AHRQ Annual Highlights, 2008 (continued)

Developing and Promoting the Use of Evidence

AHRQ supports efforts improve health care by building the foundation of evidence for interventions and approaches in clinical practice. Patients, providers, and payers all need information on which treatments work most effectively, whom these treatments work for, under what circumstances, and the risks involved. This information needs to be objective, reliable, understandable, and easily accessible. AHRQ supports several initiatives to help synthesize and translate evidence-based information on health care effectiveness.

Evidence-based Practice Centers

Under AHRQ's Evidence-based Practice Centers (EPCs), institutions in the United States and Canada receive multi-year contracts to review all relevant scientific literature on clinical, behavioral, organization and financing topics, methodology of systematic reviews, and other health care delivery issues, and produce evidence reports and technology assessments. The information in these reports is used by Federal and State agencies, private-sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based health care for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas.

Recent Research Findings from the EPC Program

In 2008, the 14 EPCs released 10 new evidence and technology reports. Examples include:

  • Effectiveness of Assisted Reproductive Technology. Researchers reviewed the evidence regarding the outcomes of interventions used in ovulation induction, superovulation, and in vitro fertilization (IVF) for the treatment of infertility. Interventions for which there was sufficient evidence to demonstrate improved pregnancy or live birth rates included:
    1. Administration of clomiphene citrate in women with polycystic ovarian syndrome.
    2. Metformin plus clomiphene in women who fail to respond to clomiphene alone.
    3. Ultrasound-guided embryo transfer, and transfer on day 5 post-fertilization, in couples with a good prognosis.
    4. Assisted hatching in couples with previous IVF failure.
    However, there is relatively little high-quality evidence to support the choice of specific interventions.
  • Outcomes of Maternal Weight Gain. Researchers found overall, strong evidence that supported an association between gestational weight gains and the following outcomes: preterm birth, total birthweight, low birthweight, macrosomia, large-for-gestational-age infants, and small-for-gestational-age infants. To understand fully the impact of gestational weight gain on short- and long-term outcomes for women and their offspring will require that researchers use consistent definitions of weight gain during pregnancy, better address confounders in their analyses, improve study designs and statistical models, and conduct studies with longer followup.
  • Diabetes Education for Children With Type 1 Diabetes Mellitus and Their Families. This report indicates that there is insufficient evidence to identify a particular diabetes education intervention that is more effective than standard care to improve diabetes control or quality of life or to reduce short-term complications. Successful interventions were heterogeneous and included cognitive behavioral therapy, family therapy, skills training, and general diabetes education.

Topics in Progress

The EPCs are currently working on the following topics:

  • Complementary and Alternative Medicine in Back Pain Utilization.
  • Management of Acute Otitis Media, update.
  • Nutrition.
  • Management of Chronic Hepatitis B.

For more about the Evidence-based Practice Center program, go to.http://www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html

Centers for Education and Research on Therapeutics

The Centers for Education and Research on Therapeutics (CERTs) is a national program that conducts research and provides education to advance the optimal use of drugs, biologicals, and medical devices. The CERTs program, which is administered by AHRQ in partnership with the Food and Drug Administration (FDA), was originally authorized by Congress in 1997 to examine the benefits, risks, and cost-effectiveness of therapeutic products; educate patients, consumers, doctors, pharmacists, and other clinical personnel; and improve quality of care while reducing unnecessary costs by increasing appropriate use of therapeutics and preventing adverse effects and their medical consequences.

