Patient Safety and Health Information Technology E-Newsletter

June 2, 2006, Issue No. 20

Quote of the Month

"One of every five medications prescribed by doctors to treat a health condition has not been approved by the FDA for that use."

—For more information on this study, proceed to items No. 3 and No. 8.

Today's Headlines:>

1. AHRQ Study Finds Computer Alerts Can Help Reduce Prescribing of Drugs That May Interact with Blood Thinners
2. AHRQ Joins the SOS Rx Coalition to Launch New Public Education Campaign on Safe Warfarin Use
3. AHRQ-Funded Study Finds Much Off-Label Prescribing
4. AHRQ Selects Members for Composite Measures Workgroup
5. Request for Proposals for Innovations Clearinghouse
6. Call for Abstracts for 2006 Critical Issues in eHealth Research Conference
7. State Privacy and Security Subcontract Opportunities Announced Under Expanded HHS Contract
8. AHRQ Audio Newscast Highlights Studies of Off-Label Prescribing, Domestic Violence, and Drugs to Treat Anemia
9. Latest Issue of AHRQ WebM&M Available Online
10. New Book on Improving Communication of Critical Test Results Now Available
11. Joint Commission Warns About Hand Gel Fire Risk
12. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  AHRQ Study Finds Computer Alerts Can Help Reduce Prescribing of Drugs That May Interact with Blood Thinners

Doctors ordered 15 percent fewer prescriptions for drugs that may interact with the blood thinner, warfarin, by using a computerized system that produces a safety alert whenever the interacting drug's name is keyed in, according to a new study supported by AHRQ's Center for Education and Research on Therapeutics and Patient Safety research programs.

Whenever a doctor in one of 15 primary care clinics used a computerized system to prescribe one of five potentially interacting medications to a patient taking warfarin—acetaminophen, non-steroidal anti-inflammatory drugs, fluconazole, metronidazole, or sulfamethoxasole—an alert on the screen warned of the potential adverse outcome and suggested an alternative medication. At the start of the study in December 2002, doctors were ordering 3,294 interacting drugs for every 10,000 patients receiving warfarin. By the time the study ended in March 2003, the rate had dropped to 2,804 for every 10,000 patients receiving warfarin.

The study, "Reducing Warfarin Medication Interaction: An Interrupted Time Series Evaluation," led by Adrianne C. Feldstein, M.D., of Kaiser Permanente's Center for Health Research, appeared in the May 8 issue of Archives of Internal Medicine. Select to access the abstract on PubMed®.

2.  AHRQ Joins the SOS Rx Coalition to Launch New Public Education Campaign on Safe Warfarin Use

The SOS Rx coalition, a group that includes the National Consumers League, AARP, AHRQ, FDA, CMS, and more than 80 other public- and private-sector groups, recently launched www.mybloodthinner.org as part of a new public education campaign to help the 4 million Americans taking prescription blood thinners to prevent stroke, blood clot formation, and other serious events.

To help in the effort, AHRQ developed a new booklet for patients called My Guide to Coumadin®/Warfarin Therapy. The easy-to-read booklet tells patients what to expect, what to watch for, and what to do while taking the blood-thinning medication. Supported by an AHRQ Partnerships for Implementing Patient Safety grant, the booklet was developed by a team led by James Levett, M.D., and his colleagues at Kirkwood Community College and the Cedar Rapids Healthcare Alliance in Iowa. Select for more information on the SOS Rx campaign and recent survey findings.

3.  AHRQ-Funded Study Finds Much Off-Label Prescribing

A new AHRQ-funded study shows that one of every five medications prescribed by doctors for the treatment of a health condition has not been approved by the FDA for that use. The study also found a lack of strong scientific support for three-quarters of the off-label drug use.

