August 6, 2007, Issue No. 34
Patient Safety Message of the Month
"The goal is for every hospital in Arizona to have a standardized color-coded wristband system implemented by the end of this year and raise the level of patient safety in the State."
—Barb Averyt, program director of the Arizona Hospital and Healthcare Association's Safe and Sound patient safety program.
For more information on AHRQ-sponsored research by Barb Averyt and her colleagues, select Item No. 1.
Today's Headlines
1. AHRQ's PSIC Program Helped Launch Color-Coded Wristband Program for Arizona Hospitals
2. Reengineering Hospital Discharge Process Could Improve Care, Say AHRQ Researchers
3. Adverse Events Associated with Warfarin Therapy Are Common and Often Preventable in Nursing Homes, According to AHRQ Researchers
4. AHRQ Researchers Incorporate Team Training into Neonatal Resuscitation Program
5. National Quality Forum Selects AHRQ's CAHPS® Surveys As Part of New Consensus Standards for Patient Experience with Care
6. AHRQ Participates in International Conference on Ergonomics and Patient Safety—June 25-28, 2008
7. Latest Issue of AHRQ WebM&M Available Online
8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations
1. AHRQ's PSIC Program Helped Launch Color-Coded Wristband Program for Arizona Hospitals
Arizona hospitals have begun a Statewide initiative for using color-coded wristbands to help hospital workers identify at-risk patients, including those who have do-not-resuscitate (DNR) orders, allergies, or who are at risk for falls. Wristband colors to identify at-risk patients currently vary from hospital to hospital, and since many health care workers practice at more than one hospital, there is a potential for confusion and possible medical error.
Barb Averyt, program director of patient safety at the Arizona Hospital and Healthcare Association and a member of AHRQ's Patient Safety Improvement Corps (PSIC) class of 2005-06, applied the lessons learned from the PSIC program to develop an implementation toolkit on the standards for wristbands. Researchers also determined which colors to use for each alert-red for allergy risk, yellow for fall risk, and purple to signify DNR. The program, which encourages other States to examine their current color-coding system, is at various stages of adoption by California, Colorado, Illinois, Kansas, Missouri, New Jersey, New Mexico, Oregon, and West Virginia.
Averyt's dedicated efforts in patient safety earned her an award from the Arizona Partners in Implementing Patient Safety, part of AHRQ's Partnerships in Implementing Patient Safety project. Select to learn more about the implementation toolkit (PDF Help); and for more information on AHRQ's PSIC training program, cosponsored by the Department of Veterans Affairs.
2. Reengineering Hospital Discharge Process Could Improve Care, Say AHRQ Researchers
Hospitals that institute a more formalized process for discharging patients could reduce inappropriate readmissions, produce more satisfied and informed patients, and promote better use of primary care services in the community after a hospital stay, according to AHRQ-funded research published in the June issue of the Journal of Patient Safety. In a review of how the nation's hospitals handle patient discharges, researchers from Boston University School of Medicine and Boston Medical Center promote a reengineered hospital discharge process, decrying the current approach as rife with risks and hazards, poorly standardized and one that promotes discontinuous and fragmented care.
In their article, "The Hospital Discharge: A Review of a Care Transition with a High Potential for Errors and Highlights of a Re-Engineered Discharge Process," authors Brian Jack, M.D., and colleagues delineate a checklist for hospitals to follow when they release a patient, a process they call the ReEngineered Discharge or RED. In his recent presentation to the National Patient Safety Foundation, Dr. Jack said preliminary research he and his colleagues have conducted shows that those who received these interventions were more likely to see a primary care doctor within 30 days of discharge, more prepared for discharge and their follow-up appointments, more likely to understand their medications if they were of low health literacy, and less likely to visit an emergency department.
The National Quality Forum (NQF) has endorsed the basics of Dr. Jack's research, and, in March 2007, counted the re-engineered discharge system as 1 of 30 practices that a hospital needs to be considered a "safe" institution. Select for additional information on Project RED; and, to review a PDF file of NQF's Safe Practices for Better Healthcare—2006 Update: A Consensus Report (PDF Help).
3. Adverse Events Associated with Warfarin Therapy Are Common and Often Preventable in Nursing Homes, According to AHRQ Researchers
More than 29 percent of warfarin-related adverse events that occur in the nursing home setting are preventable, according to a recent AHRQ study. Researchers, led by Jerry Gurwitz, M.D., of the University of Massachusetts Medical School, examined warfarin-related adverse events and potential events, or "near misses," within 25 nursing homes in Connecticut. The total number of residents in these facilities ranged from 2,946 to 3,212 per quarter during a 12-month observation period. Researchers identified 720 warfarin-related adverse events, of which 29 percent were preventable and 253 were near misses.
