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Patient Safety and Health Information Technology E-Newsletter

June 10, 2010, Issue No. 59

Quote of the Month

"Our study shows that this combination of technologies can make the delivery of hospital care safer. However, hospitals need the right set of resources and human talent to deploy these technologies successfully, so more research is needed to identify ways to implement them in the most cost-effective way." (For more information on this new AHRQ study, go to item no.1.)

—Eric G. Poon, M.D., M.P.H., of Brigham and Women's Hospital

Today's Headlines:

AHRQ Health IT News:

  1. AHRQ study shows using bar-code technology with eMAR reduces medication errors
  2. New report examines challenges and barriers to implementing clinical decision support
  3. National Coordinator for Health IT issues statement on establishing Beacon Communities
  4. Materials from April 8 Web conference on patient empowerment
  5. Electronic health records can prevent and reduce diagnostic errors, according to AHRQ researchers
  6. AHRQ releases action agenda for personal health information management
  7. National Coordinator for Health IT issues statement on preparing professionals for a nationwide health care transformation
  8. AHRQ in the health IT professional literature—some useful citations

AHRQ Patient Safety News:

  1. New study finds lapses in infection control practices at ambulatory surgical centers
  2. New guide helps patients take care of themselves when they leave the hospital
  3. Technical specifications for AHRQ's Common Formats allow electronic collection of patient safety data
  4. Hospital Survey on Patient Safety Culture 2010 Comparative Database Report available and data submission open
  5. Annual quality and disparities reports Include data on rates of patient safety, obesity and health insurance improved
  6. AHRQ podcast on sustaining low rates of catheter-related bloodstream infections
  7. Latest issue of Web M&M is available online
  8. Visit the AHRQ Patient Safety Network Web site
  9. AHRQ in the patient safety professional literature—some useful citations

Register Now for AHRQ's 2010 Annual Conference: Better Care, Better Health: Delivery on Quality for All Americans on September 26-29

AHRQ Health IT News:

1. AHRQ study shows using bar-code technology with eMAR reduces medication errors

Using bar-code technology with an electronic medication administration record (eMAR) substantially reduces transcription and medication administration errors, as well as potential drug-related adverse events according to a new AHRQ-funded study. Bar-code eMAR is a combination of technologies that ensures that the correct medication is administered in the correct dose at the correct time to the correct patient. When nurses use this combination of technologies, medication orders appear electronically in a patient's chart after pharmacist approval. Alerts are sent to nurses electronically if a patient's medication is overdue. Before administering medication, nurses are required to scan the bar codes on the patient's wristband and then on the medication. If the two don't match the approved medication order, or it is not time for the patient's next dose, a warning is issued. The study is published in the May 6 issue of the New England Journal of Medicine. Select to read our press release and to access the abstract.

2. New report examines challenges and barriers to implementing clinical decision support

A new report that examines the challenges and barriers to implementing clinical decision support (CDS) found that workflow, design, and clinician's level of support are just some of the issues that can affect successful CDS implementation. Challenges and Barriers to Clinical Decision Support (CDS) Implementation describes the challenges and barriers that AHRQ contractors encountered as part of their CDS demonstration project. These challenges and barriers can be successfully addressed by employing several key strategies, which include utilizing standard data exchange formats, providing clinicians with appropriate training, and modifying CDS to address clinicians' needs. Select to access the report (PDF File, Plugin Software Help).

3. National Coordinator for Health IT issues statement on establishing Beacon Communities

The National Coordinator for Health Information Technology, David Blumenthal, M.D., M.P.P., recently stressed the importance of establishing Beacon Communities for nationwide advances in health information technology. The Beacon Community Cooperative Agreement Program, by its very design, was intended to shine a spotlight on health IT innovators, so that we all might learn from them. In a May 5 statement, Dr. Blumenthal referenced an HHS press release announcing the award of $220 million to establish 15 Beacon Communities throughout America. These community consortia—selected from 130 applicants—have demonstrated leadership in developing advanced health IT solutions to help improve specific health outcomes. They also share a strong conviction in the benefits of health IT as a critical pillar to advance broad and sustainable health system improvement. The average award amount is $15 million over 36 months. Select to access the HHS press release.

4. Materials from April 8 Web conference on patient empowerment

Materials from AHRQ's Web conference titled "A National Web Conference, Leveraging Health Information Technology for Patient Empowerment," are now available on its National Resource Center for Health Information Technology. The event explored the latest research on how patients can utilize health IT to increase participation in their health care. Experts provided an overview of challenges and innovations facing patient empowerment and health IT systems; discussed findings from a randomized controlled trial to evaluate the impact of a personal health record (PHR); explained how PHRs link patients to their health information in their physician's electronic medical record; discussed ongoing research in developing evidence-based tools to support patient-centered care; and, shared experiences of empowering patients via IT systems in clinical settings and the key barriers and enablers to success. Select to access the audio recording of the presentation.

