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Quality Improvement & Patient Safety Section Newsletter - December 2008, Vol 10, #1

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow From the Editor
circle_arrow Emotional Intelligence
circle_arrow Handoff Grant Progress Report
circle_arrow View from Washington
circle_arrow Quality and Safety Articles
circle_arrow Annual Meeting Minutes
circle_arrow Section Annual Report

Newsletter Index

Quality Improvement & Patient Safety Section



The Chair’s Letter

Robert Broida, MD, FACEP

broidaThank you for the honor to serve as Chair of the ACEP Quality Improvement and Patient Safety Section for this year.  Our Section has worked hard to create a string of successes over the last several years and I look forward to building upon these in 2009 in keeping with our goals of advancing quality and safety in emergency medicine and assisting our members in providing better care and service to our patients.  

Thanks to our Section leadership and active members, the QIPS Section was presented with three awards at the recent ACEP Scientific Assembly in Chicago: 

  1. Service to College Award (to Jack Kelly, DO, FACEP, Chair 2006-2007)
  2. Service to Section Award (to Jack Kelly, DO, FACEP, Chair 2006-2007)
  3. Section Newsletter Award of Distinction (to Drs. Broida, Thallner and Ruben, 2006-2007 Editors)  

Even more impressive, it was the third year in a row that our Section received multiple awards!  Congratulations and thanks to all of you who volunteered your time and expertise in order to make this possible. 

As the year closes, it is instructive to look at where we have been and to plan for the future.

2008’s accomplishments included: 

  • Presentation of the ED Quality Course at the International Conference in Emergency Medicine in San Francisco this past April.  This was the second presentation of the course which was the subject of a previous Section Grant spearheaded by past Chair David John, MD, FACEP.  It included lectures by David John, MD FACEP, Azita Hamedani, MD MPH, Shari Welch, MD FACEP and Kevin Klauer, DO FACEP, along with a panel discussion including Dr. Klauer, Michael Phelan, MD FACEP, Helmut Meisl, MD FACEP, Richard Griffey, MD MPH, and ENA president-elect William Briggs, RN MSN CEN FAEN.  The goal of the course is to provide strategies and best practices to implement a successful ED quality program. 


  • Continued work on the ACEP Section Grant for the development of a national EM Quality Curriculum. Jack Kelly, DO, FACEP is Chair of this project, which is nearing completion.  We anticipate submitting the curriculum for publication in Annals.


  • Award of a new ACEP Section Grant on ED Hand-Offs, headed by the outgoing QIPS Chair, Dickson Cheung, MD, MBA, MPH.  This project is off to a great start, having already completed an initial survey at the ACEP Council meeting. The group is preparing to write a White Paper on the topic as well as a "canned" PowerPoint presentation for use nationwide.  


  • Continuation of the outstanding QIPS Newsletter tradition by Editor Elaine Thallner, MD, FACEP with 4 editions published and posted on the website. Highlights included a new section on Historical Figures in Quality, along with timely articles on QI topics, CMS measures, Conference Reviews, Project Updates, Patient Safety and Literature updates.


  • Active participation with other ACEP Leaders on the Quality and Performance Committee which works with other medical specialties, quality organizations, payers and the various federal agencies to help influence future quality and payment methodologies.  Recent QIPS Chairs David John, David Meyers, Jack Kelly, Helmut Meisl and I all sit on this important Committee.  

For 2009 we are planning: 

  • Completion of the Quality Curriculum
  • Completion of the Hand-Offs White Paper
  • A new ACEP Section Grant approval (Please forward any ideas for a new project! Grant applications are due in February)

As I look at the Section, there are several other areas for improvement that I am adding as additional goals for the 2008-2009 year: 

  • Membership:  Our current membership is in the 240-250 range.  With over 4,000 hospital EDs nationwide, I see plenty of room for growth.  I would like to see the QIPS section develop as a resource for the designated quality person at each site; a place for timely, pertinent information and cutting-edge resources. The goal is 100 new members for this year, including both community hospitals and academic sites.  We plan to work through the state chapters to access interested parties, but I would also like to challenge each of you to personally contact 3 potential new members.  Only in this way can we continue our important work and develop new leaders for the future.  New members can sign up by clicking here.


  • Communication:  By their very nature, quality and patient safety tend to be data-intense and not amenable to casual review.  I would like to see our communications, mostly the newsletter, adopt a more user-friendly approach.  To this end, our newsletter Editor, Drew Fuller will try some new things this year, and we will attempt to provide content that is valuable to the new, casual (or time-pressed) reader, as well as for the more hard-core quality gurus among us.


