AHRQ's '10 Patient Safety Tips for Hospitals' (plus Dr. Gastaldo's remarks)

Attn: Gerri Michael Dyer
Electronic Dissemination Advisor
Agency for Healthcare Research and Quality
Via

Please see my note to you at the very end...

10 PATIENT SAFETY TIPS FOR HOSPITALS (PLUS DR. GASTALDO'S REMARKS)

(Dr. Gastaldo's remarks are interspersed #####)

AHRQ says:

Medical errors can occur at many points in the health care system,
particularly in hospitals. These 10 tips for hospitals resulted from
findings resulting from studies by the Agency for Healthcare Research
and Quality (AHRQ), which has funded more than 100 patient safety
projects since 2001.
Select to download print version (PDF File, 135 KB). PDF Help.

#### I gave AHRQ a simple way to immediately stop INTENTIONAL medical
errors - eg. - MDs senselessly closing birth canals up to 30% and MDs
senselessly robbing babies of up to 50% of their blood...

See AHRQ: MDs tearing vaginas: Action Item
for William Hyde/AHRQ...
http://health.groups.yahoo.com/group...t/message/4260

#### AHRQ never responded.

#### AHRQ says further...

Many findings from AHRQ research can immediately be put into practice
in hospitals...

#### That which AHRQ is ignoring^^^ can also be immediately put into
practice...

....by following 10 simple tips:

1. Survey staff in individual units and throughout the hospital need to
assess and improve the culture of patient safety, as noted in the 1999
Institute of Medicine report, To Err is Human. The AHRQ survey and its
accompanying toolkit materials are designed to provide hospital
officials with the basic knowledge and tools needed to conduct a safety
culture assessment, along with ideas for using the data. 1

2. Limit shifts of more than 24 hours for medical residents and make
sure they do not drive home after working extended shifts. Medical
residents who work longer than 24 hours are more than twice as likely
to have a car crash leaving the hospital and 5 times as likely to have
a near-miss incident on the road than medical interns who work shorter
shifts. 2

3. Eliminate the tradition of shifts of more than 30 consecutive hours
by interns working in hospital ICUs. The rate of serious medical errors
at two Boston hospital intensive care unites (ICUs) committed by
first-year interns dropped by 36 percent when 30-hour-in-arow work
shifts were eliminated. 3

4. Adopt interventions to reduce the incidence of ventilator-associated
pneumonia in critically ill patients. Putting patients in a
semi-recumbent position and using sucralfate rather than H2-
antagonists to prevent stress ulcers can prevent ventilator-associated
pneumonia in critically ill patients. 4

#### WARNING: Placing women dorsal/on their backs closes the birth
canal up to 30%; placing women semi-recument at delivery just closes
the birth canal with more force.

5. Count surgical instruments and sponges before and after procedures,
and X-ray patients after surgery to reduce the likelihood of objects
being left inside patients. These simple techniques can reduce the
incidence of these types of medical errors, which occur in more than
1,500 patients each year. 5

6. Use senior nurses and maintain appropriate round-the-clock staffing
levels in ICUs to prevent airway tube complications. A study of adverse
events occurring in adult and pediatric ICUs found that more than half
were considered preventable. Airway events occurred less frequently
during daytime hours (7:00 a.m. to 3:00 p.m.), and their negative
impact was limited by skilled assistants, backup, and cross-coverage.
ICU managers should take steps to ensure that appropriate staffing and
training levels are maintained to limit the impact of adverse events. 6

#### The baby's initial "airway tube" is the umbilical cord. Nurses -
senior and otherwise - need to stop MD (and CNMwives) from performing
"immediate cord clamping" - severing the baby nature's resuscitation
unit (mom) only to rush baby across the room for - resuscitation. This
senseless adverse event likely increases the number of infants in
pediatric ICUs...

7. Ensure that personal digital assistant-based drug information is
readily available at the point of care. Epocrates RxPro, Lexi-Drugs,
and mobileMicromedex met AHRQ's quality and safety criteria by reducing
potential errors associated with insufficient or incomplete drug
information. 7

8. Download a free software tool to identify ways to improve medication
safety in the ambulatory care setting. The tool, called the Medication
Safety Best Practices Guide, helps hospitals identify ways to create
safe practices for medication use, manage medical errors, and
contribute to patient safety education in the ambulatory care setting.8
Go to: http://chrp.creighton.edu/documents/bestpractices.pdf. PDF Help.

