Patient Safety and Health Information Technology E-Newsletter

March 3, 2006, Issue No. 17

Quote of the Month

AHRQ researchers found that the number of patients admitted by U.S. hospitals to treat complications resulting from surgery or medical treatment increased by nearly 150,000—from 305,000 in 1993 to 452,000 in 2003. Researchers also found that the average cost to hospitals for treating these complications increased by nearly $2,800—from $6,840 in 1993 to $9,600 in 2003. [Source: Agency for Healthcare Research and Quality, HCUP NIS.]

Today's Headlines:

1. Register now for AHRQ's listening sessions on Patient Safety Organizations set for March 8, 13, and 16
2. Ambulatory Care Quality Alliance announces pilot project
3. Study suggests CPOE helps lower medication errors in hospitals but not outpatient settings
4. Children in outpatient pediatric settings received incorrect doses for 22 common medications
5. AHRQ Pediatric Quality Indicators software and documentation are available
6. AHRQ launches new "Learning Resources" to help providers adopt health IT
7. Call for nominations for 2006 John M. Eisenberg Patient Safety and Quality Awards program
8. Mark your calendars for AHRQ's 2006 Annual Patient Safety and Health IT Conference in June
9. Register now for NPSF's Eighth Annual Patient Safety Congress in May
10. AHRQ in the patient safety professional literature—some useful citations

1. Register Now for AHRQ's Listening Sessions on Patient Safety Organizations Set for March 8, 13, and 16

As part of its work to implement the Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), AHRQ is inviting the public to provide information to assist the Agency, either in person or by telephone call-in, at three public meetings on Patient Safety Organizations (PSOs) this month. The three public meetings will be held on March 8, March 13, and March 16 (from 12:30 p.m., EST, until 3:30 p.m., EST, at the latest).

The meetings on March 8 (on PSO relationships, contracts, and disclosures) and March 13 (on operation of a component PSO) will be held in the AHRQ Conference Center, 540 Gaither Road, Rockville, MD 20850. The meeting on March 16 (on security and confidentiality issues) will be held at the Hilton Washington Embassy Row, 2015 Massachusetts Ave. NW, Washington, DC 20036. Select to read the Federal Register notice announcing the meetings or to register for the meetings.

2. Ambulatory Care Quality Alliance Announces Pilot Project

The Ambulatory Care Quality Alliance (AQA)—a group of 125 organizations that seeks to improve health care quality through a process in which key stakeholders agree on a strategy for measuring, reporting, and improving performance at the physician level—has announced six sites for a pilot project that will, for the first time, combine public and private information to measure and report on physician practice in a meaningful and transparent way for consumers and purchasers of health care.

The pilot will not only measure care quality, but will identify those high quality providers who are able to deliver efficient care to patients, avoiding unnecessary complications and costs. It is expected that the results of this pilot will provide a national framework for performance measurement and public reporting.

The organizations selected by AQA as initial pilot sites are the following:

• California Cooperative Healthcare Reporting Initiative, San Francisco, CA.
• Indiana Health Information Exchange, Indianapolis, IN.
• Massachusetts Health Quality Partners, Watertown, MA.
• Minnesota Community Measurement, St. Paul, MN.
• Phoenix Regional Healthcare Value Measurement Initiative, Phoenix, AZ.
• Wisconsin Collaborative for Healthcare Quality, Madison WI.

The pilot project will be supported with funding from the Centers for Medicare & Medicaid Services and AHRQ. "AHRQ is very pleased to help support this pilot project, which will help set the stage for effective, useful reporting of physician practice and performance," said AHRQ Director Carolyn Clancy, M.D. Select to read our press release.

3. Study Suggests CPOE Helps Lower Medication Errors in Hospitals but Not Outpatient Settings

A new study by AHRQ researchers found that facilities with Computerized Prescriber Order Entry (CPOE) systems reported fewer hospital-based errors and more outpatient errors than facilities that didn't have such systems in place. The study, published in the February 15 issue of the American Journal of Health-System Pharmacy, suggests that CPOE may prevent errors from reaching and harming patients. But the authors, led by AHRQ's Chunliu Zhan, M.D., Ph.D., and Marge Keyes, M.A., concluded that data from a voluntary medical error reporting system could not be used to statistically quantify whether facilities with CPOE make fewer medication errors than those without it.

The authors analyzed medication errors submitted to a national voluntary medication error reporting system—MEDMARX, which is sponsored by the United States Pharmacopeia—to compare facilities with and without CPOE. They found substantial variation across facilities in the frequency and patterns of medication errors reported. Select to read the abstract of the study, entitled "Potential Benefits and Problems with Computerized Prescriber-Order-Entry: Analysis of a Voluntary Medication Error-Reporting Database."

4. Children in Outpatient Pediatric Settings Received Incorrect Doses for 22 Common Medications

Researchers supported by AHRQ found that nearly 15 percent of children in ambulatory pediatric settings were dispensed 22 common medications at a potentially incorrect dose based on their weight.

Approximately 8 percent of medications were potentially dispensed in doses that were too high, while 7 percent were dispensed in doses that were potentially too low. For children who weighed less than 35 kilograms (77 pounds), only 67 percent of prescriptions were within recommended doses; 1 percent were dispensed at more than twice the recommended maximum dose.

