Improving the Safety and Quality of Health Care

In support of its mission to improve the quality, safety, efficiency, and effectiveness of health care, AHRQ supports research and develops successful partnerships that help generate the knowledge and tools required for long-term improvements. Finding ways to eliminate medical errors and improve patient safety have been an integral part of the Agency's research agenda since 2001. AHRQ-funded research projects and partnerships identify, develop, test, and implement patient quality and safety measures.

In 2007, AHRQ-funded patient safety research projects resulted in the development of toolkits to assist health care providers in implementing safe practices; DVDs on evidence-based hospital design; and training programs and resources for health care personnel in a systems-based approach to patient safety, creating a culture of patient safety within the health care workplace, and encouraging consumers to become more active in their health care.

AHRQ Patient Safety Network (PSNet) AHRQ s PSNet (www.psnet.ahrq.gov) is a national Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates on patient safety literature, news, tools, and meetings and a vast set of carefully annotated links to important research and other information on patient safety. Supported by a robust patient safety taxonomy and Web architecture, the AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse users to customize the site around their interests.

Partnerships in Implementing Patient Safety (PIPS)

In 2007, AHRQ released 17 toolkits to assist providers in implementing safer health care practices and ultimately reduce medical errors. These toolkits resulted from the over $9 million awarded in 2005 for Partnerships in Implementing Patient Safety (PIPS) grants. The projects consisted of 2-year cooperative agreements that intended to assist health care institutions in implementing safe practice interventions that demonstrated evidence of eliminating or reducing risks, hazards, and harms associated with the process of care. Their goals were 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 PIPS projects focused on safe practice interventions that can be generalized to other settings of care. The toolkits are free, publicly available, and can be adapted to most health care settings. While some of the toolkits focus on identifying high-risk practices, others are designed to help health professionals reduce medication errors or other patient harms. Examples of the kinds of interventions that the toolkits promote include:

• The Re-Engineered Hospital Discharge "Project RED" toolkit standardizes the hospital discharge process through a set of manuals and software designed to improve communication between patients and clinicians.
• The Medications at Transitions and Clinical Handoffs "MATCH" toolkit identifies patient risk factors frequently responsible for inaccurate medication reconciliation, including limited English proficiency and low health literacy, complex medication histories, or impaired mental status.
• The ED Pharmacist as a Safety Measure in Emergency Medicine toolkit focuses on improving medication safety and reconciliation through the implementation of a program that assigns pharmacists to hospital emergency departments.

More information and a list of the 17 toolkits can be found at www.ahrq.gov/qual/pips.

Transforming Hospitals: Designing for Safety and Quality

Transforming Hospitals: Designing for Safety and Quality, is a DVD released by AHRQ in 2007 that reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of care, and employee retention, and results in a positive return on investment. The DVD presents the experiences of three model hospitals—Griffin Hospital in Derby, CT; Holy Cross Hospital in Silver Spring, MD; and Woodwinds Health Campus in Woodbury, MN—that incorporated evidence-based design elements into their construction and renovation projects.

Hospital executives planning or executing a major capital construction project or minor renovations can use the information presented in this DVD to help identify how evidence-based design can improve the quality and safety of their hospitals' services. "Evidence-based design" is a term used to describe how the physical design of health care environments affects patients and staff. Key characteristics of evidence-based design in hospital settings include single-patient rooms, use of noise-reducing construction materials, easily accessible workstations, and improved layout for patients and staff.

More information on the DVD can be found at www.ahrq.gov/qual/transform.htm.

Patient Safety Improvement Corps

The Patient Safety Improvement Corps (PSIC) seeks to improve patient safety by providing knowledge, skills, and intervention initiatives to teams of hospital staff, patient safety officers, and others responsible for patient safety reporting and analysis. The PSIC is a partnership program between AHRQ and the Department of Veterans Affairs. The program content includes a number of topics, tools, and methods designed to help participants reduce medical error and improve patient safety.

In 2007, AHRQ and the Department of Veterans Affairs National Center for Patient Safety developed a new DVD that presents a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level. Eight modules provide processes and tools that can be used to develop a systems-based approach to patient safety:

• Patient Safety, Why Bother?
• Creating a Culture of Safety.
• When to do a Root Cause Analysis.
• How to do a Root Cause Analysis.
• Human Factor Engineering.
• Management of Risk.
• Proactive Risk Assessment Tools.
• Statistical Tools and Patient Safety Indicators.

