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Patient Safety and Health Information Technology E-Newsletter

January 14, 2011, Issue #64

Today's Headlines:

AHRQ Health IT News:

  1. AHRQ health IT portfolio 2009 annual report now available
  2. Two new reports from NIST deliver guidance on EHR usability
  3. Report on computer-based clinical decision support tool to assess patients' risk for deleterious BRCA mutations is available
  4. AHRQ releases new health IT success stories
  5. AHRQ in the health IT professional literature—some useful citations

AHRQ Patient Safety News :

  1. HHS issues patient safety guidance
  2. AHRQ seeks submissions by February 15 for Nursing Home Survey on Patient Safety Culture Comparative Database
  3. Latest Issue of AHRQ WebM&M is available online
  4. National Awards Program to Recognize Achievements in Eliminating Healthcare-Associated Infections—Applications due January 29
  5. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

AHRQ Health IT News:

1. AHRQ Health IT Portfolio 2009 Annual Report Now Available

The AHRQ health IT portfolio's 2009 annual report is now available online. The report is published in an abridged version (PDF file; Plugin Software Help), which provides an overview of the health IT portfolio, and a comprehensive version (PDF file; Plugin Software Help), which includes the overview and 180 individual summaries of all AHRQ health IT-funded grants and contracts that were active in 2009. Each summary provides an overview of the projects' long-term objectives; status updates on specific aims; and descriptions of completed and ongoing project activities and various categories such as the target population and strategic and business goals of the project. The AHRQ National Resource Center for Health IT Web site offers the ability to search the project summaries by various categories under AHRQ funded-projects. Project summaries were also developed for grants that ended in 2007 and updated for projects that ended in 2008. Final grant reports for grants that ended in 2007, 2008, and 2009 are also available at the website.

2. Two New Reports from NIST Deliver Guidance on EHR Usability

Two new publications from the National Institute of Standards and Technology (NIST) are intended to help developers of software and computer systems improve the ease of use of electronic health records (EHRs). Efforts to improve the usabilityof EHRs are widely recognized as key to achieving widespread adoption and meaningful use of these systems. Select to access each report:

  1. NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records (NISTIR 7741) (PDF file; Plugin Software Help)
  2. Customized Common Industry Format Template for Electronic Health Record Usability Testing (NISTIR 7742) (PDF file; Plugin Software Help)

In addition, a recent AHRQ report identified gaps in the processes and practices used by EHR vendors to ensure the usability of their products. The report highlighted the lack of standard approaches and formats for testing and reporting usability of EHR products across the industry. Select to access the AHRQ report (PDF file; Plugin Software Help). For questions about the NIST reports, please contact Ben Stein (bstein@nist.gov; 301-975-3097).

3. Report on Computer-based Clinical Decision Support Tool to Assess Patients' Risk for Deleterious BRCA Mutations Is Available

AHRQ's Effective Health Care Program released a new technical report, A Primary Care-Focused, Computer-based Clinical Decision Support Tool to Assess Patients' Risk for Deleterious BRCA MutationsThe report, conducted by the RTI International DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) Center, describes development of a clinical decision support tool that could be used to screen for risk of BRCA mutations in primary care settings and assist in the implementation of the U.S. Preventive Services Task Force recommendations regarding referrals for genetic counseling and evaluation for BRCA1 and BRCA2 genes. The first version of the BRCA clinical decision support tool is not considered ready for clinical use but is available to researchers, upon request, for further evaluation and modification. Select to access the report. People who wish to obtain a CD of the tool for research and evaluation should send an e-mail to ProjectManagerCE@ahrq.hhs.gov.

4. AHRQ Releases New Health IT Success Stories

AHRQ's health IT portfolio has released a new report, Success Stories from the AHRQ Funded Health IT Portfolio (2009), that features eight easy-to-follow overviews on various types of projects that address important gaps in research literature and/or health IT implementation that can be translated into other health care settings. Select to access the report (PDF file; Plugin Software Help).

5. AHRQ in the Health IT Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical suppo

Fontaine P, Ross SE, Zink T, et al. Systematic review of health information exchange in primary care practices. J Am Board Fam Med 2010 Sep-Oct; 23(5):655-70. Select to access the abstract.

Kaafarani HM, Rosen AK, Nebeker JR, et al. Development of trigger tools for surveillance of adverse events in ambulatory surgery. Qual Saf Health Care 2010 Oct; 19(5):425-9. Select to access the abstract.

