December 10, 2007, Issue No. 39
Patient Safety Quote of the Month
"At some point... we have to acknowledge the fact that a human being can work only so
long without sleep deprivation becoming a factor. Research shows that we do not do well in
transitions of care... but limiting these transitions by having work hours that are not
compatible with human physiology is not the answer."
—Carolyn M. Clancy, M.D., Director, AHRQ, in remarks from December
3 opening address at the Institute of Medicine workshop on resident work hours and patient
safety (For more information, go to Item No. 1).
Today's Headlines:
1. AHRQ director delivers opening remarks at Institute of Medicine workshop
on resident work hours and patient safety
2. AHRQ releases new toolkits for reducing medical errors
3. AHRQ releases new DVD about designing hospitals for safety and
quality
4. AHRQ-sponsored tools help improve health care delivery efficiency
5. AHRQ grantee delivers presentations on patient safety culture
6. AHRQ patient safety grantee receives honor from Institute for Safe
Medication Practices
7. AHRQ director helps consumers navigate the health care system in a new
advice column on the Web
8. AHRQ Annual Conference presentations now available
9. AHRQ-sponsored DVD addresses questions after diagnosis, safe medication
practices
10. AHRQ to participate in International Conference on Ergonomics and Patient
Safety in June 2008
11. AHRQ in the patient safety professional literature—some useful
citations
1. AHRQ Director Delivers Opening Remarks at Institute of Medicine Workshop on Resident Work Hours and Patient Safety
AHRQ Director Carolyn M. Clancy, M.D., discussed the need for incentives to
promote safe work schedules in graduate medical education settings as a part
of her opening remarks at a public meeting of the Institute of Medicine's
new committee on December 3. Dr. Clancy told members of the IOM Committee
on Optimizing Graduate Medical Trainee Hours and Work Schedules that AHRQ research
has shown a correlation between extended work hours and quality of care. Although
the maximum number of hours that medical residents should work was capped at
80 hours a week in 2003 by the Accreditation Council for Graduate Medical Education,
the culture and traditions in training remain strong and, as a result, the
problem continues to exist throughout health care. Dr. Clancy also identified
four primary areas of focus for the IOM committee—developing a current
evidence base on resident work hours and schedules and their impact on safety;
identifying and developing strategies for implementing reasonable work hours;
analyzing the benefits and harms of updating work hours and schedules; and
developing recommendations for action by various stakeholders. AHRQ is
sponsoring an IOM study that is expected to produce recommendations on resident
work hours in late 2008. Select to view Dr.
Clancy's remarks; objectives
of the IOM committee; and a list of future IOM
meetings on the topic.
2. AHRQ Releases New Toolkits for Reducing Medical Errors
AHRQ recently released 17 Partnerships in Implementing Patient Safety (PIPS) toolkits,
developed by AHRQ-funded experts who specialize in patient safety research. Inspired
by the Institute of Medicine report To Err is Human: Building a Safer Health
System, the toolkits are designed to help doctors, nurses, hospital managers,
patients, and others reduce medical errors. The toolkits include checklists to help
reconcile medications when patients are discharged from the hospital, processes to
enhance effective communication among caregivers and with patients, and toolkits to
help patients taking medications. Select for a complete listing of the
17 interventions and to view
AHRQ's press release.
3. AHRQ Releases New DVD about Designing Hospitals for Safety and
Quality
AHRQ released a new DVD that provides evidence to help hospital officials
and architects design safer, high-quality hospitals. This new two-part DVD
illustrates the value of evidence-based hospital design—a phrase used
to describe how the physical design of health care environments affects patients
and staff. The first part, entitled Transforming Hospitals: Designing
for Safety and Quality, gives a brief 13-minute overview and provides
current examples of how evidence-based hospital design increases
patient safety, satisfaction, and quality of care that results in higher staff
satisfaction, recruitment, and retention. The second part, Transforming
Hospitals: Three Case Studies, is 36 minutes and features the experiences
of three hospitals that incorporated principles of evidence-based hospital design into
new construction and renovation projects. With an estimated $250 billion construction
boom in the hospital industry over the next 10 years, the DVD is expected
to be of significant interest to hospital executives and architects planning
or implementing construction and renovation projects. Select for more
information on Transforming
Hospitals: Designing for Safety and Quality or AHRQ's research
in evidence-based hospital design. Copies of the DVD can be obtained by
sending an E-mail to ahrqpubs@ahrq.hhs.gov.
4. AHRQ-Sponsored Tools Help Improve Health Care Delivery Efficiency
With support from AHRQ, Denver Health, the safety net system for Denver, Colorado,
has applied Lean techniques to redesign processes throughout its delivery
system. According to Denver Health, it has saved at least $2.7 million to date
by implementing the transformation. Lean is a business system for organizing
and managing product development, operations, suppliers, and customer relations.
The objectives of the 18-month project included developing structures and processes
capable of coordinating and aligning approximately 50 rapid-cycle process improvement
projects, developing evaluation methods, providing timely feedback to participants,
and assessing the overall contribution of the projects to hospital improvement,
as well as drawing lessons for future efforts at Denver Health and elsewhere.
Select to read the summary for
further details.
