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Quality Improvement & Patient Safety Section Newsletter - July 2009, Vol 10, #3

Quality Improvement & Patient Safety Section 

circle_arrow  The Chair’s Corner 
circle_arrow  Editors Note 
circle_arrow  The National Quality Forum 
circle_arrow  QIPS Research Poster Presentation 
circle_arrow  March QIPS Survey Results: Handwashing in the ED 
circle_arrow  Snap Survey: Patient Safety as a Dedicated ED Role 
circle_arrow  QIPS TIPS 3.  Mistake Proofing 
circle_arrow  Concept of a Learning Organization 
circle_arrow  ED Information Systems: Promise and Reality for Safety and Quality 
circle_arrow  ACEP Update 
circle_arrow  Quality and Safety Articles 

Newsletter Index 

Quality Improvement & Patient Safety Section 

The Chair’s Corner
Robert I. Broida, MD, FACEP

broidaEveryone in Washington is talking about Quality these days.  Of course, when they do, they really mean limiting costs.  Healthcare reform appears to be on the fast track through Congress this summer, and few really know what this "reform" will look like.  I know it will come as somewhat of a shock to most emergency physicians that some people are viewed as having no "access to care" in the US, but it’s pretty clear that healthcare reform will address this issue by expanding coverage to the uninsured.  That may represent a financial "win" for EM, but I think the jury’s still out. 

It’s important for emergency physicians to be at the table when reform is discussed.  There are trade-offs and unintended consequences from any major change in policy, and we need to be there to advocate for our patients and our specialty. 

I was personally dismayed to learn (through visits to my Senators’ offices at ACEP Leadership & Advocacy last month) that it is commonly believed that "most" ED visits are unnecessary.  CDC’s own statistics show that this number is actually around 12%.  That’s hardly "most."  Our elected officials are trying to limit these "unnecessary visits," as well as "overuse" of labs, x-rays and hospital admissions.  Sure, society can limit "unnecessary" visits, ancillary tests, and admissions, but the risk to patient safety (and increased professional liability) is quite real.  Will reform address this reality?  

There will be a call for increased Health Information Technology (HIT) as a way to improve quality and patient safety while decreasing costs.  While HIT certainly can do this, I have yet to see an ED information system that did not adversely impact physician productivity.  The trade-off is a need for additional staffing, less time spent at the bedside or interacting with other caregivers, increased lengths of stay and more overcrowding.  Will reform address this reality?  

 Action Items:    

  1. Get Involved:  Schedule an appointment with your US Representative and Senators (or at least call/write) and tell them the truth about the ED:  We are the healthcare safety net.  Most ED visits are necessary.  Reform must address increased liability.  HIT implementation has hidden costs that need to be addressed.  Invite them to visit your ED.  
  2. Elections Announcement:  The following leadership positions will be up for election at this Octobers QIPS section meeting in Boston: Chair, Vice-Chair, and Secretary/Newsletter Editor.   Please feel free let us know of your interest in one of these positions.   One of the goals of the sections is for leadership development.  QIPS has a dynamic and extensive range of former leaders that continue to remain involved and mentor others along the way.  Please join us.
  3. Request for Council Resolutions:  QIPS members are welcome to submit ideas for quality or patient safety-related resolutions for possible submission at the ACEP Council meeting in Boston.   Please address submissions to Angela Franklin ( ).
  4. QIPS Membership:  Please think of 1-2 of your colleagues that might be interested in joining QIPS.  Personal contact by you is our best membership tool.  Email them this link ( and encourage them to join!   
  5. Member Survey:  We need your vote!   VOTE TODAY in our interactive QIPS Survey: "Does your department have a dedicated Patient Safety Officer?" (click here). 


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Editors Note
Drew C. Fuller, MD, MPH

Drew FullerThis quarter’s newsletter provides our membership with a breath of interesting and practical information for improving quality and safety in our nation’s emergency departments.