From 2003 through 2006, the PSIC program was focused primarily on States and their selected hospital partners. Because of its past success, the PSIC program was extended into 2008, and the participant focus is being expanded beyond State teams. Additional information on the PSIC and the DVD can be found at www.ahrq.gov/qual/psicdvd.htm.

Patient Safety Culture Surveys

As part of its goal to support a culture of patient safety and quality improvement in the Nation's health care system, AHRQ sponsors the development of patient safety culture assessment tools for hospitals, nursing homes, and ambulatory settings. In 2006, the Agency introduced the Patient Safety Culture Survey Database as a central repository for survey data so that hospitals and their units could determine how well they were doing in establishing a culture of safety in comparison to other hospitals or hospital units. Health care organizations can use these survey assessment tools to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of specific patient safety interventions.

In 2007, AHRQ released the Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. The report is based on data collected using AHRQ's Hospital Survey on Patient Safety Culture, a tool to help hospitals evaluate how well they had established a culture of safety in their institutions. Based on data provided voluntarily by nearly 400 U.S. hospitals, the Report provides an initial set of results that hospitals can use as benchmarks in establishing a culture of safety. The Report presents statistics on the patient safety culture areas, hospital characteristics (bed size, teaching status, ownership and control, and region) and respondent characteristics (hospital work area/unit, staff position, and interaction with patients). For example:

• Most hospitals are nonteaching (76 percent) and nongovernment-owned (voluntary/nonprofit or proprietary/investorowned) (72 percent).
• The majority of respondents within hospitals (70 percent) gave their work area or unit a grade of either "A-Excellent" (22 percent) or "B-Very Good" (48 percent) on patient safety.
• On average, the majority of respondents within hospitals (53 percent) reported no events in their hospital over the past 12 months. It is likely that this percentage represents an underreporting of events, and was identified as an area for improvement for most hospitals because potential patient safety problems may not be recognized or identified, and therefore may not be addressed.

Additional information on the Patient Safety Culture Surveys can be accessed at www.ahrq.gov/qual/hospculture/.

Hospital Survey on Patient Safety Culture helps pharmacy students learn to create a culture of safety Campbell University School of Pharmacy uses AHRQ's Hospital Survey on Patient Safety Culture in classes that teach pharmacy students to understand and create a culture of safety in their future careers. Robert Cisneros, PhD, Assistant Professor in Campbell's School of Pharmacy, uses the survey in medication error and management classes. Over 100 students have taken the classes since the survey was incorporated as a teaching tool. Since 2006, Cisneros has also used the survey to demonstrate what a culture of safety should be about when he gives presentations to pharmacists during Continuing Education classes.

TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety

TeamSTEPPS™ was developed by the Department of Defense in collaboration with AHRQ. TeamSTEPPS™ is an evidence-based teamwork system training curriculum aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into your health care system. TeamSTEPPS™ is presented in a multimedia format, with tools to help a health care organization plan, conduct, and evaluate its own team training program. It includes an instructor guide, PowerPoint™ presentations, a DVD, spiral-bound pocket guide, a CD-ROM with printable materials, and a poster to announce TeamSTEPPS™ activities in a heath care organization. More information on can be found at http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.

Pharmacy Tools

In 2007, AHRQ released two new tools to help pharmacies provide better quality services to people with limited health literacy: Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide and Strategies to Improve Communication between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff. The pharmacy assessment tool can help raise pharmacy staff awareness of health literacy issues, detect barriers that may prevent individuals with limited literacy skills from using and understanding health information provided by a pharmacy, and may help identify opportunities for improving services. This tool includes an assessment to be completed by trained, objective auditors; a survey for completion by pharmacy staff; and a guide for focus groups with pharmacy patients. The training program for pharmacy staff includes the use of explanatory slides, small group breakout discussions, role play, and a question-and-answer session. These tools can be found online at www.ahrq.gov/qual/pharmlit/.

TeamSTEPPS™ training reaches over a thousand clinicians in Singapore Two hospitals in Singapore: Singapore General and Changi General Hospital used TeamSTEPPS™ to train over 1,000 hospital staff. The Singapore clinicians were trained in less than four days by TeamSTEPPS™ trainers Sue Hohenhaus, registered nurse and clinical human factors nurse researcher at Duke University Health System; Jay Hohenhaus, certified registered nurse anesthetist at Soldiers and Sailors Memorial Hospital in Wellsboro, Pennsylvania; and Stephen Powell, managing principal of Healthcare Team Training and a captain for a major airline. In addition, the training team conducted a "Train the Trainer" session in Singapore for CEOs and other executives, nurses, and physicians.