5. Electronic health records can prevent and reduce diagnostic errors, according to AHRQ researchers

AHRQ researchers suggest that electronic health records (EHRs) promise multiple benefits, including the potential for preventing, minimizing, and mitigating diagnostic errors. The authors, AHRQ-funded researchers Gordon Schiff, M.D. and David Bates, M.D., Brigham and Women's Hospital Division of General Internal Medicine, Boston, explain that through improved design efforts of EHR systems, visual functions can be enhanced so clinicians can make more rapid decisions; documentation of patient history and ongoing assessment can be better facilitated; communications and actions for ordering tests and tracking results can be better ensured; and checklists can be incorporated to help prompt key questions leading to relevant diagnoses. The authors recommend that patients, clinicians, and other caregivers be engaged in the process of developing and improving such systems. The editorial, "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?" was published in the March 25 issue of the New England Journal of Medicine. Select to access the editorial. Exit Disclaimer

6. AHRQ releases action agenda for personal health information management

AHRQ has released a new resource, Managing Personal Health Information: An Action Agenda (PDF File, Plugin Software Help), that provides a framework for studying personal health information management and patient-centered health IT to advance research, implementation, and policy development. AHRQ also is making available a consumer-oriented video on keeping a personal health record. This record ensures your medical history is available in an emergency and may be the only place where all your medical information—including insurance information; lab results; the names and phone numbers of doctors; and details of injuries, illnesses, surgeries, allergies, and treatments—is available in one document. The video features experts discussing what information you need; how to gather the information; what format works best; and how patients can become more engaged in their health care by maintaining a personal health record. Select to access the video.

7. National Coordinator for Health IT issues statement on preparing professionals for a nationwide health care transformation

The National Coordinator for Health Information Technology, David Blumenthal, M.D., M.P.P., recently issued a message on the HHS award of $84 million to 16 institutions of higher education to fund the Health IT Workforce Development Program. The Program focuses on several key resources required to rapidly expand the availability of health IT professionals who will support broad adoption and use of health IT in the provider community. Those resources include:

  • A community college training program to create a workforce that can facilitate the implementation and support of an electronic health care system.
  • Quality educational materials that institutions of higher education can use to construct core instructional programs.
  • A competency examination program to evaluate trainee knowledge and skills acquired through non-degree training programs.
  • Additional university programs to support certificate and advanced degree training.

Select to access the HHS press release.

8. 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 support staff for possible remedies.

Devine EB, Hollingworth W, Hansen RN, et al. Electronic prescribing at the point of care: a time-motion study in the primary care setting. Health Serv Res 2010 Feb; 45(1):152-71. Select to access the abstract.

Kaushal R, Kern LM, Barrón Y, et al. Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med 2010 Feb 26. Select to access the abstract.

Tejani N, Dresselhaus TR, Weinger MB. Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses. J Biomed Inform 2010 Feb; 43(1):75-80. Select to access the abstract.

AHRQ Patient Safety News:

9. New study finds lapses in infection control practices at ambulatory surgical centers

Two-thirds of a sample of ambulatory surgical centers (ASCs) in three states had infection control lapses identified during routine inspections, according to a study funded by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) and published in the June 8 issue of the Journal of the American Medical Association. In a statement on the study, HHS Secretary Kathleen Sebelius said that ensuring the safety of all patients in all health care settings is a top priority for HHS and noted that HHS has committed $50 million in American Recovery and Reinvestment Act (ARRA) funds to help states fight health care-associated infections (HAIs). "This is concerning, because when lapses in infection control occur, in any health care setting, it puts patients at risk," Secretary Sebelius said of the study findings. "However, the good news is that we have seen progress in the reduction of HAIs in the hospital setting," she added. Select to access the HHS statement. Of the ARRA funding, $10 million went to states to improve the process and increase the frequency of inspections for ASCs. AHRQ is contributing to the reduction of infections in ASCs by investing in research projects to better understand the factors that lead to HAIs in such settings. Select to access information on AHRQ's HAI projects.

10. New guide helps patients take care of themselves when they leave the hospital

AHRQ has developed a new easy-to read guide, called Taking Care of Myself: A Guide for When I Leave the Hospital, that hospital staff and patients can use during the discharge process. With this guide, patients can track their medication schedules, upcoming medical appointments, and important phone numbers. The guide is adapted from the AHRQ-funded Re-Engineered Hospital Discharge project, known as Project RED, which was developed by Brian Jack, M.D., Associate Professor of Family Medicine at Boston University, and Timothy Bickmore, Ph.D., Assistant Professor in the College of Computer and Information Science at Northeastern University. Project RED showed that preparing patients to care for themselves when they leave the hospital can improve patient safety and reduce re-hospitalization rates by 30 percent. Select to access the English and Spanish versions of the guide, including a print version and fillable PDF.

