November 4, 2010, Issue #62
Quote of the Month
"We know that infections can occur in any health care setting. With these new projects, we can apply what has worked in reducing infections in hospitals to other settings and ultimately help patients feel confident they are in safe hands, regardless of where they receive care." (For more information on AHRQ's recent press release, go to item no.1.)
—AHRQ Director Carolyn M. Clancy, M.D.
- AHRQ awards $34 million to expand fight against healthcare-associated infections
- New report on the impact of human factors on home health care quality and safety is available
- Special AHRQ-funded journal issue highlights ergonomics and human factors
- Now available: commenting tool for adverse event reporting on health IT Common Format
- Three new Medicaid-CHIP case studies now available
- AHRQ in the patient safety and health IT professional literature—some useful citations
English and Spanish-language consumer patient safety videos are available
1. AHRQ Awards $34 Million To Expand Fight Against Healthcare-Associated Infections
Today, AHRQ announced the award of $34 million for projects focused on preventing one of the top 10 leading causes of death in the United States—healthcare-associated infections (HAIs). This new funding will help improve the quality of care delivered to patients and expand the fight against HAIs in hospitals, ambulatory care settings, end-stage renal disease facilities and long-term care facilities. Based on estimates from the Centers for Disease Control and Prevention (CDC), each year there are nearly 2 million HAIs in hospitals, which contribute to almost 100,000 deaths. While there is a growing body of knowledge regarding the number of infections and methods to reduce those infections within hospitals, there is not enough information currently available on infections originating in other health care settings. These awards are a part of a Department-wide effort to address HAIs. To maximize the impact of the HAI investment, AHRQ has collaborated with CDC, the Centers for Medicare and Medicaid Services (CMS), and the National Institutes of Health (NIH) to identify research gaps to improve HAI prevention. With this new funding, researchers will be able to address some of these gaps, learn why infections occur, find ways to prevent them from happening, improve antibiotic prescribing practices and delivery, and enhance communication and teamwork among health care providers. Select to access AHRQ's press release and a complete list of institutions and projects funded in fiscal year 2010 under the $34 million.
2. New Report on the Impact of Human Factors on Home Health Care Quality and Safety Is Available
A new AHRQ-funded report examines the impact of human factors on home health care quality and safety. The report includes seven commissioned papers on topics that include matching care to people in their home care environments; the prevalence, characteristics, and care provision ability of informal caregivers; medical devices and information technology and systems in home care; impact of social, cultural, and community environments on home care; and the effects of policy, reimbursement, and regulation on home health care. Based on proceedings from an October 2009 workshop, the report, "The Role of Human Factors in Home Healthcare: Workshop Summary and Papers," also features summaries of the discussion at the workshop on how home care quality and safety are impacted by the capabilities and limitations of patients and providers in the use of technologies. Select to access the workshop summary report, which is published by the National Academies' National Research Council under contract to AHRQ. A final consensus report and designers' guide for home-based consumer health IT developers, which build on the workshop proceedings, are under development and will include recommendations related to the safety and quality of home health care. The report and designers' guide are expected to be released in Spring 2011.
3. Special AHRQ-Funded Journal Issue Highlights Ergonomics and Human Factors
The October special supplement, "Contributions from Ergonomics and Human Factors," to Quality and Safety in Health Care, funded by AHRQ, features 15 articles on diverse range of issues covering ergonomics/human factors in health care. Kerm Henriksen, Ph.D., AHRQ's Human Factors Adviser for Patient Safety, served as one of the supplement's editors. In the issue, authors examine various types of incidences and events in a busy, urban emergency department; assess the risk of transitioning neonates from the neonatal intensive care unit to the ambulatory care setting; address the need for valid and reliable assessment of provider performance; examine studies on the use of checklists and rating scales as evaluation tools; describe team-based approaches for identifying the active and latent breaches to defensive barriers in obstetric emergency care; and analyze human factors and ergonomics issues that focus on home-based consumer health IT applications. Overall, the authors share the sentiment that safer health care involves taking into account human strengths and limitations as systems are designed. Many of the articles stemmed from the Healthcare Systems Ergonomics and Patient Safety international conference held in Strasbourg, France, in 2008. Following are links to abstracts of several key articles featured in the issue:
- Towards a safer healthcare system, by Kerm Henriksen and Sara Albolino. Select to view the full article.
