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Agency for Healthcare Research Quality

AHRQ Annual Highlights, 2006

The Agency for Healthcare Research and Quality (AHRQ), is committed to helping the Nation improve our health care system. To fulfill its mission, AHRQ conducts and supports a wide range of health services research. This report presents key findings from AHRQ's research portfolio during 2006.

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Improving the Safety and Quality of Health Care
Health Information Technology to Improve Patient Safety and Quality
Promoting the Use of Evidence
Eliminating Disparities in Health Care
Ensuring the Value in Health Care
Developing Tools and Data for Research and Policymaking
Preparing for Public Health Emergencies
Looking to the Future
In Conclusion


Americans spend nearly $2 trillion on health care each year. U.S. hospitals, physicians, nurses, and other health care providers offer some of the best care in the world, but far too many people still do not receive the quality of care that they expect, deserve, and purchase. The health care system in the United States is working to improve the quality of care. These changes require that health care providers, policymakers, and consumers get accurate, unbiased information in order to make the best decisions along with tools and practices they can use to improve the Nation's health care system.

The Agency for Healthcare Research and Quality (AHRQ), 1 of 12 agencies within the Department of Health and Human Services (HHS), is committed to helping the nation improve our health care system. AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To fulfill this mission, AHRQ conducts and supports health services research that:

  • Reduces the risk of harm from health care services by using evidence-based research and technology to promote the delivery of the best possible care.
  • Transforms research into practice to achieve wider access to effective health care services and reduce unnecessary health care costs.
  • Improves health care outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment choices/decisions.

The Agency's mission and goals help HHS achieve the objectives set forth in the Secretary's 2006 priority initiatives, especially those of health care transparency, health care technology, value-based health care, Medicaid modernization, personalized health care, prevention, and public health preparedness.

AHRQ's Customers

AHRQ customers include clinicians and other health care providers, such as:

  • Hospitals and hospital systems.
  • Consumers and patients.
  • Health care policymakers at the Federal, State, and local levels.
  • Purchasers and payers, such as employers and public and private insurers.
  • Medical school faculty.

The evidence developed through AHRQ-sponsored research and analysis helps clinicians, consumers, patients, and health care providers make informed choices about what treatments work, for whom, when, and at what cost.

Clinicians who provide direct care and services to patients use AHRQ's evidence-based research to deliver high-quality health care and to work with their patients as partners. AHRQ also provides clinicians with clinical decision-support tools as well as access to guidelines and quality measures.

Policymakers, purchasers, and other health officials use AHRQ research to make better informed decisions on health care services, insurance, costs, access, and quality. Public policymakers use the information produced by AHRQ to expand their capability to monitor and evaluate changes in the health care system and to devise policies designed to improve its performance. Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services. Health plan and delivery system administrators use the findings and tools developed through AHRQ-sponsored research to make choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.

AHRQ research helps consumers and patients get and use objective, evidence-based information on how to choose health plans, doctors, or hospitals. In addition, AHRQ can help patients and their families play an active role in their health care and reduce the likelihood that they will be subject to a medical error. Personal health guides developed by AHRQ help individuals keep track of their preventive care and other health services they receive. AHRQ's goal is to help people become better informed consumers and to be partners in their own care.

Healthcare 411

In 2005, AHRQ created Healthcare 411 to help Americans become informed about the Agency's latest health care research findings, news, and information. This audio newscast features synopses of AHRQ's latest findings and information on current health care topics. The newscasts are distributed through Apple® iTunes®, Yahoo® PodCasts, and other Web sites that provide health information to their customers, patients, students, employees, or health care personnel. They can be heard through a computer or downloaded to a portable digital player such as an iPod®.

Examples of newscasts released in 2006 include:

  • Medical intern fatigue and errors.
  • Making surgery safer.
  • Weighing the benefits and risks of a medication or treatment.
  • Health care for minority women.
  • Obesity surgery.

For more information on Healthcare 411 and to listen to the newscasts, go to

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Improving the Safety and Quality of Health Care

AHRQ supports research that helps to improve patient safety and the quality of health care. Since 2001, AHRQ has supported research that is focused on reducing medical error and, in turn, improving patient safety. Research projects funded by the Agency identify, develop, test, and implement patient quality and safety measures. Key to reducing medical errors and improving quality is the dissemination and translation of these research findings and methods into practice, as well as the development of strategies to implement promising research and evaluate its impact.

