September 1, 2011, Issue #71
Quote of the Month
An average of 84 percent of nursing home staff agree that they can discuss ways to keep residents safe, tell someone if they see something that might harm a resident, and talk about ways to keep incidents from happening again. (For more information AHRQ's new study, go to Item No.1.)
—Nursing Home Survey on Patient Safety Culture, 2011 User Comparative Database Report.
Patient Safety and Health IT News:
- New AHRQ Safety Culture Report Shows Strengths, Areas for More Effort in Nursing Homes
- Common Format for Venous Thromboembolism to be Released in October
- Web Conference Explores Care for Elderly Using Health IT
- New AHRQ Report Highlights Impact of Human Resources on Safety and Quality
- AHRQ Releases New Spanish Language Medication Tracking Tool
- AHRQ's 2011 Annual Conference: AHRQ: Leading Through Innovation & Collaboration
- AHRQ in the Professional Literature: Some Useful Citations
AHRQ Patient Safety News:
1. New AHRQ Safety Culture Report Shows Strengths, Areas for More Effort in Nursing Homes
Results from the first edition of AHRQ's nursing home safety culture show that 86 percent of participating nursing home staff believes that residents are safe and well cared for. But only half (51 percent) said they felt safe reporting mistakes. The new report, Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report provides a comparative assessment of 16,155 responses from 226 U.S. nursing homes that implemented AHRQ's Nursing Home Survey on Patient Safety Culture. It also includes information that can help users understand how to compare their results to others and how to target improvement efforts. Select to access the Web-only report.
2. Common Format for Venous Thromboembolism to be Released in October
A beta version of a Common Format for venous thromboembolism (VTE), developed by AHRQ, will be available next month for public comment. Common Formats refer to the common definitions and reporting formats, specified by AHRQ, that allow health care providers to collect and submit standardized information about patient safety events to Patient Safety Organizations. The beta version of the Common Format for VTE includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). The format will be revised based on public input and incorporated into the next version of the Common Formats to be used by acute care hospitals and skilled nursing facilities. More information on AHRQ's Common Format is available at the PSO Privacy Protection Center .
3. Web Conference Explores Medication Management for Elderly Patients Using Health IT
A clinical decision support system (CDSS) for physicians prescribing medications for nursing home residents with renal insufficiency can improve the quality of prescribing decisions, according to results of a study conducted by University of Massachusetts Medical Center and examined at an August 18 Web conference sponsored by AHRQ. In the randomized control trial of 22 long-term care units, researchers developed a CDSS that provided recommendations for dosing, drug frequency, drugs to avoid, and drug order alerts. Medication ordering among physicians using the CDSS was correct 63 percent of the time, compared to 52 percent among those who did not. Select for information about the Web conference and learn about findings and challenges in using health IT to improve medication management for elderly patients.
4. New AHRQ Report Highlights Impact of Human Resources on Safety and Quality
A new report funded by AHRQ examines the growing support for a link between innovative human resources staffing patterns, also known as high-performance work practices, and improvements in safety and quality in health care settings. Key findings included the importance of engaging staff with an organization's mission, vision, goals and objectives; and using a high-performance organizing framework, such as Six Sigma or Lean production to clarify the link with quality and safety outcomes. The report's findings confirm the importance of high-performance work practices to organizational success in general, especially those that engage individual staff. Promoting Safety and Quality Through Human Resources Practices also lays the groundwork for future research to establish a more definitive link between high-performance work practices and quality outcomes. Select to access the report.
5. AHRQ Releases New Spanish Language Medication Tracking Tool
A newly revised Spanish language medication tracking tool, Su medicamento: Infórmese. Evite riesgos (Your Medicine: Be Smart. Be Safe), is now available from AHRQ. It can help Spanish-speaking patients learn more about how to take medicines safely. The guide includes a detachable, wallet-size card that can be personalized to help patients keep track of all medicines they are taking, including vitamins and herbal and other dietary supplements. Select for a copy of the tool (Plugin Software Help). To order copies, contact the AHRQ Publications Clearinghouse at AHRQPubs@ahrq.hhs.gov.
6. AHRQ's 2011 Annual Conference: AHRQ: Leading Through Innovation & Collaboration
Registration is still open for AHRQ's fifth annual conference, scheduled for Sept.18-21, at the Bethesda North Marriott Hotel & Conference Center in Bethesda, MD. Learn from leading pioneers in health care who are leading change based on innovative approaches to solving safety, quality and access issues. Engage authorities in health care research and policy about tools, information and strategies that can improve care in your communities. For more information about the conference and to register, please visit the AHRQ Annual Conference Web site.
7. AHRQ in the Professional Patient Safety and Health IT Literature: Some Useful Citations
The following abstracts include hyperlinks to journal articles describing AHRQ-funded research. Contact your technical support staff for possible remedies if you experience any problems accessing these articles.
Patient Safety articles
Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011 Mar 15; 154(6):384-90. (Supported by grant RO1 HS 16929). Select to access the abstract on PubMed.®.
Hanlon JT, Sloane RJ, Pieper CF, et al. Association of adverse drug reactions with drug-drug and drug-disease interactions in frail older outpatients. Age Ageing 2011 Mar; 40(2):274-7. [Supported by grant R01 HS18721 (to first author).] Select to access the abstract on PubMed.®.
Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. The ability of intensive care units to maintain zero central line-associated bloodstream infections. Arch Intern Med 2011 May 9; 171(9):856-8. [Supported by grant 1 UC1 HS14246; other authors report receiving previous/additional AHRQ support.] Select to access the abstract on PubMed.®.
Martinez EA, Thompson DA, Errett NA, Kim GR, Bauer L, Lubomski LH, Gurses AP, et al. High stakes and high risk: a focused qualitative review of hazards during cardiac surgery. Anesth Analg 2011 May; 112(5):1061-74. [Supported by grants K08 HS13904-02 (to first author) and K01 HS18762 (to seventh author).] Select to access the abstract on PubMed.®
Mukamel DB, Harrington C, Spector WD, et al. Does state regulation of quality impose costs on nursing homes? Med Care 2011 Jun; 49(6):529-34. [Fourth author is a researcher in AHRQ's Center for Delivery, Organization, and Markets.] Select to access the abstract on PubMed.®
Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med 2011 May; 39(5):934-9. [Supported by grant 1 UC1 HS14246; other authors report receiving previous/additional AHRQ support.] Select to access the abstract on PubMed.®
Current as of September 2011
Patient Safety and Health Information Technology E-Newsletter. September 1, 2011, Issue No. 71. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews71.htm