11. Technical specifications for AHRQ's Common Formats allow electronic collection of patient safety data

AHRQ recently released technical specifications for its revised Common Formats (Version 1.1) that make possible electronic data collection and reporting of patient safety information in the hospital setting, including adverse events, near misses and unsafe conditions. Technical specifications promote standardization by ensuring that data collected by patient safety organizations (PSOs) and other entities are clinically and electronically comparable. The technical specifications provide direction to software developers so the Common Formats can be implemented electronically. They specify rules for data collection and submission and provide guidance for how and when to create data elements, their valid values, conditional and go-to logic, and reports. AHRQ's revised Common Formats (Version 1.1) and the technical specifications, along with accompanying user information, are available at no charge through AHRQ's PSO Web site.

12. Hospital Survey on Patient Safety Culture 2010 Comparative Database Report available and data submission open

The recently released Hospital Survey on Patient Safety Culture 2010 Comparative Database Report contains more data than any previous report, providing results from nearly 350,000 hospital staff in 885 hospitals. The 2010 report also presents results showing changes over time for 321 hospitals that submitted data more than once. Select to access the report. Print copies are available by sending an E-mail to ahrqpubs@ahrq.hhs.gov. In addition, registration is now open for data submission for the AHRQ 2011 hospital comparative database. Hospitals and health systems in the United States or one of its territories that have already completed administration of the AHRQ patient safety culture survey and are prepared to submit their data by June 30 are eligible. Select for information about data submission or select to register. Exit Disclaimer

13. Annual quality and disparities reports Include data on rates of patient safety, obesity and health insurance improved

Improvements in patient safety continue to lag, according to AHRQ's 2009 National Healthcare Quality Report and National Healthcare Disparities Report. The 2009 reports include a new section on lifestyle modifications, because preventing or reducing obesity is a crucial goal for many Americans and an important task for health care providers. The reports indicate that the lack of health insurance slows improvement in health care quality and reduction of disparities. For many services, not having insurance is the single strongest predictor of poor quality care, exceeding the effects of race, ethnicity, income or education. Select to read our press release. The quality and disparities reports are available online. Print copies are available by sending an E-mail to ahrqpubs@ahrq.hhs.gov.

14. AHRQ podcast on sustaining low rates of catheter-related bloodstream infections

In a recent Healhcare 411 radiocast, William Munier, M.D., director, AHRQ's Center for Quality Improvement and Patient Safety, discusses improvements that have been made toward reducing and sustaining central line-associated bloodstream infections. Dr. Munier explains that AHRQ-funded research showed that using a checklist and other standardized procedures when inserting or removing catheters helped more than 100 hospitals in Michigan lower their infection rates to near zero and keep them there for more than 3 years. These procedures include staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders. Select to access the Healthcare 411 program or transcript.

15. Latest issue of Web M&M is available online

The June issue of AHRQ Web M&M is now available online. The Perspectives on Safety section examines patient safety in emergency medicine and features Pat Croskerry, M.D., Ph.D., of Dalhousie University, Halifax, Nova Scotia, an expert in both emergency medicine and cognitive errors. In the accompanying perspective piece, David P. Sklar, M.D., and Cameron Crandall, M.D., both of the University of New Mexico, Albuquerque, discuss emergency department safety. The Spotlight Case, "Fatal Error in Neonate: Does 'Just Culture' Provide an Answer?," features a commentary by Sidney W.A. Dekker, Ph.D., of Lund University in Sweden, discussing the balance between just culture, accountability, and learning. The second case, "Tacit Handover, Overt Mishap," features a commentary by Jeffrey B. Cooper, Ph.D., and Brinda B. Kamdar, M.D., both of Harvard University, Boston, discussing the risks of handoffs in anesthesia and the benefits of getting them right. The third case, "Acute Respiratory Arrest in Pregnancy ," features a commentary by Baha Sibai, M.D., of the University of Cincinnati, discussing key safety issues in diagnosis and management of pre-eclampsia. 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.

16. Visit the AHRQ Patient Safety Network Web site

AHRQ's national Web site—the AHRQ Patient Safety Network (PSNet)—continues to be a valuable gateway to resources for improving patient safety and preventing medical errors. AHRQ PSNet is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Viewers can customize the site around their unique interests and needs through the Web site's unique "My PSNet" feature.

17. 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.

Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med 2010 Feb; 55(2):171-80. Select to access the abstract.

Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010 May; 25(5):441-7. Select to access the abstract.

Loren DJ, Garbutt J, Dunagan WC, et al. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf 2010 Mar; 36(3):101-8. Select to access the abstract.

Register Now for AHRQ's 2010 Annual Conference: Better Care, Better Health: Delivery on Quality for All Americans on September 26-29

Register now for AHRQ's fourth annual conference, scheduled for September 27-29, at the Bethesda North Marriott Convention Center in Bethesda, MD. Experts and leading authorities in health care research and policy will hold sessions around five critical areas: transforming health care delivery; developing new patient care models; strengthening preventive care and reducing health disparities; improving quality and patient safety; and, measuring and reporting on provider and system performance. As with previous years, the conference will also include the mAHRQet Place Café, featuring posters and displays of Agency-sponsored research and implementation activities.

Current as of June 2010

Internet Citation:

Patient Safety and Health Information Technology E-Newsletter. June 10, 2010, Issue #59. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews59.htm

 
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