| March 15, 2022, Issue #805  Editor's note: Look Thursday for another special edition of AHRQ News Now in support of Patient Safety Awareness Week. As the nation's lead agency dedicated to protecting patients from harm, AHRQ is pleased to again support Patient Safety Awareness Week. Ongoing investments in safety research, the development of safety toolkits and training resources, and a growing emphasis on improving diagnostic safety are all part of a mission to make healthcare safe for all Americans. Access more information about AHRQ's support of Patient Safety Awareness Week, including a special introductory video from Jeff Brady, M.D., director of the Center for Quality Improvement and Patient Safety; information about how to get involved in Patient Safety Awareness Week activities; and recent patient and diagnostic safety resources, including: AHRQ has released a new training course that teaches clinical teams how to apply TeamSTEPPS® communication and teamwork principles to improve diagnosis. The new TeamSTEPPS for Diagnosis Improvement course applies four TeamSTEPPS competency areas: communication, leadership, situation monitoring and mutual support. The course includes seven modules for teams and individuals. The modules can be delivered in a classroom setting or virtually, with supplemental resources such as the participant workbook, real-life case studies and assessment tools to use before and after the course. Access more information about how to get started. Pediatric intensive care units (PICUs) that participated in a multisite diagnostic stewardship intervention saw potentially unnecessary blood culture orders drop by 34 percent, according to a new AHRQ-funded study in JAMA Pediatrics. Severe sepsis has an 8 percent prevalence in critically ill hospitalized children and a 25 percent mortality rate, according to researchers. However, blood cultures can be collected excessively among PICU patients without specific symptoms, increasing the risk of unnecessary antibiotic prescribing and resistance. To identify areas for improvement, 14 PICUs formed the Bright Star Collaborative to test and evaluate blood culture practices using a diagnostic stewardship intervention. Researchers found that blood cultures per 1,000 patient days per month declined by 34 percent while rates of mortality, length of stay, readmissions and sepsis remained stable. Rates of central line-associated bloodstream infections in the 14 sites also dropped by 36 percent. Access the abstract. As part of Patient Safety Awareness Week, AHRQ will host a Twitter chat on diagnostic safety on March 17 from noon to 1 p.m. ET. Discussion topics will include diagnostic safety and approaches to improving diagnosis. Access AHRQ's Twitter channel to participate and use the hashtags #AHRQChat and #PSAW22. In addition, AHRQ is participating in an Ask HRSA & Partners webinar titled, "Effect Positive Change," on March 17 at 2 p.m. Register to learn strategies that healthcare organizations can implement immediately to improve safety culture.  Sigall K. Bell, M.D., associate professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, has long recognized the value of patient experience in detecting potential diagnostic errors. Now, her AHRQ-funded work is drawing from the input of patients who can view and contribute to their visit notes after an ambulatory care appointment. Patient insights have helped Dr. Bell create a framework to understand more precisely where and how often diagnostic breakdowns take place. Her research has also led to the creation of a new tool, compatible with major electronic health record systems, which lets patients note concerns about potential breakdowns in the diagnostic process. Access Dr. Bell's profile, and well as additional AHRQ profiles of researchers working to improve diagnosis, including Dr. Hardeep Singh, Dr. David Newman-Toker, Dr. Eric Thomas and Dr. Ronilda Lacson. Access more information about Patient Safety Awareness Week and AHRQ's diagnostic safety resources. | AHRQ's Patient Safety Network (PSNet) highlights journal articles, books and tools related to patient safety. Articles featured this week include: Review additional new publications in PSNet's current issue or access recent cases and commentaries in AHRQ's WebM&M (Morbidity and Mortality Rounds on the Web). AHRQ's Center for Quality Improvement and Patient Safety is hiring a director for its Division of Healthcare-Associated Infections (HAIs). Candidates from the public or federal workforce are encouraged to apply. The physician selected will be responsible for leading the HAI division and providing clinical expertise for a range of research and programmatic activities related to health services research. Technical expertise in HAIs, implementation research, antimicrobial-resistant bacteria and antibiotic stewardship are required. Duties may include: developing a comprehensive strategy to prevent and reduce HAIs and combat antibiotic-resistant bacteria; participating in federal committees and workgroups; delivering oral presentations; and cultivating research partnerships among federal agencies and others. April 1 is the deadline to apply. Access more information, including required qualifications, salary range and application instructions. | AHRQ in the Professional Literature Understanding diagnostic processes in emergency departments: a mixed methods case study protocol. Daniel M, Park SY, Seifert CM, et al. BMJ Open. 2021 Sep 24;11(9):e044194. Access the abstract on PubMed®. Analyzing diagnostic errors in the acute setting: a process-driven approach. Griffin JA, Carr K, Bersani K, et al. Diagnosis (Berl). 2021 Aug 23;9(1):77-88. Access the abstract on PubMed®. Implementation of patient safety structures and processes in the patient-centered medical home. Oberlander T, Scholle SH, Marsteller J, et al. J Healthc Qual. 2021 Nov-Dec;43(6):324-39. Access the abstract on PubMed®. Patient perceptions of safety in primary care: a qualitative study to inform care. Lasser EC, Heughan JA, Lai AY, et al. Curr Med Res Opin. 2021 Nov;37(11):1991-99. Epub 2021 Sep 22. Access the abstract on PubMed®. Leapfrog Hospital Safety Score, magnet designation, and healthcare-associated infections in United States hospitals. Pakyz AL, Wang H, Ozcan YA, et al. J Patient Saf. 2021 Sep 1;17(6):445-50. Access the abstract on PubMed®. Making patient safety event data actionable: understanding patient safety analyst needs. Puthumana JS, Fong A, Blumenthal J, et al. J Patient Saf. 2021 Sep 1;17(6):e509-e14. Access the abstract on PubMed®. Behavioral economics and ambulatory antibiotic stewardship: a narrative review. Richards AR, Linder JA. Clin Ther. 2021 Oct;43(10):1654-67. Epub 2021 Oct 23. Access the abstract on PubMed®. Promoting health equity for deaf patients through the electronic health record. James TG, Sullivan MK, Butler JD, et al. J Am Med Inform Assoc. 2021 Dec 28;29(1):213-16. Access the abstract on PubMed®. Contact Information For comments or questions about AHRQ News Now, contact Bruce Seeman, (301) 427-1998 or Bruce.Seeman@ahrq.hhs.gov. |
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