AHRQ-Supported Conference on September 22–25 Will Explore Diagnostic Errors

Electronic Newsletter, Issue 391

AHRQ's Electronic Newsletter summarizes Agency research and programmatic activities.

August 6, 2013


Editor's Note: The AHRQ Electronic Newsletter will not publish next week. Look for your next issue on August 19.

AHRQ Stats

From 2000 to 2010, the total number of outpatient prescription drug purchases for persons under age 40 increased for anti-diabetics, anti-hypertensives and statins—41 percent, 49 percent and 179 percent, respectively. (Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey Statistical Brief #407, Trends in Utilization and Expenditures of Prescribed Drugs Treating Diabetes, Hypertension, and High Cholesterol for Persons Under Age 40 in the U.S. Civilian Noninstitutionalized Population, 2000 and 2010.)

Today's Headlines

  1. AHRQ-Supported Conference on September 22–25 Will Explore Diagnostic Errors.
  2. AHRQ's Health Care Innovations Exchange Focuses on Improving Health Through Clinical-Community Collaboration.
  3. Register for National Quality Strategy Webinar on August 8.
  4. AHRQ's Web M&M Examines Diagnostic Errors and Emergency Surgery.
  5. AHRQ's Patient Safety Network Offers Primer on Root Cause Analysis in Health Care.
  6. AHRQ in the professional literature.

 1. AHRQ-Supported Conference on September 22–25 Will Explore Diagnostic Errors

Diagnostic errors—defined as missed, delayed or incorrect diagnoses—account for significant harm to patients but are underemphasized and understudied. The AHRQ-supported Diagnostic Error in Medicine (DEM) 6th International Conference, to be held September 22 to 25 in Chicago, will explore ways to define, measure and reduce diagnostic errors. The DEM Conference is dedicated solely to the problem of diagnostic error, bringing together stakeholders with a shared goal of improving patient safety.

Noted speakers include renowned safety experts:

  • Christine Cassel, M.D., President and CEO of the National Quality Forum.
  • Brent James, M.D., Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare, Salt Lake City.
  • Robert Wachter, M.D., Professor and Associate Chair of the Department of Medicine at the University of California, San Francisco, and editor of AHRQ's Patient Safety Network and Web M&M.

Select to register for this conference.  

 2. AHRQ's Health Care Innovations Exchange Focuses on Improving Health Through Clinical-Community Collaboration

The latest issue of AHRQ's Health Care Innovations Exchange features three programs that provide successful examples of clinical–community collaboration to improve health. One of the featured profiles describes a multi-stakeholder community collaborative in New York. The Rochester Blood Pressure Collaborative encourages and supports the development of programs to improve blood pressure control in metropolitan Rochester, NY. After the collaborative's members, which include the Rochester Business Alliance and the Finger Lakes Health Systems Agency, defined goals for the program, a series of workgroups designed and supported implementation of initiatives within provider organizations, employers and community-based organizations. Early evidence suggests that this collaborative program has spurred implementation of a variety of promising initiatives at provider, employer and community sites; attracted growing interest from primary care physicians and their patients; and increased the proportion of hypertensive patients who have achieved blood pressure control. 

Select to access more innovation profiles, tools and resources related to clinical–community collaboration and partnerships on the Innovations Exchange Web site, which contains more than 800 searchable innovations and 1,550 quality tools.

 3. Register for National Quality Strategy Webinar on August 8

Join us for a free webinar on August 8 from 12:30 to 2:00 p.m. ET for an inside look at the 2013 Annual Progress Report to Congress on the National Quality Strategy for Quality Improvement in Health Care. Released in July, the Annual Report provides details on implementation activities by the private and public sectors, efforts to align quality measures and successes in the six priority areas, including patient safety, community health, and affordability. The webinar will offer:

  • An update from the HHS lead for National Quality Strategy implementation.
  • A presentation from the California Department of Health Care Services on its Quality Strategy, modeled on the National Quality Strategy.
  • Insight on tools and resources to help you promote and align to the strategy's aims and priorities.

