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Patient Safety E-Newsletter

January 12, 2007, Issue No. 27

Patient Safety Message of the Month

"Academic medicine is failing both doctors and patients by routinely requiring exhausted doctors to work marathon 30-hour shifts. The human brain simply does not perform reliably for 30 consecutive hours without sleep."

—Charles A. Czeisler, Ph.D., M.D., Director, Division of Sleep Medicine, Brigham and Women's Hospital.

For more information on the study by Dr. Czeisler and his colleagues at Brigham and Women's Hospital, select Item No. 2.

Today's Headlines

1. AHRQ Issues Fourth Annual National Reports on Health Care Quality and Disparities
2. Physicians' Extended Work Shifts Associated With Increased Risk of Medical Errors That Harm Patients
3. AHRQ To Fund Studies on Safety and Quality in Ambulatory Care Settings
4. New Study Finds Intervention Lowers Catheter-Related Bloodstream Infections in Hospital ICUs
5. AHRQ's Recent Healthcare 411 Audio Podcast Programs Highlight Patient Safety Findings
6. Latest issue of AHRQ WebM&M Available Online
7. Do You Know How AHRQ's Research Is Being Used?
8. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1. AHRQ Issues Fourth Annual National Reports on Health Care Quality and Disparities

Two new annual reports released yesterday by the Agency for Healthcare Research and Quality (AHRQ) show that health care providers could do more to help Americans avoid disease or serious complications but that significant gains have been made in hospital care. The 2006 National Healthcare Quality Report and National Healthcare Disparities Report both found that the use of proven prevention strategies lags behind other gains in health care. For example, only 52 percent of adults reported receiving recommended colorectal cancer screenings, and fewer than half of obese adults reported being counseled about diet by a health care professional.

Meanwhile, the Quality Report found that hospital care for heart attack patients improved 15 percent and for pneumonia patients 11.7 percent. AHRQ attributes these significant improvements in hospital care in part to initiatives sponsored by the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance. The Disparities Report documented how Hispanics, blacks, the poor, and other groups are less likely to receive quality care.

The reports represent the most comprehensive annual analyses of the nation's health care system. Select for the National Healthcare Quality Report and the National Healthcare Disparities Report. Print copies of the reports also can be obtained by calling 1-800-358-9295 or by sending an E-mail to ahrqpubs@ahrq.hhs.gov.

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2. Physicians' Extended Work Shifts Associated With Increased Risk of Medical Errors That Harm Patients

First-year doctors-in-training reported that working five extra-long shift-of 24 hours or more at a time without rest-per month led to a 300 percent increase in their chances of making a fatigue-related preventable adverse event that contributed to the death of a patient.

Preventable adverse events are defined as medical errors that cause harm to a patient. Interns were three times more likely to report at least one fatigue-related preventable adverse event during months in which they worked between one and four extended-duration shifts. In months in which they worked more than five extended-duration shifts, the doctors were seven times more likely to report at least one fatigue-related preventable adverse event and were also more likely to fall asleep during lectures, rounds, and clinical activities including surgery.

The study, funded by AHRQ and the Centers for Disease Control and Prevention's (CDC) National Institute for Occupational Safety and Health, was published on December 12, 2006, in the online journal PLoS Medicine. Select to access our press release and an abstract of the study, "Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures."

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3. AHRQ To Fund Studies on Safety and Quality in Ambulatory Care Settings

AHRQ will fund up to $26 million in new research projects to improve the safety and quality of ambulatory health care. Four separate funding opportunity announcements under AHRQ's new Ambulatory Safety and Quality grant program were published in the December 5 NIH Guide.

Ambulatory Safety and Quality Program: Improving Quality through Clinician Use of Health IT will provide $9 million to fund 20 to 40 new projects intended to support the development of health IT to assist clinicians, practices, and systems improve the quality and safety of care delivery and medication management. The application deadline is February 14.
Ambulatory Safety and Quality Program: Enabling Quality Measurement through Health IT will provide $6.8 million to fund 12 to 24 new projects to support the development of health information technology (IT) to assist clinicians, practices, and systems measure the quality and safety of care in ambulatory care settings. Note: This funding opportunity notes that AHRQ intends to award at least $1.8 million from patient safety funds that specifically focus on development and implementation of quality and patient safety measures that do not directly involve health IT. The application deadline is February 13.
Ambulatory Care Patient Safety Proactive Risk Assessment will provide $4 million to support 20 projects to support proactive risk assessments and model risks and known hazards that threaten patient safety. The application deadline is February 16.
Ambulatory Safety and Quality: Enabling Patient-Centered Care through Health IT will provide $6 million to fund 15 to 20 demonstration projects that will explore the use of health IT and related policies and practices to establish and enhance patient-centered care. The application deadline is February 15.

Select for more information on all of these funding announcements and instructions on electronic submission of applications.

