June 4, 2007, Issue No. 32
Patient Safety Message of the Month
"About half of the adverse events that occur in the emergency department are due to communications failures among professionals working in these settings. We are attempting to mimic the chaos we see everyday in the emergency department and push health professionals to practice in a way that will keep patients safe when they encounter these situations in real life." (For more information on the research by Dr. Patterson and her colleagues, go to item no. 1.)
—Mary Patterson, M.D., Assistant Professor of Clinical Pediatrics, Children's Hospital Medical Center, Cincinnati, OH.
For more information on the research by Dr. Patterson and her colleagues, select Item No. 1.
Today's Headlines
1. AHRQ Patient Safety Grantee Dr. Mary Patterson and Her Colleagues Are Working To Mitigate Medical Errors in Children's Hospital Emergency Departments
2. Lower Infection Rates for Elderly Patients Found at Better Staffed Hospital ICUs
3. Latest AHRQ Healthcare 411 Podcast Features Story on Mistake-Proofing
4. U.S. Health Care Sector Moves Rapidly To Provide Consumer Information on Value
5. Register Now for AHRQ Web Conference on Reducing Pressure Ulcers and Improving Quality in Long-Term Care
6. Latest Issue of AHRQ WebM&M Available Online
7. "Improving Health Care, Improving Lives": Save the Date for AHRQ's 2007 Annual Conference
8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations
1. AHRQ Patient Safety Grantee Dr. Mary Patterson and Her Colleagues Are Working To Mitigate Medical Errors in Children's Hospital Emergency Departments
AHRQ patient safety researcher and pediatrician Mary Patterson, M.D., Assistant Professor of Clinical Pediatrics, Children's Hospital Medical Center in Cincinnati and a team of investigators are working to mitigate medical errors in children's hospital emergency departments (EDs) through the application of a simulation-based safety curriculum that uses human patient simulators and emphasizes team behaviors for all health care providers, including medical residents.
The simulation-based curriculum, which can be used by emergency department personnel and house staff, as well as trauma teams in hospitals, includes a 12-hour, half-day course, didactic sessions, simulations, video review and discussion, video background presentations, wrap-up and post-testing, and evaluations. Researchers have found that reconditioning health care providers in a training environment can break down silos and reveal the large number of latent threats or system breakdowns. As a result, care providers can practice in a way that will keep patients safe when they encounter similar situations in real life. Dr. Patterson is an AHRQ Partnerships in Implementing Patient Safety grantee and 1 of 19 new AHRQ Medical Simulation grantees. Select to learn more about Dr. Patterson's research.
2. Lower Infection Rates for Elderly Patients Found at Better Staffed Hospital ICUs
Hospitals with better working conditions for nurses are also safer for elderly patients in intensive care units (ICUs), according to a new AHRQ-funded study. A review of outcomes data for more than 15,000 patients in 51 U.S. ICUs found that those with high nursing staffing levels, or an average of 17 registered nurse hours per day, had a lower incidence of hospital-associated infections. By contrast, higher levels of overtime were associated with increased rates of infection and skin ulcers.
Hospital-associated infections are the sixth leading cause of death in the United States, according to CDC. Researchers at Columbia University also found that ICUs with higher staffing had lower incidence of central line-associated bloodstream infections, a common cause of mortality in intensive care settings. Other measures such as ventilator-associated pneumonia and skin ulcers were also reduced in units with high staffing levels. Patients were also less likely to die within 30 days in higher staffed units.
The study, "Nurse Working Conditions and Patient Safety Outcomes," led by Patricia Stone, Ph.D., M.P.H., R.N., of Columbia University School of Nursing, New York, NY, was published in the June 2007 issue of Medical Care. Select to review the abstract.
3. Latest AHRQ Healthcare 411 Podcast Features Story on Mistake-Proofing
AHRQ's latest Healthcare 411 audio podcast features comments on mistake-proofing in health care from John R. Grout, Ph.D., the newly appointed dean of Berry College's Campbell School of Business. Dr. Grout produced a synthesis for AHRQ of ways to improve patient safety by making simple changes in health care settings. The 12-minute podcast also includes stories about HCUP data on traumatic brain injury and the release of AHRQ's new handbook for creating and operating patient registries. Select to access the audio podcast or to access Dr. Grout's synthesis Mistake-Proofing the Design of Health Care Processes.
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 and receive notice of all future AHRQ podcasts, visit our Healthcare 411 series main page.
4. U.S. Health Care Sector Moves Rapidly To Provide Consumer Information on Value
Less than a year after launching his Value-Driven Health Care Initiative, HHS Secretary Leavitt announced that more than 100 million Americans are now served by health plans that are committed to providing consumers with transparent quality and cost information. The Federal government; half of the States; about 775 employers, including almost half of the top 200 U.S. corporations; and numerous unions, communities, doctors, and hospitals have joined the movement.
