5. Latest Issue of AHRQ WebM&M Available Online
6. Visit the AHRQ Patient Safety Network Web Site
7. Patient Safety Awareness Week Is March 4-10
8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations
1. AHRQ's FY 2008 Budget Request is $329.6 Million
The Agency for Healthcare Research and Quality's (AHRQ) fiscal year (FY) 2008 budget request is $329.6 million, an increase of $10.9 million or 3.4 percent from the FY 2007 continuing resolution level. Specifically, the FY 2008 request for patient safety research is $93.9 million, an increase of $9.9 million, or 11.8 percent from the FY 2007 continuing resolution level. This includes $3.4 million in new health information technology grants and $2.5 million in new patient safety grants. It is expected that these new grants will build on proposals developed for AHRQ's FY 2007 ambulatory patient safety program.
The FY 2008 budget request also proposes a new Personalized Healthcare Initiative funded at $15 million. Non-patient safety research totals $235.6 million, an increase of $0.9 million. The request will provide $3.7 million to support 42 new grants that will continue research in AHRQ's 3 strategic plan goal areas and 10 research portfolios of work. Support for non-patient safety contracts totals $84.8 million, an increase of $4 million from the FY 2007 continuing resolution level. Of this increase, $3.7 million will support contracts related the Department of Health & Human Services (HHS) Value-Driven Healthcare Initiative. AHRQ's Medical Expenditure Panel Survey is funded at $55.3 million, maintaining the same level of support as the FY 2007 continuing resolution level. In addition, the FY 2008 request for the Effective Healthcare Program continues AHRQ's $15 million investment. Select for more information on AHRQ's FY 2008 budget request.
2. New Evidence Report on Strategies to Prevent Health Care-Associated Infections Available
AHRQ released a new evidence report that finds several approaches and practices implemented to prevent health care-associated infections are promising and warrant additional research. However, there is insufficient evidence to recommend the best strategy or combination of strategies.
The report, Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6—Prevention of Healthcare-Associated Infections, evaluated published studies of strategies to improve the use of practices to prevent post-surgical infections, blood infections from central intravenous lines, pneumonia from ventilator use, and urinary tract infections from catheter use. Effective strategies include reducing inappropriate catheter use by using "stop orders" (which require that a catheter be removed after a certain period of time if it is no longer needed) and improving the use of proper infection control practices through clinician education and use of detailed guidelines. The reviewed studies were generally of suboptimal quality.
Most studies: 1) included only one assessment before and after the strategy was used or 2) evaluated infection rates or adherence to the use of practices to prevent infection, but not both. Therefore, it was not possible to assess the impact these strategies had on infection rates. The report was prepared by AHRQ's Stanford University, University of California, San Francisco, Evidence-based Practice Center in California. Select to review the report. A print copy is available by sending an E-mail to ahrqpubs@ahrq.hhs.gov.
3. AHRQ Patient Safety Grantee Dr. Jeanne-Marie Guise and Her Colleagues Are Working To Improve Obstetric Care and Reduce Medical Errors
AHRQ patient safety researcher Jeanne-Marie Guise, M.D., M.P.H., Director, State Obstetric and Pediatric Research Collaborative (STORC), Oregon Health and Science University National Center of Excellence in Women's Health, and a team of multidisciplinary investigators are working to combine simulation and team training to promote safety and improve outcomes for obstetric care.
Dr. Guise and her colleagues are using mannequin patients to simulate obstetric emergencies and crew resource management training. The simulated curriculum is designed for teams to practice responding to rare obstetric emergencies and teach crew resource management team training principles that clinicians can apply to improve teamwork and responses to routine and emergent situations.
Researchers also created a Web site (http://www.obsafety.org) that serves as an anonymous reporting system designed for any health care worker to report safety stories anonymously, issues or problems they have heard about, witnessed, or participated in and share solutions in an effort to improve safety for mothers and babies. To learn more about Dr. Guise's research, go to the STORC Web site.