Researchers, led by Heather A. McPhillips, M.D., Assistant Professor of Pediatrics at the University of Washington and Children's Hospital and Regional Medical Center, Seattle, reviewed automated pharmacy data for claims for the 22 medications prescribed to 1,933 children. Each drug was prescribed to a maximum of 122 patients. They also found that drugs dispensed for the treatment of pain (analgesics) were the class of drugs mostly likely to be prescribed in too high a dose (15 percent) and that drugs used for the treatment of epilepsy (antiepileptics) were the class of drugs most likely to be prescribed in too low a dose.

Select to read the abstract of the study, "Potential Medication Dosing Errors in Outpatient Pediatrics," published in the December 2005 issue of the Journal of Pediatrics.

5. AHRQ Pediatric Quality Indicators Software and Documentation Are Available

AHRQ's Pediatric Quality Indicators (PedQIs) module, Version 3.0, the software, and documentation are now available for download or viewing on the AHRQ Quality Indicators Web site. The PedQIs are indicators of children's health care utilizing inpatient administrative data and are designed to help hospitals examine both the quality of inpatient care and the quality of outpatient care that can be inferred from inpatient data, such as potentially preventable hospitalizations.

The module consists of 13 provider-level indicators, such as iatrogenic pneumothorax in at-risk neonates, respiratory failure and postoperative respiratory failure in non-neonates, and five area-level indicators, including admission rates for children with asthma, diabetes, short-term complications, and gastroenteritis.

6. AHRQ Launches New "Learning Resources" to Help Providers Adopt Health IT

AHRQ launched a new suite of "learning resources" designed to help health care providers adopt health information technologies quickly and effectively. The step represents a new phase for the AHRQ National Resource Center on Health Information Technology, as the Agency acts rapidly to convey the lessons learned through AHRQ-funded projects and other sources.

The new resources are at the center's Web site. Select to read our press release. On behalf of AHRQ Director Carolyn M. Clancy, M.D., AHRQ's Scott Young, M.D., delivered remarks at the Healthcare Information and Management Systems Society 2006 Conference in San Diego on February 13. Select to read the remarks.

7. Call for Nominations for 2006 John M. Eisenberg Patient Safety and Quality Awards Program

The Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum are accepting applications for the 2006 John M. Eisenberg Patient Safety and Quality Awards, which are designed to recognize individuals and health care organizations that are making significant contributions in improving patient safety and quality. To submit nominations, complete the nomination form (PDF file; PDF Help) on the Joint Commission on Accreditation of Healthcare Organizations' Web site. The deadline for nominations is May 1.

8. Mark Your Calendars for AHRQ's 2006 Annual Patient Safety and Health IT Conference in June

Mark your calendars! AHRQ's 2006 Annual Patient Safety and Health IT Conference will be held June 5-7 in Washington, DC. All of AHRQ's patient safety and health IT grantees as well as external stakeholders are invited and should plan on attending this annual conference.

This event will be held during Health IT week, in conjunction with a meeting sponsored by the Healthcare Information and Management Systems Society, and will offer exciting opportunities for networking, receiving technical assistance, and for learning from leading experts in patient safety and health IT. Details about registration will be available in future issues of this newsletter.

9. Register Now for NPSF's Eighth Annual Patient Safety Congress in May

Register Now! The Eighth Annual Patient Safety Congress will be held on May 10-12 in San Francisco, CA. The meeting, entitled "Leadership for Safety: The Time is Now," is sponsored by the National Patient Safety Foundation and cosponsored by AHRQ and other organizations. It will focus on effective implementation of programs that result in cultural change and sustained improvement.

Plenary sessions and workshops will highlight the effective implementation of policies and programs that result in cultural change, and sustained improvement processes toward a safer environment.

10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Buscemi N, Vandermeer B, Hooton N, Pandya R, Rjosvold L, Hartling L, Baker G, Klassen TP, Vohra S. The efficacy and safety of exogenous melatonin for primary sleep disorders. A meta-analysis. J Gen Intern Med 2005 Dec;20(12):1151-8. Select to read the abstract in PubMed®.

Nast PA, Avidan M, Harris CB, Krauss MJ, Jacobsohn E, Petlin A, Dunagan WC, Fraser VJ. Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit. J Thorac Cardiovasc Surg 2005 Oct;130(4):1137. Select to read the abstract in PubMed®.

Zhan C, Smith M, Stryer D. Accidental iatrogenic pneumothorax in hospitalized patients. Med Care 2006 Feb;44(2):182-6. Select to read the abstract in PubMed®.

AHRQ's Patient Safety and Health Information Technology E-Newsletter Contact:

Please address comments and questions regarding the newsletter to Salina Prasad at SPrasad@ahrq.hhs.gov or (301) 427-1864.

Update your subscriptions, modify your password or E-mail address, or stop subscriptions at any time on your Subscriber Preferences Page. You will need to use your E-mail address to log in.

If you have any questions or problems with the subscription service, E-mail: updates@subscriptions.ahrq.gov. For other inquiries, Contact Us.

If you have questions about AHRQ's activities, please try to find the answers by checking our Home Page, where we have established links to various topical areas. Also check the News & Information section and Frequently Asked Questions. You may also Search or Browse the Web Site. These features are designed to assist you in obtaining the information you are seeking.

This service is provided to you at no charge by the Agency for Healthcare Research and Quality (AHRQ).

Current as of March 2006

---

Internet Citation:

Patient Safety E-Newsletter. March 3, 2006, Issue No. 17. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews17.htm

---