Recent research findings on patient safety and the quality of health care

• Implementing a simple five-step checklist reduced catheter-related bloodstream infections in Michigan hospital intensive care units by 66 percent. The steps in the checklist are: hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin around the catheter insertion site with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter days decreased from 2.7 infections at baseline to none at 3 months after implementing the infection control intervention.
• First-year doctors-in-training reported that working five extra-long shifts—of 24 hours or more at a time without rest—per month led to a 300 percent increase in their chances of causing a fatigue-related preventable adverse event that contributed to the death of a patient. Interns were three times more likely to report at least one fatigue-related preventable adverse event during months in which they worked between one and four extended-duration shifts. In months in which they worked more than five extended-duration shifts, interns were seven times more likely to report at least one fatigue-related preventable adverse event and were also more likely to fall asleep during lectures, rounds, and clinical activities, including surgery.
• An AHRQ-funded study found that teamwork breakdowns involving medical residents, fellows, and interns also caused a significant number of errors to occur during patient handoffs. Adverse outcomes were serious: one-third resulted in significant physical injury, one-fifth in major physical injury, and one-third resulted in death. Teamwork factors accounted for 70 percent of the cases involving trainee errors. A lack of supervision accounted for 54 percent of the trainee errors, and handoff problems accounted for 19 percent. Attending physicians' failure to oversee the work of trainees was identified as a factor in 82 percent of the 129 cases where a lack of supervision contributed to a medical error.

AHRQ WebM&M AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is a popular online journal and forum on patient safety and health care quality that features expert analysis of medical errors reported anonymously by readers, interactive learning modules on patient safety, perspectives on safety, and online discussions. CME and CEU credit are available. WebM&M can be accessed at www.webmm.ahrq.gov/.

Institute of Medicine study will examine resident work hours and patient safety AHRQ is sponsoring an Institute of Medicine study that is expected to produce recommendations in late 2008 on the issue of resident work hours and safety. The maximum number of working hours for medical residents was capped at 80 hours a week in 2003 as part of an effort to reduce sleep deprivation and the chances of medical errors. Since then, health care experts have debated whether the limits have improved or hindered patient safety and quality of care. Two workshops have been held that explored the impact of duty hour requirements on residents' education and patient safety as well as the enforcement of schedule requirements. A committee is reviewing the evidence on the relationship between residents' work schedules, their performance, and the quality of care they deliver to patients.

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Using Health Information Technology to Improve Patient Safety and Quality

As part of its mission to improve the quality, safety, effectiveness, and efficiency of health care, AHRQ has worked for many years to harness the power of health information technology (health IT) to improve the health of all Americans. By developing secure and private electronic health records and making health information available electronically when and where it is needed, health IT can improve the quality of care, even as it makes health care more cost-effective. More than $210 million in grants and contracts fund over 100 projects to support and stimulate investment in health IT. The goals of AHRQ's health IT initiative are to:

• Improve the safety and quality of prescription drug management via the integration of utilization of medication management systems and technologies.
• Improve the delivery and utilization of evidence-based care in ambulatory settings.
• Improve the delivery of patient centered care in ambulatory care settings, including specific focus on transitions of care, personal health records, and improved patient-provider communication and decision-making.
• Foster the development, deployment, and reporting of measures of safety and quality in ambulatory care settings and across high risk transitions in care.

Ambulatory Safety and Quality Grants

In 2007, AHRQ awarded 53 health IT grants totaling about $21 million as part of its Ambulatory Safety and Quality program. The program's goal is to improve the safety and quality of ambulatory, or outpatient, health care in the United States. The program accentuates the role of health IT in three areas:

• Enabling Quality Measurement Through Health IT.
• Improving Quality Through Clinician Use of Health IT.
• Enabling Patient-Centered Care Through Health IT.

Reports on Privacy and Security Solutions for Secure Exchange of Health Information

On August 1, 2007, AHRQ released a set of reports titled Privacy and Security Solutions for Interoperable Health Information Exchange. The 34 reports (33 States and Puerto Rico) review State Health Information Exchange plans and identify the challenges and feasible solutions for ensuring the safety and security of electronic health information exchange. Some of the key findings of the reports point to the need for additional research and guidance on:

• Identifying different interpretations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule among States and increasing awareness among stakeholders.
• Addressing variations regarding the potential intersections between Federal/State privacy laws.
• Evaluating the technologies available to protect the security and privacy of individuals as well as the associated administrative processes and liabilities.
• Developing a system that accurately and consistently matches individual patients with their health record information—one that is created and updated by various health care providers/organizations.
• Developing a standard set of definitions and terms to facilitate sharing of health information.

