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Patient Safety and Health Information Technology E-Newsletter

September 9, 2005, Issue No. 12

Quote of the Month

We want to be informed on what [medications] the patients are taking, and we want to engage patients with the importance of knowing about their medications and the importance of communicating honestly with the health care practice."

—Ronald Stock, M.D., Director, Center for Senior Health, PeaceHealth,

(Select for more information about the electronic shared medication list developed by Dr. Stock and his colleagues.)

Today's Headlines:

  1. Hurricane Katrina may affect the continuous quality data reporting necessary for Hospital Compare project
  2. Study finds ICU patients at significant risk for adverse events and serious errors
  3. More than 4.3 million doctor visits were made in 2001 for treating adverse drug effects
  4. AHRQ patient safety grantee Dr. Stock and his colleagues develop electronic medication list and reconciliation tool to help physicians collaborate with their patients
  5. Researchers examine current processes of nurses' medication management in home care
  6. National Conference on Connecting Americans to Their Health Care set for October 11
  7. Do you know how AHRQ's Hospital Survey on Patient Safety Culture is being used to improve patient safety?
  8. Latest issue of AHRQ WebM&M is available online
  9. New version of AHRQ Quality Indicators now available
  10. National Guideline Clearinghouse™ features patient safety-related guidelines
  11. Calling all AHRQ researchers! "Help us to help you"
  12. AHRQ in the patient safety professional literature—some useful citations

1.  Hurricane Katrina May Affect the Continuous Quality Data Reporting Necessary for Hospital Compare Project

The Centers for Medicare & Medicaid Services (CMS) is continuing to update the Hospital Compare Web site—a tool used to compare the quality of care hospitals provide through quality measures that determine how well area hospitals care for their adult patients with certain medical conditions. Meanwhile, hospitals throughout the Southeast are involved in response and relief efforts related to Hurricane Katrina, which ravaged the Gulf Coast on August 29. As a result, some Gulf Coast hospitals may not be able to continue to fully participate in the project in the short term, according to Nancy Foster, Vice President for Quality and Patient Safety Policy for the American Hospital Association. She and others involved with the Hospital Quality Alliance—a private-public collaboration that was established to promote reporting on hospital quality of care and helped create Hospital Compare—point out that hospital medical records no doubt were damaged and the opportunity to abstract data from those records for the quality initiative and for public reporting purposes might be lost. Many of those same hospitals may not be in service for some time. Also, other hospitals that have been receiving patients transferred from the affected hospitals may have some information collection issues and problems in reporting the data. The aftermath of Katrina will continue to impact hospitals and the quality project, and experts are now in the process of determining the next steps to help resolve the issue of reporting data crucial for Hospital Compare. For hospital quality information, go to the Hospital Compare Web site.

2.  Study Finds ICU Patients at Significant Risk for Adverse Events and Serious Errors

A new AHRQ-funded study shows that patients face a significant risk for preventable adverse events and serious medical errors in hospital critical care units. Researchers, led by Jeffrey M. Rothschild, M.D., and Charles A. Czeisler, Ph.D., M.D., of Brigham and Women's Hospital in Boston, found that over 20 percent of the patients admitted to two intensive care units at an academic hospital (a medical intensive care unit and a coronary critical care unit) experienced an adverse event. Because these patients are among the sickest, they may be more vulnerable to errors in care and therefore more susceptible to injury. Of the adverse events in the sample, almost half (45 percent) were preventable. A significant number of the adverse events involved medications—most commonly, giving patients the wrong dose. Over 90 percent of all incidents occurred during routine care, not on admission or during an emergency intervention. The study, "The Critical Care Safety Study: The Incidence and Nature of Adverse Events and Serious Medical Errors in Intensive Care" (AHRQ grant no. HS12032), was published in the August issue of Critical Care Medicine. Select to read our press release and to read the abstract in PubMed®.

3.  More than 4.3 Million Doctor Visits Were Made in 2001 for Treating Adverse Drug Effects

More than 4.3 million patient visits were made to physicians' offices, hospital outpatient departments, and hospital emergency departments for treatment of adverse drug effects in 2001—an increase of 1.6 million visits from 1995, according to a recent study by HHS researchers. In 2001, nearly three-fourths of all visits for treating adverse drug effects were made to physicians' offices, 20 percent to hospital emergency departments, and 6 percent to hospital outpatient departments. Antibiotics and other anti-infectives were the medications most frequently associated with visits for adverse drug effects, followed by hormones and other synthetic substitutes. The most frequent adverse effects suffered were dermatological symptoms, such as a skin rash, followed by gastrointestinal symptoms, such as nausea, vomiting, and abdominal pain. Researchers, led by Chunliu Zhan, M.D., Ph.D., of AHRQ, and Irma Arispe, Ph.D., of the National Center for Health Statistics, took a new approach to the study of safe use of medications. They examined just those visits for the effects of the adverse drug events that were serious enough to prompt a patient to seek medical care and were diagnosed as having resulted from an adverse drug event. A limited number of copies of the article are available by sending an E-mail to AHRQPubs@ahrq.hhs.gov. Select to read the abstract of the study, "Ambulatory Care Visits for Treating Adverse Drug Effects in the United States, 1995-2001," published in the July issue of the Joint Commission Journal on Quality and Patient Safety in PubMed®.

