Npsf.org

October (2) 2006
Adverse Effects of Cyclooxygenase 2 Inhibitors on Renal and Arrhythmia
Events: Meta-analysis of Randomized Trials.
Association of Perceived Medical Errors With Resident Distress and Empathy:
A Prospective Longitudinal Study.
Avoiding Common Scheduling and Staffing Mistakes.
Constructing a Team Model: Creating a Foundation for Evidence-based Teams.
Disclosure of Medical Errors Involving Gametes and Embryos.
Emergency Physicians and Disclosure of Medical Errors.
Ethical Drift: When Good People Do Bad Things.
Fixing America’s Hospitals.
How Common Are Electronic Health Records in the United States? A Summary
of the Evidence.
How Direct-To-Consumer Television Advertising for Osteoarthritis Drugs
Affects Physicians’ Prescribing Behavior.
In Post-Katrina New Orleans, Efforts Under Way to Build Better Health Care.
Inter-Disciplinary Focus Groups on Telephone Medicine: A Quality
Improvement Initiative.
Medicare Payment for Selected Adverse Events: Building the Business Case for
Investing in Patient Safety.
Medication Reconciliation (Case Study).
Patient Care Transformation: The Plan and the Reality.
Quality Improvement in Gynecologic Surgery: The New Frontier.
The Grade is: 66 Out of 100: Commonwealth Gives U.S. Healthcare a Sickly
Ranking, but Some Say It’s Time to Offer Solutions, Not Point Out Problems.
The Safety Culture in a Children’s Hospital.
2006 Update on Consumers’ Views of Patient Safety and Quality Information.
U.S. Health System Performance: A National Scorecard.
NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 1 Adverse Effects of Cyclooxygenase 2 Inhibitors on Renal and Arrhythmia Events:
Meta-analysis of Randomized Trials.
Zhang J., Ding E.L., Song Y.
JAMA. 2006 (Oct 4); 296(13):1619-1632.
The objective of this study was to quantitatively assess adverse risks of renal events,
(renal dysfunction, hypertension, and peripheral edema and arrhythmia events), and to
examine drug class effects and temporal trends of effects of the COX-2 inhibitors. The
methodology included a definitive search of pertinent literature bibliographies in
EMBASE and MEDLINE, along with FDA reports and pharmaceutical industry clinical
trial databases. Studies analyzed included 114 randomized double-blind clinical trials
with 116,094 participants. The analysis showed that rofecoxib was associated with
increased renal and arrhythmia risk, while a COX-2 inhibitor class effect was not
apparent. The authors suggest that this study indicates that future safety monitoring is
warranted and may benefit from an ongoing cumulative surveillance system. Multiple
tables are included in the article.
Association of Perceived Medical Errors With Resident Distress and Empathy: A
Prospective Longitudinal Study.
West C.P., Huschka M.M., Novotny P.J., et al.
JAMA. 2006 (Sep 6); 296(9):1071-1078.
This study was conducted to assess the frequency of self-perceived medical errors among
resident physicians and to ascertain any association of self-perceived medical errors with
resident quality of life, burnout, depression and empathy. A prospective longitudinal
cohort study of internal medicine residents at the Mayo Clinic Rochester was conducted.
Data was collected by means of quarterly surveys administered between 2003and May
2006. The results showed that 34% of residents reported making at least one major
medical error during the study period, with a mean of 14.7% at each quarter reporting
making an error in the preceding 3-month period. The authors conclude that self-
perceived medical errors are common among internal medicine residents and are
associated with significant subsequent personal distress.

Avoiding Common Scheduling and Staffing Mistakes.
Gesensway D.
ACP Observer. 2006 (Sep):1-4.
This article concerns the 7 days on/7 days off work schedule of hospitlists. The author
points out that with this schedule, a hospitalist’s workload is compressed into only 182.5
days per year and argues that this workload should be spread out over a longer period to
avoid work overload and stress that could contribute to potential medical errors.
Suggestions to ease scheduling problems include: reducing the daily workload, avoiding
set times for beginning and ending shifts, and taking advantage of flexible physicians.
The author also suggests “slightly” overstaffing rather than understaffing as a way to
ease the work crunch many hospitalists feel.

NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 2 Constructing a Team Model: Creating a Foundation For Evidence-based Teams.
Porter-O’Grady T., Alexander D.R., Blaylock J., Minkara N., Surel D.
Nurs Admin Q. 2006 (Jul/Sep); 30(3):211-220.
The authors of this article outline the Dynamic Cybernetic Team (DCT) model as a state-
of-the-art model for the creation of evidence-based teams. Theoretical and conceptual
foundations for the model are discussed as are influences affecting a working team
model. Leavitt’s framework is discussed as the backbone of the DCT model, as are
Nonaka and Nishiguchi’s team core structure. Five process factors are listed and
discussed along with team performance outcomes.
Disclosure of Medical Errors Involving Gametes and Embryos.
The Ethics Committee of the American Society for Reproductive Medicine.
Fertility and Sterility. 2006 (Sep); 86(3):513-515.
This article discusses the ethical obligation of disclosing errors involving gametes and
embryos in reproductive settings. Two types of errors are discussed: medical errors that
result in a loss of gametes and embryos and the diminished reproductive opportunity
such loss can bring; and the less frequent error where gametes or embryos are
mistakenly implanted in the wrong person, potentially resulting in the birth of a child of
an unintended genetic parentage. Although fear of legal repercussions can be a
deterrent to medical error disclosure, the author states that some studies suggest patients
who are informed of errors are less likely to pursue legal action. The author also
suggests that reproductive facilities should have a program in place that addresses the
procedures to prevent errors and the protocol in the event of an error.
Emergency Physicians and Disclosure of Medical Errors.
Moskop J.C., Geiderman J.M., Hobgood C.D., Larkin G.L., Silbergleit R., Knopp R.K.
Annals of Emergency Medicine. 2006. In Press.
The authors of this article discuss many facets of emergency physicians’ disclosure of
medical errors. After outlining the concept of medical error, the authors discuss several
aspects of disclosure, including professional duty to truthfulness as an argument for
disclosure, and various barriers to disclosure. The authors also suggest changes to
create a system for disclosure and offer practical guidelines to promote an environment
of openness to disclosure of medical errors.

Ethical Drift: When Good People Do Bad Things.
Kleinman C.S.
JONA. 2006 (Jul/Sep); 8(3):72-76.
This article addresses the phenomenon of ethical drift: “a gradual erosion of ethical
behavior that occurs in individuals below their level of awareness.” Components of
ethical drift and the underlying theory are discussed. Scenarios involving ethical drift
are included in the article, as are employable actions to avoid this phenomenon.

NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 3 8. Fixing
America’s
Hospitals.
This article highlights how ten American hospitals are using innovation, hard work and imagination to improve the overall care and quality they provide. Boston’s Brigham and Women’s hospital used an adverse event at their hospital as the catalyst in becoming a leader in patient safety. Cooley Dickinson hospital utilizes a deceptively simple and affordable method of using wallet-sized index cards to keep them on top of patient information. Other examples include a hospital that helps children in trouble by offering a cutting edge therapy program that is fast becoming a model for other hospitals, and Kaiser Permanente hospitals in California which are replacing the frozen and microwave food often associated with hospitals with fresh vegetables and fruit from the farmer’s markets sponsored by the hospitals. These hospitals and others cited in the article are solving their problems in creative and innovative ways.
9.
How Common Are Electronic Health Records in the United States? A Summary of
the Evidence.
Jha A.K., Ferris T.G., Donelan K., et al.
Health Affairs. 2006 (Oct 11): w496-w507.
In this study the authors employ a systematic review of all existing surveys on Electronic
Health Record (EHR) adoption to better understand the use of EHR. In their review the
authors included surveys that measured either “adoption” or “use” of EHRs, although
these two terms often have different meanings with regard to the implementation of
EHRs. The surveys were completed between 1995-2004 and included both published and
unpublished data reports. The American Association for Public Opinion Research
(AAPOR) was used for the survey abstraction process. The results provide three distinct
sets of observations. The authors make four future recommendations for measuring EHR
use.

NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 4 How Direct-To-Consumer Television Advertising For Osteoarthritis Drugs Affects
Physicians’ Prescribing Behavior.
Bradford W.D., Kleit A.N., Nietert P.J., Steyer T., McIlwain T., Ornstein S.
Health Affairs. 2006 (Sep/Oct); 25(5):1371-1377.
In this study direct-to-consumer (DTC) advertising is analyzed to determine what, if any,
effect it has on physician prescribing habits. The authors chose to focus on osteoarthritis
patients and the drugs Vioxx and Celebrex for their study. Clinical information for fifty-
seven primary care practices was analyzed on a monthly basis for the period 2000-2002.
Patient data was obtained from the Practice Partner Research Network (PPRNeT)
located at the Medical University of South Carolina (MUSC), while advertising data was
obtained from Competitive Media Reporting Incorporated (CMR). This information was
matched to monthly brand-specific advertising data for local and network television. A
Medline search was also conducted to tally the monthly articles related to Vioxx,
Celebrex or both. Results of the study showed that DTC advertising for Vioxx had a
positive effect on rates of Vioxx prescribing, with a possible positive effect on rates of
Celebrex prescribing as well; DTC advertising for Celebrex had little effect on Celebrex
prescribing, but did have a positive effect on Vioxx prescribing.
In Post-Katrina New Orleans, Efforts Under Way to Build Better Health Care.
Voelker R.
JAMA. 2006 (Sep 20); 296(11):1333-1334.
Voelker discusses the state of healthcare in post-Katrina New Orleans. He reports that
there has been a loss of physicians as high as 65% after the devastating hurricane. Also
frustrating the healthcare system in New Orleans is the lack of specialists such as
psychiatrists and dentists, making it almost impossible for patients to obtain preventive
care, health screenings, and diagnostic tests. Although there are many challenges facing
the New Orleans healthcare system, new opportunities are emerging. Unlikely health
partnerships are starting to fill the void, such as a network including the Louisiana State
Universities Health Care Services Division, Charity and University Hospitals, The New
Orleans Health Department, and several federally qualified health centers.

Inter-Disciplinary Focus Groups on Telephone Medicine: A Quality Improvement
Initiative.
Whitson H.E., Hastings S.N., McConnell E.S., Lekan-Rutledge D.A.
Journal of the American Medical Directors Association. 2006 (Sep); 7(7):407-411.
The authors of this article describe a pilot project they conducted at the Extended Care
and Rehabilitation Center (ECRC) at the Durham VA Medical Center in Durham, North
Carolina. The pilot project was intended to identify opportunities for quality
improvement in long-term care telephone medicine. Two forty-five minute focus groups
were conducted in June 2004, where volunteer participants were asked three open-ended
questions related to telephone medicine. Participants included registered or licensed
practical nurses and geriatric medicine fellows. The results were categorized into four
domains describing the characteristics of nurses and doctors who practice the best
telephone medicine. The authors report that information derived from the focus groups
has been used to implement several quality improvement initiatives. Several tables
illustrating data from the focus groups are included.
NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 5 Medicare Payment for Selected Adverse Events: Building the Business Case for
Investing in Patient Safety.
Zhan C., Friedman B., Mosso A., Pronovost P.
Health Affairs. 2006 (Sep/Oct); 25(5):1386-1393.
This study was conducted to assess how much Medicare, under its Diagnosis-Related
Group (DRG) –Based Prospective Payment Plan (PPS), pays hospitals for five types of
adverse events and how much of the cost is absorbed by the hospital. The objective of the
study was to prove that patient safety is the cost-effective choice and worth investing in.
Data used was the 2002 Healthcare Cost and Utilization Project (HCUP) Nationwide
Inpatient Sample (NIS), developed by the Agency for Healthcare Research and Quality
(AHRQ). Five of AHRQ’s Patient Safety Indicators (PSIs) were used in identifying
adverse events; they include decubitus ulcer (DU), iatrogenic pneumothorax (IP),
postoperative hematoma or hemorrhage (H/H), postoperative pulmonary embolism or
deep vein thrombosis (PE/DVT), and postoperative sepsis (PS). Study results showed
that Medicare paid 0.27% of $177 billion dollars in 2002 for adverse events and that
hospitals absorb most of the cost of treating these events.