Report issued to Congress on electronic prescribing to reduce errors and cut costs

In April 2007, AHRQ released an evaluation report, Findings From The Evaluation of EPrescribing Pilot Sites, to Congress that revealed the results of an electronic prescribing (eprescribing) pilot project that assessed the ability to adopt new e-prescribing standards. These standards, required by the Medicare Modernization Act of 2003, were designed to reduce both medication errors and health care costs. The pilot project demonstrated that three initial standards are already capable of supporting e-prescribing transactions in Medicare Part D. These are standard transactions that provide physicians with patients' formulary and benefit information, medication history, and the fill status of their medications. The report also found that, with some adjustments, e-prescribing can work successfully in long-term care settings.

National Resource Center for Health Information Technology

The AHRQ National Resource Center for Health Information Technology (NRC) continued to be an important resource for the health care community in 2007. Much of the research and lessons learned from AHRQ's health IT initiative is conducted and coordinated through the NRC. The NRC helps facilitate adoption of health IT by disseminating the latest health IT tools, best practices, and research results:

• Health IT Evaluation Toolkit—provides guidance on how to evaluate health IT. Example measures relevant to quality, safety and efficiency are provided along with suggested data sources and the relative costs to collect the measures.
• Health IT Costs & Benefits Database Project—a searchable database that contains the results of a literature search on the relative costs and benefits of health IT.
• The Health Information Privacy and Security Collaboration Toolkit (new to the NRC in July 2007) provides guidance for conducting organization-level assessments of business practices, policies, and State laws that govern the privacy and security of health information exchange.
• HIE Evaluation Toolkit—provides guidance on how to evaluate health information exchange.
• Time and Motion Database—enables organizations to measure the impact of health IT systems on clinical workflow through the collection of time-motion study data.
• Health IT Literacy Guide—the Accessible Health Information Technology (IT) for Populations with Limited Literacy: A Guide for Developers and Purchasers of Health IT provides health IT developers with structure, strategies, and other resources for the development of health IT technologies for populations with limited literacy.

Recent research findings on health IT

• Researchers modified a computerized order entry system so that age-specific drug alerts only occurred when clinicians prescribed target drugs to elderly patients. The system then suggested an alternative medication. This approach limited the number of unnecessary alerts faced by prescribers, while still maintaining the effectiveness of the drug-specific alerts. Age-specific alerts resulted in continued effectiveness of the drug-specific alerts over a 1-year period and led to fewer false-positive alerts for clinicians.
• Researchers found that fewer than one in four Massachusetts practices had adoptedelectronic health records (EHRs). Adoption rates were lower in smaller practices, those not affiliated with hospitals, and those that did not teach medical students or residents. About 80 percent of doctors whose practices had not yet adopted EHRs cited financial factors, including start-up financial costs, ongoing financial costs, and loss of productivity, as barriers to technology adoption. The majority of physicians also pointed to lack of computer skills, lack of technical support, lack of uniform standards, and technical limitations of systems as important barriers, and 55 percent voiced concerns about privacy or security as a barrier to adopting use of EHRs.
• Bar code medication administration (BCMA) technology is being implemented slowly in hospitals across the United States. A human factors engineer and a pharmacist observed use of BCMA technology during medication administrations to identify work system factors that affected nurses' use of and interaction with the technology when they administered medications. Nurses varied in the order in which they performed steps of the medication administration process, with a total of 18 different sequences identified. Some of these sequences were contrary to hospital policy and the original design of the medication administration process, and could be considered "workarounds" or potentially unsafe acts. Interruptions and patient factors typically were precursors to medication errors and workarounds.

More information on AHRQ's health IT initiative, toolkits, and copies of reports can be found at http://healthit.ahrq.gov/.

AHRQ 2007 Annual Conference Over 20 plenary and concurrent sessions on health IT were held at AHRQ s 2007 Annual Conference. Findings from recent studies and how health IT is being used to enhance performance, quality, and patient safety were presented. Topics included: Improving Quality of Care for Children through Health Information Technology. Implementing Health Information Technology in the Long-Term Care Setting. Medication Management and Safety. e-Prescribing Standards and e-Prescribing Implementation. Physician Adoption of Health Information Technology. Patient Centered Health Information Technology. Beyond Implementation: Achieving Success with Integration of Health Information Technology in Ambulatory Care. Navigating Privacy and Security Issues for Health Information Exchange. Using Health Information Technology to Improve Quality of Care Among Racial and Ethnic Minorities. Assessing Quality of Telehealth.

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