  • Visibility:  With the coming national attention that we expect to be focused on healthcare reform, emergency medicine is poised to be a central player.  We can allow the discussion to be solely about cost, or we can work to assure that quality and patient safety are also in the mix.  As the ACEP Section devoted to these issues, we must take a leadership role and bring these issues to greater visibility within the College, and provide the resources and expertise to interested external parties.  This will be a significant challenge for our specialty in the next few years as the new administration tries to do the impossible; provide more health care to more people for less money.  

Our officers for the coming year are:


 Chair / Alternate Councilor  Robert I. Broida, MD, FACEP
 Chair-Elect  Elaine A. Thallner, MD, MS, FACEP
 Secretary / Newsletter Editor  Drew C. Fuller, MD, MPH
Councillor  Dickson S. Cheung, MD, MBA, MPH, FACEP

Our Board liaison is Andrew Sama, MD, FACEP and our ACEP Section liaison is Angela Franklin, Esq., who has worked tirelessly to help our Section achieve its goals and advance emergency medicine in general.  Angela, your advice, guidance (and perseverance) have been critical aspects of our success. 

Dr. Broida is Chief Operating Officer of Physicians Specialty Limited, Risk Retention Group (PSLRRG), a South Carolina captive insurance company serving the Ohio-based Emergency Medicine Physicians, Ltd. (EMP) group. He specializes in risk management activities to help protect emergency physicians from avoidable practice liability.  He serves on the Board of Directors of the Ohio Chapter of ACEP, where he also serves as Treasurer.  He is a member of the national ACEP Medical-Legal and Quality and Performance Committees.  




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From the Editor

Drew Fuller, MD, MPH

Drew FullerBeginning the role as Editor, I am motivated by our history of producing an award-winning newsletter with an impressive selection rich and diverse content.  No doubt we have been a success.  Our goal for 2009 is to continue this success and to seek new ways to deliver content to our members and others interested in improving quality and safety in our nations emergency departments.  In order to do this well we will pursue a broad approach and will seek to: 1.) Continue to provide important messages and updates from our leadership and members on section and college activities, 2.) Focus and highlight articles and other resources that can have tangible impact on our practices and policies, 3.) Seek input from our members on improving our "product", 4.) Explore additional pathways for delivering our messages and content to the world of patient safety and quality improvement, 5.) Implement a system for improving access to past content referral and resource use.

These are just some of the ways we will work to improve the process and product for your use.  As always we are eager to hear from our membership.  If you have any comments or if you would like to submit a piece on quality or patient safety to the section, please contact us.  We look forward to serving you.




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Emotional Intelligence

Elaine Thallner, MD, MS

thallnerEmotional intelligence is crucial for our success, happiness, and satisfaction in our work and in our personal lives.  Since Daniel Goleman’s landmark 1999 book, Emotional Intelligence: How it can matter more than IQ, Emotional Intelligence has received much attention in the business and management communities, with many companies investing significant resources to assist and encourage their leadership teams to develop EI competencies.   Unlike IQ (Intelligence Quotient) and contrary to many people’s beliefs, an individual’s emotional intelligence competencies do increase over time, and this growth can be catalyzed by attention and effort, often achieved through executive coaching.  Goleman defines Emotional Intelligence as "the capacity for recognizing our own feelings and those of others, for motivating ourselves, and for managing emotions well in ourselves and in our relationships".   There is a strong link between EI and leadership effectiveness. 

There are two clusters of emotional intelligence: 1) self management, which includes self-awareness, self-regulation, and motivation and 2) relationship management, which includes empathy and social skill.  We are all aware of seemingly capable colleagues who lack some emotional intelligence capacity that is holding them back professionally.  In the business world (and I suspect in our field), one of the most common reasons for professional ‘derailment’ (burnout) is lack of self control.  Of course, self awareness is necessary prior to development of self control and self control can be improved with effort.  All leadership efforts, including quality improvement activities require interactions with other people.  The building and maintenance of these key relationships is another important skill.  Goleman defines empathy as ‘the thoughtful consideration of someone else’s feelings in the process of making intelligent decisions’.  Empathy is easily recognized, but unfortunately rarely expressed in our dealings with our patients, our colleagues, and our healthcare team. 

As emergency physicians, we are leaders in clinical and other settings (even if there is no official title).  Physicians often fail to recognize how their emotional state affects the people with whom they work.  We need to recognize that we have a responsibility for creating a positive work environment for our healthcare team in the service of providing excellent care to our patients.  There is a link between provider satisfaction and patient satisfaction.  Some studies suggest an association between the quality of the relationship between the physician and the patient with patient compliance with treatment recommendations.  As we develop our own emotional intelligence competencies, we can improve our leadership skills and our work environments, and by extension our service to our patients. 