Recent Research Findings from the CERTs Program

  • Examining 217 blood cultures taken from children, researchers from the University of Pennsylvania CERT found that two common bacteria, Escherichia coli and Klebsiella, are showing resistance to the broad-spectrum antibiotics called fluoroquinolones. Children are not generally prescribed these drugs, but adults receive the two most common fluoroquinolones: ciproflaxin and levofloxacin. Researchers were unable to determine risk factors for infection with the resistant bacteria in children.
  • The HMO Research Network Center for Education and Research on Therapeutics studied a nationally representative group of Medicare beneficiaries and found that implementation of the Medicare Part D drug plan was associated with a small, but significant, decrease in the prevalence of cost-related medication nonadherence (CRN). Nearly a year after implementation of Medicare Part D, the prevalence of CRN had declined by about 15 percent and spending less on basic needs to afford medicines declined by approximately 40 percent, compared to prior years. While CRN did not decrease among individuals who were seriously ill, they did report reductions in foregoing basic needs to afford medication that were similar to those among beneficiaries in good to excellent health.

More information about the CERTs program can be found at http://certs.hhs.gov/about/certsovr.htm.

National Guideline Clearinghouse™

In 2008, AHRQ's National Guideline Clearinghouse™ (NGC), in conjunction with the AHRQ's National Quality Measures Clearinghouse™ (NQMC), officially began publishing Expert Commentary. Together the two resources published 10 Expert Commentaries, 2 of which were applicable to both the guideline and measures communities. Topics of the NGC-specific expert commentaries covered: guideline development methodology; guideline development challenges and potential solutions; and, clinical practice recommendation gaps in published guidelines. Relating guidelines and quality measures occurred in expert commentary on the patient safety revolution and a successful program to get cardiology guidelines implemented into practice. These commentaries were authored either by members of the NGC/NQMC Editorial Board or by experts the Editorial Board sought out.

The NGC is a Web-based resource for information on over 2,200 evidence-based clinical practice guidelines. Since becoming fully operational in 1999, the NGC has had over 46 million visits and now receives approximately 1 million visits each month. The NGC helps health care providers, health plans, integrated delivery systems, purchasers, and others obtain objective, detailed information on clinical practice guidelines.

For more information about the NGC, go to http://www.guideline.gov.

United States Preventive Services Task Force

In 2008, the U.S. Preventive Services Task Force (Task Force) continued to provide the "gold standard," recommendations that are the evidence base for preventive services provided in this Nation. It was first convened by the U.S. Public Health Service in 1984. Sponsored by AHRQ since 1998, the Task Force is the leading independent panel of private-sector experts in prevention and primary care. The Task Force conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. AHRQ provides technical and administrative support, but the recommendations of the panel are its own. The mission of the Task Force is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.

Three evidence-based consumer checklists released by AHRQ in 2008 are based in part on Task Force recommendations: Men: Stay Healthy at Any Age, Your Checklist for Health; Women: Stay Healthy at Any Age, Your Checklist for Health; and Staying Healthy at 50+, an accompanying timeline wall chart that can be posted in both clinical and community settings. Checklists for Health, available in English and Spanish, are brochures that adults can take along to medical appointments and are designed to help patients and clinicians engage in discussions about necessary preventive screening tests. Patients can use the checklists to record their screening test history and plan follow-up medical appointments. Both checklists also provide tips about other things to do to stay healthy, such as eating a healthy diet and exercising. The checklists are available on the AHRQ Web site at http://www.ahrq.gov/ppip/healthymen.htm and http://www.ahrq.gov/ppip/healthywom.htm.

The Task Force released the following new or updated recommendations in 2008:

  • Screening for Illicit Drug Use—concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.
  • Screening for Chronic Obstructive Pulmonary Disease Using Spirometry—recommends against screening adults without symptoms of chronic obstructive pulmonary disease using spirometry.
  • Screening for Prostate Cancer—recommends against screening for prostate cancer in men age 75 and older, and concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening in men younger than age 75.
  • Screening for Lipid Disorders in Adults—recommends screening men aged 35 and older and women aged 45 and older; for those who are at increased risk for coronary heart disease, men aged 20 to 35 and women aged 20 to 45 should be screened.
  • Screening for Asymptomatic Bacteriuria—recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later, and recommends against screening for asymptomatic bacteriuria in men and nonpregnant women.
  • Screening for Gestational Diabetes—concludes that the evidence is insufficient to recommend for or against routine screening for gestational diabetes.
  • Screening for Type 2 Diabetes Mellitus in Adults—recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg, and concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening asymptomatic adults with blood pressure of 135/80 mm Hg or lower.
  • Screening for Bacterial Vaginosis in Pregnancy—recommends against screening for bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery, and concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in asymptomatic pregnant women at high risk for preterm delivery.
  • Screening for Newborn Hearing Loss—recommends screening for hearing loss in all newborn infants.
  • Screening for Congenital Hypothyroidism—recommends screening for congenital hypothyroidism in newborns.
  • Screening for Phenylketonuria—recommends screening for phenylketonuria in newborns.

In 2008, the Task Force began releasing a series of short videos online to assist physicians in applying "I statements" (indicating that the current evidence is insufficient to assess the balance of benefits and harms of the specific service):

  • Screening for Prostate Cancer.
  • Screening for Coronary Heart Disease with Exercise Tolerance Testing in Adults.
  • Screening and Interventions for Overweight in Children and Adolescents.
  • When the Evidence is Insufficient, Adult Recommendations.
  • When the Evidence is Insufficient, Pediatric Recommendations.

The videos are available at http://www.uspreventiveservicestaskforce.org/ivideos.htm.

More information on the Task Force as well as copies of reports and guides can be found at http://www.ahrq.gov/clinic/uspstfix.htm.

Translating Evidence into Improved Care

To speed the implementation of research into practice, AHRQ supports two programs: primary care Practice-Based Research Networks (PBRNs) and Accelerating Change and Transformation in Organizations and Networks (ACTION). PBRNs are composed principally of community-based primary care practices with ten or fewer physicians. Understanding the care provided in these settings is important since over two-thirds of primary care physicians currently work in small (less than ten physician) practices where—despite the recent growth of large HMOs—the majority of Americans continue to receive primary care services. ACTION helps accelerate the translation of research into practice by performing field-based research and promoting rapid-cycle research and implementation by linking large health care systems with top health services researchers.

Primary Care Practice-Based Research Networks

Primary care practice-based research networks (PBRNs) are organized groups of primary care clinicians and practices that work together with academic researchers to study issues related to health care, including improvement of the quality of care. The 120 primary care PBRNs known to be active in the United States include about 20,000 practices of pediatrics, family medicine, and general internal medicine located in all 50 States. These practices provide care for more than 20 million Americans.

Practice-Based Research Network Resource Center

Since 2002, AHRQ has supported the Practice- Based Research Network Resource Center. The Center manages a national registry of active primary care PBRNs across the country, and provides resources and assistance to registered PBRNs engaged in clinical and health services research.

A National Medication Error and Adverse Drug Event Reporting System for Ambulatory Care (MEADERS)

Through its PBRN Resource Center, AHRQ has supported PBRN researchers and practitioners in the design and testing of a user friendly system for reporting medication errors and adverse drug events observed in primary care practices. Since the system is Internet-based, it can be made accessible to any primary care practice with Internet access, while maintaining tight data security. Analytic tools that allow aggregation of error reports are built into the software. With a single click, practitioners can opt to forward their report to the FDA's MedWatch program. MEADERS was tested in 26 primary care practices that participate in four AHRQ-supported PBRNs. The pilot testing was successful. The practices found the Web site easy to use, and staff and physicians reported over 500 medication errors and adverse drug events. AHRQ expects to make the software available to the public in 2009.