4.  AHRQ Patient Safety Grantee Dr. Stock and His Colleagues Develop Electronic Medication List and Reconciliation Tool to Help Physicians Collaborate with Their Patients

AHRQ patient safety researcher Ronald Stock, M.D., of PeaceHealth Oregon Region, and a team of patients and colleagues have been examining ways to improve the accuracy of medication lists throughout the continuum of care. As lead investigator of an AHRQ-funded project (grant no. HS014315), Dr. Stock, who is the Medical Director of PeaceHealth's Geriatrics and Care Coordination Services, has helped to create a single, updated, medication list that is electronically accessible to patients, caregivers, and health care providers. The medication list is a component of a community-wide Web-based personal health record called the Shared Care Plan. This tool encourages providers to collaborate with their patients and each other and enables all members of the care team to know exactly what medications each patient currently takes, what medications have been discontinued, and the patient's medication allergies. Through the Shared Care Plan, patients and their caregivers can document or retrieve their list of medications, advance directives, personal health goals such as losing weight or reducing cholesterol, or other important components of their personal medical history. Patients also can produce a wallet-size version of their entire personal health record to keep it portable. In future years, the Shared Care Plan and medication list will be offered to area clinics, physicians' offices, nursing homes, assisted living facilities, home health agencies, pharmacies, and specialist groups in all five PeaceHealth regions located in Washington State, Alaska, and Oregon. Although the patient's actual Shared Care Plan tool is password protected, you may view a mock personal health record by selecting "Explore a sample."

5.  Researchers Examine Current Processes of Nurses' Medication Management in Home Care

In an effort to better understand medication management in home care, AHRQ researchers have developed a description of processes used by home health nurses as they work with patients to manage medications. Their analysis was conducted on the following three processes: drug utilization review (duplicative and harmful interactions); drug administration by the patient, family member, and/or caregiver; and occurrence of side effects. Since the nurses' role in home care medication management is based on complex and comprehensive assessments for monitoring and evaluating patients, researchers can use these findings to identify the steps taken by nurses and suggest system changes that can help decrease errors. Investigators also conducted a pilot study to estimate the potential medication error rate at one home health agency. They found that approximately 60 percent of patients 65 and older with hypertension or diabetes had one or more medication alerts generated by an electronic drug utilization review program that indicated a potential drug-to-drug interaction or duplicative drug therapy at start of care. The AHRQ-funded study, "Examining Nurses' Decision Process for Medication Management in Home Care" (grant no. HS11523) was led by Christine Kovner, Ph.D., R.N., a Professor of Nursing at New York University, and is published in the July 2005 issue of the Joint Commission Journal on Quality and Patient Safety. Select to read an abstract of the study in PubMed®.

6.  National Conference on Connecting Americans to Their Health Care Set for October 11

The Markle Foundation, the Robert Wood Johnson Foundation, and AHRQ are sponsoring a National Conference—"Connecting Americans to Their Health Care: Empowered Consumers, Personal Health Records and Emerging Technologies"—to be held October 11 at the JW Marriott Hotel in Washington, DC. The conference will focus on the empowerment of patients and health care consumers through health IT. AHRQ Director Carolyn M. Clancy, M.D., is among the hosts for the conference, which features keynote speakers HHS Secretary Mike Leavitt; Eric Dishman, Intel Corporation; and Newt Gingrich, former Speaker, U.S. House of Representatives. The registration deadline is September 30.

7.  Do You Know How AHRQ's Hospital Survey on Patient Safety Culture Is Being Used to Improve Patient Safety?

As reported previously, AHRQ worked with Premier, Inc., the Department of Defense, and the American Hospital Association on its Hospital Survey on Patient Safety Culture. The survey, which Premier has now made available in Spanish, is designed to assess the safety culture of a hospital as a whole and specific units within hospitals, as well as to track changes in patient safety over time and evaluate the impact of patient safety interventions. At AHRQ, 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 examples are used by AHRQ in testimony, budget documents, and speeches. Therefore, if you are actively using this survey instrument, we would like to hear from you. Please contact Nate Robinson at NRobinso@ahrq.gov with your examples. Select for more information on AHRQ's Hospital Survey on Patient Safety Culture.