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Handoff Grant Progress Report

Dickson Cheung, MD MBA MPH FACEP

Dr. Dickson Cheung 
In July 2008, QIPS received its 3rd section grant in as many years.  The Section Grant has traditionally been used as a tool to "rally the troops" behind a QI project that we can all support as a section.  And our Section Grant on handoffs has been no exception.

Since our kickoff in early September we have had intense participation and made good progress on our grant project.  Early obstacles included the blunt realization that the ED community empirically knew very little about handoff issues.  Therefore, we decided to conduct an early Pilot Survey to generate data about relevant issues and an open ended hypothesis generating survey to elicit discussion and build a game plan to tackle the relatively uncharted area of ED patient handoffs.  After three months of work, we are ready to embark on writing a white paper to address issues that have been crystallized by our earlier work.
To date, we have completed the following tasks:

  1. Solicited over 30 active members to participate in the project via personal contacts, use of the list serve and newsletter announcements
  2. Developed a virtual community through a secured Google groups webshare
  3. Held 5 one hour long conference calls
  4. Secured an IRB from Johns Hopkins to publish our survey findings
  5. Produced two surveys: a pilot survey and a hypothesis generating survey on Survey Monkey
  6. Collected over 300+ pilot survey responses at the Scientific Assembly council meeting
  7. Held an hour long face to face meeting after our QIPS section meeting in Chicago
  8. Collected responses from an open ended hypothesis generating survey
  9. Generated a 150+ article bibliography for use by our grant team to write the white paper

We had a healthy return rate of 83% (of 304 surveys distributed) of our initial Pilot Survey that was conducted at the ACEP Council meeting in Chicago on October 26, 2008.  Interesting early results include:

  • On a scale of 1-5 (5 was excellent), respondents rated their existing ED sign out practices a 3.38 (SD = 0.81) which is a clear sign that there is room for improvement.
  • Most respondents said their sign outs consisted of less than 5 patients (56%).  9% of respondents said they didn’t sign out any patients.
  • Less than 13% of respondents said that they usually or always perform bedside handoffs but 55% of respondents said they usually or always visit at least some patients after the handoff.
  • 35% of respondents reported that a common problem related to deficient handouts were due to an unknown patient in the ED that was not signed out.
  • When asked how they would fix ED handoff deficiencies, the top three answers were to 1) eliminate/reduce handoffs 2) practice bedside handoffs and 3) standardize the process.

The project is expected to wrap up by the end of February 2009.  Deliverables will include an ACEP white paper, a standardized slide set that can be used for teaching ACEP members and EM residents and hopefully one or two publishable surveys. 

If you are interested in joining group discussions, please contact me at and I will give you access to our conference calls and group webshare.



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View from Washington

Angela Franklin, Esq.



Background. The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during the second half of 2007. CMS named this program the Physician Quality Reporting Initiative (PQRI). 

CMS Releases 2009 PQRI Measure Specifications; 9 EM Measures Included

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275) made the PQRI program permanent, but only authorized incentive payments through 2010. Eligible professionals who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2009 - December 31, 2009, will earn an incentive payment of up to 2.0 percent of their total allowed charges for Physician Fee Schedule (PFS) covered professional services furnished during that same period (the 2009 calendar year).  This is an increase over the 2008 PQRI reporting program, which provided an incentive amount of 1.5 percent.


The 2009 PQRI consists of 153 quality measures and 7 measures groups. Nine (9) may be reported as "emergency medicine" measures:


Aspirin at Arrival for Acute Myocardial Infarction (AMI)

#31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for
Ischemic Stroke or Intracranial Hemorrhage
#34 Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered
#54 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
#55 12-Lead Electrocardiogram (ECG) Performed for Syncope
#56 Community-Acquired Pneumonia (CAP): Vital Signs*
#57 Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation*
#58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status*
#59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic*

* Clinicians utilizing the critical care code (99291) must indicate the emergency department place of service (23) on the Part B claim form in order to report this measure.

CMS to Address 2007 PQRI Issues; Report 
In response to concerns voiced by the AMA and other physician groups, on December 4th CMS met with several medical societies including ACEP, to discuss issues participants had with the 2007 Physician Quality Reporting Initiative.  CMS acknowledged several problems with the program related to coding errors, NPIs and split claims (where quality data codes were stripped and claims were rejected or not credited as a result).  These issues are addressed in the recently released report, "2007 PQRI Reporting Experience," which provides a detailed analysis of the 2007 program.  The report outlines issues identified for 2007 and CMS plans for modifications to the analytics for the 2008 PQRI. In addition, CMS will apply these modifications to the 2007 PQRI data and re-run the data. CMS expects that additional eligible professionals will qualify for an incentive payment for both 2007 and 2008 based on these efforts. It is anticipated that these activities will be completed by the fall 2009. 

