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Quality Improvement & Patient Safety Section Newsletter - September 2010, Vol 11, #4

Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow Editor’s Note
circle_arrow On the Other Side of the Needle
circle_arrow QIPS TIPS “Patient Assignments and Work Loads”
circle_arrow Organizational Design
circle_arrow Safety Culture: What is it and why does it Matter?
circle_arrow The ‘Other’ Hospital Accreditation Organization
circle_arrow Perfect Storm? Convergence of Quality and Health IT in the ED
circle_arrow Annual Meeting Notice 
circle_arrow Articles of Interest 

Newsletter Index

Quality Improvement & Patient Safety Section

The Chair’s Letter
Elaine Thallner, MD, MS, FACEP

Elaine ThallnerWe hope to see you to at the annual section meeting in Las Vegas on September 29th at 10:30 am.  It will be a time to make new connections and renew old ones and learn more about quality and patient safety.  

As my tenure as chair of the QIPS Section is ending, and I reflect back over the past year, I am very appreciative.   I am thankful for the relationships that have developed and strengthened, and for what we have learned and accomplished together.  Many of us have found each other’s friendly voices to be a source of encouragement and strength during good times as well as during times of tragedy.  I am astonished at how quickly this year has passed and thank you.  I am reminded of a truth learned from one of my mentors: “Life is too long to not have fun.”  This truly has been fun!   

When I think of the section, I am aware of how much more can be envisioned, considered, and accomplished when working collaboratively in positive, ‘can-do’ groups as opposed to going it alone.  Building on the successes of past years, the QIPS Section continued to offer four high-value newsletters, section members authored an article published in Annals, "Improving Handoffs in the Emergency Department", developed an EM resident quality award program, and applied for and were awarded two section grants.  Since January of this year, our section membership increased from 261 to 309 members, reflecting the growing interest and focus on quality and safety issues in healthcare.  

In conclusion, I look forward to continuing working together as we learn how to most effectively deliver quality care in a patient-safety oriented environment for our patients.

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Editor’s Note

Emergency Department Benchmarking Alliance

Heather Farley, MD, FACEP

Heather FarleyThe Emergency Department Benchmarking Alliance (EDBA) is a not-for profit organization founded in 1994 as an association of 30 high volume EDs interested in pursuing solutions to common operational challenges.  The EDBA has since expanded in scope and mission, and now includes members that are leaders in over 300 EDs throughout the country.  As touted on its website (, the organization seeks to identify, develop, and implement future best practices in emergency medicine by: 

  • Maintaining an independent, unbiased database of demographic and performance metrics;
  • Fostering community, sharing, support, and mutual advice for people with operational    responsibilities in emergency services;
  • Co-sponsoring regular educational events relating to ED management;
  • Sponsoring consensus conferences, which bring together authoritative people from and relating to our field, in order to set national standards and influence national practice; and
  • Providing a framework and support for research relating to ED operations. 

The EDBA is currently chaired by Dr Charles L. Reese, IV, MD (Christiana Care Health System), who welcomes all emergency department administrators (physicians, nurses, managers) to apply for membership.

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On the Other Side of the Needle

Dickson Cheung, MD, MBA, MPH

Dr. Dickson CheungIt had already been a rough two weeks.  Wesley, my oldest who is 5 years old, came down with his primary HSV outbreak May 14th and I stayed home with him for two days and tried to make it the most boring time imaginable so that he would want to go back to school.  It worked.  His fever broke, his perioral blisters crusted and he couldn’t wait to get back to kindergarten.  Three days later, Ethan our 3 year old had fevers to 104 which we all assumed was the same virus.  So after consultation with a few pediatricians (my wife being one), we started him empirically on valtrex to reduce the chances of a prolonged course.  I was sidelined for another few days.  This time watching reruns of Caillou.  My wife also came down with a low grade temp and tender cervical adenopathy which we thought a little strange since we both had our primary HSV infections but we didn’t think too hard about it.  After all, we were in survival mode, juggling dual careers, office drama, and sick kids.   