In 2006, AHRQ-funded patient safety research projects emphasized teamwork, ways to reduce medical errors, and creating a culture of patient safety within the health care workplace. The use of health information technology (health IT) can accelerate the progress we have made in patient safety and quality during the next decade. AHRQ has also developed tools and resources that measure the quality of health care and disseminates this information to help our stakeholders take action in areas that need improvement. Descriptions of several current initiates follow.

TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety

AHRQ and the Department of Defense released TeamSTEPPS™, a new evidence-based team training and implementation toolkit that demonstrates techniques of effective communication and other teamwork skills. The new toolkit is designed to optimize team performance and outcomes across the health care delivery system. TeamSTEPPS™ is presented in a multimedia format, with tools to help a health care organization plan, conduct, and evaluate its own team training program. It includes an instructor guide, PowerPoint™ presentations, a DVD, spiral-bound pocket guide, a CD-ROM with printable materials, and a poster to announce TeamSTEPPS™ activities in a heath care organization.

More information on TeamSTEPPS™ can be found at

AHRQ Patient Safety Network (PSNet) Provides Resources for Improving Patient Safety and Preventing Medical Errors

AHRQ's PSNet ( is a national Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates on patient safety literature, news, tools, and meetings and a vast set of carefully annotated links to important research and other information on patient safety. Supported by a robust patient safety taxonomy and Web architecture, the AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse users to customize the site around their interests.

Minnesota Used AHRQ Products to Inform Their Work on the Adverse Health Events Reporting Law

The State of Minnesota used the AHRQ Patient Safety Network ( and the AHRQ WebM&M ( to assist in the development and implementation of Minnesota's Adverse Health Events Reporting Law. Minnesota is the first State in the nation to institute a mandatory adverse health event reporting system. The law requires hospitals and ambulatory surgical centers to report 27 types of "never events"—events that are serious, largely preventable, and of concern to both the public and health care providers—as well as the subsequent findings of root-cause analyses and the corrective action plan.

The Minnesota Department of Health publishes an annual public report of the adverse events and the corrective actions at each hospital and ambulatory surgical center in Minnesota. The 2006 Annual Report detailed 106 adverse events and included AHRQ's Consumer Web page ( as a resource to support consumers in making informed decisions about health care safety and quality. Minnesota's 2006 report is available at

Hospital Survey on Patient Safety Culture

Released in 2005, the Hospital Survey on Patient Safety Culture (Culture Survey) is a tool to help hospitals and health systems evaluate employee attitudes about patient safety within their facilities. The survey can also be used to track changes in patient safety over time and evaluate the impact of specific patient safety interventions.

Because of increasing interest from hospitals and other facilities that want to use the AHRQ Culture Survey, in 2006 the Agency established the Patient Safety Culture Survey Database as a central repository for survey data. Facilities will be able to compare their patient safety culture survey results with those of other facilities in support of patient safety culture improvement efforts. The database will also produce average scores and percentiles on the survey items and composites to help users assess their own results and identify strengths and opportunities for improvement.

Other examples of how the Culture Survey is being used and adapted include:

  • Employees of the Cincinnati Children's Hospital Medical Center completed the survey. The highest-scoring results were in the categories called "teamwork within hospital units" and "hospital management support for patient safety." The lowest areas were for "non-punitive response to error" and "hospital handoffs and transitions." Department heads selected areas to work on with their staff for improvement.
  • The University of Pittsburgh School of Medicine adapted AHRQ's Culture Survey to survey nursing home staff as part of ongoing research on patient safety in nursing homes. The effort yielded a 69 percent response rate. Nursing home staff scored significantly worse than hospital staff benchmarks on 5 of the 12 patient safety culture dimensions. These significant differences were reported in nonpunitive response to error, teamwork within units, communication openness, feedback and communication about errors, and organizational learning.
  • Northwestern Memorial Hospital in Chicago administered AHRQ's Culture Survey and received a 28 percent response rate among clinicians—four times the rate of a shorter paper survey administered in 2002. Staff voiced concern about handoffs, communication between workgroups, and lack of feedback about reported issues. The survey also highlighted that staff were more uncomfortable with filing reports of adverse events than was previously recognized. The patient safety team focused on strategies to address these concerns including new processes and technical support to improve team training and the institution of new monthly patient safety morbidity and mortality conferences. Northwestern plans to repeat the survey approximately every 18 months.
  • The Multnomah County Health Department in Portland, Oregon, used AHRQ's Culture Survey in a project that covers the county's 27 patient care delivery sites, which include primary care health centers, school-based health centers, and the Department of Corrections health program, in addition to clinics serving HIV patients and those with sexually transmitted diseases and tuberculosis. The Corrections Health Quality Improvement Committee has begun working with its management team to identify, prioritize, and initiate performance improvement activities in response to the survey data.

