Join Section

Quality Improvement & Patient Safety Section Newsletter - April 2007, Vol 8, #2

Quality Improvement & Patient Safety Section

circle_arrow From the Chair
circle_arrow Call for 2008 Section Grants
circle_arrow Medication Reconciliation Update
circle_arrow Medicare Value Based Purchasing: Changing Payment for High Quality and Efficient Care - Are You Ready?
circle_arrow Analysis of a Case 
circle_arrow CMS Physician Quality Reporting Initiative (PQRI) - Reporting Begins July 1
circle_arrow QIPS Quality Course at Spring Congress
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section


From the Chair

Jack Kelly, DO, FACEPJack Kelly, DO, FACEP

Here at Einstein we have our Pneumonia Core Measures down to a culture!  We reached Second Decile in our peer group last year and have done very well since.

STEMI Core Measures continue to be a major challenge. Don't get me wrong - we have really worked hard and improved our processes!  But so has everyone across the country! Our weekday 0700-1800 Door-to-Balloon times (D2B) are 99% successful in under 90 minutes. It is the evenings, nights, and weekend STEMIs we are attempting to fix... and this is when the CathLab lights are off and the team off campus. We are trying new ideas.

We have attempted to have "quick park" right in the HeartCenter driveway for the CathLab team. Before this, they were spending 10 minutes looking for a parking space in the garage!  We have brought Security into the team to secure the elevators and help with swift transfer to the CathLab.

We are working on other ideas, too!

In addition, our Department has been "reminded" frequently to use the CMS-worded phrases that describe legitimate delays to Thrombolytics or to PCI. We continue to review each STEMI case to make sure we are improving and are documenting the delays and reasons for delays. I have attached the CMS STEMI Documentation caveats for you to use in your Department. We put them right onto our ED intranet site and are folding them into our EMR that will be introduced in the next 6 months.

Our ACEP QIPS Leaders phone conferences continue monthly. All are invited to listen in and participate, however. Please contact our staff liaison, Angela Franklin c/o for details.

David John and our QIPS Quality Course Group continue to plug along and the course is being built this month. It is already in rough draft form and is shaping up very well!  Please consider attending the course at ACEP’s Emergency Medicine Spring Congress in San Diego on April 25th, from 2:30 to 6:30 pm. It is sure to be excellent and will be a definite benchmark for EM Quality Leaders.

We have some excellent articles in this month's Newsletter. Please feel free to email me c/o or call me at (215) 456-2461 about any ideas, innovations, or issues you have!

Regards to all,


Back to Top

Call for 2008 Section Grants

Jack Kelly, DO, FACEP

Over the years, the QIPS Section has quite successfully proposed and completed several Section Grants, including a grant for Quality Tips for Patient Safety (QTIPS)—whereby brief medical pearls of wisdom are taken from ACEP lectures and tallied by our group; a grant to develop quality indicators for presenting ED complaints, including syncope, abdominal pain, headache, chest pain, shortness of breath and altered mental status, and a grant to fund this year’s Quality Course, which will be presented at this year’s ACEP EM Spring Congress in San Diego, on the afternoon of April 25th. Please help us keep up the tradition!

Members may apply for a grant through the current Section Chair, it is expected that projects funded by the Section Grant Program  will be complete within 18 months, and any products of the grant will belong to ACEP. Grant amounts vary, but typically range up to $5,000 per section. The 2008 Section Grant schedule is not yet available; however, an initial letter of intent is typically due in early January.

Further details about the ACEP Section Grant Program can be found on ACEP's Web site. Please also feel free to email c/o or call me at (215) 456-2461, or the QIPS staff liaison, Angela Franklin c/o, (202) 728-0610 x3014, with your ideas or questions regarding a Section Grant.



Back to Top

Medication Reconciliation Update

Helmut Meisl, MD, FACEPHelmut Meisl, MD, FACEP

Recently I sent out an e-mail requesting members of our Section to share how they are complying with Joint Commission (JCAHO) National Patient Safety Goal (NPSG) number 8, to "accurately and completely reconcile medications across the continuum of care." Thanks to all who sent in their comments, which I will summarize later. First, below are the original requirements as taken from JCAHO.

Accurately and Completely Reconcile Medications
Across the Continuum of Care

Requirement 8A
There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.

Rationale for Requirement 8A 
Patients are most at risk during transitions in care (hand-offs) across settings, services, providers, or levels of care. The development, reconciliation and communication of an accurate medication list throughout the continuum of care are essential in the reduction of transition-related adverse drug events.

Implementation Expectations for Requirement 8A
(M) C 1. The organization, with the patient’s involvement, creates a complete list of the patient’s current medications at admission/entry.

(M) C 2. The medications ordered for, administered to, or dispensed to the patient while under the care of the organization are compared to those on the list and any discrepancies (e.g., omissions, duplications, potential interactions) are resolved.

Requirement 8B 
A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the organization.

Implementation Expectations for Requirement 8B 
(M) C 1. The patient’s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside the organization

(M) C 2. The next provider of service checks the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed.

(M) C 3. The complete list of medications is also provided to the patient on discharge from the organization.

 *Source: Joint Commission

There is no doubt that inadequate patient education, lack of knowledge of patients’ medications, confusion about dosing, duplicate medications, and lack of communication between providers was causing patient harm. We have all seen patients who have been admitted or suffered an adverse event due to confusion about their medications and taking duplicate, conflicting or inadequate medications, e.g. taking both Lopressor and Metoprolol at prescription renewal time. That this area needed attention we all knew, and simple medication wallet cards or lists from primary care physicians would have been advisable decades ago. The challenge is that the hospitals have to comply with this requirement. There was some confusion initially about many aspects of implementation, such as how extensive the research about the patient’s medications would have to be, who could perform the reconciliation, and importantly for us, whether the requirement was only for in-patients or also for ED patients. This January 2007, JCAHO (I will continue to use this term), issued a 17-page FAQs which answers many of the questions. I cannot summarize the whole document here so I will refer you to their Web site. Briefly: medications that have to be reconciled are defined and the process does indeed involve the ED. I will just present some main issues related to EDs and my comments