On Wednesday, I developed a fever.  It went up to 104.8 and never did defervesce much despite antipyretics.  I was delirious at times.  By Friday, I conceded that I was too ill to work my weekend shifts and imposed upon my partners to cover them.  That night, I developed a hard lump in my left groin.  I got a formal ultrasound in the evening and was relieved to find out it was just a very large inguinal lymph node.  Then on Saturday morning, I woke up, took a shower and laid down on the living room sofa.  A rash began creeping down my left thigh.  And I couldn’t stand up without feeling like I was going to pass out.  

My wife humored me by taking my blood pressure… 50/P.  I repeated it myself with the same result.  Concern started to set in.  After piling our kids into the car, we rolled down the hill for 0.8 miles into the ED where I work. 

My initial blood pressure in the ED hovered around 70.  My left leg was hot, red and swollen.  “Just give me a couple of liters and I’ll be fine,” I argued with the ED physician who just happened to be my boss.  After a few liters, my blood pressure did not improve.  "Maybe you should stay for a couple of days," he persuaded.  "Ah, I’ll be alright," I reassured him.  Then my labs came back: WBC 16.2 (37% bands), Cr 4.0, lactic acid 4.4.  Fine petechiae began to break out across my chest.  My blood pressure continued to fall.  My otherwise calm wife activated the panic button.  My mother-in-law flew across the country, neighbors and workmates picked up the kids. 

“Do whatever you need to do,” I surrendered.  The team quickly whisked me away to one of the critical care rooms to place lines and prepare for the worst.  Under the drapes, random thoughts crossed my mind.  Did he wash his hands?  Is he going to use an ultrasound?  Is it going to hurt?  How many shifts am I going to miss?  Am I ready to die?  When the ICU physician saw my INR of 1.5, he asked, “Did we send a DIC panel?”  And then an event occurred that I will forever deny.  I was noted to come back to consciousness and peer out of my drapes yelling, “It is on the order set.  Just follow the order sets!”  

After imaging studies to rule out necrotizing fasciitis, several bags of fluids, multiple antibiotics and IVIG (nasty stuff), I began having difficulty breathing and my oxygen saturation plummeted.  "ARDS," explained the intensivist, "and impaired EF due to sepsis."  OK, the sepsis catheter and foley were bad enough.  No ventilator?  Can we try some lasix?  I feel like the Michelin man.  Fortunately, my condition improved by night fall and I never needed to experience the thrill of being on the other end of an ET tube.  Two days on levophed, several liters of fluid mobilized, five days in the ICU, a PICC line and three weeks of antibiotics.  The fatigue, de-conditioning and lack of drive would linger but I had been spared.  The cultures never did grow out an organism.  “Probably some bad beta-hemolytic strain of streptococcus” was the only explanation the infectious disease service could offer.  I'll never know where the infection came from but it did make me think about all the exposures we get on a daily basis. 

Despite the ARF, DIC, ARDS (and PTSD), I consider my sabbatical with sepsis a blessing.  I am fortunate in that I expect a full recovery and it was a relatively transient episode.  And I had a lot of time to just lay in bed and take inventory of all the clutter that had accumulated in my life; both in our house and in our schedules.  Certain desires surfaced.  Some expected, some not; to unpack.  Strange yearning after a near death experience but I felt a great need to finally settle after having moved to Denver three years ago.  More time writing; specifically journaling to my kids. My one big regret would have been to leave while they were still young and not be there when they grew up.  More focused effort using my talents for something other than professional accomplishments.  More time giving thanks.  More time spent in purposeful conversation.  My wife has forgotten old friends and former groomsmen, colleagues, neighbors, and even casual new acquaintances. 

Clinically, there are some things I will not quickly forget.  The acerbic taste of the prepackaged saline flushes (did you know that this was common?), the lapses of consciousness, the drowning of your lungs in fluid, the dependence on a diuretic to urinate and breathe, the burn of the foley catheter, the feeling of being "strapped down" to the bed with tubing, wires, cuffs.  Amidst that vulnerable experience, a more guttural appreciation emerged for all we do in committee meetings, administrative tasks and academic work, occasionally mind-blowing, but mostly mundane.  The efforts focused on hand washing, protocols, ultrasound, central lines, airway management, communication, and efficiency.   