Background. The PQRI program was implemented on July 1, 2007 through December 31, 2007 with claims-based reporting on 74 quality measures. 

  • A 2007 PQRI confidential Feedback Report is available by Tax Identification Number (TIN).
  • Participants who successfully reported could earn an incentive payment of up to 1.5 percent of their total allowed charges, subject to a cap, based on volume of reporting.
  • If participants correctly reported at least one quality data code for the 2007 reporting period a Feedback Report is available via the PQRI Portal on the Quality Net website ( ).  

The 2008 PQRI consists of 119 quality measures, including 2 structural measures, and 4 measures groups.

  • Participants can report either through the claims-based method or through approved clinical registries. 
  • Participants who successfully reported could earn an incentive payment of up to 1.5 percent of their total allowed charges, subject to a cap, based on volume of reporting.
  • Feedback Reports are expected to be made available by National Provider Identifier (NPI).

Members are urged contac Angela Franklin with comments, so that we may provide additional comments to CMS.  More information regarding PQRI may be found on the CMS website:

CMS Hosts Value Based Purchasing Listening Session

CMS PVBP Workgroup Tasks
Expected Timeline

2008  Sep  Charter Workgroup, Subgroups Develop Issues Paper 
  Dec Conduct Listening Session for Stakeholder Input on Issues Paper
2009 Jan Develop Options Paper
  Jul Proposed Listening Session for Input on Options paper
  Nov Prepare draft PVBP Plan Report
2010 May 1 Final PVBP Plan Report to Congress

On December 9th, CMS hosted a listening session to explain CMS’s work in developing a plan to transition to Medicare value based purchasing for physician and other professional services, which will be known as Physician Value Based Purchasing (PVBP).  The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), Section 131(d) requires the Department of Health and Human Services to develop a plan to transition to a value-based purchasing program for Medicare payment for physician and other professional services.  The HHS Secretary must report to Congress with a plan and recommendations for legislative and administrative action no later than May 1, 2010.  CMS distributed its PVBP Issues Paper for public comment by mid-December. 

At the listening session, CMS officials reiterated that their the goal is to focus on ways to keep the physician reporting burden to a minimum while focusing on using measures that truly improve quality of patient care and physician resource use.  In future, CMS plans to disseminate the data from quality measure reporting in ways that engage consumers and help doctors, groups, systems improve their care delivery.

CMS emphasized that the focus going forward will be on using quality measures that accomplished shared savings across settings, developing measures that are outcomes based, with the example of "reducing hospital readmissions" as a frequent example, and developing episodes and composite measures.

ACEP staff are reviewing the CMS Issues Paper and will provide comments.



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Quality and Safety Articles

Helmut Meisl MD FACEP

meislHere again is a list of recent articles for your interest. These are compiled by AHRQ PSNet at ( ).
Learning from never events: one hospital's reaction to a wrong-site surgery.
Jt Comm Perspect Patient Saf. December 2008;8:8-10.

Is health care getting safer? 
Vincent C, Aylin P, Franklin BD, et al. BMJ. 2008;337:a2426.

Hospital ethical climate and teamwork in acute care: the moderating role of leaders.
Rathert C, Fleming DA. Health Care Manage Rev. 2008;33:323-331.

Event reporting: the value of a nonpunitive approach.
Youngberg BJ. Clin Obstet Gynecol. 2008;51:647-655.

Hospital readmissions: physician awareness and communication practices.
Roy CL, Kachalia A, Woolf S, et al. J Gen Intern Med. 2008 Nov 4.

Changing conversations: teaching safety and quality in residency training.
Voss JD, May NB, Schorling JB, et al. Acad Med. 2008;83:1080-1087.

Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety.
Moore C, Saigh O, Trikha A, Lin JJ. J Patient Saf. 2008 October 16.

Cutting out human error.
Feinmann J. BMJ. 2008;337:a2370.

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

Emergency department medication lists are not accurate. 
Caglar S, Henneman PL, Blank FS, Smithline HA, Henneman EA. J Emerg Med. 2008 Sep 29.

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.
Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2008 Sep 27.

Patient safety climate in US hospitals: variation by management level.
Singer SJ, Falwell A, Gaba DM, Baker LC. Med Care. 2008;46:1149-1156.

The medical emergency team system and not-for-resuscitation orders: results from the MERIT Study.
Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S; for MERIT Study Investigators for the Simpson Centre and ANZICS Clinical Trials Group. Resuscitation. 2008 Oct 24.