In this Issue, Bob Broida brings his experience and insight on active political and policy issues coming our way, in a discussion of the National Quality Forum. The results of our first "Snap" survey are presented along with commentary alerting us to why Hand Hygiene compliance will become an increasingly important issue in our practices.  We learn about the importance of developing  "Learning Organizations" (Elaine Thallner) that are open to gaining valuable lessons from their mistakes and failures by fostering transparency and encouraging participation rather than resorting to practices of denial, shame or blame. We also gain insight into the concept of proactively looking for systems and processes that can fail and and the importance of attempting to make them "Mistake Proof" (Shari Welch) or resilient to human and system factors, limitations and variability.  David Meyers describes how the recently passed American Recovery and Reinvestment Act (ARRA) may impact EHR and HIT and provides his perspective as a national leader about some of the general issues and challenges with current HIT systems.  Concluding, Angela Franklin provides a helpful update on ACEP issues pertinent to the section, while Helmut Meisl shares a list of recent articles on quality and safety.


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The National Quality Forum
Robert I. Broida, MD, FACEP

The National Quality Forum (NQF) is a major player in the healthcare reform debate.  It is a not-for-profit organization ( ) that was established in 1999 and is based in Washington, DC.   It was created to develop and implement a "national strategy" for health care quality measurement and reporting.  Leaders in both the public and private sectors created the NQF as a mechanism to bring about national change due to a shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and health care costs.


The mission of the NQF is to:

  1. Improve the quality of American healthcare by setting national priorities and goals for performance improvement
  2. Endorse national consensus standards for measuring and publicly reporting on performance
  3. Promote the attainment of national goals through education and outreach programs.

Key goals are those of the Institute of Medicine—health care that is safe, effective, patient-centered, timely, efficient and equitable.  Together, the members of the NQF promote a common approach to measuring and reporting healthcare quality and fostering system-wide improvements in patient safety, healthcare quality, and an overall better healthcare system.


NQF has broad participation from all sectors of the health care system, including national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement.  ACEP is a member of the NQF. 

National Priorities Partnership 

NQF is a member of the National Priorities Partnership. This group, convened by NQF in 2008, is working to transform the nation’s healthcare system to ensure all Americans have access to safe and affordable healthcare. The group is co-chaired by Don Berwick, President and CEO of the Institute for Healthcare Improvement (IHI), and Peggy O’Kane, President of the National Committee for Quality Assurance (NCQA). 

The NQF Partners are collaborating on actions around six National Priorities that, together, represent the greatest potential for change:

The NQF considers these National Priorities to have the greatest potential to eradicate disparities, reduce harm, and remove waste from our healthcare system.  The Partnership’s work is now well underway , and the NQF encourages everyone in the healthcare community to get involved  in the effort to provide Americans with safer, affordable healthcare. 

To learn more about the projects already underway:

HHS Contract to Expand Performance Measures 

On January 29, 2009 the U.S. Department of Health and Human Services (HHS) awarded a contract to the NQF to establish quality and efficiency measures that would allow HHS to evaluate whether healthcare spending is achieving the best results for patients and taxpayers.

The contract is part of a provision in the Medicare Improvements for Patients and Providers Act of 2008 that directed the HHS Secretary "to contract with a consensus-based entity, such as the NQF." The contract provides $10 million for fiscal year 2009 with the option for renewal each year through 2012 for NQF to:

  • Develop a prioritized list of conditions that impose heavy health burden on beneficiaries and account for significant costs
  • Identify and endorse measures that can be used to assess and improve the care provided to beneficiaries with these conditions, and the performance of providers
  • Identify programs to track and disseminate measures
  • Ensure performance measures are updated and relevant for public reporting
  • Promote the use of electronic health records (EHR) for performance measurement, reporting and improvement
  • Report annually to Congress on the status of the project.

Upon receipt of the contract, Janet Corrigan, NQF President said, "We are on the cusp of an historic opportunity to fundamentally reform healthcare, which accounts for 16% of America’s economy and touches every American.  Performance information is needed to support quality improvement, reform payment programs to promote value; and engage patients in making better choices and managing their health conditions. Performance measurement alone is not enough; to transform healthcare, our country must dramatically enhance its ability to measure, report and improve performance. But performance measurement is a key building block, and this initial investment in standardized measures is a step in the right direction. "

HHS wants the measures to focus on "outcomes and efficiencies that matter to patients, align with electronic collection at the front end of care, encompass episodes of care when possible, and be attributable to providers where possible. A premium must be placed on developing measures in key areas that will have the greatest impact in improving quality and value, rather than focusing on developing a large number of measures that may be easiest to produce, such as process measures."

The HHS contract will be administered through HHS’ Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary for Planning and Evaluation (ASPE).