PBRN Research in Progress

AHRQ has awarded master contracts to 10 PBRN's or PBRN consortia and the participating networks have received funding for 12 task orders. Two examples of projects carried out under PBRN task orders are:

  • The North Carolina Network Consortium is conducting a comparative analysis of the costs incurred by eight primary care practices in North Carolina in the process of collecting and reporting performance data. The study also focuses on the barriers and facilitators to practices as they begin to report quality-related information.
  • The Oklahoma Physicians Resource/Research Network developed and pilot tested simple internet and telephone-based resources to assist small primary care practices prepare for the expected patient surge in the event of a pandemic influenza outbreak. The materials, produced in English and Spanish, are designed to allow practices to provide their patients with information about caring for themselves while sheltering in place and complete automated initial triaging concerning the need to be seen by a clinician. AHRQ expects to make the tools available to the public in 2009.

For more information on PBRNs and their research projects, got to http://pbrn.ahrq.gov.

Accelerating Change and Transformation in Organizations and Networks

Accelerating Change and Transformation in Organizations and Networks (ACTION) was begun in 2006 as the successor to AHRQ's Integrated Delivery System Research Network. ACTION is a 5-year model of field-based research that fosters public-private collaboration in rapid-cycle, applied research. It links many of the Nation's largest healthcare systems with its top health services researchers. Each of ACTION's 15 partnerships has a demonstrated capacity to "turn research into practice" for proven interventions targeting those who manage, deliver, or receive health care services. As a network, ACTION provides health services in a wide variety of organizational care settings to at least 100 million Americans. ACTION has over 150 collaborating organizations in all States. The partnerships provide access to large numbers of providers, major health plans, hospitals, long-term care facilities, ambulatory care settings, and other care sites. Each partnership includes health care systems with large, robust databases, clinical and research expertise, and the authority to implement health care interventions.

From 2006 through 2008, ACTION partnerships received 59 awards totaling $30.6 million. AHRQ funding focused primarily on Health IT, patient safety, prevention, and the organization of health care delivery. During this time, ACTION has promoted "rapid-cycle" implementation research, dissemination, and uptake of evidence-based and highly promising products, strategies, and findings. Two examples of ACTION projects include creating a pill card to help people take their medications correctly and reducing methicillin-resistant Staphylococcus aureus (MRSA) infections in hospitals.

How to Create a Pill Card

About 25 percent of Americans do not take medicines as prescribed, often because they don't understand how to do so. Researchers at Emory University developed pill cards using pictures and simple phrases to show each medicine, its purpose, how much to take, and when to take it. Free, online instructions were developed to give step-by-step instructions to patients or caregivers to create a pill card using a computer and a printer. To date, there have been over 10,000 Web hits and 1,000 downloads of the Pill Card Manual from the Web site available at http://www.ahrq.gov/qual/pillcard/pillcard.htm.

MRSA Infection Reduction in Indianapolis Hospitals

More than 5,000 patients die as a result of MRSA infections in hospitals annually, resulting in over $2.5 billion excess health care costs. Indiana University developed and implemented a novel approach to reduce MRSA in ICUs in several hospital systems in Indianapolis. They significantly improved surveillance, hand hygiene, contact isolation, and achieved an average 60 percent reduction in MRSA infections in intervention units and 20 percent reduction in control units.

More information on ACTION partnerships and projects can be found on the AHRQ Web site at http://www.ahrq.gov/research/action.htm.

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Improving the Safety and Quality of Health Care

In support of its mission to improve the quality, safety, efficiency, and effectiveness of health care, AHRQ supports research and develops successful partnerships that help generate and implement the knowledge and tools required for long-term improvements in health care. Finding ways to eliminate medical errors and improve patient safety have been an integral part of the Agency's research agenda since 2001. AHRQ-funded research projects and partnerships identify, develop, test, and implement patient safety and quality measures.

Patient Safety Organizations

In February 2008, HHS published a proposed regulation which detailed the establishment and implementation processes for Patient Safety Organizations (PSOs). PSOs are entities that collect and analyze patient safety events reported by health care providers. These organizations will help improve the quality and safety of health care as providers can voluntarily report patient safety events to PSOs without fear of new tort liability. In addition, the PSOs allow for clinicians and health care organizations to voluntarily share data on patient safety events more freely and consistently within a protected environment. Under the proposed regulation, PSOs can collect, aggregate, and analyze data and can provide feedback to help clinicians and health care organizations to improve health care quality. Strong confidentiality provisions are the key to voluntary reporting, and breaches of these confidentiality provisions may result in the imposition of civil monetary penalties.

