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Patient Safety E-Newsletter

October 3, 2007, Issue No. 37

Patient Safety Quote of the Month

"Our goal is to have better health at lower cost for all Americans."

—HHS Secretary Mike Leavitt, addressing the AHRQ annual conference on September 28.

For more information on the Department of Health & Human Services's (HHS) value-driven health care initiative and the Agency for Healthcare Research and Quality's (AHRQ) recent annual meeting, select Item No. 1.

Today's Headlines:

1. HHS Secretary Leavitt Announces Plan to Share Medicare Physician Performance Measurement Results Through Local Value Exchanges at AHRQ's 2007 Annual Conference
2. AHRQ Awards More Than $11 Million to Iowa Foundation for Medical Care to Serve as Privacy Protection Center for Patient Safety Organizations
3. Patient Records Show Poor Documentation of Risks and Education When Interacting Drugs are Co-Prescribed
4. 2007 John M. Eisenberg Patient Safety and Quality Award Recipients Announced
5. New Patient Safety Training Tool Now Available
6. AHRQ's Free Notification Service Brings News and Information to Your E-mail Inbox
7. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1. HHS Secretary Leavitt Announces Plan to Share Medicare Physician Performance Measurement Results Through Local Value Exchanges at AHRQ's 2007 Annual Conference

Last week, HHS Secretary Mike Leavitt delivered the keynote address to approximately 1,200 attendees at AHRQ's largest-ever annual conference where he announced a plan to make Medicare performance measurement information available at the community level. As part of this initiative, AHRQ is developing a process to recognize communities—known as Value Exchanges—that support the vision of fostering health care reform at the local level by engaging providers, consumers, and other key stakeholders.

Attendees of the conference also heard from AHRQ researchers, including patient safety and health information techonology (IT) researchers, policymakers, and other stakeholders.

On September 26, presentations featured various topics on AHRQ's health information technology and patient safety research activities including aggregation of patient safety data, e-Prescribing, strategies and tools for patient safety and quality improvement, implementation of health IT developed to improve quality of care for children, medication management safety, patient safety culture, and patient-centered health IT.

On September 27-28, sessions were organized into the following topic areas, with an emphasis on implementation of research findings to change health care practice and policy: data sharing, health care reporting, and the public trust, medication management and safety, strategies and tools for quality/safety improvement, value and sustainability in health IT, improving health care decisionmaking, system design and organizational change, and HHS' value-driven health care initiative.

Select to access the HHS fact sheet for more information about the Medicare performance measurement announcement. Select to read the remarks delivered by Secretary Leavitt at the AHRQ conference.

2. AHRQ Awards More Than $11 Million to Iowa Foundation for Medical Care to Serve as Privacy Protection Center for Patient Safety Organizations

AHRQ has awarded more than $11 million to the Iowa Foundation for Medical Care, the state's Medicare Quality Improvement Organization, to serve as the Patient Safety Organization (PSO) Privacy Protection Center. The focus of the 3-year contract will be to develop an infrastructure that collects various types of data on patient safety issues; manages secure, confidential, non-identifiable information; and provides technical assistance to PSOs.

The Patient Safety and Quality Improvement Act passed by Congress in 2005 established PSOs to collect, aggregate, and analyze confidential information reported by health care providers. As a result, PSOs will be able to identify patterns of failures and propose measures to eliminate patient safety risks and hazards.

Select for more information on the Patient Safety and Quality Improvement Act of 2005 and for information on the contract.

3. Patient Records Show Poor Documentation of Risks and Education When Interacting Drugs are Co-Prescribed

While medical records often document concomitant use of select interacting drugs, they poorly document the risks of patient education associated with simultaneous use of such drugs, according to a recent AHRQ-funded study. In fact, 20 percent of patients using warfarin and NSAIDs, 32 percent using digoxin and verapamil/diltiazem, and 36 percent using lovastatin/simvastatin and diltiazen/verapamil concomitantly had no acknowledgement of associated risks, patient education, or a relevant clinical management change.