[8A&B] Is this just an inpatient requirement?
No, it is not just for inpatients. As the Goal states, it applies "across the continuum of care." Any time a patient/client/resident enters a health care organization—whether an emergency department, an ambulatory clinic, a home care service, or other setting or service—if medications are to be used or the patient/client/resident’s response to the treatment or service could be affected by medications that the patient/client/resident has been taking, then this Safety Goal applies. [2/06]
There are some minimal use situations that are allowed by JCAHO, as below, However, usually we are not exempt, as we often give an analgesic in the ED or a prescription for such on discharge (we must do Pain Control), or often the patients do not have a regular provider.
Further, if all of the following conditions apply, communication of the list of the patient’s current medications (requirement 8B) is not necessary:
  • The "minimal medication use" is in the context of a brief outpatient encounter 
  • The medications in question act locally with negligible systemic effect (for example, minimally absorbed topical agents; low volume local infiltration anesthetics; nonabsorbable enteric contrast agents) 
  • No other medications are used during the encounter 
  • No new medications are prescribed for or provided to the patient for use after discharge 
  • There are no changes to the patient’s "current medications" 
  • Any provider of care to whom the patient is being referred, already has the patient’s current medication information. [Revised, 1/07]

There was debate as to how much effort must be expended to obtain this medication list in order to perform the reconciliation. Initially there was concern that for every ED patient on medications, calls would have to be placed to the prescribing physicians or pharmacies. This could paralyze an ED even more if every elderly patient with an ankle sprain required multiple phone calls. There are now levels of reconciliation, with "medical relevance" included

New—[8A] What is the current expectation for medication reconciliation in the Emergency Department (ED)? Can we use different levels of medication reconciliation depending on the severity of the patient’s condition?

A consensus recommendation of the American Association of Emergency Medicine (AAEM), the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA) provides for three levels of intensity of the medication reconciliation process in the ED, as follows:

  1. "Screening reconciliation" for all ED patients should include routinely obtaining from each patient at each ED visit a list of the patient’s current medications (usually done by the triage nurse)

  2. "Focused reconciliation," as directed by the emergency physician, based on medical relevance, should include seeking additional information about the patient’s medications (exact drug list, dosage/route, etc.) from the patient’s pharmacy, primary care physician, family, etc. 

  3. "Full reconciliation" for admitted patients should be completed by the receiving inpatient unit and pharmacist

This consensus recommendation from the AAEM, ACEP, and ENA is in full compliance with NPSG requirement 8A since each level includes obtaining a list of the patient’s current medications to be used when ordering or prescribing medications in the ED. Therefore, this is approach is acceptable to The Joint Commission in meeting requirement 8A. [New, 1/07]

An emergency condition does not relieve us of this obligation either.

[8A] Do I have to acquire the list of patient medications in an emergent or urgent admission/entry situation?
In urgent situations or when the resulting delay would harm the patient/resident/client, including situations in which the patient/resident/client experiences a sudden change in clinical status, immediate care takes precedence. However, as soon as possible thereafter, the organization should take steps to acquire this information and compare it to the medications it is providing. [2/06]

A brief analgesic or antibiotic also still requires the reconciliation.

New—[8B] If an antibiotic and/or pain medication is prescribed for an ambulatory or ED patient to be taken only for a short period of time, and the patient is given the prescriptions at discharge, must this temporary medication be added to the home medication list and given to the patient at discharge?
Yes; if a new medication is added to be taken by the patient following the episode of care, even if only temporarily or "as needed" (prn), the list of the patient’s current medications should be updated to reflect this change. [New, 1/07]

There was also debate as to how to communicate this medication list to the next provider and this could be major problem if this had to be directly from provider to provider. A list given to the patient appears acceptable.

New—[8B] What are the medication reconciliation requirements for an organization that caters to a transient population with respect to communicating the discharge list to the next provider of care?
In this situation, the treating organization is expected to make a reasonable effort to identify the patient/client/resident’s primary care provider (if one exists) and to offer to communicate the discharge list of medications (and any other relevant discharge documentation) to that next provider of care. The patient/client/resident may accept or decline that offer. In either case, the information must be given to the patient/client/resident. [New, 1/07]
New—[8B] If a patient is referred to a specialist, must the medication list be sent directly to the specialist rather than be carried by the patient?
Yes, if the patient has accepted a scheduled appointment with the specialist. On the other hand, if the patient is simply advised to make an appointment with the specialist, the information may be communicated but only with the patient’s authorization. Lacking that, the patient can assume responsibility for bringing the information to the practitioner or the practitioner can request the information from the sending organization once the patient has established a relationship with the specialist. If the specialist is in the same health care organization and has ready access to the medical records, then it is not necessary to communicate the medication list separately. [New, 1/07]
New—[8B] When a patient is discharged home from the hospital emergency department, do we always need to communicate an updated list of the patient’s medications to the "next provider of care" (usually the patient’s primary care provider) whenever there is any change in the patient’s medications? Sometimes the change is only a temporary over-the-counter pain medication or a short course of antibiotic. Can’t we just give the list to the patient?
When a patient is discharged home from the emergency department (ED), a discharge medication list must be provided to the patient but, in this situation (ED to home), communicating the list to the next provider of care is not required as long as the patient understands that the list must be brought to the provider at the time of the next visit and is judged competent to do so. Otherwise, it is the responsibility of the ED to communicate the list to the next provider of care. [New, 1/07]

We cannot just document updates and changes to the patient’s medications.

New—[8B] When patients are discharged to home from the ED following treatment, can we provide a list of newly prescribed and recommended over-the-counter medications as well as a list of those medications to be discontinued, rather than a single updated list?
No. This suggested alternative to a single updated medication list will result in multiple documents, which the patient is now being asked to reconcile. This has the potential for increasing the risk for medication errors and does not comply with requirement 8B. [New, 1/07]

Summary of Comments from QIPS Members

Presented to you with some minor editing, and starting with an excellent commentary and letter by Anthony Ferroggiaro, as well as Donald R. Kamens, who have similar concerns about overall ED patient care and costs. Hopefully this information and comments will be beneficial to your own environments.

Anthony Ferroggiaro, MD, FACEP
NACS Quality Director · Portland, OR

I have attached a letter I sent to the CQO based on the EM perspective with the goal to encourage the administration to employ additional pharmacy techs to obtain the list of medications. Of the 5 hospital sites, only one hospital, the main urban site, added RN students in order to obtain the medication lists. Otherwise the ED RNs and ED MDs are completing the MR on all patients at ED entry. Currently our Quality Committee has discussed many issues surrounding MR and so I will provide them here.