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

The September issue of the AHRQ WebM&M online patient safety journal is now available. The Perspectives on Safety section highlights patient safety initiatives, with particular focus on translating safety research into practice. The first perspective features an interview with AHRQ Director Carolyn M. Clancy, M.D., about how patient safety research and health IT can drive improvement in quality and safety. Select to read Dr. Clancy's interview. The second perspective is by Robert M. Wachter, M.D., Professor and Associate Chairman, University of California, San Francisco, Department of Medicine; Chief of the Medical Service, UCSF Medical Center; and Editor, AHRQ WebM&M and AHRQ Patient Safety Network. Dr. Wachter discusses the oft-traveled path toward patient safety progress, namely, the adoption of successful practices from other fields, ranging from aviation to elementary education, a process he calls "translocational research." Select to read Dr. Wachter's commentary. This month's user-submitted cases include one in which a woman in labor who is receiving medications for preeclampsia, labor induction, and hydration from a multi-channel infusion pump is mistakenly given an extra intravenous dose of the wrong medication. In another case, a few minutes after an unsuccessful code is terminated, a nurse rushes from the patient's room stating that the patient is now breathing on her own. Select to access a video simulation of the commentary. In the Spotlight Case, an elderly man with diabetes admitted to the hospital with hypoglycemia is switched from a combination pill to a single drug, only to return with mental status changes 2 weeks later. As always, the Spotlight Case includes a downloadable set of slides. By completing the Spotlight Quiz, physicians can receive CME credit, nurses can obtain CEUs, and trainees can receive certification in patient safety. Please submit cases to AHRQ WebM&M via the "Submit Case" button. All previously published cases and commentaries are available under "Case Archive."

9.  New Version of AHRQ Quality Indicators Now Available

AHRQ Quality Indicators are now available in a Windows Application Version 1.0. This version replicates the indicator specification and rate calculation of the currently available versions of the SAS and SPSS syntax for the three AHRQ QI modules: 1) prevention quality indicators; 2) inpatient quality indicators; and 3) patient safety indicators. The new version requires Microsoft Windows 2000 or Microsoft Windows XP, with the Microsoft.NET platform and an available Microsoft SQL Server database. (A public-use version of Microsoft.NET and the SQL Server database are included with the software.) AHRQ QIs, which include specific pediatric and neonatal indicators, were refined through an AHRQ contract with the University of California at San Francisco-Stanford University Evidence-based Practice Center. To introduce the new software and describe its major features and functionality, the AHRQ QI support team will hold a Web-based training session on Wednesday, September 14, 2005, at 3:00p.m., EDT. To register, send an E-mail to webmeetings@qualityindicators.ahrq.gov with your name, organization, and E-mail address. Access to the training session is limited. A follow-up E-mail invitation will be sent to you that will include a link to the Web presentation and a telephone number and access code for the voice presentation. For questions, please contact support@qualityindicators.ahrq.gov or leave a voicemail at (888) 512-6090. To learn more about AHRQ QIs and download the software, installation guide, and user guide, go to the AHRQ QI Web site.

10.  National Guideline Clearinghouse™ Features Patient Safety-Related Guidelines

Approximately 250 of over 1,700 guidelines included in the National Guideline Clearinghouse™ have been categorized in the Institute of Medicine's domain of "safety." The NGC team catalogues a guideline as patient safety-related when it provides recommendations on how care should be given. Traditionally, guideline recommendations assist in decisionmaking on what care should be given, when, to whom, where, and why. With the increasing emphasis on the need to reduce medical errors and improve patient safety, guideline developers may purposefully include statements about how that care should be given, such as checking patient identification before dispensing medication, and by whom it should be given. To find these safety-related evidence-based guidelines, use the detailed search feature (scroll approximately two-thirds down, select "safety" in the IOM Domain field box, scroll to the bottom of page, and select Search).

11.  Calling All AHRQ Researchers! "Help Us To Help You"

As you may know, AHRQ can help you promote the findings of your research, but we can't do it without you. AHRQ has been successful in working with our grantees and contractors to promote findings to the media and transfer knowledge based on the research to appropriate audiences in the health care community. However, we know that we can do better. We need you to notify us when you have an article accepted for publication. Please send a copy of the manuscript, anticipated publication date, and contact information for the journal and your institution's communications office to your AHRQ project officer and to AHRQ Public Affairs at journalpublishing@ahrq.gov. Your manuscript will be reviewed to determine what level of marketing we will pursue. Please be assured that AHRQ always honors the journal embargo. Thank you for your cooperation.

12.  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.

Gallagher TH, Lucas MH. Should We Disclose Harmful Medical Errors to Patients? If So, How? J Clin Outcomes Manage 2005 May;12(5):253-9. Select to read the abstract.

Holzmueller CG, Pronovost PJ, Dickman F, et al. Creating the Web-based Intensive Care Unit Safety Reporting System. J Am Med Inform Assoc 2005 Mar-Apr;12(2):130-9. Select to read the abstract in PubMed®.

Hurley JS, Roberts M, Solberg LI, Gunter MJ, Nelson WW, Young L, Frost FJ. Laboratory Safety Monitoring of Chronic Medications in Ambulatory Care Settings. J Gen Intern Med 2005 Apr;20(4):331-3. Select to read the abstract in PubMed®.

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Current as of September 2005

Internet Citation:

Patient Safety E-Newsletter. September 9, 2005, Issue No. 12. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews12.htm

 
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