If I was on vacation in a remote area, I have no doubt that I would have died.  It happened that quickly.  I know that if it were not for immediate access to great medical care the outcome would have been much different.  It is because of safe and efficient systems that I survived.  To my colleagues devoted to quality and safety, continue to strive to make our hospitals a more functional place.  Believe me, it all matters especially when you are the one on the other side of the needle.

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QIPS TIPS “Patient Assignments and Work Loads”

Shari Welch, MD, FACEP

Shari WelchIn another example of how poorly our industry understands the delivery of healthcare in the emergency department setting, we have attempted to tackle the related subject of how patients are assigned to providers.  As our effort was made to catalogue the various strategies and models currently in use, it became clear:  The language and terminology don’t even exist to discuss the topic!  

How patients are assigned to providers has implications in terms of worker satisfaction, efficiency and flow.  Yet most departments do not have a clearly articulated strategy for making these assignments.  A few concepts should be acknowledged when designing the best model for patient assignments. 

  • Models that utilize teams are superior because they enhance communication and improve workflow, this in turn improves efficiency;
  • Models that utilize geographic zones are superior because they also enhance communication, teamwork and efficiency;
  • Models that empower providers with regard to work load are preferred by providers;
  • A Patient Flow Coordinator overseeing patient flow for the department is increasingly an integral role and part of a patient assignment system.  The old charge nurse role has been morphed into an effective coordinator, policing the department and each zone for inefficiencies, backlogs and delays, and workloads;
  • Patient segmentation, grouping patients according to resources needed and anticipated length of stay is an innovative new concept and part of the best patient assignment models;
  • The move toward objective measures of workloads for physicians and nurses will continue and aid in patient assignments; and
  • Load leveling, or making equivalency in workload is an important concept in ED work for both physicians and nurses, and integral to patient assignment systems. 

A few of the more commonly seen Patient Staffing Models for Physicians are listed below: 

Free-range staffing: The health care provider self assigns himself or herself to the patient and staffs until the patient’s disposition is complete. 

By assignment: Patients are assigned to ED health care providers by a designated provider in charge.  

Rotational: Some EDs assign patients using a rotation system where physicians alternate patient assignments in a planned sequence. 

Zone assignments. Analogous to zone nursing, the physician staffs a zone and cares for the patients who are assigned to that zone.  

Team assignments. A team including a physician, nurse(s), tech(s) and in some models PAs, a HUC, and a scribe inhabit a geographic zone. Patients are “fed” into the zone and are then staffed by that team.  

 Work Load Feeding:  Technology is required; the computerized tracking system would calculate the workload of a zone, predict overcrowding in the zone, and cue where in the department the next patient should be    placed. 

The point is this:  Give some thought as to how patients are assigned and have a model that makes sense for your department in terms of layout and staffing! 

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Organizational Design 

Elaine Thallner, MD, MS, FACEP

Jay Galbraith is an internationally known organizational design scholar and I would like to review his book Designing Dynamic Organizations (2002, AMACOM) and introduce his Star Model. Organizational design “is the deliberate process of configuring structures, processes, reward systems, and people practices and policies to create an effective organization capable of achieving the business strategy.”  It is more than a reporting grid.  As you read this, it may be useful to consider it at several different levels: for yourself, your emergency department and for your health system as a whole. 

With this in mind, the five points of the star are:  Strategy, Structure, Processes and Lateral Capability, Reward Systems, and People Practices.  I limit this discussion to the level of system of the emergency department and hospital. 

Strategy sets the direction of the organization and the goals need to be clear; the vision and mission should be known and explicitly stated.  Strategy is the foundation upon which all else is built. When the strategy is unclear or not agreed upon, it is almost impossible to move ahead with designing the other four points of the star because the group does not know what the goal is.  How many of us are clearly able to articulate the goals, vision, and mission of our hospitals or even of our emergency departments? 

The organizational structure “determines where formal power and authority are located.”    This includes the configuration of work groups as well as the roles within the configuration.  Are our work group configurations structured to accomplish the goals set out by our strategy? 