  1. What is the legal responsibility when the ED MD reconciles? The danger here is that if the list is incomplete, though entered into a reconciliation computer program, RxPad, and thus "reconciled" according to the JCAHO requirement [to the best ability], is the physician responsible? Certainly the IOM ideal was to involve computer programming for this activity; looking at Leape’s data – lack of knowledge of the medications and the patient resulted in the majority of ADEs.

  2. Associated with #1 – why is the ED MD being required to "reconcile" when the physician is untrained for such work? Is the reconciliation process, using a computer program, the actual reconciliation, regardless of MD involvement? This I think is the JCAHO ideal yet legally no one is coming after a computer when the 85 year old develops Digoxin toxicity due to a dosing error propagated by the EMR.

    Interesting that one site in our system employed RN students, obviously the least expensive labor; which perhaps defines the commitment to quality of some organizations. This goal of MR is worthy – considering the IOM "To Err…" and especially in the ED – I refer you to Hohl CM, Dankoff J, Colacone A, Afilalo M. "Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department." Ann Emerg Med. December 2001;38:666-671. Unfortunately the system’s cost analysis got in the way of a quality ideal.

  3. Finally, I am pursuing a study to look at the approach to medication listing in ED subgroups. Again the elderly are prone to ADEs and also have worse outcomes from ADEs – I suspect a more focused approach involving pharmacy contact or PCP, rather that direct interviewing would be more effective for MR in this population; likewise, the simple 1-3 medication patient who can communicate adequately would have more reassuring data/list. My goal would be to provide feedback and recommendations to the admin based on subgroups in effort to move away from one standard approach and toward specific actions based on presentation and complexity.

Thank you.

Dr. Ferroggiaro’s Letter 

Donald R. Kamens, MD, FACEP, FAAEM
Co-chair, HL7 Emergency Care SIG
St. Vincent's Medical Center · Jacksonville, FL

Thanks for this important information. I am not sure whether this JCAHO Update is a relief, or an added dimension to the every complex MR forest. What happens to those patients who are discharged and then identified as having potential MR issues ex post facto?

Quite likely this could account for a rather unexpected volume of patients, since there is no real-time contact to sort out questions. There remains a potential nightmare under the surface, with medico legal as well as work flow, cost, responsibility issues.

I think that QIPS should begin working on an ACEP policy regarding Medication Reconciliation, one that would reflect support for the general principle of MR, but delineate the role that ED physicians can practically play in the MR schema (transmit available data, modify treatment plan if alerted in sufficient time).

At the same time, a strong position should be stated that would help ED physicians avert shouldering the cost/burden of MR, and call attention to the potential disastrous safety issues that might occur if JACHO requires the institution of mechanisms that might increase ED wait-times, overcrowding.

Perhaps something like this:

  • ACEP supports the JCAHO Safety Goals and initiatives, and in particular Safety Goal #8, Medication Reconciliation

  • Because of the precarious time-related events in EDs, it is important that actualization and implementation of this goal not put other critical safety efforts in jeopardy (e.g. the timely evaluation of patients, and efforts to reduce overcrowding)

  • We recommend that all ED physicians and all ED departments support this goal by providing medication data when available

  • We recommend that the hospital or institution make coordinated efforts to support this goal, usually through its department of pharmacy, by rapidly analyzing the provided data, and giving feedback regarding reconciliation of any issues that may appear

  • It is imperative that such coordination between the ED and pharmacy be established so that the time frame of patient admission to discharge is not impaired, as this will increase ED overcrowding nationally

  • When timely coordination between the pharmacy and the ED cannot be established, patient flow in the ED should never be put at risk. In these cases, the institution will need to provide mechanisms to alert and protect patients when reconciliation issues are identified.

John J. Kelly DO, FACEP
Associate Chair, Department of Emergency Medicine
Albert Einstein Medical Center · Philadelphia, PA

The Chair of Medicine was charged with this task at Einstein. The Dept of Medicine created a new H&P that has a new section outlining Meds Reconciliation...this H&P is completed by the Medicine Admitting Resident and this document is carried thru the patient's hospital stay. There was also a new Discharge Instruction (developed by Medicine) that reconciles the Medications Prescribed upon Discharge. The Joint Commission was not totally satisfied with our newest model for Meds Reconciliation when they reviewed us last month. Einstein Administration has this as an action item for this year; we will need to send out improvement strategy to the Joint Commission.


The obvious solution is to have a pharmacist in the ER. If your volume is adequate they can do med reviews, reconcile medications, counsel patients (and physicians) as well as administer and keep track of the meds. We have one almost 24/7 and she is invaluable. This takes a task from the MD and transfers it to a (less expensive) professional who does it better.

Helmut Meisl MD, FACEP
Quality Improvement Director, Emergency Department
Good Samaritan Hospital · San Jose, CA

Here is what is done at my hospital, which is anything from ideal, but is what could finally be implemented after many months of meetings. The Medical Staff ignored the issue totally initially, then tossed it to Nursing, who would not do it, as well as Pharmacy, who said they did not have the resources. Now after much wrangling it is a somewhat joint effort between Nursing and the Medical Staff.

Inpatients. On admission, a list of the patient's medications is obtained by nursing, put into the hospital computer, which then is transferred to a form which the admitting physician is to review and sign that Med Reconciliation has been done. Problems are properly obtaining the list of meds, having Nursing print the form and put it into the chart, and the physician actually signing the form.

On discharge, a variant of the Admission Med List is printed, with space for the discharging physician to make any changes. Another alternative is for the Discharging Physician to write out a complete list of meds that the patient should be taking. Problems are again having Nursing print the form and put it into the chart, and the physician actually completing the form.

Outpatients (Still working on this one). On admission to ED or Outpatient area, a list of the patient's medications is obtained by nursing, put onto an NCR form, with this reconciliation to be somewhat department specific, generally an attestation that the reconciliation was done by the physician.

On discharge, a copy of the NCR (with some changes in wording) is given to the patient with any necessary alterations and additions made by the physician. So that is the less than ideal mechanism at my hospital, where no additional resources were committed to this task.




Back to Top

Medicare Value Based Purchasing: Changing Payment for High Quality and Efficient Care - Are You Ready?

Susan Nedza MD, MBA, FACEP

Reprinted with the permission of the Illinois College of Emergency Physicians

Over the last year, I have discussed how CMS is embarking on a bold plan to change its payment system. This transformation is from a system that rewards volume, to one that rewards health care delivery that provides safe, effective, efficient, patient-centered, timely and equitable care. This effort is accelerating in a number of areas that will have an impact on emergency medicine and on your current and future practice.