Physicians can legally prescribe approved medications for any diagnosis, even when the diagnosis is not specified on the drug's label or in the application for FDA approval. Off-label prescribing allows physicians the freedom to innovate but also raises questions about patient safety and costs, since off-label uses do not receive the same level of scientific scrutiny as approved uses. The drugs most likely to be prescribed off-label were cardiac medications, anticonvulsants, and drugs for the treatment of asthma. The off-label use of psychiatric drugs had the least scientific support.

The study, "Off-label Prescribing Among Office-Based Physicians," appeared in the May 8 issue of the Archives of Internal Medicine. Select to access the abstract on PubMed®.

4.  AHRQ Selects Members for Composite Measures Workgroup

AHRQ has selected 17 experts to serve on the AHRQ Quality Indicators Composite Measures Workgroup for its Inpatient Quality Indicators and Patient Safety Indicators. The workgroup plans to identify a composite methodology that would meet the needs of various stakeholders for public reporting. This work is expected to occur this summer; a final report will be made publicly available in the fall.

Members of the workgroup include: John Birkmeyer, M.D., University of Michigan; Bruce Boissonnault, Niagara Health Quality Coalition; John Bott, Employer Health Care Alliance Cooperative; Dale Bratzler, Ph.D., Oklahoma Foundation for Medical Quality; Sharon Cheng, MedPAC; Elizabeth Clough, Wisconsin Collaborative for Healthcare Quality; Nancy Dunton, University of Kansas, School of Nursing; John Hoerner, Hospital Industry Data Institute; David Hopkins, Pacific Business Group on Health; Gregg Meyer, M.D., Massachusetts General Physicians Organization; Elizabeth Mort, Massachusetts General; Janet Muri, National Perinatal Information Center; Vi Naylor, Georgia Hospital Association; Eric Peterson, M.D., Duke University Medical Center; Martha Radford, M.D., New York University Hospitals Center; Gulzar Shah, National Association of Health Data Organizations; and Paul Turner, Vermont Program for Quality in Health Care.

An additional 13 experts will serve as liaison members and technical advisors. Select to access the announcement, which includes the complete list of members.

5.  Request for Proposals for Innovations Clearinghouse

AHRQ is soliciting proposals for a 5-year (3 years, with one 2-year extension option) reimbursable contract to establish an Innovations Clearinghouse that will be a database-driven, Internet-accessible, public clearinghouse of innovations in health service delivery.

The Innovations Clearinghouse will facilitate collection of innovative health service practices and present them in a standardized format accompanied by expert commentary; promote their dissemination, replication, adaptation, and use; and foster innovation in the U.S. health care service industry. Select to read the Request for Proposals. Proposals are due July 25.

6.  Call for Abstracts for 2006 Critical Issues in eHealth Research Conference

Abstracts are being sought for the "Critical Issues in eHealth Research Conference: Toward Quality Patient-Centered Care" to be held on September 11-12 in Bethesda, MD. This free conference is cosponsored by AHRQ, NIH, and the Office of Disease Prevention and Health Promotion in collaboration with the American Medical Informatics Association and the Health e-Technologies Initiative.

The conference will convene scientists from government, academia, survey research and the private sector, practitioners from the private and public sectors, and students to discuss the methodological, technological, and conceptual aspects of research on patient-centered care and e-health.

7.  State Privacy and Security Subcontract Opportunities Announced Under Expanded HHS Contract

HHS announced that 22 states and territories have entered subcontracts with RTI International, Inc. to address privacy and security policy questions affecting interoperable health information exchange. Additional states are expected to sign subcontracts within the next 2 weeks. HHS' Office of the National Coordinator for Health Information Technology and AHRQ jointly manage and fund AHRQ's contract with RTI for this work.

HHS is adding more than $5.7 million to the existing contract with RTI, bringing its total value to $17.2 million. The additional funding will make it possible to fund all proposals with technical merit submitted in response to a January request for proposals. Select to access HHS' press release.

