July 2, 2007, Issue No. 33
Patient Safety Stat of the Month
Seventy-eight percent of hospital staff say that there is a positive environment of teamwork within their units, but nearly 45 percent say there is room for improvement in the areas of handoffs and transitions.
For more information on AHRQ's New 2007 Hospital Survey on Patient Safety Culture Comparative Database Report, select Item No. 1.
Today's Headlines
1. AHRQ's New 2007 Hospital Survey on Patient Safety Culture Comparative Database Report Says Teamwork is Working but Handoffs Need to Improve
2. AHRQ Research Used to Launch New Mentoring Program for Emergency Department Pharmacists
3. CAPS Releases Guide for Patient Safety Consumer Champions
4. "Did You Wash Your Hands?" Dr. Clancy Discusses Hand Washing in Health Care Settings
5. AHRQ Seeks Submissions to Build Its New Health Care Innovations Exchange
6. AHRQ's 2007 Annual Conference: Improving Health Care, Improving Lives—Register Now!
7. Visit the AHRQ Patient Safety Network Web Site
8. Latest Issue of AHRQ WebM&M Available Online
1. AHRQ's New 2007 Hospital Survey on Patient Safety Culture Comparative Database Report Says Teamwork is Working but Handoffs Need to Improve
More than three-fourths (78 percent) of hospital staff say that there is a positive environment of teamwork within their units, but nearly half (45 percent) say there is room for improvement in the areas of handoffs and transitions, according to the Agency for Healthcare Research and Quality's (AHRQ) recent 2007 Hospital Survey on Patient Safety Culture Comparative Database Report. The report presents results from the first compilation of aggregated national data from AHRQ's 2004 Hospital Survey on Patient Safety Culture and is based on data from 382 U.S. hospitals and survey responses from 108,621 hospital staff.
The report found a number of strengths among hospitals as well as areas for patient safety culture improvement. The database report provides the first national benchmarks for hospital staff assessments about patient safety issues, medical errors, and event reporting from a wide range of hospitals that participated in the AHRQ hospital safety culture survey.
The report provides results by hospital characteristics such as bed size, teaching status, ownership, geographic region, patient safety grade (overall management support of patient safety and staff perceptions of patient safety), and number of events reported. It also offers results by respondent characteristics such as respondent work area/unit, staff position, and interaction with patients.
Select to access the report online. A print copy is available by sending an E-mail to ahrqpubs@ahrq.hhs.gov.
2. AHRQ Research Used to Launch New Mentoring Program for Emergency Department Pharmacists
The American Society of Health-System Pharmacists (ASHP) recently launched a new mentoring program for emergency department (ED) pharmacists that is based on AHRQ research. The program is designed to connect teams of ED pharmacists with pharmacists who wish to develop these practices in their own hospitals.
Twenty pharmacists, including one in Ireland, have been chosen to take part in the 6-month pharmacy certificate program, which focuses on the positive impact that pharmacists have on patient care. Program participants will develop a job description and justification for an ED pharmacist program; identify strategies for obtaining program support from hospital leaders and staff; develop a plan for implementing the program; and, devise methods for monitoring and quality assurance once the program is established.
The mentoring program was based on work by AHRQ patient safety researcher Rollin J. Fairbanks, M.D., of the University of Rochester, New York. Dr. Fairbanks' research will result in the development of a toolkit to help hospitals implement ED pharmacist programs. Select for more information on the program and for information on Dr. Fairbanks' project.
3. CAPS Releases Guide for Patient Safety Consumer Champions
Consumers Advancing Patient Safety (CAPS) released a guide entitled Building the Future for Patient Safety: Developing Consumer Champions—A Workshop and Resource Guide. The guide, funded in part by AHRQ, describes the CAPS workshop process and methodology used for the World Health Organization's Patients for Patient Safety initiative to develop future-oriented consumer champions as partners in patient safety work. The guide includes related tools that provide examples of materials to assist in launching a workshop experience for consumer champions. Select to review the press release and to access the toolkit.
4. "Did You Wash Your Hands?" Dr. Clancy Discusses Hand Washing in Health Care Settings
AHRQ's latest Healthcare 411 audio podcast features an interview with AHRQ Director Carolyn M. Clancy, M.D., about the World Health Organization's efforts in patient safety and the importance of hand washing. Select to access the 6-1/2-minute audio podcast.
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.
5. AHRQ Seeks Submissions to Build Its New Health Care Innovations Exchange
AHRQ is seeking submissions to build its new Health Care Innovations Exchange database— a dual-component initiative designed to support health care professionals in sharing and adopting innovations that improve health care quality. The Web-based national repository of health service innovations and dynamic communities of learning was developed to accelerate change and transformation in real-world health care.
Physicians, nurses, and other health professionals and providers will soon be able to use the Web site to obtain detailed profiles of innovative activities and tools, and have opportunities to exchange successes, failures, stories, and lessons learned with innovators and fellow adopters. Innovations found on the Web site will represent varying degrees of novelty and scientific rigor and cover many clinical disciplines and care settings in both the public and private sector. To learn more about how to submit innovations, visit the AHRQ Health Care Innovations Exchange Web site.
6. AHRQ's 2007 Annual Conference: Improving Health Care, Improving Lives—Register Now!
Register now for AHRQ's 2007 Annual Conference: "Improving Health Care, Improving Lives," to be held September 26-28 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. Sessions will feature leading experts active in research and implementation projects aimed at improving quality, safety, efficiency, and effectiveness of care. Select to register.
7. Visit the AHRQ Patient Safety Network Web Site
New material is being added to the AHRQ Patient Safety Network, or AHRQ PSNet, every week. The Web site continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is a comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety.
The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature. Select to visit the AHRQ PSNet Web site.
8. Latest Issue of AHRQ WebM&M Available Online
The June issue of AHRQ WebM&M is now available. This month, the Perspectives on Safety section moves from global to local as we explore State error reporting systems. There is an interview with Diane Rydrych of the Minnesota Department of Health. Jill Rosenthal of the National Academy for State Health Policy, discusses how State reporting systems can advance patient safety.
In the first Spotlight Case, preoperative evaluation of an elderly man for elective surgery missed an abdominal mass and markedly elevated alkaline phosphatase. A week later, the patient was admitted and diagnosed with pancreatic cancer. Had this been known preoperatively, the patient would not have had surgery. The author, Gerald Smetana, M.D., of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, discusses the elements of preoperative evaluation and the limited role of preoperative laboratory testing. In the second case, a healthy woman who volunteered for a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. After further evaluation, she was diagnosed with uterine cancer. In the third case, based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered. This change was neither explained nor noted in the chart, and the patient suffered an unusual complication. Commentary authors are Conrad Fernandez, M.D., of IWK Health Centre and Dalhousie University (Canada) and Stuart White, F.R.C.A., B.Sc., M.A., of Brighton and Sussex University Hospitals National Health Services Trust (United Kingdom). 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.
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 July 2007
Internet Citation:
Patient Safety E-Newsletter. July 2, 2007, Issue No. 33. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews33.htm
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