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Patient Safety and Health Information Technology E-Newsletter

October 6, 2006, Issue No. 24

Quote of the Month

"As practitioners on the 'sharp edge' of patient care, you can serve as drivers of this evolution—as indispensable leaders in building a culture of quality for your hospitals, for your patients, and for your future at the forefront of patient care in America."

—Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality (AHRQ), from her Sept. 25 keynote address to the Nurse Alliance of the Service Employees International Union Networking Conference on Quality.

For more on Dr. Clancy's remarks, select Item No. 3.

Today's Headlines:

  1. Medicare Pays Hospitals $300 Million a Year for Treating Adverse Events, but Payments Cover Less than One-Third of Additional Costs
  2. New Study Examines Teamwork Climate in Labor and Delivery Units
  3. AHRQ Director Gives Keynote Address at Nurse Alliance of SEIU on Quality
  4. AHRQ Director Participates in Remaking American Medicine™—PBS Series on Health Care
  5. Kaiser and AHRQ Medical Errors Survey Released
  6. Latest AHRQ Healthcare 411 Audio Newscast Features Stories on Medical Errors
  7. Latest Issue of AHRQ WebM&M Available Online
  8. New Handbook on Current Concepts and Methods of Human Factors and Ergonomics Now Available
  9. NQF and JCAHO Announce the 2006 John M. Eisenberg Patient Safety and Quality Awards
  10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  Medicare Pays Hospitals $300 Million a Year for Treating Adverse Events, but Payments Cover Less than One-Third of Additional Costs

Despite a growing emphasis on preventing medical errors and paying providers for high-quality care, Medicare pays hospitals a substantial amount of money for adverse events that occur during hospitalization, according to a new AHRQ study published in the September/October issue of Health Affairs. The study found that Medicare paid an additional $300 million per year, or 0.3 percent of annual Medicare hospital spending, for five types of adverse events in hospitals in 2003. However, these extra payments covered less than one-third of the additional costs that hospitals incurred in treating these adverse events.

Under Medicare's hospital payment system, hospitals are reimbursed a set amount for a patient's condition or Diagnosis-Related Group (DRG), determined at admission. The study by AHRQ's Chunliu Zhan, M.D., Ph.D., found the DRG changed only in a small number of cases. For example, the DRG changed in only 1 percent of cases where a patient had post-operative bloodstream infections and 10 percent for patients who experienced post-operative bleeding. Even if the DRG doesn't change, adverse events may result in additional costs, for example if the patient needs to spend more time in the hospital.

Select to access an abstract of the study, "Medicare Payment for Selected Adverse Events: Building the Business Case for Investing in Patient Safety."

2.  New Study Examines Teamwork Climate in Labor and Delivery Units

AHRQ researchers have measured the climate of teamwork in hospital labor and delivery units. The work includes the development of a teamwork climate scale that measures health care workers' job satisfaction, staff perceptions of management, stress recognition, and working conditions. The researchers surveyed over 3,000 physicians, nurses, nurse managers, technicians, and other caregivers from labor and delivery units in 44 hospitals. They found that perceptions of teamwork vary significantly by type of caregiver and hospital. For example, physicians and nurse managers had more positive perceptions of teamwork than nurses and technicians.

The study also established teamwork perception benchmarking data that can be used to explore the links to clinical and operational outcomes. Led by J. Bryan Sexton, Ph.D., of Johns Hopkins University, the study was published in the August issue of the Journal of Perinatology. Select to access an abstract of the study, "Variation in Caregiver Perceptions of Teamwork Climate in Labor and Delivery Units."

3.  AHRQ Director Gives Keynote Address at Nurse Alliance of SEIU on Quality

AHRQ Director Carolyn M. Clancy, M.D., gave a September 25 keynote address at the Nurse Alliance of the Service Employees International Union (SEIU) Networking Conference on Quality in St. Louis, MO. Dr. Clancy discussed the need for a complete change in culture that will change the way that many facilities do business. The SEIU Nurse Alliance consists of more than 84,000 R.N.s in 23 States working together to raise nursing standards and improve patient care. Select to access Dr. Clancy's remarks.

