AHRQ Speaks Up for Patient Safety During Patient Safety Awareness Week

Issue 606
AHRQ News Now is a weekly newsletter that highlights agency research and program activities.
March 13, 2018

AHRQ Stats: Pressure Ulcer Rates of Hospital Patients

About 1.2 million cases of hospital-acquired pressure ulcers occurred in 2015. That reflected a rate of about 36 per 1,000 discharges, a decrease over the 2010 rate of 40 per 1,000 discharges. (Source: AHRQ, 2017 National Healthcare Quality and Disparities Report, Chartbook on Patient Safety.)

Today's Headlines:

AHRQ Speaks Up for Patient Safety During Patient Safety Awareness Week

AHRQ is working with the Institute for Healthcare Improvement/National Patient Safety Foundation (IHI/NPSF) and our sister HHS agencies to promote a wide variety of information and activities for Patient Safety Awareness Week. The annual event raises awareness about the importance of patient engagement and promoting a culture of safety across health care settings. On Monday, Jeffrey Brady, M.D., director of AHRQ's Center for Quality Improvement and Patient Safety, joined a panel of presenters during IHI/NPSF's webinar, "Engaging Patients and Providers: Speaking Up for Patient Safety."  In addition, Dr. Brady co-authored a blog post with IHI Chief Clinical & Safety Officer Tejal Gandhi, M.D., "Patient Safety: Distinct Roles, One Goal." Also this week:

  • Today, AHRQ Director Gopal Khanna, M.B.A., and AHRQ Chief Medical Officer David Meyers M.D., join colleagues from the Health Resources and Services Administration for a panel discussion titled, "United in Mission to Ensure Patient Safety."
  • On Wednesday, access a new grantee profile featuring AHRQ-funded researcher Gregory Maynard, M.D., chief quality officer at the University of California Davis Medical Center. Dr. Maynard has used AHRQ funding to combine quality improvement principles with safe practices to develop protocols that reduce patient harm.
  • On Thursday, an AHRQ Views blog post by Richard Ricciardi, Ph.D, AHRQ's senior nursing advisor, and Majorie Shofer, B.S.N., director of AHRQ's general patient safety program, will highlight "New Tools for Ambulatory Patient Safety."
  • On Friday from noon to 1 p.m. ET, join a Twitter chat, "Building a Culture of Safety in Health Care." Use the hashtag #PSAW18 to participate.

Learn more about AHRQ's ongoing work to protect patient safety, including tools and resources for diverse health care settings as well as Impact Case Studies that illustrate the impact of AHRQ's patient safety initiatives.

Surgical Site Infections Reduced in African Hospitals That Adapted Strategy and Tools From AHRQ Project

Surgical site infections decreased about 60 percent and prevention measures improved in four African hospitals after researchers adapted strategies and tools from a U.S.-based AHRQ supported project to promote safe surgery. Surgical site infections are the most frequent healthcare-associated infection in low- and middle-income countries. The strategies, including interventions to improve teamwork and facilities' patient safety culture, were used in about 4,300 surgeries performed in Kenya, Uganda, Zambia and Zimbabwe. The study, funded by AHRQ and the World Health Organization, was published March 5 in The Lancet Infectious Diseases. Access the abstract. AHRQ's Toolkit To Promote Safe Surgery provides tools to help hospitals reduce surgical site infections and other complications.

Highlights From AHRQ's Patient Safety Network

AHRQ's Patient Safety Network (PSNet) highlights journal articles, books and tools related to patient safety. Articles featured this week include:

Review additional new publications in PSNet's current issue or access recent cases and commentaries in AHRQ's WebM&M (Morbidity and Mortality Rounds on the Web).

"Questions Are the Answer" Initiative Offers Tools To Promote Patient Involvement

"Questions Are the Answer," AHRQ's ongoing public education initiative on patient involvement, offers several information tools to help clinicians and their patients communicate to make health care safer. AHRQ's website features these valuable tools:

  • A seven-minute DVD of patients and clinicians discussing the importance of asking questions and sharing information, which is ideal for a lobby or waiting room area.
  • A brochure, "Be More Involved in Your Health Care: Tips for Patients," that offers helpful suggestions to follow before, during and after a medical visit.
  • Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

"Questions Are the Answer" is designed to promote safer care and better health outcomes. To request a free supply of these materials, email AHRQpubs@ahrq.hhs.gov or call 1-800-358-9295.