According to researchers, such omissions call into question the adequacy of medical record documentation, which can have health and legal implications. Appropriate documentation validates that a patient was informed and accepted the alternative risks as well as the potential benefits, associated with combination therapy.

Results of the study, led by Jennifer Elston Lafata, Ph.D., a research scientist at the Henry Ford Health System's Center for Health Services Research, Detroit, appear in "What do medical records tell us about potentially harmful co-prescribing?" published in the July issue of the Joint Commission Journal on Quality and Patient Safety. Select to review an abstract of the study.

4. 2007 John M. Eisenberg Patient Safety and Quality Award Recipients Announced

The National Quality Forum (NQF) and the Joint Commission have announced the 2007 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards.

The honorees, by award category:

Individual Achievement—Flaura Koplin Winston, M.D., Ph.D., the Children's Hospital of Philadelphia and the University of Pennsylvania, and Darrell A. Campbell, Jr., M.D., University of Michigan Hospitals and Health Centers, Ann Arbor.
Research—Eric J. Thomas M.D., M.P.H., The University of Texas Health Science Center, Houston.
Innovation in Patient Safety and Quality at a National or Regional Level—Beth Israel Deaconess Medical Center, Harvard Medical School, Boston.
Innovation in Patient Safety and Quality at the Local or Organizational Level—Evanston Northwestern Healthcare, Evanston, IL.

Select to read NQF's press release (PDF Help).

5. New Patient Safety Training Tool Now Available

A new tool, sponsored by AHRQ and the Department of Veterans Affairs' National Center for Patient Safety, features a self-paced, modular approach to training individuals involved in patient safety activities at the institutional level.

The DVD, "Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety," presents eight modules that provide processes and tools that can be used to develop a systems-based approach to patient safety, including: investigation of medical errors and their root causes; identification, implementation, and evaluation of system-level interventions to address patient safety concerns; and, steps necessary to promote a culture of safety within a hospital or other health care facility. Each module includes one to five separate lessons, as well as tools and other resources that can be downloaded from the DVD. Select to order the DVD.

6. AHRQ's Free Notification Service Brings News and Information to Your E-mail Inbox

AHRQ has recently launched a free user-friendly service on its Web site that allows subscribers to receive automatic E-mail notices when there is new information about the Agency, its publications, data, and research results. AHRQ's customizable service offers up to 44 subscription items in 10 categories, so subscribers will receive notices only on topics in which they are interested.

As a current subscriber to AHRQ's Patient Safety E-Newsletter, you will continue to receive the newsletter and also may signup for additional information through this service. You will be able to access and update your account information at any time. To find a link to the new service, look for the red envelope icon under the home page banner and select "E-mail Updates" or go to: https://subscriptions.ahrq.gov/service/multi_subscribe.html?code=USAHRQ

Subscribers need only sign up for the service once; however, if their interests or E-mail addresses change, they will be able to access and update their account information at any time.

7. 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.

Buscemi N, Vandermeer B, Friesen C, et al. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med 2007 Sep;22(9):1335-50. Select to access the abstract in PubMed®.

Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J 2007 Oct;24(10):716-8. Select to access the abstract in PubMed®.

Sinopoli DJ, Needham DM, Thompson DA, et al. Intensive care unit safety incidents for medical versus surgical patients: A prospective multicenter study. J Crit Care 2007 Sep;22(3):177-83. Select to access the abstract in PubMed®.

The Patient Safety E-newsletter is archived online at http:www.ahrq.gov/news/ptsnews.htm.

AHRQ's Patient Safety E-Newsletter Contact:

Please address comments and questions to Salina Prasad atSalina.Prasad@ahrq.hhs.gov or (301) 427-1864.

Current as of October 2007

Internet Citation:

Patient Safety E-Newsletter. October 3, 2007, Issue No. 37. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews37.htm