- Partial truths in the pursuit of patient safety, by Kerm Henriksen. Select to view the full article.
- Incidence and types of non-ideal care events in an emergency department, by Kendall K. Hall, Stephen M. Schenkel, Jon Mark Hirshon, Yan Xiao, and Gary A. Noskin. Select to access the full article.
- Simulation and patient safety: evaluative checklists for central venous catheter insertion, by Leigh V. Evans and Kelly L. Dodge. Select to access the full article.
- Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies, by William Riley, Stan Davis, Kristi M. Miller, Helen Hansen, and Robert M. Sweet. Select to access the full article.
- Considerations for the design of safe and effective consumer health IT applications in the home, by Teresa Zayas-Cabán and Brian E Dixon. Select to access the full article.
4. Now Available: Commenting Tool for Adverse Event Reporting on Health IT Common Format
AHRQ has released a new Common Format designed to help health care providers collect information about adverse events related to health IT and devices. This Common Format, titled Device or Medical/Surgical Supply including HIT Device, is currently available as a beta version for public review and comment. The format will be revised based on feedback and released with AHRQ's Common Formats Version 1.2 in August 2011. The Agency has contracted with the National Quality Forum to assist with gathering and analyzing feedback on this Common Format. Select to access the tool to post comments about the Device or Medical/Surgical Supply including HIT Device Common Format. AHRQ appreciates the time and effort individuals invest in providing comments. All feedback received will be reviewed and considered to guide the development of a revised version. To view AHRQ's full set of Common Formats (Version 1.1) along with technical specifications and accompanying user information, visit the AHRQ's PSO Web site. Select to read the October 22 Federal Register notice.
5. Three New Medicaid-CHIP Case Studies Now Available
AHRQ has released three new case studies focused on the beneficial outcomes for Medicaid and CHIP agencies who implement health IT and/or health information exchange to improve the quality of care for their beneficiaries. The new case studies are:
- Leveraging Existing Leadership to Support Health IT and HIE: Lessons Learned from Minnesota's Medical Assistance Program
- Developing an Electronic Prescribing Incentive Program: Lessons Learned from New York Medicaid
- Developing a Universal Consent Form: Lessons Learned from Florida Medicaid
Select to access these case studies and for more resources on health IT and health information exchange activities for Medicaid and CHIP.
6. AHRQ in the Patient Safety and 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.
Evans LV, Dodge KL, Shah TD, et al. Simulation training in central venous catheter insertion: improved performance in clinical practice. Acad Med 2010 Sep; 85(9):1462-9. Select to access the abstract.
Galanter WL, Hier DB, Jao C, et al. Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance. Int J Med Inform 2010 May; 79(5):332-8. Select to access the abstract.
Hellinger FJ, Encinosa WE. The cost and incidence of prescribing errors among privately insured HIV patients. Pharmacoeconomics 2010; 28(1):23-34.Select to access the abstract.
Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant. Jt Comm J Qual Patient Saf 2010 Sep; 36(9):402-10. Select to access the abstract.
English and Spanish-Language Consumer Patient Safety Videos Are Available
AHRQ has a series of 60-second educational health videos in Spanish for consumers, based on the monthly Web column series, Consejos de salud. Two videos are now available online: Advice on Taking Medicines Safely and Tips for Having Surgery, which also are available in English.
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Current as of November 2010
Patient Safety and Health Information Technology E-Newsletter. November 4, 2010, Issue No. 62. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews62.htm