The effects of emergency department staff rounding on patient safety and satisfaction.
Meade CM, Kennedy J, Kaplan J. J Emerg Med. 2008 Oct 7.

Analysis of medical emergency team calls comparing subjective to "objective" call criteria.
Santiano N, Young L, Hillman K, et al. Resuscitation. 2008 Oct 24.

Engaging patients as safety partners: some considerations for ensuring a culturally and linguistically appropriate approach. 
Johnstone MJ, Kanitsaki O. Health Policy. 2008 Sep 29.

Hospital financial condition and the quality of patient care. 
Bazzoli GJ, Chen HF, Zhao M, Lindrooth RC. Health Econ. 2008;17:977-995.

Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data. 
Raleigh VS, Cooper J, Bremner SA, Scobie S. BMJ. 2008;337:a1702.

The top 10 list for a safe and effective sign-out. 
Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.

Measuring mobile patient safety information system success: an empirical study. 
Jen WY, Chao CC. Int J Med Inform. 2008;77:689-697.

Addressing prehospital patient safety using the science of injury prevention and control.
Meisel ZF, Hargarten S, Vernick J. Prehosp Emerg Care. 2008;12:411-416.

An intervention to decrease narcotic-related adverse drug events in children's hospitals.
Sharek PJ, McClead RE Jr, Taketomo C, et al. Pediatrics. 2008;122:e861-e866.

Violations of behavioral practices revealed in closed claims reviews.
Griffen FD, Stephens LS, Alexander JB, et al. Ann Surg. 2008;248:468-474.

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics. 
Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, Happ MB, Devita MA. Qual Saf Health Care. 2008;17:377-381.

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study. 
McKay J, Bowie P, Murray L, Lough M. Qual Saf Health Care. 2008;17:339-345.

Interprofessional communication and medical error: a reframing of research questions and approaches.
Varpio L, Hall P, Lingard L, Schryer CF. Acad Med. 2008;83(Suppl 10):S76-S81.

Discrepancies between home medications listed at hospital admission and reported medical conditions. 
Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.

Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department. 
Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.

Patient care, square-rigger sailing, and safety. 
Henkind SJ, Sinnett JC. JAMA. 2008;300:1691-1693.

Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.

Standardised proformas improve patient handover: audit of trauma handover practice.
Ferran NA, Metcalfe AJ, O'Doherty D. Patient Saf Surg. 2008;2:24.

Gaps in pediatric clinician communication and opportunities for improvement. 
Woods DM, Holl JL, Angst DB, et al. J Healthc Qual. 2008;30:43-54.

Medical error disclosure among pediatricians: choosing carefully what we might say to parents. 
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.

Do faculty and resident physicians discuss their medical errors? 
Kaldjian LC, Forman-Hoffman VL, Jones EW, Wu BJ, Levi BH, Rosenthal GE. J Med Ethics. 2008;34:717-722.

A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience. 
Sehgal NL, Fox M, Vidyarthi AR, et al; for Triad for Optimal Patient Safety (TOPS) Project. J Gen Intern Med. 2008 Oct 2.

Medication reconciliation at hospital discharge: evaluating discrepancies.
Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals. 
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. 
Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. Int J Med Inform. 2008 Sep 10.

Missed injuries in trauma patients: a literature review.
Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.

Nosocomial infection, the Deficit Reduction Act, and incentives for hospitals.
Graves N, McGowan JE Jr. JAMA. 2008;300:1577-1579.

Factors associated with intern fatigue.
Friesen LD, Vidyarthi AR, Baron RB, Katz PP. J Gen Intern Med. 2008 Sep 20.

The Daily Goals Communication Sheet: a simple and novel tool for improved communication and care. 
Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. Jt Comm J Qual Patient Saf. 2008;34:608-613.

View the world through a different lens: shadowing another provider.
Thompson DA, Holzmueller CG, Lubomski L, Pronovost PJ. Jt Comm J Qual Patient Saf. 2008;34:614-618.

Handoffs causing patient harm: a survey of medical and surgical house staff.
Kitch BT, Cooper JB, Zapol WM, et al. Jt Comm J Qual Patient Saf. 2008;34:563-570.

Adverse events during hospitalization: results of a patient survey.
Fowler FJ, Epstein A, Weingart SN, et al. Jt Comm J Qual Patient Saf. 2008;34:583-590.

Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. 
Metlay JP, Hennessy S, Localio AR, et al. J Gen Intern Med. 2008;23:1589-1594.

Severity of medication administration errors detected by a bar-code medication administration system.
Sakowski J, Newman JM, Dozier K. Am J Health Syst Pharm. 2008;65:1661-1666.

Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;41:1-3.

