AHRQ Views Blog: In Pandemic’s Wake, We Must Recommit to Patient and Workforce Safety
Issue Number
843
December 13, 2022
AHRQ Stats: Access to Treatment for Illicit Drug Use
In 2020, the percentage of people who needed and received treatment for illicit drug use at a specialty facility was below 10 percent. (Source: AHRQ 2022 National Healthcare Quality and Disparities Report [PDF, 15.5 MB].)
Today's Headlines:
- AHRQ Views Blog: In Pandemic’s Wake, We Must Recommit to Patient and Workforce Safety.
- Researchers Find Four Themes Around Successful Infection Prevention During the Pandemic.
- Limited Patient Access to Spanish-Language Services in a Postpartum Unit.
- Highlights From AHRQ’s Patient Safety Network.
- AHRQ Releases Learning Modules in Spanish, Tagalog, Haitian Creole for Nursing Home Staff.
- Available Now: Updated AHRQ Surveys on Patient Safety Culture™ Action Planning Tool.
- New Research and Evidence From AHRQ.
- AHRQ in the Professional Literature.
AHRQ Views Blog: In Pandemic’s Wake, We Must Recommit to Patient and Workforce Safety
In a new AHRQ Views blog, Director Robert Otto Valdez, Ph.D., M.H.S.A., describes the co-creation of a new public–private group that will recommit to ensuring the safety of patients and the healthcare workforce. Formation of The National Action Alliance to Advance Patient Safety was announced at a Nov. 14 HHS safety event attended by 800 people online and 200 in person. Attendees noted ongoing and new safety challenges heightened by the COVID-19 pandemic and voiced support for stronger efforts to protect patients and healthcare workers. Federal leaders cited an Institute for Healthcare Improvement blueprint with timely solutions to persistent safety issues titled, Safer Together: A National Action Plan to Advance Patient Safety. And on Dec. 12, HHS published a new Request for Information that seeks public input on how the National Action Alliance can be most effective; comments are due by Jan. 26. Access the blog post. To receive all blog posts, submit your email address and select “AHRQ Views Blog.”
Researchers Find Four Themes Around Successful Infection Prevention During the Pandemic
Successful maintenance of healthcare-associated infection (HAI) prevention activities during the COVID-19 pandemic depended on four common elements, according to a new study by AHRQ and AHRQ-funded researchers. The article in BMJ Open Quality draws upon interviews with participants in the AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI who continued with recommended prevention activities such as daily huddles, multidisciplinary rounds and central line and indwelling urinary catheter monitoring despite pandemic barriers. The article summarizes how intensive care unit teams adapted their practices around four themes: continuing CLABSI and CAUTI prevention teams, policies and practices established before the pandemic; being flexible in implementation of those policies and practices; maintaining consistent buy-in for and engagement in HAI prevention activities among both leadership and care teams; and learning from other units in their facility and others. Access the abstract.
Limited Patient Access to Spanish-Language Services in a Postpartum Unit
AHRQ-funded research showed that certified Spanish-language interpreters were underused in the postpartum unit of a tertiary academic medical center in the southeastern United States. A clinician certified in medical Spanish or an interpreter was offered to only 12 of 50 patients upon admission to the unit and to 7 of 50 of patients for daily maternal and infant medical rounds, according to the article in Nursing for Women’s Health. Providers only sought translation help when they deemed the encounter to be a critical emergency. Not having trained interpreters during patient encounters left providers using hand gestures, broken Spanish or apps when talking to their patients, which can lead to patient harm and is a violation of human rights in childbirth and federal law. Researchers recommended improved interpreter staffing and request workflow, enhanced patient access to interpreter and bilingual clinician services, and accountability for clinicians regarding their utilization of interpreter services when patients are in need. Access the abstract.
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:
- Association of measured quality and future financial performance among hospitals performing cardiac surgery.
- Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.
- Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial.
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).
AHRQ Releases Learning Modules in Spanish, Tagalog, Haitian Creole for Nursing Home Staff
AHRQ has released translations in Spanish, Haitian Creole and Tagalog of learning modules that nursing home staff can watch at their own pace to learn about COVID-19 prevention and how to support residents’ and staff emotional health. Each of the six modules—intended for nursing assistants, housekeeping, dietary, and maintenance staff and others—takes about five minutes to complete. Access the modules.
Available Now: Updated AHRQ Surveys on Patient Safety Culture™ Action Planning Tool
AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) updated Action Planning Tool is intended for healthcare organizations that have completed a SOPS survey and seek to develop an action plan to improve patient safety culture. The tool has been modified into a three-step process that includes identifying areas to improve, planning your improvement initiatives and communicating your action plan. An Action Plan Template is also included to help draft an organization action plan.
New Research and Evidence From AHRQ
- Systematic review (draft open for comment): Postpartum Care Up To One Year After Pregnancy: A Systematic Review.
- Systematic review (draft open for comment): Management of Postpartum Hypertensive Disorders of Pregnancy.
AHRQ in the Professional Literature
Pragmatic clinical trial of population health, portal-based depression screening: the PORTAL-Depression study. Franco MI, Staab EM, Zhu M, et al. J Gen Intern Med Epub 2022 Sep 20. Access the abstract on PubMed®.
Unpacking complex interventions that manage care for high-need, high-cost patients: a realist review. Chang E, Ali R, Berkman ND. BMJ Open 2022 Jun 9;12(6):e058539. Access the abstract on PubMed®.
Direct-to-patient telehealth equity: reaching diverse pediatric populations in primary care. Jones SA, Van Driest S, Sommer EC, et al. Fam Syst Health Epub 2022 Jun 9. Access the abstract on PubMed®.
High-risk patient experiences associated with an intensive primary care management program in the Veterans Health Administration. Schuttner L, Guo R, Wong E, et al. J Ambul Care Manage 2023 Jan-Mar;46(1):45-53. Epub 2022 Aug 27. Access the abstract on PubMed®.
Systematic review of international studies evaluating MDRD and CKD-EPI estimated glomerular filtration rate (eGFR) equations in Black adults. Umeukeje EM, Koonce TY, Kusnoor SV, et al. PLoS One 2022 Oct 18;17(10):e0276252. Access the abstract on PubMed®.
Effective facilitator strategies for supporting primary care practice change: a mixed methods study. Sweeney SM, Baron A, Hall JD, et al. Ann Fam Med 2022 Sep-Oct;20(5):414-22. Access the abstract on PubMed®.
Association of Medicaid expansion in Arkansas with postpartum coverage, outpatient care, and racial disparities. Steenland MW, Wilson IB, Matteson KA, et al. JAMA Health Forum 2021 Dec 17;2(12):e214167. Access the abstract on PubMed®.
Warfarin monitoring in safety-net health systems: analysis by race/ethnicity and language preference. Sharma AE, Khoong EC, Rivadeneira N, et al. J Gen Intern Med 2022 Aug;37(11):2703-10. Epub 2022 Jan 6. Access the abstract on PubMed®.
Collaborative to increase lethal means counseling for caregivers of youth with suicidality. Leyenaar JK, Tolpadi A, Parast L, et al. Pediatrics 2022 Dec 1;150(6):e2021055271. Access the abstract on PubMed®.