Fatigue in Healthcare – Hashtags of the Week (HOTW): (Week of July 7, 2014)

Asleep in the Library

Each week the Healthcare Leaders chat (#HCLDR) is fabulous, covering relevant fascinating topics of great interest to me. I can’t highlight them every week, but I am often tempted to do so. This one was huge — how do we manage fatigue when it impacts on doctors, nurses, residents, students?

Webinar: Team training and patient safety

The Agency for Healthcare Research and Quality (AHRQ) will host a 1-hour webinar on the use of the agency’s teamwork training program, TeamSTEPPS® & what evidence is available to demonstrate the program’s efficacy in improving patient safety.  David Baker, Ph.D., TeamSTEPPS® Master Trainer & Senior Vice President at IMPAQ International, will discuss the following objectives:

  1. The key components of teamwork
  2. How to develop teamwork in health care
  3. The core components of TeamSTEPPS®
  4. The TeamSTEPPS deployment process
  5. The evidence on team training effectiveness
  6. The effectiveness of TeamSTEPPS

AHRQ Update: Making Health Care Safer II

safetyThe AHRQ has put out an updated Making Health Care Safer report as a sequel to the initial 2001 report.  The influential and controversial 2001 report became the cornerstone of many patient safety practices, but many safety indicators haven’t improved as much as was hoped.  As a result, the current report sought to look at more context and generalization, as well as unintended consequences.

The current report was made by conducting a systematic literature review that provides a clear look at a large number of patient safety practices. Here’s a few of the STRONGLY encouraged patient safety practices:

  • Preoperative checklists and anesthesia checklists to prevent operative and post-operative events.
  • Bundles that include checklists to prevent central line-associated bloodstream infections.
  • Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.

There’s also a list of encouraged patient safety practices that were important enough to be mentioned, but didn’t quite make in on the STRONGLY encouraged list. Here’s a few things from that list:

  • Multicomponent interventions to reduce falls.
  • Use of clinical pharmacists to reduce adverse drug events.
  • Documentation of patient preferences for life-sustaining treatment.

Incidentally, UMHS has an active Patient Safety MovementDr. Sanjay Saint, for example, has done a lot of research on patient safety and catheter-associated UTIs, which is one of the strongly suggested items on the AHRQ report. To learn more about his research , you can watch this interview of him discussing the topic.

Patient & family engagement in hospital quality & safety

From the Agency for Healthcare Research & Quality (AHRQ):

A new online resource from the Agency for Healthcare Research and Quality (AHRQ) helps hospitals improve quality and safety by building productive partnerships between health care professionals, patients, and family members. Patient and family engagement is a critical part of what hospitals should already be doing.  The Guide to Patient and Family Engagement in Hospital Safety and Quality outlines concrete opportunities to engage patients and families in individual care and at an organizational level.

The guide includes strategies that hospitals can implement such as adding layperson advisors and improving communications during admissions; at the bedside during shift changes; and with discharge planning. Each strategy has tools, materials, and trainings for patients, families, hospital clinicians, and staff. You can also find out what other hospitals did and the lessons learned.

Hazards leading to surgical site infections at ambulatory surgical centers

From the Agency for Healthcare Research & Quality (AHRQ):

A recently completed AHRQ-funded study explores the use of a proactive risk assessment to identify hazards that can lead to surgical site infections in the ambulatory surgery center setting. Select to access the report, “Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers,”which describes the use of a tool called the Socio-Technical Probabilistic Risk Assessment to estimate the risk of surgical site infections in the ambulatory surgery environment. The report examines single point failures as well as combinations of events that lead to the outcome of interest and proposes an intervention for future deployment.

Taubman Librarian Acknowledged in American Heart Association Scientific Statement

WhitneyIn the August 5th issue of Circulation, the magazine of the American Heart Association, our very own Whitney Townsend was lauded for her contributions to the latest scientific statement from the American Heart Association: Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork.

Working in tandem with a team of librarians from a wide range of institutions, Whitney was instrumental in conducting the extensive critical literature searches which underpin the research and inform recommendations made in the scientific statement. A hearty kudos to Whitney and her far-flung colleagues!


And with that, dear readers, I wish you a fond farewell as I end my tenure managing the Taubman Health Sciences Library News Blog. It has been tremendously fun and educational, and I am honored to pass the baton to Caitlin‘s capable hands!

Hospital Survey on Patient Safety Culture (SOPS) Database Reopening


AHRQ’s Hospital Survey on Patient Safety Culture (SOPS) Database will soon be reopening for submission and reporting of Hospital SOPS data. The database was specifically made to gather the “AHRQ Hospital Survey on Patient Safety Culture into a central repository.”

Beginning in October 2013, data from Medical Office Survey on Patient Safety can be submitted.