Time out: an analysis. 
Dillon KA. AORN J. 2008;88:437-442.

Questionable hospital chart documentation practices by physicians. 
Sharma R, Kostis WJ, Wilson AC, et al. J Gen Intern Med. 2008 Aug 27.

Older patients' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries. 
Herndon MB, Schwartz LM, Woloshin S, et al. J Gen Intern Med. 2008;23:1547-1554.

Development and evaluation of the Institute for Healthcare Improvement global trigger tool. 
Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. J Patient Saf. 2008;4:169-177.

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.
Orrico KB. J Manag Care Pharm. 2008;14:626-631.

Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system.
Niazkhani Z, van der Sijs H, Pirnejad H, Redekop WK, Aarts J. Int J Med Inform. 2008 Aug 28.

The use of a CPOE log for the analysis of physicians' behavior when responding to drug-duplication reminders.
Long A-J, Chang P, Li Y-C, Chiu W-T. Int J Med Inform. 2008;77:499-506.

Consequences of inadequate sign-out for patient care.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.

Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities.
Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-1153.

Building physician work hour regulations from first principles and best evidence.
Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.
Lin C-P, Payne TH, Nichol WP, et al. J Am Med Inform Assoc. 2008;15:620-626.

Medication errors in pediatric inpatients: prevalence and results of a prevention program. 
Otero P, Leyton A, Mariani G, Ceriani Cernadas JM; and Patient Safety Committee. Pediatrics. 2008;122:e737-e743.

The effect of electronic prescribing on medication errors and adverse drug events: a systematic review.
Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. J Am Med Inform Assoc. 2008;15:585-600.

Implementing online medication reconciliation at a large academic medical center.
Bails D, Clayton K, Roy K, Cantor MN. Jt Comm J Qual Patient Saf. 2008;34:499-508.

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center. 
Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

Incentives for patient safety: holding healthcare executives accountable. 
Risk Management Reporter. August 2008;27:1-10.

Development and evaluation of a required patient safety course. 
Sukkari SR, Sasich LD, Tuttle DA, Abu-Baker AM, Howell H. Am J Pharm Educ. 2008;72:65. 

Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. 
Yin HS, Dreyer BP, van Schaick L, et al. Arch Pediatr Adolesc Med. 2008;162:814-822.

Single-patient rooms for safe patient-centered hospitals. 
Detsky ME, Etchells E. JAMA. 2008;300:954-956.    

Does error and adverse event reporting by physicians and nurses differ? 
Rowin EJ, Lucier D, Pauker SG, et al. Jt Comm J Qual Patient Saf. 2008;34:537-545.

Fault/no fault: bearing the brunt of medical mishaps.
Silversides A. CMAJ. 2008;179:309-311.

Emergency department visits for antibiotic-associated adverse events.
Shehab N, Patel PR, Srinivasan A, Budnitz DS. Clin Infect Dis. 2008;47:735-743.

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. 
Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.

Teamwork during resuscitation. 
Weinstock P, Halamek LP. Pediatr Clin North Am. 2008;55:1011-1024. 

A review of the current evidence base for significant event analysis. 
Bowie P, Pope L, Lough M. J Eval Clin Pract. 2008;14:520-536.

Medication errors reported by US family physicians and their office staff.
Kuo GM, Phillips RL, Graham D, Hickner JM. Qual Saf Health Care. 2008;17:286-290. 

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.
Mills PD, DeRosier JM, Ballot BA, Shepherd M, Bagian JP. Jt Comm J Qual Patient Saf. 2008;34:482-488.

Peer support: healthcare professionals supporting each other after adverse medical events.
van Pelt F. Qual Saf Health Care. 2008;17:249-252.

"Every error counts": a web-based incident reporting and learning system for general practice. 
Hoffmann B, Beyer M, Rohe J, Gensichen J, Gerlach FM. Qual Saf Health Care. 2008;17:307-312.

Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
Landrigan CP, Fahrenkopf AM, Lewin D, et al. Pediatrics. 2008;122:250-258.

Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.
Khuri SF, Henderson WG, Daley J, et al; and Principal Investigators of the Patient Safety in Surgery Study. Ann Surg. 2008;248:329-336.

Planning and implementing a systems-based patient safety curriculum in medical education. 
Thompson DA, Cowan J, Holzmueller C, et al. Am J Med Qual. 2008;23:271-278.

New patient safety organizations lower roadblocks to medical error reporting. 
Clancy CM. Am J Med Qual. 2008;23:318-321.

Does the Leapfrog program help identify high-quality hospitals? 
Jha AK, Orav EJ, Ridgway AB, Zheng J, Epstein AM. Jt Comm J Qual Patient Saf. 2008;34:318-325.