Legislation Mandating the Transformation 
Section 5001 (b) of the Deficit Reduction Act of 2005 (DRA) requires that CMS develop a plan to implement hospital pay-for performance beginning October 2008. In addition, Division B, Title 1, Section 109 of the TRHCA 1 requires that CMS develop hospital outpatient and ambulatory surgical center pay-for-reporting programs for January 2009.

At the present time, emergency physicians will be immediately affected by the expansion of the Hospital Quality measure set.2 This expanded set includes measures of patient care experience, thirty-day mortality for key conditions, pediatric asthma care, and surgical infection prevention. As hospitals are being measured on an expanded set of measures of quality, emergency departments and physicians will also be indirectly measured. Successful emergency department groups will be those who work closely with their hospital leadership in order to improve on these publicly reported measures.

A second impact will be the implementation of the Physician Pay for Reporting program that begins July 1, 2007. This program was mandated by Congress in the Tax Relief and Health Care Act of 2006. 3 Physicians who meet a given threshold of reporting on quality measures that they submit to CMS will be eligible for a 1.5% bonus payment to be paid out in 2008. Because this legislation was only recently enacted, the details of the process for reporting and the program instructions will be developed in early 2007. As regulatory details become available, I will work with ICEP and its committees to disseminate information to members.

The legislation mandates the use of quality measures that are identified as 2007 physician quality measures under the Physician Voluntary Reporting program.4 The website also currently has reporting and technical specifications for 45 of the measures. 5 Currently 66 measures are listed, with additional modifications allowed as the result of a January 2007 consensus process. These changes must be published on the CMS website by April 1, 2006.

In addition,  Section 5001 (c) of the Deficit Reduction Act requires CMS to (1) identify at least two complicating conditions that it will no longer pay for and  (2) implement a present on admission indicator to differentiate these conditions from those acquired during the hospitalization. This provision can be considered as "not paying for poor performance" and again has implications for the emergency department as a portal of entry into the hospital. This is a major shift in policy and will certainly affect your care processes.

Finally, efforts in health care IT are expanding across Illinois and other states. Local and regional entities are discussing using similar programs that require hospitals and physicians to share data, to document performance, and most importantly to improve clinical care and efficiency.

So What Should You Do?

  1. Stay informed. Stay linked to ICEP and to ACEP for information on this rapidly evolving change in payment. Become an active member of the dialogue.

  2. Become expert on your own department. Each department will need to understand variations in quality and efficiency. These include variation due to practice patterns (quality and resource use), hospital restraints (processes and finances), patient populations (insurance mix, co-morbidities, and supply and demand within the local community), access to primary care and technology. Successful emergency department groups will understand or own the process of measuring these environmental factors in their local health care delivery system. 

  3. Talk to medical staff leaders. Every specialty will be affected by these changes and so will your local relationships and practice patterns.

  4. Talk to hospital leadership. Emergency department groups need to be aware of the overlap in these efforts, to recognize how their practice may change, and to integrate efforts to collect quality data.

  5. Review the measure set. Physicians should know not only which measures will be reportable by emergency physicians, but also be aware of measures affecting referring physicians, consultants, and other hospital based specialists. This is especially true for the coordination of care measures.

  6. Engage in health IT. Consider how you will capture data, educate your doctors and communicate information regarding performance to CMS and to your physicians for process improvement. Understand how HIT will enable utilizing evidence based decision tools and to practice EBM.

  7. Define quality EM. This remaking of the payment system presents a great deal of opportunity to improve day-to-day care of patients. Let the gaps define the measures.

  8. Re-engineer to achieve ED efficiency. Many of the hospital measures will include system changes and affect ED processes. This is especially true of the infection measures. This includes managing inputs, throughput, and outputs such as the discharge process.

  9. Collaborate. During times of change, it is important to share best practices and lessons learned about failure. Illinois EM represents some of the best and the brightest. Collaborative efforts will be critical across academic centers, rural hospitals, suburban systems, and public hospitals.

  10. Seize the opportunity to lead. Emergency care as always will be affected both directly and indirectly. Your input and leadership is critical at the local, chapter and national level.

Emergency physicians are recognized as decision makers, for being team players, on their ability to deal with uncertainty and as patient advocates. The EM advocacy agenda has been successful in garnering attention and the recognition of the value of its service. The ultimate outcome of that advocacy now depends on the level of leadership and the types of comprehensive systems solutions that the specialty embraces. It is the measure by which the specialty will ultimately be measured in revaluation of health care services.

Are you ready?



Back to Top

Analysis of a Case

Dickson Cheung, MD, MBA

As patient safety and quality assurance leaders, we are often asked to review a case involving medical error. How one performs this task is often up to the individual. Yes, there are some common methods such as Root Cause Analysis and Failure Modes and Effects Analysis but there is no standard tool to identify the contributing factors. In a recent JCAHO article published in the February 2006 Journal on Quality and Patient Safety entitled "A Practical Tool to Learn from Defects in Patient Care" (Pronovost PJ, Holzmueller CG, Martinez E, et al. "A practical tool to learn from defects in patient care" Jt Comm J Qual Patient Saf 2006 Feb; 32(2):102-8), authors put forth a tool to help make this process more concrete. Below is a table they suggest to help organize factors in a medical error in terms of positively or negatively contributing to an adverse event. In this first section of a two-part article, we will use this tool to identify the contributing factors in a real case. In part two, we will offer proposals to mollify the factors that continue to make the system vulnerable to error.