AHRQ coordinates the development of Common Formats for event reporting to PSOs. On August 29, 2008, AHRQ published the availability of Common Formats (Version 0.1 Beta) for patient safety event reporting in the Federal Register. Common Formats describe the technical requirements and reporting specifications that allow health care providers to collect and submit standardized information regarding patient safety events. AHRQ is currently receiving public comment and feedback on the Common Formats. AHRQ awarded a task order to the National Quality Forum for convening an expert panel to review the feedback received on the Common Formats. The expert panel began meeting in September, 2008. De-identified information sent to the Network of Patient Safety Databases using the Common Formats will be used to develop reports for AHRQ's annual National Healthcare Quality Report.

On October 8, 2008, AHRQ released Interim Guidance that outlines the statutory requirements for entities to be listed as a PSO. AHRQ will administer the rules for listing qualified PSOs. HHS anticipates release of the final regulation on PSOs to occur before the end of 2008.

AHRQ Patient Safety Network (PSNet)

AHRQ's PSNet (http://www.psnet.ahrq.gov) is a national Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates on patient safety literature, news, tools, and meetings and a vast set of carefully annotated links to important research and other information on patient safety. Supported by a robust patient safety taxonomy and Web architecture, the AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse users to customize the site around their interests. Its Patient Safety Primers (http://psnet.ahrq.gov/primerHome.aspx) guide users through key concepts in patient safety with each primer providing background and context and highlighting relevant content from AHRQ PSNet and AHRQ WebM&M.

Partnerships in Implementing Patient Safety

AHRQ has released an array of toolkits designed to help doctors, nurses, hospital managers, patients, and others reduce medical errors. The 17 toolkits were developed through AHRQ's Partnerships in Implementing Patient Safety (PIPS) program and correlate with the Joint Commission's National Patient Safety Goals, which promote system wide improvements in patient safety. In developing the toolkits, researchers examined best practices in a variety of health care settings, including small rural facilities, large urban hospitals, health clinics, and hospital emergency departments.

While some of the toolkits focus on identifying high-risk practices, others are designed to help health professionals reduce medication errors or other patient harms. Examples of the kinds of interventions that the toolkits promote include:

  • Your Guide to Preventing and Treating Blood Clots—an easy-to-read consumer brochure that helps consumers spot and prevent dangerous blood clots called deep vein thrombosis (DVT). Hundreds of thousands of Americans develop DVT each year and many die from complications. The guide is being marketed to consumer groups and clinicians as a patient education tool.
  • Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement—a 50-page guide to help hospital-based clinicians prevent DVT in their facility. It offers tools and sample forms to support a prevention effort as well as step-by-step instructions on building a collaborative improvement model in the hospital setting. Both the consumer and physician guides were released in coordination with The Surgeon General's Call to Action on Deep Vein Thrombosis and Pulmonary Embolism.
  • "Door to Doc"—this AHRQ-funded project focused on improving patient flow in the emergency department to expand treatment capacity and improve patient safety by helping to reduce or eliminate patients leaving without treatment. The "Door to Doc" (D2D) was developed and implemented in eight Banner Health hospitals. The D2D program, conjointly developed by Banner Health and Arizona State University, improves the safety of care for patients in the emergency department by reducing the time patients wait to be seen by a physician.

More information can be found at http://www.ahrq.gov/qual/pips.