Registration is required. Select to register for the webinar.  

 4. AHRQ's Web M&M Examines Diagnostic Errors and Emergency Surgery

The current issue of AHRQ Web M&M features a Spotlight Case describing an 81-year-old woman who arrived at the hospital with acute abdominal pain, nausea and vomiting. The patient, who had a history of pancreatitis, was diagnosed with small bowel obstruction and taken for emergency surgery, which was halted following complications. She died of progressive multi-organ system failure the next day. The hospital's case review committee believed the patient had severe acute pancreatitis and that the diagnostic error resulted in a preventable death because surgery would not have been needed to manage her pancreatitis. 

A commentary on the case is provided by Nicholas Symons, M.B.Ch.B., M.Sc., Honorary Clinical Research Fellow at Imperial College London. The Perspectives on Safety section features an interview with J. Bryan Sexton, Ph.D., M.A., associate professor and director of Duke University Health System's Patient Safety Center. Physicians and nurses can receive free CME, CEU, or training certification by taking the Spotlight Quiz. Select to read the current issue of AHRQ Web M&M.

 5. AHRQ's Patient Safety Network Offers Primer on Root Cause Analysis in Health Care

Root cause analysis (RCA) is a widely used, structured method to analyze errors in health care from a systems approach and eliminate the underlying causes that lead to patient harm. AHRQ's Patient Safety Network (PSNet) offers a primer to guide health care providers and leaders through RCA as a key concept in patient safety, with background and contextual information, highlighting relevant materials to support RCA in the health care environment. The Joint Commission has mandated the use of RCA to analyze sentinel events (such as wrong-site surgery) since 1997, and many states require that RCA be performed and reported after a serious event. Select to access the full patient safety primer, titled "Root Cause Analysis."

 6. AHRQ in the Professional Literature

Moy E, Mau MK, Raetzman S, et al. Ethnic differences in potentially preventable hospitalizations among Asian Americans, Native Hawaiians, and other Pacific Islanders: implications for reducing health care disparities. Ethn Dis 2013 Spr; 23(1):6–11. Select to access the abstract on PubMed®.

Haynes K, Beukelman T, Curtis JR, et al. Tumor necrosis factor α inhibitor therapy and cancer risk in chronic immune-mediated diseases. Arthritis Rheum 2013 Jan; 65(1):48-58. Select to access the abstract on PubMed®.

Trikalinos TA, Olkin I. Meta-analysis of effect sizes reported at multiple time points: a multivariate approach. Clin Trials 2012 Oct; 9(5):610-20. Select to access the abstract on PubMed®.

Chen J, Dharmarajan K, Wang Y, et al. National trends in heart failure hospital stay rates, 2001 to 2009. J Am Coll Cardiol 2013 Mar 12; 61(10):1078-88. Select to access the abstract on PubMed®.

Federspiel JJ, Mudrick DW, Shah BR, et al. Patterns and predictors of stress testing modality after percutaneous coronary stenting: data from the NCDR. J Am Coll Cardiol Cardiovasc Imaging 2012 Oct; 5(10):969-80. Select to access the abstract on PubMed®.

Volandes AE, Paasche-Orlow MK, Mitchell SL, et al. Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol 2013 Jan 20; 31(3):380-6. Select to access the abstract on PubMed®.

Clement RC, Carr BG, Kallan MJ, et al. Volume-outcome relationship in neurotrauma care. J Neurosurg 2013 Mar; 118(3):687-93. Select to access the abstract on PubMed®.

Davidoff AJ, Weiss SR, Baer MR, et al. Patterns of erythropoiesis-stimulating agent use among Medicare beneficiaries with myelodysplastic syndromes and consistency with clinical guidelines. Leuk Res 2013 Mar 21. Select to access the abstract on PubMed®.

Contact Information

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Page last reviewed August 2013
Internet Citation: AHRQ-Supported Conference on September 22–25 Will Explore Diagnostic Errors: Electronic Newsletter, Issue 391. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/e-newsletter/391.html