Patient Safety and Health Information Technology E-Newsletter

August 11, 2006, Issue No. 22

Quote of the Month

"Medication errors that harm hospitalized children are common, and the drugs involved in many of these mistakes tend to be some of the oldest and most commonly used painkillers and antibiotics."

—Rodney W. Hicks, M.P.A., M.S.N., of the United States Pharmacopeia Center for the Advancement of Patient Safety, in the August 2006 issue of the Journal of Pediatric Nursing.

For more information on Hicks' study, select Item No. 1.

Today's Headlines:

1. AHRQ Study Finds Harmful Medication Errors in Children
2. AHRQ Releases Evaluation of Military Medical Team Training Programs
3. AHRQ Patient Safety Grantee Ellen Flink and Her Colleagues Work To Improve Adverse Event Reporting Within Hospitals
4. Institute of Medicine Releases Report on Preventing Medication Errors
5. New Regulations To Facilitate Adoption of Health Information Technology
6. New Statistical Brief Shows Potentially Preventable Hospitalizations Are Common Among Blacks and Hispanics
7. ISMP and FDA Campaign Aims To Eliminate Use of Error-Prone Medical Abbreviations
8. AHRQ Selects Members for Quality Indicators Risk Adjustment Workgroup
9. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ Study Finds Harmful Medication Errors in Children

Medication errors that harm hospitalized children are common, and the drugs involved in many of these mistakes tend to be some of the oldest and most commonly used painkillers and antibiotics, according to a new AHRQ-supported study.

Published in the August 2006 issue of the Journal of Pediatric Nursing, the study found that from 1999 to 2003, 19,350 pediatric medication error reports were received by the U.S. Pharmacopeia MEDMARX reporting system from 160 U.S. hospitals and health centers. In 4.2 percent of these cases, the records show that medication errors caused harm to the patient. Eleven of the 242 different medications involved in harmful outcomes were involved in more than one-third of the errors. Older, commonly used drugs were also associated with a considerable number of harmful errors. Wrong dosing and omission errors were common and were associated with therapeutic classes such as opioid analgesics, antimicrobials, and antidiabetic agents.

The study was conducted by Rodney W. Hicks, M.P.A., M.S.N., and his colleagues at the United States Pharmacopeia Center for the Advancement of Patient Safety, under a partnership with the AHRQ-sponsored University of North Carolina Center for Education and Research on Therapeutics in Chapel Hill. Select to read the abstract of the study.

2.  AHRQ Releases Evaluation of Military Medical Team Training Programs

AHRQ released a report evaluating three medical team training programs designed for military hospitals. Prepared by the American Institutes of Research at the request of AHRQ and the Department of Defense's (DoD) TRICARE program, the report is part of an ongoing collaborative effort between AHRQ and DoD to promote patient safety based on principles of good communication and teamwork.

The programs reviewed—MedTeams™, Medical Team Management, and Dynamics Outcomes Management©—are adapted from the U.S. Army's Crew Resource Management training system. Investigators reviewed student and instructor guides and other materials, attended classes, and collected pre- and post-training information on the students' expectations and post-training reactions to the programs. They found that the programs shared several desirable characteristics, notably their use of active learning techniques and interdisciplinary approaches. They suggested several needed improvements, including comprehensive pretraining needs analysis, opportunities for structured practice and feedback, and strategies for post-training reinforcement.

3.  AHRQ Patient Safety Grantee Ellen Flink and Her Colleagues Work To Improve Adverse Event Reporting Within Hospitals

AHRQ patient safety researcher Ellen Flink, M.B.A., Director of Research in Patient Safety and Quality Initiatives in the Office of Health Systems Management for the New York State Department of Health, and a team of multidisciplinary investigators have been examining ways to improve the reporting of medical errors within hospitals and develop interventions that could improve patient safety. With AHRQ's support, Ms. Flink and her colleagues worked with the New York Patient Occurrence Reporting and Tracking System to develop interventions for three common adverse events: new pulmonary embolism/deep vein thrombosis; peri-operative acute myocardial infarction (unrelated to cardiac procedure); and postoperative wound infections.

To learn more about Ellen Flink's research, access the following abstract examining the connection between organizational factors, medical errors, and patient safety; and, several articles that appear in AHRQ's Advances in Patient Safety: From Research to Implementation—a four-volume set of 140 peer-reviewed articles that represent what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last 5 years.

4.  Institute of Medicine Releases Report on Preventing Medication Errors

Preventing Medication Errors, a report issued by the Institute of Medicine (IOM) on July 20, puts forth a national agenda for reducing medication errors based on estimates of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies. The report finds an average of 1.5 million medication errors occur every year, costing the Nation an estimated $3.5 billion annually.

The report also outlines a comprehensive approach to decreasing the prevalence of these errors. This approach will require changes from doctors, nurses, pharmacists, and others in the health care industry including, the FDA and other government agencies, hospitals and other health-care organizations, and patients. Select to access the IOM press release and to order the report.