4. AHRQ's Recent Healthcare 411 Audio Podcast Programs Highlight Patient Safety Findings
A recent edition of AHRQ's Healthcare 411 program features AHRQ Director Carolyn M. Clancy, M.D., as she discusses the main findings of AHRQ's 2006 National Healthcare Quality Report and 2006 National Healthcare Disparities Report. She explains that while the reports show that the overall quality of the U.S. health care system is improving, there still are many missed opportunities to help Americans avoid disease or serious complications, especially among minorities and low-income groups. Select to access this 7-minute audio podcast.
You can listen to the audio program directly through your computer—if it has a sound card and speakers and can play MP3 audio files—or you can download it to a portable audio device. In either case, you will be able to listen at your convenience. To access any of AHRQ's podcasts and special reports, or to sign up for a free subscription to the series to receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.
5. Latest Issue of AHRQ WebM&M Available Online
The February issue of AHRQ WebM&M is available online. This month, our Perspectives on Safety section looks at diagnostic errors in medicine. Mark Graber, M.D., vice chairman, academic affairs, State University of New York at Stony Brook, offers his perspective on what doctors and umpires have in common when it comes to decisionmaking. There also is an interview with Joseph Britto, M.D., CEO, and co-founder of Isabel Healthcare, a clinical decision support system designed to enhance the quality of diagnosis decision making.
In the first Spotlight Case, a parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the emergency department, where an x-ray reveals a fractured tibia. The commentary, authored by Niraj Sehgal, M.D., M.P.H., assistant professor of medicine at the University of California, San Francisco, discusses patient-centered care and its relationship to safety, quality, and patient satisfaction. In the second case, a woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her international normalized ratio level. In the third case, in an urgent care clinic, a 5-year-old with fever and sore throat receives a rapid strep test, which is negative. Later, the child seems worse, and the father takes her to the emergency department, where another rapid strep test is strongly positive for group A streptococcal infection. Commentary authors are Steven Kayser, Pharm.D., of the University of California, San Francisco, and Edward Kaplan, M.D., of the University of Minnesota Medical School. A Spotlight slide presentation is available for download.
As always, you can receive continuing medical education (CME), continuing education units (CEU), or trainee certification by taking the Spotlight Quiz. All previously published commentaries are available under "Case Archive." Please submit cases to AHRQ WebM&M via the "Submit Case" button.
6. Visit the AHRQ Patient Safety Network Web Site
AHRQ's national Web site—the AHRQ Patient Safety Network, or AHRQ PSNet—continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety.
The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature. Select to visit the AHRQ PSNet Web site.
7. Patient Safety Awareness Week Is March 4-10
This year's Patient Safety Awareness Week (March 4-10) is themed Patient Safety: A Road Taken Together and focuses on improving the patient-provider partnership. It is a national education and awareness-building campaign for improving patient safety at the local level. Hospitals and health care organizations across the country are encouraged to plan events to promote patient safety within their own organizations. Educational activities are centered on educating patients on how to become more involved in their own health care, as well as working with hospitals to build partnerships with their patient community.
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, ask your technical support staff for possible remedies.
Bittle MJ, Charache P, Wassilchalk DM. Registration-associated patient misidentification in an academic medical center: causes and corrections. Jt Comm J Qual Patient Saf 2007 Jan;33(1):25-33. Select to access the abstract in PubMed®.
Bolcic-Jankovic D, Clarridge BR, Fowler FJ Jr, et al. Do characteristics of HIPAA consent forms affect the response rate? Med Care 2007 Jan;45(1):100-3. Select to access the abstract in PubMed®.
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf 2007 Jan;33(1):5-14. Select to access the abstract in PubMed®.
Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf 2007 Jan;33(1):34-47. Select to access the abstract in PubMed®.
Poon EG, Cina JL, Churchill W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med 2006 Sep 19;145(6):426-34. Select to access the abstract in PubMed®.
The Patient Safety E-newsletter is archived online at http://www.ahrq.gov/news/ptsnews.htm.
Contact Information
Please address comments and questions to Salina Prasad at Salina.Prasad@ahrq.hhs.gov.
Current as of February, 2007
Internet Citation:
Patient Safety E-Newsletter. February 9, 2007, Issue No. 28. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews28.htm
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