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. 
Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-162.

Hospital mortality: when failure is not a good measure of success.
Shojania KG, Forster AJ. CMAJ. 2008;179:153-157.

Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? 
Engel KG, Heisler M, Smith DM, et al. Ann Emerg Med. 2008 Jul 9.

Comparison of adverse events during procedural sedation between specially trained pediatric residents and pediatric emergency physicians in Israel.
Shavit I, Steiner IP, Idelman S, et al. Acad Emerg Med. 2008;15:617-622.




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Annual Meeting Minutes


Section of Quality Improvement and Patient Safety (QIPS)
Monday, October 27th, 2008
1:30 to 3:00 pm
Continental C – Hilton Chicago


Present for all or part of the meeting were: Dickson S. Cheung, MD MBA, outgoing Section Chair; Robert I. Broida MD FACEP, incoming Section Chair; Elaine A. Thallner, MD, outgoing Secretary/Newsletter Editor and incoming Section Chair-elect ; John J. Kelly, DO FACEP, Immediate Past Section Chair, Andy Sama, MD FACEP, Board Liaison; Helmut W. Meisl, MD, FACEP, Past Section Chair; David L. Meyers, MD, FACEP, Past Section Chair; speakers Dennis M. Beck, MD, FACEP, Chair, Quality and Performance Committee,  Susan Nedza, MD, FACEP and Dr. John Vozenilek, MD FACEP.  Other attendees included members and guests Drs. Arthur, Beach, Dalsey, Dickey-White, Farley, Fuller, Garcia, Garvey, Griffey, Hall, Hamedani, Hamedani, John, Jones, Kamens, Khare, Klauer, McClay, McCullough, O’Connor, Phelan, Poirer, Rohe, Schuur, Simons, Thompson, Venkatesh, Welch, and Angela J. Franklin, JD, Staff Liaison (38).


  • Welcome
  • Curriculum Project
  • Section Grant regarding Handoffs
  • Election: New Leadership
  • Councilor’s Report
  • Educational Portion – Guest Speakers
  • Voting, Operational Guidelines
  • Open Forum

Main Points Discussed

Dickson S. Cheung, MD, MBA, Chair, welcomed everyone to the section meeting and discussed Section activities that took place in 2007-08.  The Section increased its membership from approximately 235 to about 250 members, and produced a total of four (award-winning) newsletters.  Dr. Cheung also reported that the Section was the recipient of three ACEP awards:

  • The Service to College Award, Presented to John J. Kelly, DO, FACEP, Chair 2006-2007,
  • The Service to Section Award (2006-2007), Presented to John J. Kelly, DO, FACEP, Chair 2006-2007, and
  • The Section Newsletter Award of Distinction (2006-2007), Presented to John J. Kelly, DO, FACEP, Chair 2006-2007, Robert Broida, Editor, and Elaine A. Thallner, MD, FACEP and Geoffrey L. Ruben, MD, FACEP, Newsletter Co-Editors.

Dr. Cheung received a Certificate of Appreciation for his service as Chair of the QIPS Section in 2007-2008. 

Dr. Cheung next turned to the Section Grant awarded to QIPS to develop a white paper and presentation regarding ED hand-offs.  The grant team is being led by Drs. Cheung and Kelly. Work on the project is well underway and the grant team scheduled a brief meeting immediately following the QIPS Annual Meeting.  Work to date included assembling a team of over 30 members, securing an IRB from Johns Hopkins to publish survey findings, providing a pilot survey that debuted at the ACEP Council Meeting on October 25-26, providing a hypothesis generating survey, and generating a substantial and growing bibliography to support development of the white paper. 

Dr. Kelly provided an update on work on a national quality improvement curriculum.  Drs. Kelly and Thallner are leading the project, which is very close to completion.  As the project now stands, several gaps in the proposed curriculum outline have been closed and an extensive bibliography has been generated.  The goal of this phase of the project is to have the outline published in the Annals of Emergency Medicine. 

Dr. Cheung then asked Dr. Meyers to preside over the election of new officers.  The nominees were: Chair-Elect: Elaine A. Thallner, MD, FACEP.  Drew C. Fuller, MD was nominated from the floor to serve as Secretary/Newsletter Editor.  The nominees were elected to office by acclamation.  Dr. Meyers announced the 2007-2008 QIPS Officers:


Chair/Alternate Councilor Robert I. Broida, MD, FACEP
Immediate Past Chair/Councilor   Dickson S. Cheung, MD, MBA
Chair-Elect      Elaine A. Thallner, MD, FACEP
Secretary/Newsletter Editor   Drew C. Fuller, MD

Educational program. Dr. Cheung introduced the speakers for the educational program:

  • Susan Nedza, MD, MBA, FACEP, Vice President, Clinical Quality and Patient Safety, American Medical Association.  Dr. Nedza discussed the "Quality Enterprise: Report from the Front".
  • Dennis M. Beck, MD, FACEP, Chair, ACEP Quality and Performance Committee (QPC), who discussed the work of the QPC to date, as well as future plans
  • John Vozenilek, MD FACEP, principal investigator for the "HANDOFF Study Group," supported by an AHRQ grant.  Dr. Vozenilek discussed ED to ED Clinician Handoffs. 