5.  New Regulations To Facilitate Adoption of Health Information Technology

HHS Secretary Mike Leavitt announced last week the final regulations that will support physician adoption of electronic prescribing and electronic health records technology. The final rules create new exceptions and safe harbors to two key Federal fraud and abuse laws for arrangements involving the donation of certain electronic health information technology and services.

Select to access the HHS press release; and to access the final rules, "Medicare and State Health Care Programs: Fraud and Abuse; Safe Harbors for Certain Electronic Prescribing and Electronic Health Records Arrangements Under the Anti-Kickback Statute," available in the August 8 Federal Register.

6.  New Statistical Brief Shows Potentially Preventable Hospitalizations Are Common Among Blacks and Hispanics

According to a recent AHRQ report, blacks are almost five times more likely than non-Hispanic whites, and Hispanics are almost four times more likely than non-Hispanic whites, to be hospitalized for uncontrolled diabetes and other conditions that good quality outpatient medical care can often prevent or control. This statistical brief is produced by AHRQ's Healthcare Cost and Utilization Project (HCUP).

The statistical briefs are useful to a wide variety of audiences, including policy analysts, decisionmakers, media personnel, and others in need of summary facts and figures on current health care issues. For more information, access the report, HCUP Statistical Brief No. 10: Racial and Ethnic Disparities in Potentially Preventable Hospitalizations, 2003.

7.  ISMP and FDA Campaign Aims To Eliminate Use of Error-Prone Medical Abbreviations

The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA) recently launched an educational campaign to help eliminate the use of ambiguous and error-prone medical abbreviations, symbols, and dose designations-a practice that contributes to the more than 7,000 medication errors each year, according to the IOM.

ISMP and FDA recommend that ISMP's list of error-prone abbreviations, symbols, and dose designations (PDF Help) be referenced whenever and wherever medical information is being communicated. The campaign seeks to educate health care professionals and students, medical writers, and the pharmaceutical industry, through a variety of targeted educational materials, including a patient safety video and an online toolkit. Select to access the toolkit and to learn more.

8.  AHRQ Selects Members for Quality Indicators Risk Adjustment Workgroup

AHRQ has selected nine experts to serve on the AHRQ Quality Indicators (QI) Risk Adjustment Workgroup that will evaluate risk-adjustment and hierarchical modeling methodologies.

The selectees:

• Dan R. Berlowitz, Bedford Veterans Affairs Medical Center, Bedford, MA.
• Cheryl L. Damberg, Pacific Business Group on Health, Santa Monica, CA.
• R. Adams Dudley, Institute for Health Policy Studies, University of Califorinia, San Francisco.
• Marc Nathan Elliott, RAND Corporation, Santa Monica, CA.
• Byron J. Gajewski, University of Kansas Medical Center, Kansas City, KS.
• Andrew L. Kosseff, SSM Health Care, Madison, WI.
• John Muldoon, National Association of Children's Hospitals and Related Institutions, Alexandria, VA.
• Sharon-Lise Teresa Normand, Department of Health Care Policy Harvard Medical School, Boston, MA.
• Richard J. Snow, Doctors Hospital, OhioHealth, Worthington, Ohio.

An additional six experts will serve as liaison members, and another five will serve as technical advisors. The workgroup will meet this summer to evaluate appropriate technical and methodological approaches and also will discuss and suggest strategies as to what risk adjustment approach(s) would best fit AHRQ QI user needs. A final report will be made publicly available in the fall. Select to access the announcement.

9.  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.

Cina JL, Gandhi TK, Churchill W, Fanikos J, McCrea M, Mitton P, Rothschild JM, Featherstone E, Keohane C, Bates DW, Poon EG. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf 2006 Feb;32(2):73-80. Select to access the abstract in PubMed®.

Judge J, Field TS, DeFlorio M, Laprino J, Auger J, Rochon P, Bates DW, Gurwitz JH. Prescribers' responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc 2006 Jul-Aug;13(4):385-90. Select to access the abstract in PubMed®.

Kaushal R, Jha AK, Franz C, Glaser J, Shetty KD, Jaggi T, Middleton B, Kuperman GJ, Khorasani R, Tanasijevic M, Bates DW. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc 2006 May-Jun;13(3):261-6. Select to access the abstract in PubMed®.

Leape LL, Rogers G, Hanna D, Griswold P, Federico F, Fenn CA, Bates DW, Kirle L, Clarridge BR. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Health Care 2006 Aug;15(4):289-95. Select to access the abstract in PubMed®.

Needleman J, Buerhaus PI, Stewart M, Zelevinsky K, Mattke S. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood) 2006 Jan-Feb;25(1):204-11. Select to access the abstract in PubMed®.

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Current as of August 2006

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Internet Citation:

Patient Safety E-Newsletter. August 11, 2006, Issue No. 22. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews22.htm

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