Processes and Lateral Capability addresses the capacity to overcome the barriers created by the organizational structure.  For example, in a business where there is no thought or planning to developing mechanisms to collaborate across boundaries created by the organization, gridlock is the expected outcome.  The ‘silo mentality’ so prevalent in medicine is an example of such a structure that can easily lead to gridlock without conscious effort to address this.  We often see work repeated or not done due to lack of coordination with other work groups. 

Reward systems are the result of the metrics chosen to base our performance on as well as the recognition given if we achieve the metric benchmarks.  Without a thoughtful reward system that recognizes the objectives that are important to the group and established in the strategy, frustration (and turnover) often ensue. Having a discussion about considering metrics beyond RVUs makes sense if the organization desires to pay more attention to other concerns.  For example, a group may wish to consider if it wishes to measure patient satisfaction surveys, employee satisfaction surveys, throughput, perhaps even quality of handoffs or other measures of citizenship.   

Galbraith’s fifth category is ‘people practices.’  Ideally, (beyond basic technical and licensure requirements) people will be hired who are capable of contributing and becoming empowered and engaged contributors. 

Galbraith says that if all the above components are not aligned, optimal organizational performance cannot be achieved.  In medicine (as well as in many businesses), adequate attention is not paid to ensuring optimal organizational design.

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Safety Culture: What is it and why does it Matter?

Drew C. Fuller, MD, FACEP

Drew FullerYou may have recently noticed your hospital’s leadership showing a strong interest in “safety culture.” Many hospitals have taken steps to assess the culture through hospital-wide surveys that are most often completed by nursing and ancillary staff.  

The focus on safety culture is driven by a growing body of evidence that demonstrates better performance, such as lower accident/error rates, better QI measures and higher patient & staff satisfaction, in departments and hospitals that have higher safety culture scores. In addition, the Joint Commission now requires that hospitals assess safety culture on a regular basis.  

Good to know, but what is “Safety Culture?”  Safety culture in healthcare can be defined as the shared practices, values and beliefs of the people working in an organization; more practically stated, it is “the way we do things around here.”  When broadly assessed, it gives us valuable insight into the many dimensions of our local environment of care and how culture may impact safety.   

Some of the key dimensions of safety culture can include: 

  • Perceptions of teamwork;
  • Perceptions of norms and behaviors relating to quality of care and patient safety;
  • Job satisfaction;
  • Perceptions of management (department level and hospital wide);
  • Stress recognition (and impact on performance);
  • Adequacy of training and supervision;
  • Institutional learning and responses to error;
  • Beliefs about causes of errors and adverse events;
  • Adequacy of equipment, information, processes and resources;
  • Incident reporting infrastructure, feedback and information; 

The Joint Commission and the Institute for Healthcare Improvement (IHI) recently reported that “a clinical area with a strong safety culture demonstrates effective coordination of care, sees mistakes as opportunities to learn, and has engaged caregivers who proactively and thoughtfully bring solutions forward.” The converse of this is also true.

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The ‘Other’ Hospital Accreditation Organization

Jack Kelly, DO, FACEP

kellyIn a rapid query of all hospitals in the 150 mile Philadelphia area, the Joint Commission seemed to be the universal accreditation organization....yet one hospital was accredited by "the other" accrediting organization.  That organization is DNV Healthcare Inc. (DNVHC), and approved by CMS to be a Healthcare Accreditation organization in 2008.  The National Integrated Accreditation for Healthcare Organizations (NIAHO) is the accreditation entity within DNV Healthcare (DNVHC). 

Take a minute to study the comparison table at this link and skim thru the FAQs ( ).

I think you will find this interesting...however, for the near future the Joint Commission seems to have the market share!