4.  AHRQ Director Participates in Remaking American Medicine™—PBS Series on Health Care

On September 27, AHRQ Director Carolyn M. Clancy, M.D., was a keynote speaker at the national symposium kickoff for Remaking American Medicine™, a Public Broadcasting System (PBS) series on health care that will air this month. PBS will broadcast the four-part series, Remaking American Medicine™—Health Care for the 21st Century, on four consecutive Thursdays at 10 p.m., the first of which aired yesterday—check your local listings for details. Dr. Clancy is interviewed in the episode that will air October 26. Select to access Dr. Clancy's speech and to view the webcast of the symposium.

5.  Kaiser and AHRQ Medical Errors Survey Released

The Kaiser Family Foundation and AHRQ on September 27 released an updated survey capturing the public's views and knowledge of medical errors and their experiences in taking steps aimed at improving the quality of their care. Since the Institute of Medicine (IOM) issued its landmark study 7 years ago on medical errors in hospitals, there have been a wide range of efforts by hospitals, doctors, health plans, and purchasers to improve the quality and coordination of health care. The new survey updates key questions about these issues that had been asked in 2000, 2002, and 2004 surveys. Findings include:

  • About one in three people (36 percent) say they have seen information comparing the quality of care provided by health plans, hospitals, and doctors. About one in five (20 percent) say they have seen and used such data to make decisions about their care. Both numbers are statistically unchanged from 2004.
  • More than half (55 percent) of Americans say they understand the term "medical error," up from 43 percent in 2004 and 31 percent in 2002. After being given a common definition of medical errors, more than 4 in 10 (43 percent) say preventable medical errors occur "very often" or "somewhat often" when people seek care from a health professional.
  • One in three Americans (34 percent) say they have or a family member has created a set of their medical records to ensure that their health-care providers have all their medical information.
  • Substantial numbers of Americans report taking certain actions aimed at improving the coordination of care and reducing the likelihood of a medical error. These include: checking the medication given by their pharmacist against the doctor's prescription (70 percent); bringing a list of all their medications to a doctor's appointment (54 percent); and bringing a friend or relative to a doctor's appointment to help ask questions (45 percent).

Select to access the survey results.

6.  Latest AHRQ Healthcare 411 Audio Newscast Features Stories on Medical Errors

Both stories in AHRQ's recent audio newscast are about medical errors. The first reports on a study that examined the likelihood that your physician would report a medical error to you. The second features an interview with AHRQ Director Carolyn M. Clancy, M.D., in which she discusses several AHRQ-funded studies that focused on medical errors caused by fatigued hospital interns. Select to access to the 10-minute audio newscast.

The newscast can be heard if your computer 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 to the latest audio reports from AHRQ at your convenience—according to your schedule, whenever you have time to listen. 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.

7.  Latest Issue of AHRQ WebM&M Available Online

The September 2006 issue of AHRQ WebM&M is now available. This month, the Perspectives on Safety section examines the remarkable safety transformation at the Nation's Department of Veterans Affairs (VA) healthcare facilities. It features an interview with the Director of the VA National Center for Patient Safety, James Bagian, M.D., a physician, engineer, and astronaut. Ashish Jha, M.D., M.P.H., a Harvard expert on health policy who has studied the VA, offers his perspective on what lessons other health care systems can learn about patient safety from the VA's experience.

In the first Spotlight Case, a series of incomplete signouts leads to delay in diagnosing an elderly man's post-operative pneumothorax. The author is Arpana Vidyarthi, M.D., of University of California, San Francisco. In the second case, an elderly woman, who had a do-not-resuscitate (DNR) order in place, required surgery. The DNR order was suspended during surgery with the understanding that it would be reinstated postoperatively, but this fell through the cracks until an observant nurse noticed the discrepancy several days later. In the third case, a woman admitted for heart and respiratory failure is mistakenly given penicillamine (a chelating agent) rather than penicillin (an antibiotic). The error demonstrates what is becoming increasingly well appreciated—computerized order entry systems can create their own new types of errors. Commentary authors are Bernard Lo, M.D., of University of California, San Francisco, and Elizabeth Flynn, Ph.D., of Auburn University in Alabama.

