AHRQ Study: Better Drug Interaction Alerts Improve Patient Safety

AHRQ Stats: Statin Use

The number of adults who reported using prescribed statins more than doubled in 10 years, from 17.6 million in 2000–2001 to 40.8 million in 2010–2011. (Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey Statistical Brief #458: Trends in Statin Therapy among Adults (Age ≥18), United States, 2000 to 2011.)

Today's Headlines

1. AHRQ Study: Better Drug Interaction Alerts Improve Patient Safety.
2. Hospital Surveillance Practices for Venous Thromboembolism Find No Correlation to Post-Discharge VTE Rates, AHRQ-Funded Study Indicates.
3. New Patient Safety Primer on Missed Nursing Care Highlights Importance of Nurses to Safety Culture.
4. New CHIPRA Evaluation Highlight Focuses on Learning Collaboratives.
5. Summer Online TeamSTEPPS Master Trainings: Accelerated Pace Option.
6. AHRQ Health Care Innovations Exchange Focuses on Improving Quality and Performance in Primary Care Clinics.
7. Featured Impact Case Study: St. Joseph's Hospital Improves Patient Safety and Satisfaction Using Multiple AHRQ Tools.
8. AHRQ in the Professional Literature.

1. AHRQ Study: Better Drug Interaction Alerts Improve Patient Safety

Using consistent terms and definitions to indicate the potential seriousness of drug-drug interactions (DDI) and plainly identifying interacting drug pairs are among the recommendations to improve patient safety in an AHRQ-funded study. Researchers recommended increasing the usability and consistency of DDI decision support tools to help reduce "alert fatigue," which can cause safety alerts to be ignored because they are triggered so often. The researchers—a group of 24 individuals that included clinical, informatics and computer interface design experts—identified seven core elements that should be included with DDI decision support. Their recommendations focused on consistent use of terminology, symbols/icons, color, minimal text, formatting, content and reporting standards. The study, "Recommendations To Improve the Usability of Drug-Drug Interaction Clinical Decision Support Alerts," and abstract were published March 30 in the Journal of the American Medical Informatics Association.

2. Hospital Surveillance Practices for Venous Thromboembolism Find No Correlation to Post-Discharge VTE Rates, AHRQ-Funded Study Indicates

Hospitals with higher surveillance rates for venous thromboembolism (VTE) have higher inpatient rates of VTE but do not see those rates decline once patients are discharged, a new AHRQ-funded study has found. However, hospitals with higher inpatient VTE rates also have higher post-discharge rates, suggesting that surveillance may be influenced by the observed rates and not just the practice of monitoring alone. In the study of nearly 30,000 patients at 79 U.S Department of Veterans Affairs (VA) hospitals, researchers matched administrative data from the Surgical Care Improvement Program's (SCIP) VTE measurement population to outcomes from the VA Surgical Quality Improvement Program. They found that 296 patients, or 1.4 percent, had experienced a VTE during the index hospitalization, and that 114 patients, or 0.4 percent, did so within 30 days following surgery. The authors concluded that adhering to VA's surgical improvement program alone is an inadequate assessment of hospital quality because it is not associated with VTE outcomes. According to the study, hospitals seeking to reduce VTE rates should implement evidence-based guidelines beyond those required for by SCIP compliance. The study and abstract, "Association Between Inpatient Surveillance and Venous Thromboembolism Rates After Hospital Discharge," were published online April 1 in the Journal of the American Medical Association.

3. New Patient Safety Primer on Missed Nursing Care Highlights Importance of Nurses to Safety Culture

Although there is a well-established link between the adequacy of nurse staffing in hospitals and patient outcomes, the pathway that connects the two is less well understood. A new primer on missed nursing care, posted on AHRQ's Patient Safety Network, highlights one of these pathways. Missed nursing care is a subset of the category known as error of omission. It refers to needed nursing care that is delayed, partially completed or not completed at all. Missed nursing care is problematic because nurses coordinate, provide and evaluate many interventions prescribed by others to treat illness in hospitalized patients. Nurses also plan, deliver and evaluate nurse-initiated care to manage patients' symptoms and responses to care. Thus, missed nursing care not only constitutes a form of medical error that may affect safety, but also has been deemed to be a unique type of medical underuse.