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Perfect Storm?  Convergence of Quality and Health IT in the ED

PerfectStorm0910angelafranklinIn charting the course toward health care reform, the Obama administration is taking the helm on improving the quality and efficiency of care and spurring health information technology (health IT) use.  The administration recently signed two major laws designed to achieve these goals and align quality and payment policies:  (1)  the Health Information Technology for Economic and Clinical Health Act (HITECH) within the larger American Recovery and Reinvestment Act of 2009 (ARRA, or Stimulus Act), and (2) the 2010 Patient Protection and Affordable Care Act (PPACA).  The laws include carrots—and a bundle of sticks for unwary providers.  Department of Health and Human Services (HHS) is currently proposing and finalizing regulations to implement the laws, the provisions of which will come into play this year and stretch into the next decade.  Broadly, the laws address linking payment to value, quality and performance strategy and measurement, comparative effectiveness research and knowledge dissemination and use of health information technology, across the continuum of care. 

ACEP is actively engaged in the multiple processes that brought these new laws about, and has identified high priority provisions of the PPACA for emergency medicine.  Please continue to follow our advocacy efforts, the QIPS Section, the Emergency Medicine Informatics Section and other ACEP groups as the College continues to advance emergency medicine interests and help members navigate these initiatives.   

HITECH, Quality and Health IT  

A major impetus behind public and private initiatives that promote the adoption and use of interoperable health IT is aligning payment, measuring performance and improving the quality of care across the continuum of care.  The HITECH Act provides billions of new dollars to clinicians and hospitals for the “meaningful use” of certified health IT, as well as for comparative effectiveness research and privacy protections for medical records. The Act codifies the Office of the National Coordinator for Health Information Technology, provides $2 billion for its discretionary spending, and establishes a goal of “utilization of a certified electronic health record (EHR) for each person in the United States by 2014.”  Complementary final rules implementing the Act were published on July 28, 2010, the centerpiece of which is a Centers for Medicare and Medicaid Services (CMS) EHR incentive program for providers to meaningfully use EHRs—including for the purposes of quality measurement and performance reporting—beginning in 2011. Beginning in 2015, clinicians and hospitals not using certified products in a meaningful way will be penalized.  

Issues for emergency physicians  

Emergency physicians are ineligible for direct incentives under the EHR program (control over hospital systems is at issue), however, key provisions include emergency departments (EDs) in many areas where hospitals may earn incentives, for example: using computerized physician order entry (CPOE), performing drug-drug and drug-allergy interaction checks, recording demographics, recording and charting changes in vital signs and smoking status, maintaining problem, medication and allergy lists, providing patients electronic copies of their health information and discharge instructions, and incorporating clinical lab-test results into EHRs as structured data.  Hospitals must also report quality measures around median ED turnaround time, and admit to decision time to ED departure, in order to meet program requirements.   Additional details about these programs and impacts on emergency medicine are on ACEP’s website, and the rules may be accessed at the links below.  

PPACA, Quality and Health IT  

PPACA seeks to drive improvements in health care delivery and stem rising health care costs by linking quality of care across the continuum of care, payment and the use of health IT. Incentives and penalties are used in new payment and delivery models, value-based purchasing programs and mandated quality reporting.  The Act also establishes new demonstration and comparative effectiveness research initiatives. 

Issues for emergency physicians  

ACEP President, Angela F. Gardner, MD, FACEP has outlined ACEP’s high priorities for overall implementation of the PPACA and proposed new priorities and tactics —please click this link to learn more.   Quality and health IT are strong currents throughout PPACA: the PQRI provisions and other provisions around quality and health IT that are of particular interest to emergency physicians are outlined below. 

Improvements to Physician Quality Reporting Initiative “PQRI” (§3002)  

PQRI is an existing Medicare pay-for-reporting program which is currently voluntary, but per PPACA, becomes mandatory in 2015.  PPACA extends bonus payments for successful PQRI reporting from performance year 2011 through 2014. In 2015, however, those who do not successfully participate in the PQRI program face payment reductions.   PPACA also provides for the eventual linkage of the CMS Physician Quality Reporting Initiative (PQRI) to the CMS EHR incentive program discussed above, for using EHRs to report measures.    