Additional information on the Culture Survey and Database can be accessed at

Recent Research Findings on Patient Safety and the Quality of Health Care

  • An AHRQ-supported study found that wrong-site surgery is extremely rare, and major injury related to it is even more rare. A wrong-site surgery serious enough to result in a report to insurance risk managers or a lawsuit could be expected to occur approximately once every 5 to 10 years at a single large hospital. Between 1985 and 2004, the number of wrong-site surgeries conducted on limbs or organs other than the spine occurred once in every 112,994 operations.
  • A nationwide study found that 83.6 percent of interns reported work hours that did not comply with the Accreditation Council for Graduate Medical Education standards during at least 1 month in the year (July 2003 through May 2004) following implementation. About 67 percent of interns reported working shifts in excess of 30 consecutive hours. Averaged over 4 weeks, 43 percent of interns reported working more than 80 hours a week, and 43.7 percent reported not having 1 day in 7 free from work duties.
  • More than one-fourth (27 percent) of 502 critical care nurses reported making at least 1 error, and more than one-third (38 percent) reported making at least 1 near-error over the course of 28-days. The risk for making an error almost doubled when the nurses worked 12.5 or more consecutive hours. Working more than 40 hours per week increased both errors and near-errors. Almost two-thirds of the critical care nurses struggled to stay awake at least once during the study period, and 20 percent fell asleep at least once during their work shift. The risk of falling asleep at work almost doubled when shifts exceeded 8 hours and more than doubled when shifts were longer than 12 hours.

Close Call Reporting System Reports Medical Errors That Are Corrected Before Reaching the Patient

The Close Call Reporting System (CCRS), a patient safety and quality assurance mechanism developed by the University of Texas Center of Excellence for Patient Safety Research and Practice, is currently being used by nine hospitals in Texas and one hospital in New York. Developed through an AHRQ grant, CCRS is a voluntary and anonymous tool designed to gather information about "close calls," which are situations that could have resulted in an accident, injury, or illness, but did not either because of timely intervention or by chance. The system is based on an error reporting system used in commercial aviation, the Aviation Safety Action Program.

Through April 2006, 2,750 close calls have been reported via CCRS, and 5 close call alerts have been sent to participating hospitals, the Food and Drug Administration, and the United States Pharmacopeia regarding close calls related to labeling and packaging of medications. Participating hospitals are using the data to inform and guide their own quality improvement efforts.

AHRQ WebM&M Features Cases of Medical Errors and Perspectives on Patient Safety

AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is a popular online journal and forum on patient safety and health care quality. This site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety, perspectives on safety, and forums for online discussion. Continuing medical education (CME) and continuing education units (CEU) credit are available.

WebM&M can be accessed at

AHRQ-supported Research Influences Revisions to Health Canada's Process for Approving Names for Drugs

Research conducted by Bruce Lambert, Ph.D., Department of Pharmacy Administration at the University of Illinois at Chicago, focused on how auditory perception of sound-alike names can lead to medication errors. Dr. Lambert showed how similarity increases the risk of drug confusion errors and how errors occur in visual perception, auditory perception, and short-term memory. The information and discussions significantly contributed to Health Canada's policy recommendations. Under the new premarketing policy, Canadian drug manufacturers will now be required to submit a name analysis for new products to demonstrate that the proposed name is not similar to other product names. The new process is expected to avoid confusion between products, reduce the likelihood of medication mix-ups, and improve patient safety in the context of day-to-day use of products.

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Health Information Technology to Improve Patient Safety and Quality

AHRQ's $166 million health IT initiative funds more than 100 projects throughout the nation, in settings ranging from large health plans and hospitals to small practices, including rural and inner city communities. As leaders of these projects plan and implement various health IT products, they provide a clinic-level window on the pitfalls and opportunities that others will face. AHRQ will synthesize these experiences to create useful findings and tools. The projects also will measure actual benefits from AHRQ's health IT projects, providing evidence for the business case for health IT adoption.

National Resource Center for Health Information Technology

As part of the health IT initiative, AHRQ created the AHRQ National Resource Center for Health Information Technology (the National Resource Center) to help the health care community make the leap into the Information Age. In addition to providing technical assistance, the National Resource Center shares new knowledge and findings that have the potential to transform everyday clinical practice. AHRQ's National Resource Center is committed to advancing our national goal of modernizing health care through the best and most effective use of health IT.