Patients With Comorbid Conditions Have Greater Risk of Hospital-Onset C. difficile Infection

A recent AHRQ-funded study found that adult hospital patients were at greater risk for acquiring Clostridium difficile infection if they were older, had received certain medications or had comorbid conditions including weight loss, certain blood disorders, renal failure or certain neurological disorders.  Clostridium difficile, or C. diff, is a healthcare-associated intestinal infection that results in approximately 15,000 deaths per year. Using ICD-10 codes, researchers examined electronic health record data on patients admitted to the University of Maryland Medical Center between November 2015 and May 2017, and captured the presence of comorbid conditions using the AHRQ Elixhauser Comorbidity Index.  They concluded that increased Elixhauser scores are associated with increased Clostridium difficile infection risk, and that the use of methods such as the Elixhauser Comorbidity Index should be considered for risk-adjustment of Clostridium difficile infection rates.  Access the abstract of the study, published in Infection Control and Hospital Epidemiology.

Grant Funding Available for Patient Safety Research

AHRQ is seeking funding applications for research projects that investigate safe medication use, medical simulation, diagnostic safety, healthcare-associated infections (including antibiotic resistance) and patient safety learning labs, where transdisciplinary teams use systems engineering methodology to develop and test innovative ideas for addressing patient safety threats. While AHRQ funds patient safety research in all settings of care, the agency is particularly interested in projects that examine the epidemiology of patient safety in ambulatory care settings and long-term care facilities, strategies that can improve safety in these settings and evidence-based tools to facilitate the implementation of these strategies. Learn more about our patient safety funding opportunities.

Patient Perceptions Impacted by How Physicians Communicate Diagnostic Uncertainty

The manner in which a physician communicates diagnostic uncertainty to a patient's family has a significant impact on the family's view of the physician, according to a recent AHRQ-funded study. Researchers surveyed approximately 70 parents, presenting each with a fictional scenario affecting their child. Several different communication strategies were tested. Parents reacted negatively when physicians stated their uncertainty explicitly, rather than employing a strategy of presenting differential diagnoses. An explicit communications strategy was associated with lower patient perception of physician competence, less trust and lower adherence to physician recommendations. Researchers recommended further development and study of evidence-based communications strategies. Access the abstract of the study, which was published in the International Journal for Quality in Health Care.

AHRQ in the Professional Literature

A novel schema to enhance data quality of patient safety event reports. Kang H, Gong Y. AMIA Annu Symp Proc 2017 Feb 10;2016:1840-9. Access the abstract on PubMed®.

Using active learning to identify health information technology related patient safety events. Fong A, Howe JL, Adams KT, et al. Appl Clin Inform 2017 Jan 18;8(1):35-46. Access the abstract on PubMed®.

Advancing perinatal patient safety through application of safety science principles using health IT. Webb J, Sorensen A, Sommerness S, et al. BMC Med Inform Decis Mak 2017 Dec 19;17(1):176. Access the abstract on PubMed®.

Developing a similarity searching module for patient safety event reporting system using semantic similarity measures. Kang H, Gong Y. BMC Med Inform Decis Mak 2017 Jul 5;17(Suppl 2):75. Access the abstract on PubMed®.

Taking complaints seriously: using the patient safety lens. Gallagher TH, Mazor KM. BMJ Qual Saf 2015 Jun;24(6):352-5. Epub 2015 May 14. Access the abstract on PubMed®.

Perspectives on implementing quality improvement collaboratives effectively: qualitative findings from the CHIPRA Quality Demonstration Grant Program. Burton RA, Peters RA, Devers KJ. Jt Comm J Qual Patient Saf 2018 Jan;44(1):12-22. Epub 2017 Sep 29. Access the abstract on PubMed®.

What role does efficiency play in understanding the relationship between cost and quality in physician organizations? Paddock SM, Damberg CL, Yanagihara D, et al. Med Care 2017 Dec;55(12):1039-45. Access the abstract on PubMed®.

Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers. Britton MC, Ouellet GM, Minges KE, et al. Jt Comm J Qual Patient Saf 2017 Nov;43(11):565-72. Epub 2017 Oct 4. Access the abstract on PubMed®.

Contact Information

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Page last reviewed March 2018
Page originally created March 2018
Internet Citation: AHRQ Speaks Up for Patient Safety During Patient Safety Awareness Week. Content last reviewed March 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/news/newsletters/e-newsletter/606.html
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