Participants must report on specific quality measures by submitting specially designated quality measure billing codes when submitting the claim with the procedure code describing the associated service, e.g. an evaluation and management (E/M) service office visit, for which Medicare would make payment; there are several additional ways to report including (for emergency physicians) reporting on measures groups.  Registry-based and EHR reporting options are also on the near horizon.  For 2010, nine (9) individual measures and one pneumonia measure group may be reported for emergency medicine.   

Clinicians may receive up to a 1.0% bonus in 2011 and a 0.5% bonus in 2012, 2013 and 2014. Those who do not successfully report quality data will have their Medicare payments reduced by 1.5% in 2015 and by 2.0% in 2016 and each subsequent year.  A physician comparison website will be posted in 2011 publicizing the names of clinicians and practices satisfactorily reporting quality data. 

PPACA makes several improvements to PQRI, aimed at easing physician participation: 

  • In 2011, PQRI reporting will be allowed through a Maintenance of Certification program (MOCP) operated by a specialty body of the American Board of Medical Specialties; an additional 0.5 percent PQRI bonus may be earned from 2011 to 2014.  The details and criteria—as outlined in CMS’ proposed 2011 Medicare Physician Fee Schedule—remain unclear, however.  ACEP asked CMS to clarify this process in our comments regarding the fee schedule. 
  • CMS must evaluate a registry reporting option in 2011, allowing physicians an alternate, less burdensome method of reporting. 
  • CMS must give participants timelier feedback on their performance, allowing them to track progress and make course corrections.
  • CMS must establish an appeals process regarding its determinations whether clinicians have/have not successfully participated.
  • CMS must develop a plan to integrate PQRI with the EHR incentive program, to determine whether a physician is “meaningfully using” an EHR when reporting on quality measures.  

Additional details about the PQRI program may be found at the links below.

Other Provisions, Alignment

Several PPACA provisions are focused on: linking payment to value, development of a national quality strategy, evidence-based quality and performance measure development and implementation, comparative effectiveness research and knowledge dissemination and the use of health information technology, across the continuum of care.  PPACA also provides for the alignment of multiple initiatives in these areas in order to reduce duplication and increase the efficiency of these programs in the near future.  The chart at this link gives a high-level view of both the PPACA and HITECH provisions intended to help achieve these goals.

Forcast: 2011 and Beyond

These programs could present challenges, but also opportunities for emergency physicians as they are implemented over several years.  The key agencies, CMS and ONC, acknowledge they are still working out details of the programs in phases and implementation in future years will change as the programs play out. The new initiatives will ultimately be meshed with existing physician and hospital quality and pay for reporting and pay for performance programs: the PQRI, discussed above, and the hospital inpatient (“RHQDAPU”[1]), and outpatient (“HOP QDRP”[2]) value based purchasing programs.  In the interim, ACEP will keep a weather eye out, continue to educate members, and look for new ways to advance the interests of emergency medicine as these programs evolve. 


  1. The Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative was initially developed as a result of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. Section 5001(a) of Pub. 109-171 of the Deficit Reduction Act (DRA) of 2005 set out new requirements for the RHQDAPU program, which build on the ongoing voluntary Hospital Quality Initiative.  
  2. The Outpatient Prospective Payment System (OPPS) final rule released November 1, 2007, outlines the initial implementation of the Hospital Outpatient Quality Data Reporting Program (HOP QDRP). Under this program, hospitals will report data for 2008 services on the quality of hospital outpatient care using standardized measures of care to receive the full annual update to their OPPS payment rate, effective for payments beginning in calendar year (CY) 2009. The HOP QDRP is modeled on the current quality data reporting program for inpatient services, the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.

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Annual Meeting Notice

Please join us for the QIPS Section Annual Meeting at ACEP’s Scientific Assembly!  

Quality Improvement & Patient Safety (QIPS) Section Annual Meeting

Date:   Wednesday, September 29th, 2010
Time: 10:30 a.m. to 12:30 p.m.
Location:  Mariners B / MBCC North
Mandalay Bay Resort, Las Vegas

The meeting will include an educational portion and a business meeting featuring the election of new officers.  Nominations are open for a new Chair-Elect and Secretary/Newsletter Editor. 