AHRQ’s projected timeline for submission and reporting of SOPS Data is as follows:

Survey Submission Dates
Hospital Survey on Patient Safety Culture June 1 – June 15, 2013
Medical Office Survey on Patient Safety Culture October 1 – October 15, 2013
Nursing Home Survey on Patient Safety Culture Spring 2014
NEW: Pharmacy Survey on Patient Safety Culture Fall 2014

Submission specifications and other documents (including a Data Use Agreement) will be available soon.

“The SOPS database team can be reached with questions at 1-888-324-9790 or by email at DatabasesOnSafetyCulture@westat.com.

For all other questions, please contact the general SOPS helpline at 1-888-324-9749 or email at SafetyCultureSurveys@westat.com.

AHRQ News: 2013 TeamSTEPPSR National Conference

From the AHRQ Daily Digest Bulletin:

Call for Presenters for 2013 TeamSTEPPSR National Conference

Deadline is December 21

Are you passionate about TeamSTEPPS? The TeamSTEPPS National Conference organizers are looking for presenters who wish to share their stories about any new, innovative and engaging ways they are using team training to improve patient safety in their organization. The conference will take place June 12-13, 2013, in Dallas, TX. We are accepting and considering presentations or poster sessions across a wide array of topics. Examples include, but are not limited to:

• Facility-wide to unit-based implementation
• Education
• Measurement
• Strategies for success
• Creating a change team
• Leadership
• Best practices
• Developing and engaging staff
• Leveraging technology
• Long term care/SNFs/medical home
• Regulatory standards and updates

Please read the guidelines for submitting abstracts and learn more about the conference by visiting the National Conference tab at www.teamstepps.ahrq.gov.

The 2013 Call for Presentations ends FRIDAY, DECEMBER 21.

Many injury-related hospital stays among elderly result in readmission

From AHRQ:

A new AHRQ-funded study finds that about one in seven elderly patients (14 percent) admitted to the hospital for an injury will be readmitted within 30 days.  The study examined 2006 data from hospitals in 11 states for admissions with a principal diagnosis of injury using AHRQ’s Healthcare Cost and Utilization Project State inpatient databases. The most common reasons for readmission were surgery of the upper or lower extremities, pneumonia, heart failure, septicemia and urinary tract infection. Three quarters of injury patients were discharged to nursing homes or home health care. Patients who had severe injuries, received transfusions, experienced a patient safety indicator event,  had an infection, and were discharged to a nursing home or home helath care had higher readmission rates. The study’s authors suggest that strategies to reduce readmission rates among elderly injury patients should focus on preventing complications and infections during the hospital stay and also address nursing home and home health care. The report, “Thirty-Day, All-Cause Readmissions for Elderly Patients Who Have an Injury-related Inpatient Stay,” was published in the October issue of Medical Care. [PubMed]

More avoidable deaths in the US than in three European countries

From Health Affairs:

Amenable mortality—deaths that could have been avoided with timely and appropriate health care—accounts for 21 percent of deaths among men and 30 percent of deaths among women under the age of 75 in several high-income countries. A new study from Health Affairs, released today as a Web First, compared mortality rates in the Unites States, France, the United Kingdom, and Germany between 1999 and 2007. It found that amenable mortality had declined by 18.5 percent in the United States compared to 36.9 percent in the United Kingdom, 27.7 percent in France, and 24.3 percent in Germany. As a result of the slower improvement, the United States now has higher amendable mortality rates than the other three countries.

The principal source for the data about the three European countries was the World Health Organization mortality database, and the US data came from the Centers for Disease Control and Prevention. The study compares data on cause of death for amenable causes with other causes, including treatable cancer and heart disease, which the authors consider 50 percent preventable for this age group. Some key study findings, which explain the lower decline in US rates compared to other countries:

    • Lack of progress in the United States relative to other countries was observed in mortality rates among men attributed to surgical conditions and medical errors. Among those 65 to 74, the mortality rates per 1,000 men were unchanged between 1999 and 2007, while there were declines in other countries: 0.46 fewer deaths per 100,000 a year in Germany, 2.22 in the UK, and 3.11 in France.
    • Women between 65 and 74 experienced a decline in mortality rates from circulatory conditions other than heart disease in all four countries between 1999 and 2007, but the pace of change was the smallest in the United States (4.33 fewer deaths per 100,000 per year compared with 4.8 in France, 8.64 in Germany, and 11.56 in the United Kingdom).
    • Mortality from treatable cancers for men fell at similar rates in all four countries during that time period: with deaths per 100,000 declining 2.64 per year in France, 2.69 in the United States, 2.73 in the United Kingdom, and 3.46 in Germany.
    • For both sexes, the US rates of decline for those under age 65 lagged well behind the other three countries, widening the gap over the decade.

We show that the lagging progress of the United States compared to other countries, as measured by amenable mortality, is largely driven by elevated amenable mortality among those younger than age 65,” concluded the authors. “However, we also observed a slowing of improvement among older Americans, relative to their peers in the other countries we studied…. A recent comparison of factors…showed that many Americans failed to obtain recommended treatment for common chronic conditions….[T]here is no reason why all Americans cannot benefit equally from living in a country with the most expensive health care system in the world.”