Components of the online National Resource Center include:

  • Health Costs and Benefits Database Project, a searchable database that contains hundreds of studies and articles on the costs, benefits, and barriers related to health IT implementation.
  • Initiatives for Change, which highlights innovative approaches to improving health care quality and safety through health IT. Current features include an overview on health information exchange, details on the Connecting for Health Common Framework (a small set of nationally uniform technical and policy guidelines for health care organizations that share a big objective, that of rapid attainment of widespread information-sharing in support of modern health care practice), and a profile of the Indiana Network for Patient Care (an executive summary that highlights the findings from a pending white paper describing in detail the architecture and development of a successful regional health information exchange.
  • The Knowledge Library, with links to more than 6,000 health IT tools, best practices, and published evidence.

For more information on the National Resource Center and AHRQ's health IT initiative, go to

Integrating Health IT Improves Communication and Reduces Costs in a Nursing Facility

Christian Home and Rehabilitation Center, a skilled nursing facility in rural Wisconsin, implemented findings from an AHRQ-funded project. The project, "Real-time Optimal Care Plans for Nursing Home Quality Improvement," demonstrated the value of integrating standardized documentation and timely feedback reports in the facility by simplifying and reducing the number of forms used to document care by at least half and, in some cases, by as much as 70 percent. Resident information related to activities of daily living—such as bathing, eating, toileting, incontinence episodes, and dressing, as well as behaviors and weight loss—is located in one place and used to generate reports that are provided to the caregivers each week. The incontinence reports led to increased savings at the facility. By reviewing the reports, urinary tract infections were caught before they became medical issues. A reduction in the incidence of pressure ulcers translated to a savings of approximately $26,000 in the first year of full implementation.

Annual Patient Safety and Health Information Technology Conference

AHRQ sponsored the 2006 Annual Patient Safety and Health Information Technology Conference which brought together the Nation's leading innovators and implementers of on-the-ground solutions for improving health care safety and quality. Nearly 700 people attended.

The conference focused on how AHRQ-funded patient safety and health IT projects across the country are:

  • Implementing new interventions and technologies that improve care.
  • Measuring and managing innovations in everyday clinical practice that reduce medical errors.
  • Advancing community health through regional health information exchange.
  • Creating a culture of safety across various health care settings.

Recent Research Findings on Health IT

  • Computerized alerts can substantially reduce inappropriate drug prescribing for the elderly for two drug classes: long-acting benzodiazepines and tertiary amine tricyclic antidepressants (TCAs), which can cause problems such as daytime sedation and falls. Besides noting the inappropriate prescription, the alerts also suggest alternatives, such as shorter-acting and less-sedating benzodazepines and secondary amine TCAs or other medications such as buspirone. In this study, the alerts led to a 22 percent decline in inappropriate or nonpreferred prescribing from these two drug classes compared with the month prior to the drug-specific alerts. This reduction was sustained over a 2-year post-alert period and was driven primarily by decreased dispensing of nonpreferred TCAs.
  • A handheld personal digital assistant (PDA) that includes a software program to assess gastrointestinal (GI) risk factors prior to prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (which increase the risk of GI bleeding) can reduce unsafe prescribing. Physicians whose PDA software advised them to assess patient GI risk factors before prescribing NSAIDs wrote half as many unsafe prescriptions for NSAIDs as physicians whose PDA software did not include the GI risk assessment rule. The GI rule prompted physicians to assess six established risk factors for GI complications from NSAIDs (age, self-assessed health status, diagnosis of rheumatoid arthritis, steroid use, a history of GI hemorrhage or hospitalization for an ulcer, and symptoms with NSAIDs). The program also provided real-time treatment recommendations based on a patient's risk.

New Information Will Help Health Care Providers Adopt Health Information Technologies

AHRQ released the report, Costs and Benefits of Health Information Technology (AHRQ Publication No. 06-E006), a synthesis of studies that have examined the quality impact of health information technology (health IT) as well as the costs and organizational changes needed to implement health IT systems. Significant improvements in the quality of health care have occurred when utilizing health IT systems, however, these successes have occurred primarily within large health care systems that created their own health IT systems and devoted substantial commitment and resources to these efforts. Smaller medical practices and hospitals that constitute the majority of the nation's health care providers have limited technological expertise and must depend on the purchase of commercial systems. As a result, a majority of health care providers in America have not had the information they need to calculate the impact of health IT implementation on their organizations.

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