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QIPS Research Poster Presentation

Congratulations to the QIPS team lead by Dickson Cheung!  Their Poster Presentation, "Variation in the Practice of Emergency Department Handoffs" was accepted for the poster session at the ACEP Scientific Assembly in Boston.  The Poster presents the findings of last year’s survey which was distributed to all attendees at the ACEP Council Meeting.

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In your ED, what is the approximate percent of patient interactions where the caregiver has washed their hands before entering the room?

hand hygiene compliance survey graph 
This graph displays a relatively low level of confidence with proper hand hygiene compliance. While far from being statistically significant, it does demonstrate a possible pattern of suboptimal compliance. This may not surprise many practitioners in Emergency Medicine but it does highlight the need for significant improvement.


Proper Hand hygiene has been identified as a critical factor in patient safety and is a class 1A recommendation by the CDC for reducing Health Care Associated Infections (HCAI). Several agencies and oversight organizations have made improving hand hygiene as one of their highest priorities and include: The Joint Commission (National Patient Safety Goal #7), and The World Health Organization (High 5 Evidence Based Solutions for Patient Safety).

Unfortunately, compliance in many health care settings is very low or unmeasured. Past studies are limited but EDs have shown to have some of the lowest performance with hand washing as compared to other health care settings. The ED setting may present additional challenges due to the unique environment and patient care flow making compliance more difficult.

As a specialty, we need to take a leadership role in identifying process, structural, cultural and educational issues that threaten attaining the highest levels of compliance in hand hygiene. In addition, we need to play a key role in identifying and developing best practices as well as serving as an informational resource for improving compliance and patient safety in this area. For more information on Hand Hygiene see:

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Snap Survey: Patient Safety as a dedicated ED Role


"Does your department have a dedicated patient safety officer?"

Click HERE to respond! 

While safety is intended with most of what we do as clinicians, some organizations have found success by establishing dedicated patient safety positions in their departments to help identify, prioritize and act on issues relating to safety.




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QIPS TIPS 3. Mistake Proofing
Shari Welch, MD, FACEP

Shari WelchThe emergency department is the site for more and varying treatments, processes and procedures than any other real estate in your healthcare institution. Unfortunately the emergency department is also the most frequent location for death and disability related to inefficient care and a frequent site of adverse events in medicine, according to the Joint Commission. The ability to maintain quality control and patient safety for this vast myriad of activities is increasingly an unachievable goal. As other industries have appreciated, we need to design our work environment to prevent errors, to recognize and alert the team when an error has occurred and to reduce the effects of user errors. This is a monumental task, and one that deserves our effort.

Mistake proofing is the use of process or design features to prevent errors or prevent the negative impact of those errors. Mistake proofing is also known as poka-yoke (pronounced poka-yokay), Japanese slang for "avoiding inadvertent errors". Nowhere has this concept been built out and systematized better than at Toyota under the mistake-proofing guru, Shigeo Shingo (Shingo 2). Mistake proofing was formalized by Japanese manufacturers in the 1960’s and translated into English in the 1980’s. But mistake proofing is older than that. The Otis elevator brake which stopped the elevator between floors when a cable broke, was introduced in the 1850’s. In that example the elevator cable could still sever or disconnect, but the Otis brake allowed the elevator operator to mitigate the damage by stopping the elevator mid-floor.

examples of mistake proofingAnother example of mistake proofing involves the everyday filing cabinet. The early cabinets would tip over if more than one filing cabinet drawer filled with heavy files, was open at a time. The mistake proof design has one open drawer lock the others closed to prevent tipping. Another early example of mistake proofing can be seen in the design of this early medicine bottle. From the 19th century, this bottle was deliberately designed with tactile spikes. In this way the doctor, nurse or patient was alerted to the fact that a dangerous compound was inside. Human creativity and ingenuity have been used in the environment to prevent or mitigate the mistakes that humans will make. It is high time such efforts took off in our work environment. IMAGE HERE.

How about a Pyxis® or medication dispensation system that alarms if we try to open the drawer of a medication that the patient is allergic to?