Contributing Factors (Example)
Patient Factors:
Patient was acutely ill or agitated (Elderly patient in renal failure, secondary to congestive heart failure)
There was a language barrier (Patient did not speak English)
There were personal or social issues (Patient declined therapy)
Task Factors:
Was there a protocol available to guide therapy? (Protocol for mixing medication concentrations is posted above the medication bin.)
Were test results available to help make care decision? (Stat blood glucose results were sent in 20 minutes.)
Were tests results accurate? (Four diagnostic tests done; only MRI results needed quickly—results faxed.)
Caregiver Factors
Was the caregiver fatigued? (Tired at the end of a double shift, nurse forgot to take a blood pressure reading.)
Did the caregiver’s outlook/perception of own professional role impact on this event? (Doctor followed up to make sure cardiac consult was done expeditiously.)
Was the physical or mental health of the provider a factor? (Provider having personal issues and missed hearing a verbal order.)
Team Factors
Was verbal or written communication during hand offs clear, accurate, clinically relevant and goal directed? (Oncoming care team was debriefed by out-going staff regarding patient’s condition.)
Was verbal or written communication during care clear, accurate, clinically relevant and goal directed? (Staff was comfortable expressing his/her concern regarding high medication dose.)
Was verbal or written communication during crisis clear, accurate, clinically relevant and goal directed? (Team leader quickly explained and direct his/her team regarding the plan of action.)
Was there a cohesive team structure with an identified and communicative leader? (Attending physician gave clear instructions to the team)
Training & Education Factors
Was provider knowledgeable, skilled & competent? (Nurse knew dose ordered was not standard for that medication.)
Did provider follow the established protocol? (Provider pulled protocol to ensure steps were followed.)
Did the provider seek supervision or help? (New nurse asked preceptor to help her/him mix medication concentration)
Information Technology/CPOE Factors
Did the computer/software program generate an error? (Heparin was chosen, but Digoxin printed on the order sheet.)
Did the computer/software malfunction? (Computer shut down in the middle of provider’s order entry.)
Did the user check what he/she entered to make sure it was correct? (Provider initially chose .25mg, but caught his/her error and changed it to .025mg.)
Local Environment
Was there adequate equipment available and was the equipment working properly? (There were 2 extra ventilators stocked & recently serviced by clinical engineering.)
Was there adequate operational (administrative and managerial) support? (Unit clerk out sick, but extra clerk sent to cover from another unit.)
Was the physical environment conducive to enhancing patient care? (All beds were visible from the nurse’s station.)
Was there enough staff on the unit to care for patient volume? (Nurse ratio was 1:1.)
Was there a good mix of skilled with new staff? (There was a nurse orientee shadowing a senior nurse and an extra nurse on to cover senior nurse’s responsibilities.)
Did workload impact the provision of good care? (Nurse caring for 3 patients because nurse went home sick.)
Institutional Environment
Were adequate financial resources available? (Unit requested experienced patient transport team for critically patients and one was made available the next day.)
Were laboratory technicians adequately in-serviced/ educated? (Lab tech was fully aware of complications related to thallium injection.)
Was there adequate staffing in the laboratory to run results? (There were 3 dedicated laboratory technicians to run stat results.)
Were pharmacists adequately in-service/educated? (Pharmacists knew and followed the protocol for stat medication orders.)
Did pharmacy have a good infrastructure (policy, procedures)? (It was standard policy to have a second pharmacist do an independent check before dispensing medications.)
Was there adequate pharmacy staffing? (There was a pharmacist dedicated to the ICU.)
Does hospital administration work with the units regarding what and how to support their needs? (Guidelines established to hold new ICU admissions in the ER when beds not available in the ICU.)

The Case

Mrs. Pear was devastated two weeks ago after she found out her weight loss and jaundice were due to pancreatic cancer. Fortunately, a successful Whipple procedure performed by Dr. Smith at Community Hospital gave her the upper hand in this battle against her cancer and she was feeling pretty good about her chances in overcoming this ordeal. Five days after the operation she developed a fever and abdominal pain. She called 911 and the ambulance bypassed Community Hospital because it was already filled to capacity. She was brought to County Hospital instead.

Unfortunately, Mrs. Pear arrived in the middle of the day when the emergency department was experiencing its peak volume of incoming patients. After a prolonged stay in the waiting room, she underwent a series of exams, consultations and tests that revealed her pain and fever were due to an intra-abdominal abscess related to the surgery. Twenty hours later, she was admitted to the ICU at County Hospital fighting for her life again; this time with sepsis.

A timeline of the first critical hours in the hospital is shown below

1600: patient arrives in the emergency department at County Hospital
1820: patient arrives in the treatment room
1900: change of shift
1930: patient seen by medical student and resident
2030: patient is seen by the emergency physician attending
2105: patient is given oral contrast in preparation for a CT scan
0103: patient receives CT scan after delays due to transport of oral contrast and other acute patients that "bump" Mrs. Pear from the schedule
0140: CT scan is read by the radiologist
0150: initial request for surgical consult
0240: surgical resident finally returns page after several attempts
0300: surgical consult commences
0340: surgical resident speaks with his senior resident with no communication with the emergency medicine team
0450: emergency resident pages surgical resident for results of consult
0500: surgical resident informs of their intention not to admit the patient and to contact IR for surgical drainage and then admission to the medicine service
0505: unable to reach on-call IR during the weekend because no one is on the schedule. The radiologist informs the ED that the process is to call the operator if there is no IR specialist listed on the hard copy of the schedule.
0510: the call operator has no record of an on-call IR specialist
0515: calls made to IR head technician and department chair with no response
0530: the surgical team is re-contacted and informed of the inability to carry out the plan and the hospital’s unwillingness to admit a patient with a surgical and post-operative complication. The recommendation is to transfer to the University Hospital to the surgical service through the emergency department because the surgical team is unwilling to directly admit the patient on the floor.
0545: Academic Hospital emergency department informs that they are on bypass and unable to accept the patient through the ED
0600: the surgical team says it will reassess the patient for admission to their service at County Hospital when their attending arrives in the morning
0900: the surgical attending runs late on rounds and now needs to go to the operating room and refuses to accept the patient
1000: the IR specialist evaluates the patient and determines she is too ill for the procedure
1230: the patient is transferred to the medical ICU after a series of phone calls between the surgical team and the medical intensivists to determine which service would take the patient

The events that led to Mrs. Pear's downfall are common and preventable. There was no singular blunder that caused her demise but rather a series of delays and missteps. Contributing factors included routine system delays in processing tasks, undue caregiver stress, lack of teamwork within and between clinical services, gaps in knowledge and training, not utilizing available technology that impairs communication and deeply rooted institutional values that inhibit patient-centered care. On the fateful night of Mrs. Pear's arrival to County Hospital, the holes in the system aligned to form the perfect error

Patient factors contributed little to her demise. Although the patient was elderly, she had family who acted as her agents. There were no language or social barriers. But even before Mrs. Pear’s arrival to County Hospital, the system was primed for failure.

Local environment factors that set up this unfortunate case included the lack of adequate available resources and provider staffing in the hospital. The first indication that this visit was not going well was the delay in obtaining the CT scan. Although there were two CT scans in the emergency department, only one was available for use because of staffing shortages. It was also a very busy night, so the patient’s CT scan was delayed because her spot kept getting bumped for more urgent patients. These local environment factors negatively contributed to attaining a timely study.