Patient Safety Improvement Corps

The Patient Safety Improvement Corps (PSIC) is a partnership program between AHRQ and the Department of Veterans Affairs (VA). The PSIC program content includes a number of topics, tools, and methods designed to help participants reduce medical error and improve patient safety. By 2008, one or more teams had been trained in every state in the United States. The 2007-08 PSIC included teams from 21 states, Puerto Rico, and HHS's Health Resources and Services Administration. Additional information on the PSIC can be found at http://www.ahrq.gov/about/psimpcorps.htm.

Patient Safety Culture Surveys

As part of its goal to support a culture of patient safety and quality improvement in the Nation's health care system, AHRQ sponsors the development of patient safety culture assessment tools for hospitals, nursing homes, and medical offices. In 2006, the Agency introduced the Patient Safety Culture Survey Database as a central repository for survey data so that hospitals and their units could determine how well they were doing in establishing a culture of safety in comparison to other hospitals or hospital units. Health care organizations can use these survey assessment tools to assess their patient safety culture, track changes in patient safety over time, and evaluate the impact of specific patient safety interventions. Subsequent surveys include the Hospital Survey on Patient Safety Culture, Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report, and Nursing Home Survey on Patient Safety Culture. The Medical Office Survey on Patient Safety Culture will be available by the end of 2008.

Additional information on the Patient Safety Culture Surveys can be accessed at http://www.ahrq.gov/qual/hospculture/.

TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety

TeamSTEPPS was developed by the Department of Defense in collaboration with AHRQ. TeamSTEPPS is an evidence-based teamwork system training curriculum aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into a health care system. TeamSTEPPS is now a part of the Centers for Medicare & Medicaid Services (CMS) 9th Scope of Work for all Quality Improvement Organizations.

Three-day train-the-trainer sessions under the TeamSTEPPS National Implementation Project commenced in 2008 at four Team Resource Centers: Duke Medical Center, Durham, North Carolina; Carilion Clinic, Roanoke, Virginia; University of Minnesota Fairview Medical Center, Minneapolis, Minnesota; and Creighton University Medical Center, Omaha, Nebraska. These initial trainings will create a national network of master trainers, who will in turn offer TeamSTEPPS training to frontline providers in hospitals and other health care settings throughout the country. This training will be offered until September 2009.

More information on TeamSTEPPS can be found at http://teamstepps.ahrq.gov/index.htm.

AHRQ WebM&M AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) is a popular online journal and forum on patient safety and health care quality that features expert analysis of medical errors reported anonymously by readers, interactive learning modules on patient safety, perspectives on safety, and online discussions. Continuing medical education and continuing education unit credits are offered. WebM&M can be accessed at http://www.webmm.ahrq.gov/.

Institute of Medicine Study on Resident Work Hours

The findings of this study on resident work hours and the effect resident fatigue has on patient safety will be released in early December 2008. This study was directed by Congress and funded by AHRQ. The findings of this study will focus on four areas: synthesis of the current evidence base on graduate medical trainees hours and works schedules and their impact on safety; identification and development of strategies, practices, interventions and tools that can be used to implement reasonable work hours; analysis of both the potential benefits and harms of updating work hours and schedules; and short- and long-term recommendations for action by various stakeholders and interim strategies and policies for implementing these recommendations. More information on the study is available at http://www.iom.edu/CMS/3809/48553/60449.aspx.

Advances in Patient Safety

In September 2008, AHRQ released a four-volume publication—Advances in Patient Safety: New Directions and Alternative Approaches— building and expanding upon the growing body of evidence for reducing medical errors and improving patient safety. Considerable breadth of content is covered in the 115 papers, including reporting systems, taxonomies and measurement, risk assessment, safety culture, process improvement, system redesign, patient involvement, teamwork, simulation, human factors, tools and practices, health information technology, and medication safety.

Handbook for Nurses

Nurses play a vital role in improving the safety and quality of patient care—not only in the hospital or ambulatory treatment facility, but also in community-based care and the care performed by family members. It is important for nurses to know what proven techniques and interventions they can use to enhance patient outcomes. To help address this need, AHRQ, with additional funding from the Robert Wood Johnson Foundation, published Patient Safety and Quality: An Evidence-based Handbook for Nurses a comprehensive handbook for nurses on patient safety and quality.