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Concept of A Learning Organization
E. Thallner, MD, MS

thallnerBusiness has recognized that a key factor in organizational success is the ability of an organization to respond to the pressures they face, and that the opportunities when a quick response is required has increased. An alternative to the dominant mental model of thinking about organizations (the machine model in which there are multiple parts and an issue can be fixed by replacing a part) is the concept of a learning organization. Donald Schon has studied various learning organizations and notes that society and its institutions are in a state of continuous transformation and developed the concept of learning organizations. Although there is not a consensus on a definition of a learning organization, common themes can be identified. These include:

a) providing continuous learning opportunities

b) using learning to reach their goals

c) linking individual performance with organizational performance

d) fostering inquiry and dialogue, making it safe for people to share openly and take risks

e) embracing creative tension as a source of energy and renewal, and

f) are continuously aware of and interact with their environment (Kerka 1995).

Peter Senge identifies five disciplines that allow such an organization to exist: personal mastery, mental models, shared vision, team learning, and systems thinking. In such an organization, employees would excel at creating, acquiring and transferring knowledge. Twenty years of organizational research has revealed that there are three main essential factors for organizational learning and adaptability: a supportive learning environment, concrete learning processes and practices, and reinforcing leadership behavior. Creating a supporting learning environment will do much to improve patient safety efforts. Psychological safety is imperative. Imagine working where no one fears being marginalized when they disagree, verbalize a minority opinion, or admit a mistake. Learning occurs when people talk about different outlooks and opinions. Employees should be encouraged to try novel ideas, to take risks and explore the unknown without fear. Ideally, time for thoughtful review of the organizations processes would occur. Employees would ideally feel valued, not fear sharing their opinions or concerns, and develop processes to share information. Learning processes involve collecting, interpreting and sharing information in a systemized way. The US Army After Action Review (AAR) process is a good example that we may wish to emulate. Four simple questions are asked after every mission:

a) What did we set out to do?

b) What actually happened?

c) Why did it happen?

d) What do we do next time?

The results are codified by the Center for Army Lessons Learned (CALL) and disseminated. Medicine could learn much from this process and use it to improve patient care. Finally, leadership strongly influences organizational learning. When we actively listen and ask questions, others feel encouraged to learn. When we support people’s expression of alternative points of view, employees offer new ideas and options. We need to recognize that we cannot know all the answers and that we need to empower others to work with us to improve our work environment and patient care.

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ED Information Systems: Promise and Reality for Safety and Quality
David Meyers, MD, FACEP

Dr. David MeyersWith the American Recovery and Reinvestment Act (ARRA ) now signed into law by President Obama, significant efforts by the government are under way to change the way medicine is practiced in the US by encouraging, or forcing, depending on your point of view, the adoption of electronic health records into everyday clinical practice. There are basically two putative benefits related to this radical restructuring of health care practice: vast improvements in the efficiency and quality of health care and drastic reductions in the costs of health care. The Act authorizes approximately $19 billion to promote Health Information Technology (HIT) and electronic health records (EHRs) to achieve these improvements, and the Obama administration has targeted 2014 as the year when every American will have the benefit of an EHR. Significant financial incentives and penalties for physicians and hospitals as well as funding for an infrastructure to support these efforts are embodied in the law to foster successful adoption.

Dr. David Blumenthal, the newly named National Coordinator for HIT, wrote in a recent New England Journal of Medicine article ( ) that in spite of these facilitating steps, significant obstacles must be overcome. Among them are: 1) the failure of the current process through CCHIT – the quasi-governmental body which certifies that a particular EHR product meets minimal standards for ease-of-use and is designed to achieve the quality and efficiency goals in the law; and 2) getting providers to optimize their use of the clinical decision supports embedded in the EHRs to achieve better quality. Financial incentives, ie, Pay for Performance for hospitals and providers, coupled with penalties for non-adoption or non-performance are viewed as the tools to improve physicians’ practices with respect to the quality of care.

With these points in mind, let’s look at some issues in the use of Emergency Department Information Systems (EDIS). For purposes of this discussion, the term EDIS broadly includes a number of elements, among them: patient tracking, physician (EMR=Electronic Medical Record) and nurse documentation, computerized physician order entry (CPOE), discharge instructions, prescription writing and electronic transmission, operations reporting, clinical decision support, quality improvement reporting and analysis, results reporting and interfaces with the hospital’s IT platform for access to old records, discharge summaries, diagnostic study reports, etc. These features may or may not be available and/or used in any given product or location.