Nominations will be offered by the Nominating Committee, and nominations from the floor will be accepted at the meeting. Officers will be elected by a majority vote of the Section members present and voting at the meeting. For more information on the responsibilities of each office, please review the Operational Guidelines on the Section website.

Please contact our staff liaison Angela Franklin with nominations, questions, or to indicate your interest in seeking office.

Register now at:!

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Articles of Interest

Helmut Meisl, MD, FACEP   

meislThese are compiled by AHRQ PSNet at (  

Association of interruptions with an increased risk and severity of medication administration errors. 
Westbrook JI, Woods A. Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010; 170:683-690 

The value from investments in health information technology at the U.S. Department of Veterans Affairs. 
Byrne CM, Mercincavage LM, Pan EC, Vincent AG, Johnston DS, Middleton B. Health Aff (Millwood). 2010; 29:629-638.

Eight recommendations for policies for communicating abnormal test results.
Singh H; Vij MS. Jt Comm J Qual Patient Saf. 2010;36:226-232. 

Teamwork on inpatient medical units: assessing attitudes and barriers. 
O'Leary KJ, Ritter CD, Wheeler H, Szekendi MK, Brinton TS, Williams MV. Qual Saf Health Care. 2010;19:117-121.

Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations. 
Sehgal NL, Green A, Vidyarthi AR, Blegen MA, Wachter RM. J Hosp Med. 2010;5:234-239.  

The published literature on handoffs in hospitals: deficiencies identified in an extensive review. 
Cohen MD, Hilligoss PB. Qual Saf Health Care. 2010 Apr 8; [Epub ahead of print].  

CMS changes in reimbursement for HAIs: setting a research agenda. 
Stone PW, Glied SA, McNair PD, et al. Med Care. 2010;48:433-439.  

Mixed results in the safety performance of computerized physician order entry. 
Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.  

Evaluation of a redesign initiative in an internal-medicine residency. 
McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. N Engl J Med. 2010;362:1304-1311.  

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors. 
Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN. Arch Dis Child. 2010;95:286-290.  

Accuracy of computer-generated, Spanish-language medicine labels. 
Sharif I, Tse J. Pediatrics. 2010 Apr 5; [Epub ahead of print].  

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. 
Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2010;35:124-133. 

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs. 
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.  

Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals. 
Piontek F, Kohli R, Conlon P, Ellis JJ, Jablonski J, Kini N. Am J Health Syst Pharm. 2010;67:613-620.  

The effect of health information technology on quality in U.S. hospitals. 
McCullough JS, Casey M, Moscovice I, Prasad S. Health Aff (Millwood). 2010;29:647-654.  

Impact of senior clinical review on patient disposition from the emergency department. 
White AL, Armstrong PAR, Thakore S. Emerg Med J. 2010;27:262-265.  

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. 
O'Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. J Gen Intern Med. 2010 Apr 13; [Epub ahead of print].  

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. 
Kim CS, Lukela MP, Parekh VI, et al. Am J Med Qual. 2010 Mar 31; [Epub ahead of print].  

Effect of bar-code technology on the safety of medication administration. 
Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.  

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. 
Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010 May 3; [Epub ahead of print]. 

Interruptions and distractions in healthcare: review and reappraisal. 
Rivera-Rodriguez AJ, Karsh BT. Qual Saf Health Care. 2010 Apr 8; [Epub ahead of print].  

Reporting trends in a regional medication error data-sharing system. 
Anderson JG, Ramanujam R, Hensel DJ, Sirio CA. Health Care Manag Sci. 2010;13:74-83.  

Intensive care unit safety culture and outcomes: a US multicenter study. 
Huang DT, Clermont G, Kong L, et al. Int J Qual Health Care. 2010 Apr 9; [Epub ahead of print].  

ISMP medication error report analysis. 
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287. 

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution. 
Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Ann Emerg Med. 2010;55:341-344.  

Stop "borrowing" medications: protecting patients from harmful medication errors. 
Jt Comm Perspect Patient Saf. May 2010;10:5-7.  

Effect of bar-code technology on the safety of medication administration. 
Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707. 