5. AHRQ Grantee Delivers Presentations on Patient Safety Culture
AHRQ Partnerships in Implementing Patient Safety grantee Katherine Jones, Ph.D., P.T.,
Assistant Professor, Department of Physical Therapy Education, University of Nebraska
Medical Center, Omaha, recently delivered two WebEx presentations on patient safety
culture. The first presentation, titled "Understanding Reassessment Results from
the AHRQ Hospital Survey on Patient Safety Culture," defines safety culture,
discusses AHRQ's Hospital Survey on Patient Safety Culture report, and explains
how to use items within a dimension to engineer interactions between practices that produce
a safe, informed culture. In a second presentation, "Understanding
Assessment Results from the AHRQ Hospital Survey on Patient Safety Culture," Dr.
Jones discusses similar topics, including creating an action plan to engineer
a safe and informed culture. Select to view the first
presentation and the second
presentation (PDF Help).
6. AHRQ Patient Safety Grantee Receives Honor from Institute for Safe
Medication Practices
The Walworth County Patient Safety Council, funded through AHRQ's Partnerships
in Implementing Patient Safety project and Aurora Health Care, has
been selected as a recipient of this year's 10th Annual Cheers Award
from the Institute for Safe Medication Practices for its efforts at improving
medication safety for local seniors. The Cheers Awards honor individuals
and organizations that have set a superlative standard of excellence for
others to follow in the prevention of medication errors and adverse drug
events. The award was presented at the American Society of Health-System
Pharmacists Midyear Clinical Meeting on December 4. Select to view
ISMP's press release (PDF Help).
7. AHRQ Director Helps Consumers Navigate the Health Care System in
a New Advice Column on the Web
AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in new,
brief, easy-to-understand columns. The biweekly columns will help consumers
better navigate the health care system. Select to read Dr. Clancy's
new advice columns.
8. AHRQ Annual Conference Presentations Now Available
Nearly 1,200 researchers and others attended AHRQ's 2007 Annual Conference
held September 26-28. Many of the presentations are now available online. The
presentations are organized by date. Select to access the
September 26
sessions, September 27
sessions, and September 28
sessions. Save the date! Next year's conference will be September 7-10, 2008. Watch
for more information in a future newsletter.
9. AHRQ-Sponsored DVD Addresses Questions After Diagnosis, Safe Medication
Practices
Two new videos from AHRQ help answer important questions patients are likely
to have once they've been diagnosed with a condition or illness and provide
simple steps on how to take medications safely. The videos, contained in a
single DVD and produced in collaboration with Healthology, Inc., provide valuable,
easy-to-understand advice for patients that can help guide further discussions
with their health care provider. Next Steps After Your Diagnosis:
Finding Information and Support helps patients find information and resources
and addresses the various physical and emotional aspects of a new diagnosis. Check
Your Medicines: Tips for Taking Medicines Safely provides simple steps
for taking drugs safely and correctly, thus avoiding the risk of medication
errors. The program encourages patients to ask questions about their prescriptions,
to bring a list of all current medications to their doctor's appointment,
and to make sure that the medication they receive is what their doctor ordered. AHRQ
Director Carolyn M. Clancy, MD, and other experts are featured in each segment. Free
single copies are available from the AHRQ Publications Clearinghouse at
ahrqpubs@ahrq.hhs.gov.
10. AHRQ To Participate in International Conference on Ergonomics and
Patient Safety in June 2008
The International Ergonomics Association is sponsoring the second International
Conference on Healthcare Systems Ergonomics and Patient Safety from June 25-28,
2008, in Strasbourg, France. The conference is aimed at creating bridges
among different disciplines—medicine and surgery, information technology,
occupational psychology, clinical engineering and architecture, and human factors
and ergonomics—in order to share a strong interest in the promotion of
human factors and ergonomics in health care and patient safety. AHRQ's
Kerm Henriksen, Ph.D., Human Factors Advisor for Patient Safety, will serve
with other experts, including AHRQ grantees, on the conference steering committee. The
deadline for abstracts is December 15. Visit for more information
on the conference.
11. 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.
Culler SD, Hawley JN, Naylor V, Rask KJ. Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals. J Med Syst 2007 Oct;31(5):319-27. Select to read an abstract of the study.
Hansen LB, Saseen JJ, Westfall JM, Holcomb S, Nuzum DS, Pace WD. Evaluating sample medications in primary care: a practice-based research network study. Jt Comm J Qual Patient Saf 2006 Dec;32(12):688-92. Select to read an abstract of the study.
Singer S, Meterko M, Baker L, et al. Workforce perceptions of hospital safety culture: development and validation of the Patient Safety Climate in Healthcare Organizations survey. Health Serv Res 2007 Oct; 42(5):1999-2021. Select to read an abstract of the study.
Smith RB, Cheung R, Owens P, Wilson RM, Simpson L. Medicaid markets and pediatric patient safety in hospitals. Health Serv Res 2007 Oct; 42(5):1981-98. Select to read an abstract of the study.
AHRQ's Patient Safety E-Newsletter Contact:
Please address comments and questions 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 December 2007
Internet Citation:
Patient Safety E-Newsletter. December 10, 2007, Issue
No. 39. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews39.htm
540 Gaither Road Rockville, MD 20850