As more and more hospitals consider or implement automation for clinicians in order to tap into their benefits and comply with the law, EDs are tempting sites to initiate HIT efforts. The ED appears to be a relatively closed setting with relatively small numbers of staff to convince of the benefits and to train. Many of us are comfortable with technology and PCs. By the nature of our work, we are extremely adaptable. Furthermore, it may be easier to impose change on ED physician staff, in settings where practice management groups, usually outside vendors, can be tasked with getting physicians to use the tools effectively or risk financial penalties or loss of a contract.

Many of the issues surrounding the philosophical and practical questions of EDISs were addressed in a Consensus Development Conference sponsored by the Society for Academic Emergency Medicine in 2004. The proceedings of that conference were published in the Society’s journal late that year (Handler JA, Adams JG, Feied CF, Gillam M , Vozenilek J , Barthell EN , et al. Emergency medicine information technology consensus conference: executive summary . Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2004 Nov; 11(11):1112-3.). An ACEP Informatics "White Paper"  published in April 2009 (Link: ) made the statement that the report of the conference remains "one of the most definitive works on ED Information Systems, and its content as relevant today as five years ago". Further, from that report, "Implementation of commercial EHR systems have been more sobering, with some studies reporting increased or new types of errors, little benefit from decision support, and even increased mortality. It has become clear that success in any health IT project is predicated on careful system design, deliberate implementation, and attention to clinician needs."

The ACEP report is an excellent primer on the background, planning, implementation and evaluation of EDISs and should be required reading for planners at any organization contemplating a new or re-evaluating an existing EDIS and EMR. It is particularly thorough in reviewing strengths, weaknesses and desirable features of these systems.

Two great enemies of timely, safe, effective and high quality care are delays in evaluating patients and human factors which lead to wrong diagnoses. A presumed goal of HIT and EDISs ought to be the reduction of the adverse impact of these factors. Yet, real world experience reveals that EDIS and EMRs have not had the intended effects in many situations.

To the extent that efficient patient throughput is a driver of reducing delays in patient care, it is apparent that the transition to EMRs from a template-based paper record for physicians often leads to reduced physician productivity (personal communication – Dick Klaas - data from over 20 EMR/EDIS implementations with at least 10 vendors’ products). On the other hand, there is anecdotal information about sites where physician charts are produced using hand-written free text and/or dictation/transcription, where productivity has increased when an EMR Is implemented. So, in determining whether productivity changes with an EMR, it seems to depend on the charting method one is moving FROM. My experience is with transition from the template system (T-System) paper chart.

Relative Value Units (RVU) per patient increase with many if not most all of the EMR products, probably because of the relative ease of documenting more information and the prompts and reminders that are part and parcel of many EMRs. While rates of physician work (RVUs per patient or per hour) often do increase when an EMR is used, suggesting greater productivity, the number of patients per hour (pph) does not and in many cases actually goes down. Patients-per-hour, not the RVU measure, is the relevant metric which impacts patient throughput and waiting times to see a physician. It often correlates (inversely) with patients who leave without a medical screening exam, deterioration of patient condition in the waiting room and patient satisfaction. In Klaas’s data, these reductions in pph after EMR implementation in most cases have not returned to the pre-implementation baselines even more than a year later and the impact on delays has persisted. Many organizations are now looking at how to maintain patient throughput, but more quick, cheap fixes are likely to be needed. Among the most frequent options being considered are scribes to relieve the physician of the documentation burden (and perform "go-fer" functions) as well as added physician or physician-extender staffing.

Another issue which is increasingly being noted is the reduction in face-to-face verbal communication between physicians and nurses in the course of patient care. The stereotypical scenario is the doctor and nurse both engrossed in documenting on their respective terminals away from the bedside while the patient deteriorates amid a cacophony of alarms, ignored because they have been tuned out as being so much background noise rarely depicting a true patient emergency.

The communication problem seems to be one which could be overcome by EMR design. Unfortunately, a number of EMR products in wide use do not have easy access by the various care-givers to each others’ notes, further sabotaging communication. Where human performance depends on ease of use and design for efficiency, it is remarkable that so little attention seems to have been paid to these factors in product design, even (and perhaps especially) in some of the enterprise-wide products where a single vendor has developed all modules of the system. An organization with a helpful perspective on software design that considers human behavior is "Human factors International" ( ); their newsletter is full of ideas for software designers to consider in overcoming human l imitations.

