AHRQ Patient Safety and Health Information Technology E-Newsletter, Issue No. 65
Agency for Healthcare Research and Quality (AHRQ)
February 11, 2011, Issue #65
Quote of the Month
"We knew that when we applied safety science principles to the delivery of health care, we would dramatically reduce infections in intensive care units, and now we know we are also saving lives." (For more information AHRQ’s new study, go to item no.1.)
—AHRQ-funded researcher Peter J. Pronovost, M.D., Ph.D., a professor of anesthesiology and critical care medicine at The Johns Hopkins University School of Medicine, Baltimore
Today’s Headlines:
AHRQ Patient Safety News:
- Landmark initiative to reduce healthcare-associated infections cuts deaths among Medicare patients in Michigan intensive care units
- Latest issue of AHRQ WebM&M is available online
- 2010 John M. Eisenberg patient safety and quality award recipients announced
- AHRQ in the patient safety professional literature—some useful citations
AHRQ Health IT News:
- Registration now open for the Medicare and Medicaid EHR incentive programs; Medicaid payments have already been issued by two states
- JAMA commentary encourages design of patient-centered health information systems
- AHRQ in the health IT professional literature—some useful citations
AHRQ Patient Safety News:
1. Landmark Initiative to Reduce Healthcare-Associated Infections Cuts Deaths Among Medicare Patients in Michigan Intensive Care Units
Older Americans who were treated in Michigan intensive care units (ICUs) saw larger decreases in their likelihood of dying while hospitalized than similar ICU patients in other Midwestern hospitals, according to a new study evaluating an innovative quality improvement initiative funded by AHRQ. Previous research has shown that targeted quality improvement programs can reduce rates of healthcare-associated infections (HAIs). Researchers led by Allison Lipitz-Snyderman, Ph.D., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and Peter J. Pronovost, M.D., Ph.D., the Johns Hopkins University Quality and Safety Research Group, Baltimore, analyzed Medicare data for ICU patients in Michigan hospitals and 364 hospitals in 11 other Midwestern states. They looked at data before the project was initiated, while it was being phased in, and up to 22 months after implementation. The researchers found that overall a person's chance of dying decreased by about 24 percent in Michigan after the program was implemented compared with only 16 percent in surrounding Midwestern states where the program was not implemented. This study, "Impact of a Statewide Intensive Care Unit Quality Improvement Initiative on Hospital Mortality and Length of Stay: Retrospective Comparative Analysis," was published in the January 31 issue of British Medical Journal. Select to access AHRQ’s press release and the abstract.
2. Latest Issue of AHRQ WebM&M is Available Online
The February issue of AHRQ WebM&M is now available online. The Perspectives on Safety section covers educating practitioners in safety and quality and features an interview with Brent C. James, M.D., of Intermountain Healthcare, Salt Lake City. In the accompanying perspective piece, Eric J. Thomas, M.D., and faculty from the University of Texas discuss their clinical safety and effectiveness course. The Spotlight Case, “One Toxic Drug Is Not Like Another,” features a commentary by Eric S. Holmboe, M.D., of American Board of Internal Medicine, Philadelphia, distinguishing board certification, medical licensure, and credentialing and explaining that physicians must learn to recognize their range of competence. The second case, “Paradoxical Pulse,” features a commentary by Christopher Roy, M.D., Brigham and Women's Hospital, Boston, on the strengths and limits of various methods to discern cardiac tamponade, including pulsus paradoxus. The third case, “Silent Pain in the Neck,” features a commentary by Edward A. Bittner, M.D., Ph.D., of Massachusetts General Hospital, Boston, on key issues in monitoring for and managing postoperative neck hematomas to keep patients safe. Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using the “e-mail a colleague” feature.
3. 2010 John M. Eisenberg Patient Safety and Quality Award Recipients Announced
The National Quality Forum and the Joint Commission announced the 2010 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards, named after the late AHRQ director. The honorees, by award category, were for Individual Achievement: John H. Eichhorn, M.D., University of Kentucky, Lexington, KY; and James L. Reinertsen, M.D., The Reinertsen Group, Alta, WY; Innovation in Patient Safety and Quality at the National Level: Washington State Hospital Association, Seattle, WA; and Innovation in Patient Safety and Quality at the Local Level: The Children’s Hospital at Providence Newborn Intensive Care Unit, Anchorage, AK. Select to read the National Quality Forum press release.
4. AHRQ in the Patient Safety Professional Literature—Some Useful Citations
We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.
Ho PM, Tsai TT, Wang TY, Shetterly SM, Clarke CL, Go AS, Sedrakyan A, et al. Adverse events after stopping clopidogrel in post-acute coronary syndrome patients: insights from a large integrated healthcare delivery system. Circ Cardiovasc Qual Outcomes 2010 Mar 30. Select to access the abstract.
Lambert BL, Dickey LW, Fisher WM, et al. Listen carefully: the risk of error in spoken medication orders. Soc Sci Med 2010 May; 70(10):1599-1608. Select to access the abstract.
AHRQ Health IT News:
The first payments under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program were issued by Oklahoma and Kentucky. Kentucky processed payment to the University of Kentucky‘s teaching hospital, University of Kentucky Healthcare. The first payment, $2.86 million, was one-third of the hospital’s overall expected amount for participating in the program. Oklahoma issued payments to two physicians at the Gastorf Family Clinic of Durant, OK, for $21,250 each, for having adopted certified EHRs. These incentive payments for the adoption of certified EHR technology are funded under the federal Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009. Select for additional information on the action by Oklahoma and Kentucky. For more information on the Medicare and Medicaid EHR Incentive Programs, please visit CMS‘ EHR Web site.
6. JAMA Commentary Encourages Design of Patient-centered Health Information Systems
A commentary featured in the January 19 issue of the Journal of the American Medical Association from AHRQ health IT grantee, Alex Krist, M.D., Virginia Commonwealth University, Richmond, VA, calls for the design of a patient-centered health information system that goes beyond the personal health record. Dr. Krist explains that in order for technology to be used, a system should be designed to help patients access health information, interpret data from multiple sources and serve as a tool to facilitate action. Select to access the abstract.
7. AHRQ in the Health IT Professional Literature—Some Useful Citations
We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.
Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med 2010 Apr; 25(4):284-90. Select to access the abstract.
Fontaine P, Zink T, Boyle RG, et al. Health information exchange: participation by Minnesota primary care practices. Arch Intern Med 2010 Apr 12; 170(7):622-29. Select to access the abstract.
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