A Spotlight slide presentation is available for download, as always, and 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.

8.  New Handbook on Current Concepts and Methods of Human Factors and Ergonomics Now Available

Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, a new book that presents the most current knowledge on human factors and ergonomics and their applications to help improve quality, safety, efficiency, and effectiveness in patient care, is now available. It provides specific information on how to analyze medical errors with the fundamental goal of reducing errors and the harm that potentially ensues.

The book, edited by AHRQ patient safety grantee Pascale Carayon, Ph.D., Professor of Industrial Engineering and Director of the Center for Quality and Productivity Improvement at the University of Wisconsin, Madison, addresses issues related to human factors and ergonomics such as interventions, technologies, and methodologies. Following are titles and authors of select articles in the book that feature AHRQ-funded researchers:

  • "Human Factors and Patient Safety: Continuing Challenges," by Kerm Henriksen, Ph.D., AHRQ.
  • "Work System Design in Health Care," by Pascale Carayon, Ph.D., Carla J. Alvarado, Ph.D., and Ann Schoofs Hundt, Ph.D., University of Wisconsin, Madison.
  • "Human Factors in Hospital Safety Design," by John Reiling, Ph.D., and Sonja Chernos, M.P.H., St. Joseph's Community Hospital of West Bend, WI.
  • "The Physical Environment in Health Care," by Carla J. Alvarado, Ph.D., University of Wisconsin, Madison.
  • "Patient Safety and Technology, a Two-Edged Sword," by James B. Battles, Ph.D., AHRQ.
  • "New Technology Implementation in Health Care," by Ben-Tzion Karsh, Ph.D., and Richard J. Holden, Ph.D., University of Wisconsin, Madison.
  • "Video Analysis in Health Care," by Colin F. Mackenzie, M.D., and Yan Xiao, Ph.D., University of Maryland School of Medicine.
  • "Human Factors and Ergonomics in the Emergency Department," by Robert L. Wears, M.D., and Shawna J. Perry, M.D., University of Florida, Jacksonville.

Select for more information or to purchase the handbook.

9.  NQF and JCAHO Announce the 2006 John M. Eisenberg Patient Safety and Quality Awards

The National Quality Forum (NQF) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have announced the 2006 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards. The honorees, by award category:

  • Individual Achievement—Donald Berwick, M.D., Institute for Healthcare Improvement, Boston, MA.
  • Research—Jerry H. Gurwitz, M.D., University of Massachusetts Medical School, Boston, MA.
  • Innovation in Patient Safety and Quality at a National or Regional Level—Minnesota Alliance for Patient Safety, St. Paul, MN; and Pennsylvania Patient Safety Authority, Huntingdon Valley, PA.
  • Innovation in Patient Safety and Quality at the Local or Organizational Level—Wichita Citywide Heart Care Collaborative, Wichita, KS.

For more information, access the JCAHO press release.

10.  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.

Bismark MM, Brennan TA, Davis PB, et al. Claiming behaviour in a no-fault system of medical injury: a descriptive analysis of claimants and non-claimants. Med J Aust 2006 Aug 21;185(4):203-7. Select to access the abstract in PubMed®.

Grupper A, Grupper A, Rudin D, et al. Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence. Int J Qual Health Care 2006 Apr;18(2):123-6. Epub 2005 Oct 18. Select to access the abstract in PubMed®.

Hughes CM, Lapane KL. Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes. Int J Qual Health Care 2006 Aug;18(4):281-6. Epub 2006 Jul 19. Select to access the abstract in PubMed®.

Rose JS, Thomas CS, Tersigni A, et al. A leadership framework for culture change in health care. Jt Comm J Qual Patient Saf 2006 Aug;32(9):433-42. Select to access the abstract in PubMed®.

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Current as of October 2006

Internet Citation:

Patient Safety E-Newsletter. October 6, 2006, Issue No. 24. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews24.htm

 
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