In August 2006, President Bush signed an Executive Order committing the Federal government to the "four cornerstones" of value-driven care: health information technology, public reporting of provider quality information, public reporting of cost information, and incentives for value comparison. Select to review the HHS press release, or to learn more on Value-Driven Health Care.
5. Register Now for AHRQ Web Conference on Reducing Pressure Ulcers and Improving Quality in Long-Term Care
On June 12, from 2:00 p.m.-3:30 p.m., EDT, AHRQ will host a 90-minute Web conference on reducing pressure ulcers through the implementation of an evidence-based, electronic, quality improvement tool, called "On Time Quality Improvement for Long-Term Care." This Web conference is targeted for California-based nursing homes but is open to all health care providers and others.
Long-term care facilities present a unique set of issues for an extremely vulnerable patient population, and the prevalence of pressure ulcers in individual facilities can range from 2.5 percent to 24 percent.
Developed by AHRQ, the tools are innovative and designed to improve day-to-day practice in nursing homes, improve work flow, enrich work culture, and reduce pressure ulcers. Pressure ulcers are largely preventable, and, every day, caregivers in nursing homes protect their high-risk patients from pressure sores through diligent pressure-reduction efforts, incontinence care, and feeding.
More can be done to meet one of the most obtainable Healthy People 2010 objectives: reduce the proportion of nursing home residents with a current diagnosis of pressure ulcers by 50 percent. This free Web conference introduces a set of tools that can improve work experience and the quality of life experienced by nursing home residents. Continuing education credits are provided for California participants.
6. Latest Issue of AHRQ WebM&M Available Online
The May issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section focuses on international viewpoints on safety. There is an interview with Sir Liam Donaldson, M.D., M.Sc., England's Chief Medical Officer and founding chair of the World Health Organization's World Alliance for Patient Safety. Susan Burnett and Charles Vincent, Ph.D., discuss the evolution and progress of patient safety in the United Kingdom.
In the first Spotlight Case, an elderly man with seizures was admitted to the hospital due to lethargy, confusion, and decreased appetite. The team misattributed his mental status change to an infection but later discovered that the patient had phenytoin toxicity. Brian Alldredge, Pharm.D., of the University of California, San Francisco, discusses the challenges of safe use of antiepileptic medications. In the second case, on the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for an absence, the staff asked the very busy OR anesthesiologist to fill in, and a medication error occurred. The case demonstrates the ever-present tension between patient safety and "production pressures." In the third case, a young woman with a vascular condition that can cause blood pressure differences in each arm was mistakenly placed on a powerful intravenous vasopressor because of a spurious low blood pressure reading. The medication could have led to serious complications. Commentary authors are Pascale Carayon, Ph.D., of the University of Wisconsin-Madison, and Elizabeth Henneman, R.N., Ph.D., of the University of Massachusetts School of Nursing. 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.
7. "Improving Health Care, Improving Lives": Save the Date for AHRQ's 2007 Annual Conference
Save the date! AHRQ's 2007 Annual Conference, "Improving Health Care, Improving Lives," will be held September 27-29 in Bethesda, MD. The conference will offer exciting opportunities to learn about the latest AHRQ research ready for use in addressing a variety of clinical and health policy issues. In particular, sessions will feature leading experts active in research and implementation projects aimed at improving quality, safety, efficiency, and effectiveness of care.
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.
Carayon P, Schoofs Hundt A, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006 Dec;15 Suppl 1; ii50-i58. Select to access the abstract in PubMed®.
Devine EB, Wilson-Norton JL, Lawless NM, et al. Characterization of prescribing errors in an internal medicine clinic. Am J Health Syst Pharm 2007 May 15;64(10):1062-70. Select to access the abstract in PubMed®.
Raebel MA, McClure DL, Simon SR, et al. Laboratory monitoring of potassium and creatinine in ambulatory patients receiving angiotensin converting enzyme inhibitors and angiotensin receptor blockers. Pharmacoepidemiol Drug Saf 2007 Jan;16(1):55-64. Select to access the abstract in PubMed®.
Rothschild JM, Mann K, Keohane CA, et al. Medication safety in a psychiatric hospital. Gen Hosp Psychiatry 2007 Mar-Apr;29(2):156-62. Select to access the abstract in PubMed®.
Sangl J, Buchanan J, Cosenza C, et al. The development of a CAHPS instrument for nursing home residents (NHCAHPS). J Aging Soc Policy 2007;19(2):62-82. Select to access the abstract in PubMed®.
Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working conditions, organizational climate, and intent to leave in ICUs: an instrumental variable approach. Health Serv Res 2007 Jun;42(3 Pt 1):1085-104. 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 June 2007
Internet Citation:
Patient Safety E-Newsletter. June 4 2007, Issue No. 32. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews32.htm
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