4. New CHIPRA Evaluation Highlight Focuses on Learning Collaboratives

AHRQ has published the 13th Evaluation Highlight from the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program, now available on the national evaluation website under What We Learned. This Highlight describes the experiences of nine CHIPRA quality demonstration states that implemented learning collaboratives to advance the quality of children's health care in participating child-serving practices. States and practices found that a combination of strategies was needed to help practices improve medical home capacity and/or performance on clinical quality measures. Those strategies included offering incentives to encourage practice participation in the collaborative, combining classroom and interactive learning to keep practices engaged in the collaborative and providing individualized practice facilitation and support. AHRQ is leading the national evaluation of the CHIPRA Quality Demonstration Program. The Centers for Medicare & Medicaid Services funds the evaluation. If you have questions or comments, please contact the national evaluation team via email.

5. Summer Online TeamSTEPPS Master Trainings: Accelerated Pace Option

AHRQ's TeamSTEPPS® training curriculum is an evidence-based approach to improve communication and teamwork among health care teams, and spots are available in courses this summer. TeamSTEPPS Master Trainers serve within their institutions to help prepare for, implement and champion the TeamSTEPPS teamwork approach. Those interested in becoming TeamSTEPPS Master Trainers are encouraged to register and enroll for TeamSTEPPS online learning. Participants can choose a self-paced option (Noncohort 1) and complete the training in as few as four weeks or join one of several cohort courses that allow as long as 16 weeks to complete all course requirements. Participants who wish to be certified as Master Trainers must complete 11 learning modules and conduct a virtual "teach-back" session with one of AHRQ's TeamSTEPPS Master Trainers. AHRQ's subject matter experts are available throughout the course to assist participants with questions and challenges regarding implementation of teamwork initiatives in health care.

6. AHRQ Health Care Innovations Exchange Focuses on Improving Quality and Performance in Primary Care Clinics

The latest issue of AHRQ's Health Care Innovations Exchange highlights three programs that used innovative approaches to improve quality and performance in primary care clinics. The issue also features an article about AHRQ's soon-to-be-released Primary Care Practice Facilitation Curriculum. One of the featured profiles about improving quality and performance in primary care clinics describes a program at the University of Oklahoma Health Sciences Center in which external facilitators worked with primary care practices to build their quality improvement capacity. Practice enhancement assistants worked across primary care practices to improve patient care through practice audits and feedback, staff training, sharing of innovative ideas among practices, support for development of systems and infrastructure, and development and coordination of quality improvement initiatives. Practice enhancement assistants also help practices participate in research that improves primary care delivery. The program has helped practices establish structures, processes and infrastructure (e.g., patient tracking capabilities) that have led to improvements in areas such as diabetes care and delivery of preventive services.

7. Featured Impact Case Study: St. Joseph's Hospital Improves Patient Safety and Satisfaction Using Multiple AHRQ Tools

St. Joseph's Hospital, a 72-bed facility in Breese, Illinois, has improved care and increased satisfaction among patients by using three evidence-based resources from AHRQ: the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS®), the Re-Engineered Discharge (RED) Toolkit and the Medications at Transitions and Clinical Handoffs (MATCH) toolkit.

8. AHRQ in the Professional Literature

Chen LM, Nallamothu BK, Krumholz HM, et al. Association between a hospital's quality performance for in-hospital cardiac arrest and common medical conditions. Circ Cardiovasc Qual Outcomes 2013 Nov;6(6):700-7. Epub 2013 Nov 12. Select to access the abstract on PubMed®.

Arterburn D, Bogart A, Coleman KJ, et al. Comparative effectiveness of bariatric surgery vs. nonsurgical treatment of type 2 diabetes among severely obese adults. Obes Res Clin Pract 2013 Jul-Aug;7(4):e258-68. Select to access the abstract on PubMed®.

Holden RJ, Carayon P, Gurses AP. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics 2013;56(11):1669-86. Epub 2013 Oct 3. Select to access the abstract on PubMed®.

Dulai PS, Siegel CA, Dubinsky MC. Balancing and communicating the risks and benefits of biologics in pediatric inflammatory bowel disease. Inflamm Bowel Dis 2013 Dec;19(13):2927-36. Select to access the abstract on PubMed®.

Gurwitz JH, Field TS, Ogarek J, et al. An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults. J Am Geriatr Soc 2014 May;62(5):865-71. Epub 2014 Apr 29. Select to access the abstract on PubMed®.

Zhang R, Lee JY, Jean-Jacques M, et al. Factors influencing the increasing disparity in LDL cholesterol control between white and black patients with diabetes in a context of active quality improvement. Am J Med Qual 2013 Aug 12;29(4):308-14. Select to access the abstract on PubMed®.

Johnston JM, Smith JJ, Hiratsuka VY, et al. Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use. Int J Circumpolar Health 2013 Aug 5;72. Select to access the abstract on PubMed®.