9. Use computer-based order entry to reduce catheter-related urinary
tract infections. A computer-based order entry system prompting
catheter removal after 72 hours decreases the duration of urinary
catheterization by about one-third, or 3 days. 9

10. Minimize interruptions and other distractions faced by the nursing
staff in their day-to-day routines. Researchers have visually
re-created the fast-changing nature of nurses' work, highlighting areas
where interruptions can affect patient safety. 10

#### Maybe provide low cost/no cost DOULAS to all laboring women who
want them. They shorten labor.

See The Doula Effect (also: Dragonsgirl and Dr. Peaches)
http://groups.google.com/group/misc....72c276c14a0280


References for Tips, by Number

1. Project Title: Hospital Survey on Patient Safety Culture. Developed
under contract for the Agency for Healthcare Research and Quality
Reference: http://www.ahrq.gov/qual/hospculture/

2. Project Title: Effects of Extended Work Hours on ICU Patient Safety
Principal Investigator: Charles Czeisler, M.D.
Reference: Barger LK, et. al. Extended work shifts and the risks of
motor vehicle crashes among interns. N Engl J Med 2005 Jan
13;352(2):125-34.

3. Project Title: Effects of Extended Work Hours on ICU Patient Safety
Principal Investigator: Charles Czeisler, M.D.
Reference: Landrigan, CP, et. al. Effect of reducing interns' work
hours on serious medical errors in intensive care units. N Engl J Med
2004 Oct 28;351(18):1838-48.

4. Project Title: Targeting Interventions to Reduce Errors
Principal Investigator: Timothy Hofer, M.D.
Reference: Collard, HR, et. al. Prevention of ventilatorassociated
pneumonia: an evidence-based systematic review. Ann Intern Med 2003 Mar
18;138(6):494-501.

5. Project Title: Malpractice Insurers' Medical Error Prevention Study
Principal Investigator: David M. Studdert, M.D.
Reference: Gawande, AA, et. al. Risk factors for retained instruments
and sponges after surgery. N Engl J Med 2003 Jan 16;348(3):229-35.

6. Project Title: Intensive Care Safety Reporting System
Principal Investigator: Peter Pronovost, M.D.
Reference: Needham, DM, et. al. A systems factors analysis of airway
events from the Intensive Care Unit Safety Reporting System. Crit Care
Med 2004 Nov;32(11):2227-33.

7. Project Title: Training Physicians to Use a Handheld Device for
Electronic Prescribing
Principal Investigator: Kimberly Galt, Pharm.D
Reference: Galt, KA, et. al. Personal digital assistant-based drug
information sources: potential to improve medication safety. J Med Libr
Assoc 2005 Apr;93(2):229-36.

8. Project Title: Impact of Personal Digital Assistant Devices on
Medication Errors in Primary Care
Principal Investigator: Kimberly Galt, Pharm.D.
Reference: http://chrp.creighton.edu/documents/BestPractices.pdf

9. Project Title: Targeting Interventions to Reduce Errors
Principal Investigator: Timothy Hofer, M.D.
Reference: Cornia, PB, et. al. Computer-based order entry decreases
duration of indwelling urinary catheterization in hospitalized
patients. Am J Med 2003 Apr 1;114(5):404-7.

10. Project Title: Work Environment Effects on Quality of Healthcare
Principal Investigator: Bradley Evanoff, M.D.
Reference: Potter, P et. al. An analysis of nurses' cognitive work: a
new perspective for understanding medical errors. In: Battles J, et al.
(Editors). Advances in Patient Safety; Vol. 1-Research Findings (AHRQ
Publication No. 05-0021-1). Rockville, MD: February 2005; p. 39-51.



AHRQ Publication No. 06-P020
Current as of May 2006

Internet Citation:
10 Patient Safety Tips for Hospitals. AHRQ Publication No. 06-P020, May
2006. Rockville, MD, Agency for Healthcare Research and Quality.
http://www.ahrq.gov/qual/10tips.htm

END AHRQ Pub. No. 06-P020 with Dr. Gastaldo's remarks interspersed.

Copied to AHRQ via http://www.ahrq.gov/info/customer.htm and via:

Gerri Michael Dyer
Electronic Dissemination Advisor
Agency for Healthcare Research and Quality
540 Gaither Road, Suite 2000
Rockville, MD 20850
Phone: (301) 427-1898
Fax: (301) 427-1873
E-mail:

Gerry,

Mothers don't know to ask for the "extra" up to 30% in the birth canal
or the "extra" up to 50% of blood for their babies.

Please advise AHRQ that my patient safety tips should be immediately
disseminated.

Do it for the babies.

^^^Maybe AHRQ just never received or read my email (see above)?

Please inquire.

Thanks.

Sincerely,

Todd

Dr. Gastaldo
Hillsboro, Oregon
USA


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