8.  AHRQ Audio Newscast Highlights Studies of Off-Label Prescribing, Domestic Violence, and Drugs to Treat Anemia

AHRQ's latest audio newscast features an interview with AHRQ-funded researcher David Radley from Dartmouth Medical School, who discusses his research on off-label prescribing in outpatient settings. The study found that about one-fifth of medicines are prescribed for off-label uses.

The 8-minute newscast also highlights statistics from a new AHRQ study about a woman's lifetime experience with domestic violence. In addition, a new study from AHRQ's Effective Health Care Program found no clinically significant difference in the effectiveness of two drugs for managing anemia in patients undergoing cancer treatment. Select to listen to the audio newscast.

If your computer has a sound card and speakers and can play MP3 audio files, you will be able to listen to the latest newscast on your computer at your convenience—according to your schedule, whenever you have time to listen. Please visit the main page of our Healthcare 411 series to access any of AHRQ's newscasts and special reports. Sign up for a free subscription to the series to receive notice of all future AHRQ podcasts automatically.

9.  Latest Issue of AHRQ WebM&M Available Online

The May 2006 issue of AHRQ WebM&M is now available online. This month, the Perspectives on Safety section highlights outpatient safety and features a piece by Rainu Kaushal, M.D., and colleagues, on patient safety for office-based anesthesia; Nancy Elder, M.D., provides an overview of safety issues in ambulatory practice.

In the Spotlight Case, a woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery does the team realize that the X-ray was not hers. The commentary, written by Elizabeth Howell, M.D., and Mark Chassin, M.D., of Mount Sinai School of Medicine, explains the ways in which many small mishaps led to the larger error of unnecessary anesthesia (and nearly a case of wrong-patient surgery). In the second case, a pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient consequently suffers severe hyperkalemia and hyperglycemia. In the third case, a nursing student administers the wrong 'cup' of medications to an elderly man, and another student discovers the error.

Commentary authors are Robert Weber, M.S., R.Ph., of the University of Pittsburgh; Mary Blegen, Ph.D., R.N., of the University of California, San Francisco; and Ginette Pepper, Ph.D., R.N., of the University of Utah. A Spotlight slide presentation is available for download, as always, and you can receive CME, 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.

10.  New Book on Improving Communication of Critical Test Results Now Available

Getting Results: Reliably Communicating and Acting on Critical Test Results, a new book that presents practical ideas and authoritative lessons on how to determine which test results and values require timely and reliable communication, is available for sale from the Joint Commission on Accreditation of Healthcare Organizations.

The book includes articles from the February 2005 issue of the Joint Commission Journal on Quality and Patient Safety, plus new case studies and articles indicating what hospitals, medical centers, and outpatient practices are doing to improve communication of critical test results. The book was edited by AHRQ grantee Gordon D. Schiff, M.D., Director, Clinical Quality Research and Improvement, and Senior Attending Physician, Department of Medicine, at the John H. Stroger Jr. Hospital of Cook County, and is available for purchase from the Joint Commission's online catalog.

11.  Joint Commission Warns About Hand Gel Fire Risk

Although alcohol-based gel hand sanitizer dispensers are permitted in health care facilities, the Joint Commission recently issued an advisory about a potential fire risk when using alcohol-based hand rubs. A recent report has shown that these products may cause burns if workers do not allow remnants of the gel to fully evaporate before touching any potential sources of electrostatic shock or fire.

The Joint Commission recommends that facilities reduce potential electrostatic discharge in the environment by reviewing humidification strategies and other environmental concerns. Select to read the Joint Commission's advisory.

12.  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.

Scott LD, Rogers AE, Hwang WT, et al. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care 2006 Jan;15(1):30-7. Select to access the abstract on PubMed®.

Shah NR, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006. Jan-Feb;13(1):5-11. Select to access the abstract.

Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance on patient safety indicators. Med Care Res Rev 2006 Feb;63(1):29-57. Select to access the abstract.

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Current as of June 2006

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Internet Citation:

Patient Safety E-Newsletter. June 2, 2006, Issue No. 20. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews20.htm

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