So the benefits of EDIS’ are at best not without significant unintended and adverse effects. It has been often said that automating bad processes, just like building a new ED, does not solve the problems of the bad processes; it merely installs them in the new setting, "automated" or geographic. The proof of this truth is visible in many health care organizations.

The potential for electronic systems to enhance clinician performance seems very high, but as in so many other aspects of life, translating that potential into the real world is a big challenge. In future issues of our newsletter, I will review some of the other putative benefits related to safety and quality attendant to the use of EMRs and EDISs, including prompts and reminders, medication safety features around orders and prescription writing, use of macros and others. Meanwhile, I welcome your thoughts and comments.

Welcome New QIPS Members!

Andrew C. Allison, Venetia, PA
Jason K. Fleming, Honolulu, HI
Robert Flint, Hagerstown, MD
Matthew Judd, Hockessin, DE
Badrinath Kulkarni, Clovis, CA
Nisha S. Matthew, Mount Laurel, NJ
Kenneth J. Robinson, Hartford, CT
Shawna J. Perry, Mechanicsville, VA Abraham L. Warshaw, New York, NY

The ACEP Section on Quality Improvement and Patient Safety (QIPS) is always looking for prospective new members. If you know of anyone in your group who has an interest in QI/PS, please encourage them to join our section. We endeavor to keep our membership updated on the latest in the field – and the $35 per year cost is significantly less than ANY publication on the market. Click here  for information on membership.


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ACEP Update
Angela Franklin, Esq.

angelafranklinHealth care reform, quality and value-based purchasing (VBP).  

VBP has been included in nearly all policy discussions related to health care – from the President’s budget proposal, to Congress and its policy advisors. President Obama’s FY2010 budget proposal referred to "demonstration and pilot projects [to] evaluate payment reforms, ways to provide higher quality care at lower costs … and better align provider payments with costs." We expect many of these initiatives to be incorporated in legislative proposals in the next few weeks; already draft legislation unveiled in the Senate and the House include several quality and value-based purchasing provisions that could impact the practice of emergency medicine. Please see the Advocacy page (Federal Issues) on the ACEP website for more information on these legislative proposals.

CMS establishes new Toolkit, PQRI helpline.  CMS recently posted 2009 implementation advice for the 2009 Physicians Quality Reporting Initiative (PQRI).  Tools include a downloadable numerical listing of all codes included in the 2009 PQRI for incorporation into billing software, and a link to measure-specific worksheets for reporting each measure. CMS has also established a new help line for PQRI participants with questions regarding participation procedures, feedback reports, and bonus payments. The telephone number is 866-288-8912, and will be in operation between 7:00am and 7:00pm Central time. CMS plans to create a new email address for inquiries as well.  Additional information about these tools and the PQRI program may be found at  

CMS "P4P" official moves to NQF.  The National Quality Forum (NQF) has announced Thomas B. Valuck MD, JD, as its new Senior Vice President of Strategic Partnerships. Dr. Valuck was Medical Officer and Senior Adviser in the Center for Medicare Management at CMS, where his portfolio included pay for performance.  Dr. Valuck will oversee: setting national priorities for healthcare via the NQF-convened National Priorities Partnership (NPP) developing a measure development agenda; and identifying and recommending measures and composites for use in payment and public reporting programs.  ACEP is actively participating at both the NQF and NPP.

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Quality and Safety Articles

Here is again a list of recent articles. These are compiled by AHRQ PSNet at ( ).
Helmut Meisl MD FACEP May 2009
Educational strategy to reduce medication errors in a neonatal intensive care unit.
Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A. Acta Paediatr. 2009;98:782-785.

Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital.
Thomas AZ, Giri SK, Meagher D, Creagh T. BJU Int. 2009 Mar 10

Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings.
Ouchida K, Lofaso VM, Capello CF, Ramsaroop S, Reid MC. J Am Geriatr Soc. 2009;57:910-917.

Medication errors in critical care: risk factors, prevention and disclosure.
Camiré E, Moyen E, Stelfox HT. CMAJ. 2009;180:936-943.

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.
Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.
Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009 Apr 2.

Medication errors resulting from computer entry by nonprescribers.
Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA. Am J Health Syst Pharm. 2009;66:843-853.