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4. New Study Finds Intervention Lowers Catheter-Related Bloodstream Infections in Hospital ICUs

An evidenced-based intervention at 103 intensive care units (ICUs) in Michigan to reduce the incidence of catheter-related bloodstream infections substantially lowered the rate of these infections—results that continued throughout an 18-month period according to a new study funded by AHRQ and published in the December 28, 2006, New England Journal of Medicine. Central venous catheters may cause an estimated 80,000 catheter-related bloodstream infections and, consequently, up to 28,000 deaths among patients in ICUs.

As part of a larger patient safety initiative under way in Michigan hospital ICUs, researchers from Johns Hopkins School of Medicine, Baltimore, and the University of Michigan, Ann Arbor, targeted clinicians' use of five evidence-based procedures recommended by the Centers for Disease Control and Prevention (CDC) as having the greatest effect on the rate of catheter-related bloodstream infections and the lowest barriers to implementation. CDC's recommended procedures are: hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site, and removing unnecessary catheters.

Researchers reported that the overall median rate of catheter-related bloodstream infections decreased from 2.7 infections per 1,000 catheter days at baseline to 0, at 0 to 3 months following the intervention. The initial drop was sustained at 0 during 18 months of follow-up. A significant decrease in the rate of bloodstream infections was seen in teaching and non-teaching hospitals and in small and large hospitals, researchers reported.

Select to access an abstract of the study, "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU."

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5. AHRQ's Recent Healthcare 411 Audio Podcast Programs Highlight Patient Safety Findings

A recent edition of AHRQ's Healthcare 411 program features Charles Czeisler, M.D. and Laura Barger, Ph.D., explaining their PLoS Medicine study findings that interns who work five or more extra-long hospital shifts in a month are prone to making serious medical errors. The story also includes comments from AHRQ Director Carolyn M. Clancy, M.D. The newscast also announces that R01 grant applications now require electronic submission. Select to access this 9-minute audio program.

Another recent edition of Healthcare 411 featured a story about the release of TeamSTEPPS, a new team training and implementation toolkit designed to help prevent medical errors through effective communication and teamwork skills. The story also includes comments from Dr. Clancy and the Department of Defense's David Tornberg, M.D., Assistant Secretary of Defense for Health Affairs. Select to access this 7-minute audio program.

You can listen to these audio programs 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 any case, you will be able to listen at your convenience. To access any of AHRQ's newscasts and special reports or to sign up for a free subscription to the series to receive notice of all future AHRQ podcasts, visit our Healthcare 411 series Web site.

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6. Latest issue of AHRQ WebM&M Available Online

The December issue of AHRQ WebM&M is available online. This month, the Perspectives on Safety section looks at the culture of safety. Timothy J. Hoff, Ph.D., an organizational management expert at the State University of New York at Albany, offers his perspective on establishing a safety culture, particularly in teaching settings. An interview with J. Bryan Sexton, Ph.D., at Johns Hopkins in Baltimore is on efforts to measure and improve safety culture.

In the first Spotlight Case, a woman with multiple medical problems is diagnosed with heparin-induced thrombocytopenia (HIT), but is mistakenly exposed to heparin flushes during dialysis. The commentary, authored by Patrick F. Fogarty, M.D., of the University of California, San Francisco, discusses the strategies to prevent the risks of morbidity and mortality in patients with HIT. It also highlights the point that not all dangerous medications are found only in the pharmacy. In the second case, a young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again. In the third case, a man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were mislabeled with another patient's name. Commentary authors are John M. Oldham, M.D., of the Medical University of South Carolina and Michael Astion, M.D., Ph.D. of the University of Washington in Seattle. 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.

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7. Do You Know How AHRQ's Research Is Being Used?

We are always looking for ways in which AHRQ-funded research, products, and tools have changed people's lives, influenced clinical practice, improved policies, and affected patient outcomes. These impact case studies describe AHRQ research findings in action. These case studies are used in testimony, budget documents, and speeches.

We would like to know if you are aware of any impact your AHRQ-funded research has had on health care policy, clinical practice, or patient outcomes. Contact AHRQ's Impact Case Studies Program at Jane.Steele@ahrq.hhs.gov or (301) 427-1244 with your impact stories.

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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.

Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety culture vary across the intensive care units of a single institution. Crit Care Med 2007 Jan;35(1):165-76. Select to access the abstract in PubMed®.

Maidment ID, Lelliott P, Paton C. Medication errors in mental healthcare: a systematic review. Qual Saf Health Care 2006 Dec;15(6):409-11. Select to access the abstract in PubMed®.

Raab SS, Stone CH, Wojcik EM, et al. Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy. Am J Clin Pathol 2006 Dec;126(6):836-42. Select to access the abstract in PubMed®.

Schade CP, Hannah K, Ruddick P, et al. Improving self-reporting of adverse drug events in a West Virginia hospital. Am J Med Qual 2006 Sept-Oct;21(5);335-41. Select to access the abstract in PubMed®.

Voeffray M, Pannatier A, Stupp R, et al. Effect of computerization on the quality and safety of chemotherapy prescription. Qual Saf Health Care 2006 Dec;15(6):418-21. Select to access the abstract in PubMed®.

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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.

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Current as of January 2007

Internet Citation:

Patient Safety E-Newsletter. January 12, 2007, Issue No. 27. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews27.htm