Evening and night shifts are often the times the hospital is most at risk. Lack of adequate personnel, tired staff, and circadian rhythms all work against good patient care. Even though emergency departments are often busy at night they are routinely staffed at 50-80% of their equivalent daytime hours. In particular, there is a lack of senior staff and attending physician presence at an academic center at night. After 5 pm, the hospital is essentially run by inexperienced resident physicians. Because of unfavorable working conditions, the ED attracts only new graduates from midlevel programs that are generally inexperienced. The 80-hour resident work rule and other Residency Review Committee (RRC) regulations that were placed into effect at the turn of the century also limit the amount of provider coverage during night shifts. The net effect is solo attending coverage at night in the emergency department for over 30 beds. Staffing of consult services is also at a bare minimum during evening hours. Not only is there no attending coverage on most services but the resident coverage that remains has been curtailed in the past few years due to the new RRC regulations. These caregiver and staffing issues make the hospital a vulnerable place each and every night.

The case began to seriously unravel when the on-call interventional radiologist could not be reached. Not only was there no physician on the posted on-call schedule but the backup mechanisms were faulty. The operator did not know who was on-call and they did not check the schedule ahead of time to see that the slot was indeed vacant to intervene during business hours. Both the head technician and chairman of the department were unreachable by phone and did not return their pages. These small oversights led to an urgent situation in the middle of the night due to the inability to contact the specialist in an expeditious manner.

Poor communication is at the root of most medical errors. This case was no exception with communication foibles at both an intra-departmental and inter-departmental level. Sign-out is a perennial problem on clinical services. This is especially true on busy shifts such as the evening shift in the emergency department and also when patients stay for multiple shifts. Sign-out is a dangerous game of medical "telephone" when the relay of information from one shift to the next becomes less complete and more fraught with error. In this case, it may have been difficult to explain all the nuances of the patient’s visit and presenting circumstances. Likely, "the patient has abdominal pain and is waiting for a CT scan," was all the receiving provider heard. Instead, it should have been communicated that the patient was seriously ill and needed a surgical consult immediately. A lack of respect and consideration between departments also serves to bamboozle effective communication between clinical services. This is manifested not only in delayed returns of pages but insufficient communication after the consult is completed. In addition, a long-standing practice of the surgical colleagues to delay seeing the patient until after the CT scan is completed deterred the ED staff from calling them early in the visit. These team factors also increase the likelihood of creating an error.

The nature of the resident/attending physician relationship also contributes negatively to patient safety. The culture of academic institutions deters house staff physicians from bothering attending physicians with mundane clinical matters. It is an unspoken rule among residents in training that it is a sign of weakness to contact the attending physician except for the most urgent matters. It is a badge of pride to be able to handle all matters independently and not to consult their advisors. This bent toward self-sufficiency, however, primes the error-prone hospital environment for mistakes if providers with less experience and no authority are allowed to act independently.

Finally, training and task factors contributed negatively to the outcome of this patient. The tired, overworked, inexperienced provider staff did not realize quickly enough that the patient was becoming septic to allow for effective treatment in a timely manner. Even after it was discovered, protocols were not in place to expedite treatment. The patient’s condition deteriorated as the staff was slow to respond.

In part two, we’ll examine and propose solutions to these global issues.



Back to Top

CMS Physician Quality Reporting Initiative (PQRI) - Reporting Begins July 1

Angela Franklin, JD, Staff Liaison

CMS’ new Medicare "pay for reporting" program, the Physician Quality Reporting Initiative (PQRI), kicks off on July 1st. PQRI offers a modest financial reward for clinicians who elect to participate: eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment of 1.5 percent of total allowed charges for covered Medicare physician fee schedule services—subject to a cap. PQRI applies to the traditional Medicare fee-for-service program only.

CMS is viewing this year’s PQRI as a physician quality reporting "beta" test (PVRP was the "alpha" test). Participation in PQRI could prove important in helping emergency physicians (EPs) become accustomed to reporting, as the expectation is that quality measurement and reporting could become mandatory for participants the Medicare program in future years (dependent on political action).

CMS continues to provide information covering the form and manner of reporting, how successful reporting will be determined, the calculation and validation of the bonus payment, the confidential feedback process, and plans for 2008.


Quality Measures

  • Measures are Final for 2007. CMS plans to use 74 measures for PQRI, seven of which were specifically developed for Emergency Medicine (EM), with ACEP’s participation. These are found at numbers 28, and 54 through 59 on the CMS list. The final list of measures is posted on the CMS PQRI webpage.

  • Specifications are published. CMS has provided specifications for the measures on its website as well. These may continue to be "tweaked" to ensure accuracy and appropriateness up to July 1.

  • More information to come. CMS is expected to continue to provide guidance on PQRI, including via its website, all-provider calls, specialty-specific calls and through its speakers bureau.


Form and Manner of Reporting

  • Claims-based, using CPT Codes. According to CMS, quality data should be reported using CPT Category II codes or, temporary G-codes where CPT Category II codes are not yet available.

  • Reporting via Form 1500, electronic 837-P. Each measure may be reported on the paper-based CMS 1500 claims, or the electronic 837-P claims for the encounter. Quality codes, which supply the measure numerator, must be reported on the same claims as the payment codes, which supply the measure denominator. Claims submitted with quality codes only will not constitute successful reporting.

  • No Enrollment Needed. Registration or enrollment is not required to participate.


Reporting Tips

  • Begin reporting July 1. The "denominator clock" begins to run on July 1. The opportunity to successfully report enough instances – that is, report on each measure at least 80 percent of the time reporting is possible – diminishes as the reporting period progresses.

  • Report at least three measures. To ensure successful reporting, EPs are encouraged to report on at least three of the seven EM measures. Under the program, specialties with four or more measures on the CMS list (EPs), must report least three measures for at least 80 percent of the cases in which each measure was reportable.

  • Focus on the most common measures. EPs should also consider focusing on just three or four measures that relate to their high frequency conditions and procedures when deciding which measures to report. This is to ensure adequate instances of reporting, while balancing the administrative burden that goes with reporting more than three measures. According to CMS, when relatively few instances of quality measures are reported, the statutory cap on bonus payments is more likely to apply, and CMS must use sampling or other means to validate whether quality measures applicable to the services have been reported.

  • Know about 8P, but use with care. A new CPT-II Reporting Modifier, 8P, may be used to allow the reporting of circumstances when a service described in a measure’s numerator is not performed and the reason is not otherwise specified. CMS will be closely monitoring the use of 8P, however, to ensure that the modifier is not being used as a "default."