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.
Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.
O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

Hospital complications: linking payment reduction to preventability.
Averill RF, Hughes JS, Goldfield NI, McCullough EC. Jt Comm J Qual Patient Saf. 2009;35:283-285.

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.
Masica AL, Richter KM, Convery P, Haydar Z. Proc (Bayl Univ Med Cent). 2009;22:103-111.

Medication discrepancies upon hospital to skilled nursing facility transitions.
Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.

Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group.
Stock R, Scott J, Gurtel S. Jt Comm J Qual Patient Saf. 2009;35:271-279.

Pharmacists' medication reconciliation-related clinical interventions in a children's hospital.
Gardner B, Graner K. Jt Comm J Qual Patient Saf. 2009;35:278-283.

Closing the safety loop: evaluation of the National Patient Safety Agency's guidance regarding wristband identification of hospital inpatients.
Sevdalis N, Norris B, Ranger C, Bothwell S; Wristband Project Team. J Eval Clin Pract. 2009;15:311-315.

Leading successful rapid response teams: a multisite implementation evaluation.
Donaldson N, Shapiro S, Scott M, Foley M, Spetz J. J Nurs Adm. 2009;39:176-181.

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.
Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Arch Surg. 2009;144:305-311.

Development and validation of the SURgical PAtient Safety System (SURPASS) checklist.
de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Qual Saf Health Care. 2009;18:121-126.

Practising safely in the foundation years.
Long S, Neale G, Vincent C. BMJ. 2009;338:1046.

Regional surveillance of emergency-department visits for outpatient adverse drug events.
Capuano A, Irpino A, Gallo M, et al. Eur J Clin Pharmacol. 2009 Mar 18.

Patient safety and collaboration of the intensive care unit team.
Despins LA. Crit Care Nurse. April 2009;29:85-91.

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.
Golden, CO: HealthGrades, Inc.; April 2009.

Serious Reportable Events in Massachusetts Acute Care Hospitals: January 1, 2008–December 31, 2008.
Executive Office of Health and Human Services, Department of Public Health, Bureau of Health Care Safety and Quality. Boston, MA: Commonwealth of Massachusetts; 2009.

Market-based control mechanisms for patient safety.
Coiera E, Braithwaite J. Qual Saf Health Care 2009;18:99-103.

The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review.
van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. Pediatrics. 2009;123:1184-1190.

Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.
Salerno SM, Arnett MV, Domanski JP. Teach Learn Med. 2009;21:121-126.

Rating recommendations for consumers about patient safety: sense, common sense, or nonsense?
Weingart SN, Morway L, Brouillard D, et al. Jt Comm J Qual Patient Saf. 2009;35:206-215.

Do patient safety events increase readmissions?
Friedman B, Encinosa W, Jiang HJ, Mutter R. Med Care. 2009 Mar 23.

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.
Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. Ann Emerg Med. 2009 Mar 19.

Measurement of quality and assurance of safety in the critically ill.
Pronovost PJ, Sexton JB, Pharn JC, Goeschel CA, Winters BD, Miller MR. Clin Chest Med. 2009;30:169-179.

Drug-related problems in medical wards with a computerized physician order entry system.
Bedouch P, Allenet B, Grass A, et al. J Clin Pharm Ther. 2009;34:187-195.

Assessing the impact of an educational program on decreasing prescribing errors at a university hospital.
Peeters MJ, Pinto SL. J Hosp Med. 2009;4:97-101.

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

Measuring preventable harm: helping science keep pace with policy.
Pronovost PJ, Colantuoni E. JAMA. 2009;301:1273-1275.

Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians.
Koppel R, Kreda D. JAMA. 2009;301:1276-1278.

Preventing catheter-related bloodstream infections: thinking outside the checklist.
Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life.
Gurses AP, Carayon P, Wall M. Health Serv Res. 2009;44:422-443.

From tasks to processes: the case for changing health information technology to improve health care.
Walker JM, Carayon P. Health Aff. 2009;28:467-477.

Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review.
Pape H, Pfeifer R. Patient Saf Surg. 2009;3:3.

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.
Valentin A, Capuzzo M, Guidet B, et al; Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. BMJ. 2009;338:b814.

Health information technology and patient safety: evidence from panel data.
Parente ST, McCullough JS. Health Aff. 2009;28:357-360.


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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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