Recent Research Findings on Patient Safety and the Quality of Health Care

  • Potentially preventable medical errors that occur during or after surgery may cost employers nearly $1.5 billion a year, according to new estimates by AHRQ researchers. Using AHRQ's Patient Safety Indicators to identify medical errors, the study found that insurers paid an additional $28,218 (52 percent more) and an additional $19,480 (48 percent more) for surgery patients who experienced acute respiratory failure or post-operative infections, respectively, compared with patients who did not experience either error. The study also found that 1 of every 10 patients who died within 90 days of surgery did so because of a preventable error and that one-third of the deaths occurred after the initial hospital discharge.
  • A study finds that most physicians reported they had been involved in an error, and the majority agreed that they should report errors to improve patient safety. However, only 30 percent of physicians agreed that current systems to report patient safety events were adequate. Almost all (95 percent) physicians agreed that they needed to know about errors in their organization to improve patient safety. When asked what would increase their willingness to formally report error information, they said they wanted information to be kept confidential and non-discoverable, evidence that the information would be used for system improvements and not punitive action, the reporting process to take less than 2 minutes, and review activities to be confined to their department.
  • Medical residents with depression made significantly more medical errors than their nondepressed peers. Residents with depression made 6.2 times as many medication errors per resident month as residents who were not depressed. In addition, residents who were depressed or burnt out reported poorer health than peers who did not have these problems. The findings indicate that mental health may be a more important contributor to patient safety than previously suspected.
  • The Prescription Drug User Fee Act (PDUFA), which became law in 1992, sought to speed up the process of bringing new drugs to market by giving the FDA additional resources while setting deadlines of 6 months for consideration of priority-rated drug applications (drugs deemed therapeutically novel by the FDA) and 12 months (now 10 months) for other new drugs. A study that focused on new drugs approved from 1990 to 2001 found that 310 drugs had a total of 96,751 serious adverse drug reactions (ADRs) within 2 years after FDA approval-including 57,511 that required hospitalization and 17,797 that resulted in death. Mean review times for these drugs showed a declining pattern over the sample period. For example, new drugs approved from 1990 to 1992 had an average review time of 31 months while drugs approved in 1996 to 2001 had a mean review time under 17 months. A 10-month reduction in review time was associated with a 12 percent increase in serious ADRs reported during the first 2 years after FDA approval, an 11 percent increase in ADR hospitalizations, and an 11 percent increase in ADR deaths.
  • Identifying drug prescriptions that are stopped within 45 minutes of the initial prescribing is an inexpensive and quick way to detect prescribing errors. An analysis of medication orders entered into a computerized physician order entry (CPOE) system at an urban hospital and discontinued within 2 hours revealed that of 114 rapidly discontinued orders by 75 physicians during a 24-day period, two-thirds of medication orders discontinued within 45 minutes were deemed inappropriate (for example, wrong dose or drug). In addition, 55 percent of medication orders discontinued within 2 hours were deemed inappropriate.
  • Sending automated E-mails to patients after they are prescribed new drugs may help detect and prevent adverse drug events. Researchers examined actions patients took after receiving automated E-mail messages asking them about new medications they were prescribed. Of 267 patients, 128 responded to the initial E-mail, 77 percent opened the initial E-mail within a day of its being sent, and 13 percent sent responses. Patients asked about drug effectiveness, drug-related side effects, and the dose. In return, 68 percent of physicians responded to the patients' E-mails, usually within a week. Typical responses included asking questions, providing information, writing a new prescription, or changing the dose. During chart reviews, physicians identified 17 adverse drug events that were brought to light because of the E-mail exchanges.

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Current as of September 2012
Internet Citation: AHRQ Annual Highlights, 2008 (continued). September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/highlights/highlt08b.html