Voting: Updating the QIPS Operational Guidelines.  Dr. Meyers led the voting on proposed changes to the QIPS operational guidelines.  Dr. Meyers explained that at its April meeting, the ACEP Board of Directors approved updated Sample Operational Guidelines that all sections would be adopting in some form at Scientific Assembly.  Key changes allow Sections to vote by email and allow for additional funding for Section activities.  The proposed changes were approved unanimously by the QIPS Section members present.

Dr. Cheung then opened the floor for new business and brief member discussion.  Dr. Cheung also noted that a meeting for those interested in assisting with QIPS Handoff grant work would immediately follow.

There being no further business, the QIPS Annual Meeting adjourned at 3:12 p.m.


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Section Annual Report

Quality Improvement & Patient Safety Section
Section Report 2007-2008

Officers for 2007-2008


Chair/Alternate Councilor Dickson S. Cheung, MD
Immediate Past Chair/Councilor   John J. Kelly, DO, FACEP
Chair-Elect      Robert I. Broida, MD, FACEP
Secretary/Newsletter Editor   Elaine A. Thallner, MD, FACEP
Board Liaison Andrew Sama, MD, FACEP
Staff Liaison Angela J. Franklin, JD

Summary of Annual Section Meeting
October 27th, 2008, Chicago, IL

Participants.  Present for all or part of the meeting were the QIPS Section Officers, Andrew Sama, MD FACEP, Board Liaison, and Angela J. Franklin, JD, Staff Liaison, along with approximately 32 additional members and guests.

Section Activities for 2007-2008.  Section activities for the prior year were discussed, including publication of four issues of the QIPS Newsletter, an increase in Section membership from approximately 235 to about 250 members, the award of an ACEP Section Grant to QIPS to develop a white paper and presentation regarding ED hand-offs, and the award of three ACEP awards to the Section:

  • Service to College Award,
  • Service to Section Award (2006-2007), and the
  • Section Newsletter Award of Distinction (2006-2007).

The Section is completing work on a national quality improvement curriculum.  The goal of this phase of the project is to have the outline published in the Annals of Emergency Medicine. 

Voting. Elections resulted in the following officers for 2008-2009:


Chair/Alternate Councilor Robert I. Broida, MD, FACEP
Immediate Past Chair/Councilor   Dickson S. Cheung, MD, MBA
Chair-Elect      Elaine A. Thallner, MD, FACEP
Secretary/Newsletter Editor   Drew C. Fuller, MD

Andrew Sama, MD, FACEP is the QIPS Board Liaison, and Angela J. Franklin, JD is staff liaison.

The Section also unanimously approved proposed updates to the QIPS operational guidelines. 

Educational Program.  Guest speakers and topics for the meeting were as follows:

  • Susan Nedza, MD, MBA, FACEP, Vice President, Clinical Quality and Patient Safety, American Medical Association.  Dr. Nedza discussed the "Quality Enterprise: Report from the Front".
  • Dennis M. Beck, MD, FACEP, Chair, ACEP Quality and Performance Committee (QPC), who discussed the work of the QPC to date, as well as future plans
  • John Vozenilek, MD FACEP, principal investigator for the "HANDOFF Study Group," supported by an AHRQ grant.  Dr. Vozenilek discussed ED to ED Clinician Handoffs. 

Section Objectives for 2008-2009

  1. Continued Involvement with the Quality and Performance Committee regarding development and recommendation of performance measures that improve outcomes and are appropriate for Emergency Medicine.
  2. Completion of a National QI/PS Curriculum grant project and submission for publication in Annals. 
  3. Completion of the ED Patient Hand-Off Survey grant project and develop White Paper for possible publication in Annals.  
  4. Submission of another grant application addressing an ACEP Priority issue.
  5. Increase membership by 100, including community and academic centers in all states.
  6. Continued mutual co-operation on QI issues with SAEM.
  7. Continuation of production of four full Newsletters with a focus on addressing member needs.
  8. Updating/improvement of the Section Website with a focus on addressing member needs.

Submitted by Dickson S. Cheung, MD, MBA
December 16, 2008




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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.

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