Errors resulting in preventable events occurred most often at the prescribing and monitoring stages of warfarin management. Results of the study appear in "The Safety of Warfarin Therapy in the Nursing Home Setting," published in the June 2007 issue of the American Journal of Medicine. Select to review an abstract of the study.
4. AHRQ Researchers Incorporate Team Training into Neonatal Resuscitation Program
Interns in neonatal units learn how to better communicate, ask the right questions, and become more assertive as a result of incorporating teamwork skills and information about human errors into the neonatal resuscitation program, according to a new AHRQ-funded study.
Led by Eric J. Thomas, M.D., at the University of Texas' Center of Excellence for Patient Safety Research and Practice, researchers learned that interns who were randomized to the neonatal resuscitation program training course with team training exhibited more teamwork behaviors during simulated resuscitation than did interns in the standard neonatal resuscitation program course. Results of the study appear in "Teaching teamwork during the Neonatal Resuscitation Program: A Randomized Trial," published in the July issue of the Journal of Perinatology. Select to review an abstract of the study.
5. National Quality Forum Selects AHRQ's CAHPS® Surveys As Part of New Consensus Standards for Patient Experience with Care
The National Quality Form (NQF) recently announced the endorsement of seven survey instruments to assess patients' experience with care, including those from AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS®):
- CAHPS® Clinician & Group Survey®.
- CAHPS® Health Plan Survey® (adult questionnaire and children with chronic conditions supplement).
- National Committee for Quality Assurance Supplemental items for CAHPS®.
The consensus standards comprise the next step in NQF's ongoing, multi-year effort to endorse a standardized set of measures for gauging and publicly reporting the quality of ambulatory care, bringing to 112 the total of NQF-endorsed™ voluntary consensus standards for ambulatory care to date. Select to access NQF's press release (PDF Help).
6. AHRQ Participates in International Conference on Ergonomics and Patient Safety—June 25-28, 2008
The International Ergonomics Association is sponsoring the second International Conference on Healthcare Systems Ergonomics and Patient Safety. The conference is aimed at creating bridges among different disciplines—medicine and surgery, information technology, occupational psychology, clinical engineering and architecture, and human factors and ergonomics—in order to share a strong interest in the promotion of human factors and ergonomics in health care and patient safety. AHRQ's Kerm Henriksen, Ph.D., Human Factors Advisor for Patient Safety, Center for Quality Improvement and Patient Safety, will serve with other experts, including AHRQ grantees, on the conference steering committee. Select for conference details.
7. Latest Issue of AHRQ WebM&M Available Online
The July/August issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section turns to the hospital boards' role in improving patient safety. James L. Reinertsen, M.D., a former hospital CEO and now a prominent health care consultant and champion for leadership engagement in safety initiatives, is interviewed. In the accompanying perspective, John L. Haughom, M.D., Senior Vice President for Clinical Quality and Patient Safety at PeaceHealth, discusses how hospital boards can exercise their leadership to drive organizational changes.
New commentaries examine cases involving sudden cardiac arrest, wrong tooth extraction, and a problem in "copying and pasting" within an electronic medical record. In the first Spotlight Case, a code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine. The authors, Benjamin Abella, M.D., M.Phil., of University of Pennsylvania, and Dana Edelson, M.D., of University of Chicago, discuss common defibrillation failures and how to improve safety in treating sudden cardiac arrest. In the second case, a patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed. In the third case, a hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, but despite this information being copied and pasted in the record on four consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge. Commentary authors are Richard Smith, D.D.S., of the University of California, San Francisco, and William Hersh, M.D., of Oregon Health & Science University.
Now you can share AHRQ WebM&M cases easily by using our "E-mail a colleague" feature. As always, you can receive CME, 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.
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.
Killip S, Ireson CL, Love MM, et al. Patient safety in after-hours telephone medicine. Fam Med 2007 Jun;39(6):404-9. Select to review the abstract in PubMed®.
Nuckols TK, Bell DS, Liu H, et al. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care 2007 Jun;16(3):164-8. Select to review the abstract in PubMed®.
Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc 2007 Jul;55(7):977-85. Select to review the abstract in PubMed®.
Snyder RA, Abarca J, Meza JL, et al. Reliability evaluation of the adapted National Coordinating Council Medication Error Reporting and Prevention index. Pharmacoepidemiol Drug Saf 2007 May 24. Select to review 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 August 2007
Internet Citation:
Patient Safety E-Newsletter. August 6, 2007, Issue No. 34. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews34.htm
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