AHRQ Patient Safety News:

6. HHS Issues Patient Safety Guidance

HHS issued guidance on December 30 to address questions that have arisen regarding the obligations of Patient Safety Organizations (PSOs) where they or the organization of which they are a part are legally obligated to report certain information to the Food and Drug Administration (FDA) and to provide FDA with access to its records, including access during an inspection of its facilities. PSOs are organizations that share the goal of improving the quality and safety of health care delivery. Organizations that are eligible to become PSOs include: public or private entities, profit or not-for-profit entities, provider entities such as hospital chains, and other entities that establish special components to serve as PSOs. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data, thereby improving quality by identifying and reducing the risks and hazards associated with patient care. The new guidance applies to all entities that seek to be or are PSOs or component PSOs that have mandatory FDA-reporting obligations under the Federal Food, Drug, and Cosmetic Act and its implementing regulations ("FDA-regulated reporting entities") or are organizationally related to such FDA-regulated reporting entities (e.g., parent organizations, subsidiaries, sibling organizations). Select to learn more about PSOs or read the Patient Safety Guidance.

7. AHRQ Seeks Submissions by February 15 for Nursing Home Survey on Patient Safety Culture Comparative Database

AHRQ's Nursing Home Survey on Patient Safety Culture is a tool for nursing homes to use to assess provider and staff opinions about the culture of patient safety in their nursing homes. Nursing homes that have administered the AHRQ survey can register and submit their data to the new Nursing Home Survey on Patient Safety Culture Comparative Database, between January 15 and February 15. The database is a central repository for survey data from nursing homes, systems/chains, or survey vendors that have administered the AHRQ nursing home survey instrument. One of the purposes of the database is to produce comparative results to help nursing homes identify strengths and opportunities for improvement in their patient safety culture. For more information on the benefits of participation and database products, participation requirements, and registration/data submission timeline and activities, visit the AHRQ Web site.

8. Latest Issue of AHRQ WebM&M is Available Online

The December issue of AHRQ WebM&M is now available online. The Perspectives on Safety section covers risk management and patient safety and features Geri Amori, Ph.D., of The Risk Management and Patient Safety Institute, Lansing, MI. In the accompanying perspective piece, a group of faculty from Boston University and the Harvard Risk Management Foundation, Boston, led by Barry M. Manuel, M.D., discuss the relationship between risk management and patient safety. The Spotlight Case, "The Forgotten Turn," features a commentary by Susan Barbour, RN, MS, of the University of California San Francisco Medical Center, on the importance of skin assessment and efforts to prevent pressure ulcers. The second case, "Milliliters vs. Milligrams," features a commentary by Robert L. Poole, Pharm.D., and Tessa Dixon, Pharm.D., both of Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, on how individualized dosing can help prevent medication administration errors. The third case, "Failure to Reevaluate," features a commentary by Annie Wong-Beringer, Pharm.D., of University of Southern California, Los Angeles, discussing key safety issues in prescribing potentially nephrotoxic medications. Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using the "e-mail a colleague" feature.

9. National Awards Program to Recognize Achievements in Eliminating Healthcare-Associated Infections—Applications due January 29

HHS recently announced an awards program to recognize critical care teams and healthcare institutions that achieve excellence and sustained improvement in preventing healthcare-associated infections, specifically central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP), two areas of focus for AHRQ patient safety research. The goal of this program is to motivate health care and public health communities to achieve wide-scale reduction of HAIs and progress toward their elimination. HHS has partnered with the Critical Care Societies Collaborative (CCSC) to administer these awards at two levels:

  • The Outstanding Leadership Award will recognize systems of excellence that result in sustained success over at least 25 months in the prevention or elimination of CLABSI and/or VAP, as well as national leadership in
  • The Sustained Improvement Award will recognize progress in implementing systems showing sustained and consistent reductions over a period of 18 to 24 months.

Applicants must be a unit, hospital, team, enterprise, or health care system of any size and in any geographic location that provides care for critically ill patients and has at least one team member who belongs to one of the CCSC member organizations. Select to learn more about the HHS awards program. Exit Disclaimer Deadline for submitting applications is January 29.

10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Carayon P. Human factors in patient safety as an innovation. Appl Ergon 2010 Sep; 41(5):657-65. Select to access the abstract.

Muething SE, Conway PH, Kloppenborg E, et al. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. Qual Saf Health Care 2010 Oct; 19(5):435-9. Select to access the abstract.

Current as of January 2011

Internet Citation:

Patient Safety and Health Information Technology E-Newsletter. January 14, 2011, Issue No. 64. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews64.htm

 
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