The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments. 
van Noord I, de Bruijne MC, Twisk JWR. Int J Qual Health Care. 2010;22:162-169.  

Am I (un)safe here? Chemotherapy patients' perspectives towards engaging in their safety. 
Schwappach DLB, Wernli M. Qual Saf Health Care. 2010 Apr 27; [Epub ahead of print].  

Klass P. N Engl J Med. 2010;362:1358-1361.  

CPOE: strategies for success. 
Manor PJ. Nurs Manage. 2010;41:18-20.  

Reducing inappropriate diagnostic practice through education and decision support. 
Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.  

Avoiding wrong site surgery: a systematic review. 
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.  

Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. 
James KL, Davies JG, Kinchin I, Patel JP, Whittlesea C. Adv Health Sci Educ Theory Pract. 2010 May 12; [Epub ahead of print].  

ReCASTing the RCA: an improved model for performing root cause analyses. 
Pham JC, Kim GR, Natterman JP, et al. Am J Med Qual. 2010;25:186-191.  

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. 
Bernstein J, MacCourt DC, Jacob DM, Mehta S. Clin Orthop Relat Res. 2010 May 11; [Epub ahead of print].  

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. 
Weiser TG, Haynes AB, Dziekan G, et al; for the Safe Surgery Saves Lives Investigators and Study Group. Ann Surg. 2010;251:976-980.  

Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. 
Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010:36;252-260.  

Assessing legislative potential to institute error transparency: a state comparison of malpractice claims rates. 
Perez B, DiDona T. J Healthc Qual. 2010;32:36-41.  

Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. 
Hall J, Peat M, Birks Y, Golder S; on behalf of the PIPS Group. Qual Saf Health Care. 2010 Apr 27; [Epub ahead of print].  

Bar code technology and medication administration error. 
Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.  

Outpatient adverse drug events identified by screening electronic health records. 
Gandhi TK, Seger AC, Overhage JM, et al. J Patient Saf. 2010;6;91-96.  

The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems. 
Pham JC, Colantuoni E, Dominici F, et al. Qual Saf Health Care. 2010 Apr 28; [Epub ahead of print].  

A July spike in fatal medication errors: a possible effect of new medical residents. 
Phillips DP, Barker GEC. J Gen Intern Med. 2010 May 29; [Epub ahead of print].  

Improving the patient, family, and clinician experience after harmful events: the "When Things Go Wrong" curriculum. 
Bell SK, Moorman DW, Delbanco T. Acad Med. 2010;85:1010-1017.  

Developing a patient safety surveillance system to identify adverse events in the intensive care unit. 
Stockwell DC, Kane-Gill SL. Crit Care Med. 2010;38(suppl 6):S117-S125.  

Application of human error theory in case analysis of wrong procedures. 
Duthie EA. J Patient Saf. 2010;6:108-114.  

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents. 
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010 Jun 8; [Epub ahead of print].  

The relationship between patients' perception of care and measures of hospital quality and safety. 
Isaac T, Zaslavsky AM, Cleary PD, Landon BE. Health Serv Res. 2010 May 28; [Epub ahead of print].  

Single-parameter early warning criteria to predict life-threatening adverse events. 
Rothschild JM, Gandara E, Woolf S, Williams DH, Bates DW. J Patient Saf. 2010;6:97-101.  

Accountability measures—using measurement to promote quality improvement. 
Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. N Engl J Med. 2010 Jun 23; [Epub ahead of print].  

Teaching quality improvement and patient safety to trainees: a systematic review. 
Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Acad Med. 2010 Jun 10; [Epub ahead of print].  

The effect of work hours on adverse events and errors in health care. 
Olds DM, Clarke SP. J Safety Res. 2010;41:153-162.  

Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool. 
Naessens JM, O'Byrne TJ, Johnson MG, Vansuch MB, McGlone CM, Huddleston JM. Int J Qual Health Care. 2010 Jun 9; [Epub ahead of print].  

Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. 
Murphy DJ, Needham DM, Goeschel C, Fan E, Cosgrove SE, Pronovost PJ. Am J Med Qual. 2010 Jun 4; [Epub ahead of print]. 


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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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