  • Data will be analyzed by NPI. Physicians participating in the program will need to have their National Provider Identifier (NPI), because CMS will analyze physician data at the individual, NPI level.


Bonus Payment

The 1.5 percent bonus calculation is based on total allowed charges during the reporting period for professional services billed under the Physician Fee Schedule. EPs may want to look at their Medicare charges from July through December of 2006 to get a sense of their potential bonus under this program.

  • Submissions due February 29, 2008. Clinicians must ensure all claims must reach the National Claims History (NCH) file by February 29, 2008 in order to be included in the bonus calculation.

  • Lump sum bonus in mid-2008. CMS will award bonus payments in a lump sum in mid-2008.

  • Bonus applies at TIN level. While CMS will analyze data at the NPI level, the bonus payments must be distributed to the holder of record of the Taxpayer Identification Number (TIN), as required by TRHCA. TIN holders must determine further distribution of the bonus on their own.

  • No Notice Required. Physicians are not required to notify Medicare beneficiaries of their participation in PQRI and there is no beneficiary co-payment.

  • Operation of the Cap. The cap on bonus payments may apply when relatively few instances of applicable quality measures are reported.

  • Validation. TRHCA requires CMS to use sampling or other means to validate whether quality measures applicable to the services have been reported. CMS’ validation plan is currently under development.

  • No appeals. Under TRHCA, CMS’ determinations are not subject to formal administrative or judicial review; however, CMS will establish an informal inquiry process.


Confidential Feedback Reports

  • No public reporting. CMS has no plans to publicly report data provided under PQRI in 2007.

  • Reports due from CMS in 2008. CMS will make confidential feedback reports available at or near the time of the bonus payments in mid-2008 the reports are expected to include reporting and performance rates.

  • No interims. CMS will not provide interim reports – clinicians must monitor their own progress and performance under the program.

Please check the ACEP Webpage and the CMS PQRI Website often for new information on PQRI.


Useful Links

PQRI Background

On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 Section 101 (TRHCA) into law.

Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS.

This statutory program has been dubbed the Physician Quality Reporting Initiative (PQRI), and replaces the Physician Voluntary Reporting Program.

Participants in PVRP in 2006 can expect their confidential feedback reports for the 3rd and 4th quarter of 2006 to be made available to them in 2007 by CMS.

PQRI EM Measures


#28. Aspirin at Arrival for Acute Myocardial Infarction (AMI). Percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay

#54. Electrocardiogram Performed for Non-Traumatic Chest Pain. Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had an electrocardiogram (ECG) performed

#55. Electrocardiogram Performed for Syncope. Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had an ECG performed

#56. Vital Signs for Community-Acquired Bacterial Pneumonia. Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed

#57. Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia. Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed

#58. Assessment of Mental Status for Community-Acquired Bacterial Pneumonia. Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with mental status assessed

#59. Empiric Antibiotic for Community-Acquired Bacterial Pneumonia. Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed

*Developed with ACEP Input
†See pp. 76, 136-145 of the CMS Specifications

Getting Ready: Got NPI?

  • Get NPI-successful participation in PQRI will require accurate and consistent use of individual National Provider Identifiers (NPIs) on claims

  • Think of who in your practice or department needs to be educated about implementation of the PQRI

  • Think about how to capture the data, regardless of setting

  • Begin testing-providers are encouraged to begin submitting quality measures (e.g. testing billing systems), prior to the reporting period, which begins on July 1.

According to Thomas Valuck, MD, JD, CMS Medical Officer and Sr. Advisor for PQRI: "[o]ne thing physicians can do is use the current G codes and [current procedural terminology] Category II codes that are posted for 2007." HealthLeaders, Physicians to receive bonuses for quality reporting, March 2, 2007.

CMS Outreach

As part of its educational outreach on PQRI, CMS has released a MLN Matters Article, and posted a PowerPoint presentation and over 50 Frequently Asked Questions (FAQs) about the PQRI on its webpage at CMS is also conducting a series of conference calls to provide additional information.

CMS is asking clinicians to review the PQRI website early and often, is involving the Medicare Advantage Contractors (MACs) in its educational effort, and has established a Speakers Bureau as an educational resource for specialties, state medical societies, and other groups.

Information on PQRI will also be provided at ACEP’s website.

PQRI Cap Caculation

Details on CMS Site

instances of
reporting quality
data                            X       300 %       X
National average
per measure
payment amount
National average per
measure payment
(to be calculated in
2008 by the Secretary) =

National charges associated
with quality measures
(won’t be known until 2008)

National instances of

*Cap is designed to discourage minimal reporting of allpicable measures



Back to Top

QIPS Quality Course at Spring Congress

Methods to improve quality in the emergency department are difficult to develop but have been shown to be successful. Through a series of three case-based and practical lectures—the Case Review, Data Collection and Systems Fixes—ED quality experts will share important successes in quality, and provide emergency physicians and nurses the fundamentals for a successful quality program.

The final hour of the course will feature an Expert Panel, where participants can learn from quality leaders about specific case examples of successful quality improvement initiatives, engage them in discussion about barriers associated with successful implementation of quality improvement initiatives, and discuss the current status and future trends of the quality movement in emergency medicine, both the opportunities and the pitfalls.

At the conclusion of this course, attendees should be able to design an ED Quality Program or re-tool an already existing plan. Please plan to join us in sunny San Diego!

QIPS Quality Course
Emergency Medicine Spring Congress
San Diego Marriott Hotel & Marina, San Diego, CA
Wednesday, April 25
2:30 pm – 6:30 pm

To speak to an ACEP Customer Service Representative call 800-798-1822, extension 6, between 8:00 am and 5:00 pm CST, Monday through Friday--messages can be left 24 hours a day (

American College of Emergency Physicians
PO Box 619911
Dallas, TX 753261




Back to Top

Quality and Safety Articles

Helmut Meisl, MD, FACEP

Here is a further list of recent articles that may interest you. These are compiled by AHRQ PSNet at (

Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study. 
Samoy LJ, Zed PJ, Wilbur K, Balen RM, Abu-Laban RB, Roberts M. Pharmacotherapy. 2006;26:1578-1586.

Does the patient's payer matter in hospital patient safety?: a study of urban hospitals.
Clement JP, Lindrooth RC, Chukmaitov AS, Chen HF. Med Care. 2007;45:131-138.

Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety.
Moskowitz E, Veloski JJ, Fields SK, Nash DB. Am J Med Qual. 2007;22:13-17.

Patient safety and patient error. 
Buetow S, Elwyn G. Lancet. 2007;369:158-161.

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.
Liang BA, Riley W, Rutherford W, Hamman W. Am J Med Qual. 2007;22:8-12.

Anaesthetists' management of oxygen pipeline failure: room for improvement. 
Weller J, Merry A, Warman G, Robinson B. Anaesthesia. 2007;62:122-126.

Adverse Health Events in Minnesota: Third Annual Public Report. 
St. Paul, MN: Minnesota Department of Health; January 2007.

Disclosure of medical injury to patients: an improbable risk management strategy.
Studdert DM, Mello MM, Gawande AA, Brennan TA, Wang YC. Health Aff (Millwood). 2007;26:215-226.

Long working hours, safety, and health: toward a national research agenda. 
Caruso CC, Bushnell T, Eggerth D, et al. Am J Ind Med. 2006;49:930-942.

Impact of intensive care unit discharge time on patient outcome. 
Priestap FA, Martin CM. Crit Care Med. 2006;34:2946-2951.
The effect of workload on infection risk in critically ill patients. 
Hugonnet S, Chevrolet JC, Pittet D. Crit Care Med. 2007;35:76-81.

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. 
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;109:48-55.

House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service. 
Ong M, Bostrom A, Vidyarthi A, McCulloch C, Auerbach A. Arch Intern Med. 2007;167:47-52.

Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry.
Wang JK, Herzog NS, Kaushal R, et al. Pediatrics. 2007;119:e77-85.

Will my patient fall?
Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. JAMA. 2007;297:77-86.

Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors.
Sinha M, Shriki J, Salness R, Blackburn PA. Acad Emerg Med. 2006 Dec 27

Toward learning from patient safety reporting systems.
Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice. 
Kilbridge PM, Classen D, Bates DW, Denham CR. J Patient Saf. 2006;2:183-190.

Description and evaluation of an interprofessional patient safety course for health professions and related sciences students.
Galt KA, Paschal KA, O'Brien RL, et al. J Patient Saf. 2006;2:207-216.

Toward learning from patient safety reporting systems. 
Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

Registration-associated patient misidentification in an academic medical center: causes and corrections. 
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.

Focus on Computerized Provider Order Entry. 
J Am Med Inform Assoc. 2007;14:25-75.

An intervention to decrease catheter-related bloodstream infections in the ICU.
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

Patients' concerns about medical errors during hospitalization.
Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.

Potentially unintended discontinuation of long-term medication use after elective surgical procedures. 
Bell CM, Bajcar J, Bierman AS, et al. Arch Intern Med. 2006;166:2525-2531.

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.
Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2006 Dec 15.

Effect of computerisation on the quality and safety of chemotherapy prescription. 
Voeffray M, Pannatier A, Stupp R, et al. Qual Saf Health Care. 2006;15:418-421.

Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology. 
Scanlon MC, Miller M, Harris JM II, Schulz K, Sedman A. J Patient Saf. 2006;2:191-197.

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. 
Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360.

When good doctors go bad: a systems problem. 
Leape LL. Ann Surg. 2006;244:649-652.

Identifying diagnostic errors in primary care using an electronic screening algorithm. 
Singh H, Thomas EJ, Khan MM, Petersen LA. Arch Intern Med. 2007;167:302-308.

Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude.
Wallin CJ, Meurling L, Hedman L, Hedegard J, Fellander-Tsai L. Med Educ. 2007;41:173-180.

Intralipid medication errors in the neonatal intensive care unit. 
Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. 
Vogus TJ, Sutcliffe KM. Med Care. 2007;45:46-54.

Smart pumps: advanced capabilities and continuous quality improvement.
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

Factors influencing doctors' ability to calculate drug doses correctly.
Wheeler DW, Wheeler SJ, Ringrose TR. Int J Clin Pract. 2007;61:189-194.

Intralipid medication errors in the neonatal intensive care unit. 
Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. 
Williams RG, Silverman R, Schwind C, et al. Ann Surg. 2007;245:159-169.

Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

Patient-reported safety and quality of care in outpatient oncology. 
Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.
Garbutt J, Brownstein DR, Klein EJ, et al. Arch Pediatr Adolesc Med. 2007;161:179-185.

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.
Williams RG, Silverman R, Schwind C, et al. Ann Surg. 2007;245:159-169.

Nursing home administrators' opinions of the resident safety culture in nursing homes.
Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

Leadership strategies of medical school deans to promote quality and safety.
Griner PF. Jt Comm J Qual Patient Saf. 2007;33:63-72.

Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety. 
Muller MP, Hansel M, Stehr SN, et al. Resuscitation. 2007 Jan 20.

Examining medication errors in a tertiary hospital.
Maricle K, Whitehead L, Rhodes M. J Nurs Care Qual. 2007;22:20-27.

Nurses' perceptions of causes of medication errors and barriers to reporting. 
Ulanimo VM, O'Leary-Kelley C, Connolly PM. J Nurs Care Qual. 2007;22:28-33.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.
Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. Qual Saf Health Care. 2006;15:393-399.

Safety by design. 
Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency. 
Amer Surg. 2006;72:985-1149

Literacy and misunderstanding prescription drug labels.
Davis TC, Wolf MS, Bass PF III, et al. Ann Intern Med. 2006 Nov 29.

Medication prescribing errors involving the route of administration.
Lesar TS. Hosp Pharm. 2006;41:1053-1066.

Learning from litigation. The role of claims analysis in patient safety. 
Vincent C, Davy C, Esmail A, et al. J Eval Clin Pract. 2006;12:665-674.

Complying with ACGME resident duty hours restrictions: restructuring the 80-hour workweek to enhance education and patient safety at Texas A&M/Scott & White Memorial Hospital. 
Ogden PE, Sibbitt S, Howell M, et al. Acad Med. 2006;81:1026-1031.

Prioritizing patient safety interventions in small and rural hospitals.
Casey MM, Wakefield M, Coburn AF, Moscovice IS, Loux S. Jt Comm J Qual Patient Saf. 2006;32:693-702.

Pharmacist-supported medication review training for general practitioners: feasibility and acceptability. 
Krska J, Gill D, Hansford D. Med Educ. 2006;40:1217-1225.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. 
Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.




Back to Top

This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

Click here to
send us feedback