What’s New in the Patient Safety World


February 2009  


Healthcare IT: The Good and The Bad

Unintended Consequences of eGRF Reporting

CMS Plan to Stop Payment for Wrong-Site Surgery Final

Some More New AHRQ Patient Safety Primers





Healthcare IT: The Good and The Bad


Seems we’ve heard a lot lately about the unintended consequences of healthcare IT. Just look at some of our recent Patient Safety Tip of the Week columns:

Unintended Consequences: Is Medication Reconciliation Next?

Joint Commission Sentinel Event Alert on Hazards of Healthcare IT

Pattern Recognition and CPOE

Technology Workarounds Defeat Safety Intent

CPOE Unintended Consequences – Are Wrong Patient Errors More Common?


Fortunately, there is also good news! A study in last week’s Archives of Internal Medicine (Amarasingham 2009) demonstrated a strong association between implementation of health information technologies and reductions in mortality rates, complications, and costs. Using a tool developed to measure hospitals’ level of implementation of various healthcare IT tools, the authors found that for every 10-point increase in the automation of notes and records there was an associated 15% decrease in mortality. Also, higher scores for implementation of clinical decision support were associated with a 16% decrease in complications. And progressively lower costs were seen for admissions if a hospital had implemented automated test results, order entry, and decision support.


Since this was not a randomized controlled trial, the study does not prove that the healthcare IT initiatives, per se, were the cause of the positive outcomes. Hospitals that have implemented HIT tend to be ones that have more of a culture of safety and it may be the latter that is more responsible for the good outcomes. Nevertheless, this study lends credence to our position that healthcare IT is a critical component for improving patient safety and may lead to substantial cost savings as well. Of note, HealthGrades also happened to release it “top hospital” report last week and it noted that the top 5% of hospitals had a 27% lower mortality than other hospitals. Many of these hospitals are heavily computerized.


On the down side, a series of software glitches in the VA system (see Yen 2009) nationally resulted in many patients receiving unnecessary and potentially dangerous doses of medications like heparin. This apparently began when the VA did its annual software upgrade in August. Numerous instances of medical data popping up under another patient’s name were noted, as were instances where discontinued medications continued to be administered. This example, of course, shows one of the potentially dangerous unintended consequences of healthcare IT is having a single error (such as a software coding error) result in harm to multiple patients.






Amarasingham R, Plantinga L, Marie Diener-West M, Gaskin DJ, Neil R. Powe NR. Clinical Information Technologies and Inpatient Outcomes

A Multiple Hospital Study. Arch Intern Med 2009;169(2):108-114



HealthGrades press release



Yen H. Veterans exposed to incorrect drug doses. Associated Press January 14, 2009






Unintended Consequences of eGRF Reporting?


Speaking of unintended consequences, a new study questions the cost-effectiveness of using a widely used formula to estimate patients’ glomerular filtration rate (eGFR). Use of the eGFR can identify patients with chronic kidney disease (CKD) who would not have been identified by simply looking at creatinine levels. Here in Western New York, we actually pioneered community-wide use of the eGFR to promote earlier identification of CKD (see Boissonault 2003). The new study (Sydney et al 2009) appears in the Clinical Journal of the American Society of Nephrology. It confirms the positive outcomes of using eGFR (identifying CKD earlier, preventing some deaths and progression to ESRD). However, it also notes the potential impact of false negative test results (identifying some incorrectly as having CKD). Those patients often undergo further testing that may not have been necessary. The final answer on the widespread use of estimated GFR’s will await further population-based studies. But this, again, is a great example of how you must always be vigilant for unintended consequences any time you introduce an intervention you expect to have positive outcomes.






Boissonnault, BA. Chronic kidney disease project in Buffalo N.Y.: A community-wide approach identifying, education and treating CKD patients. Dialysis Times, 9:5:2–3, 7, 2003




Sydney C.W. Tang, Bing L, Andrew S.H. Lai, Clara B.Y. Pang, Wai Kuen Tso, Pek Lan Khong, Mary Ip, Kar Neng Lai. The costs and benefits of automatic estimated glomerular filtration rate reporting. Clinical Journal of the American Society of Nephrology (CJASN) 2009 4(2): February 1, 2009






CMS Plan to Stop Payment for Wrong-Site Surgery Final


In December 2008 we told you that “CMS Plans to Stop Payment for Wrong-Site Surgery”. As expected, those proposals have now become final and CMS has posted on its website its final decision memos to withhold payment for wrong surgery performed on a patient, surgery on the wrong body part, and surgery on the wrong patient.



Wrong Surgery Performed on a Patient (CAG-00401N)



Surgery on the Wrong Body Part (CAG-00402N)



Surgery on the Wrong Patient (CAG-00403N)





Some More New AHRQ Patient Safety Primers


In our August 2008 What’s New in the Patient Safety World column we highlighted “AHRQ's New Patient Safety Primers”. AHRQ has added 3 more patient safety primers to the original eight.


As we noted previously they are, in fact, primers – meaning they are very introductory works on several important areas related to patient safety. However, each has extensive links to both classic and contemporary bibliographic references and tools. The new ones are no different and are equally useful resources.


The primer on Safety Culture begins with the key characteristics seen in other high-reliability organizations (acknowledgement of hi-risk activities, determination to achieve consistently safe operations, blame-free environment, encouragement of collaboration across ranks and disciplines, and organizational commitment to safety). They go on to discuss enablers and barriers to a culture of safety and many of the tools we often discuss to improve safety (teamwork and communication, patient safety walk rounds, culture measurement tools, etc.). They stress the concept of “just culture” and avoiding hierarchical structures that may impede patient safety progress. Once again, a real strength of the primer is its links to other patient safety tools and a very useful bibliography.


The primer on Adverse Events after Hospital Discharge stresses that 20% of patients discharged from the hospital will suffer an adverse event, most of which were preventable. They focus on various failed communication opportunities and discontinuities in care. They stress the importance of discharge planning, medication reconciliation, followup on pending tests, and attention to health literacy issues. Good discussion of our favorite tools, checklists and structured communication tools, as cornerstones. And the links and bibliography are what you’ve come to expect of these fine AHRQ primers.


The primer on Teamwork Training focuses on crew resource management and lessons from the realm of human factors. As you’d expect, there is a huge emphasis on TeamSTEPPS™ (see our Our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™”), SBAR, handoffs, debriefing, and other tools.


The entire collection of patient safety primers is an extremely useful resource not only for those new to the patient safety movement but even for experienced patient safety and quality improvement personnel.






AHRQ Patient Safety Primers (home page)



AHRQ Patient Safety Primer “Safety Culture”



AHRQ Patient Safety Primer “Adverse Events after Hospital Discharge”



AHRQ Patient Safety Primer “Teamwork Training”
















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