Medication Reconciliation (Case Study).
Haig K.
American Journal of Medical Quality. 2006 (Sep/Oct); 21(5):299-304.
This case study conducted by the OSF St. Joseph Medical Center Patient Safety Program
describes the implementation of three phases of Medication Reconciliation (MR). Phase
I addresses Admission Reconciliation; phase II addresses Transfer Reconciliation, and
phase III addresses Discharge Reconciliation. The article discusses each phase and how
they were implemented. Several figures are included.
Patient Care Transformation: The Plan and the Reality.
Drexler D., Malloch K.
Nursing Administration Quarterly. 2006 (Jul/Sep); 30(3):221-229.
This article describes the vision, challenges and ultimate success story of the Bonner
Estrella Medical Center (BEMC) which built a 172-bed acute care “facility of the
future” with patient safety as the central concern. Sixty-three IT applications were
successfully implemented, as was the total Electronic Medical Record (EMR), a new
patient care delivery model, and numerous other communication technologies. Seven
planning processes are listed and monthly teamwork surveys are discussed in keeping the
vision of the hospital on track. Several tables and one figure are included.

NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 6 Quality Improvement in Gynecologic Surgery: The New Frontier.
Podratz K.C.
American Journal of Obstetrics and Gynecology. 2006; 195:891-895.
Podratz discusses the state of gynecologic surgery. He asserts that there is a need in the
field to develop standards and methods to assess quality within the discipline.
Gynecologic surgery literature, he says, shows that hysterectomies need quality
improvement. The author also outlines quality improvement programs for surgery,
quality assessment methods and the CMS Surgical Care Improvement Project (SCIP)
which was implemented in July 2006 and aims to reduce postoperative morbidity and
mortality by 25% over a five year period. Podratz strongly encourages members of the
Society of Gynecologic Surgeons and other gynecologic surgery organizations to become
actively engaged in quality improvement programs.
The Grade is: 66 Out of 100: Commonwealth Gives U.S. Healthcare a Sickly
Ranking, but Some Say It’s Time to Offer Solutions, Not Point Out Problems.
Evans M.
Modern Healthcare. 2006 (Sep 25); 36(38):6-7.
This article discusses the implications of the U.S. healthcare system’s score of 66 out of
100 in a recent ranking by the commonwealth Fund. Researchers from the
Commonwealth Fund’s Commission on a High Performance Health System have
designed a “scorecard” to be updated annually, that is intended to give policy makers
and the industry a yearly snapshot of the overall performance of the healthcare system.
Not everyone is happy about the “scorecard,” the author reports. Some criticize the
report for yet another negative account about the United States healthcare system
without providing any solutions others; however, welcome the reporting system.

The Safety Culture in a Children’s Hospital.
Grant M.J.C., Donaldson A.E., Gitte Y.
Journal of Nursing Care Quality. 2006 (Jul/Sep); 21(3):223-231.
The purpose of this study was to assess the safety culture at a children’s hospital. A
descriptive study conducted at a children’s hospital during a sixty-day period from
December 2002-January 31, 2003 involving all inpatient departments was utilized. The
Safety Attitudes Questionnaire (SAQ) was used and consisted of sixty-one questions
grouped into seven domains. The authors used the study to determine the perceptions of
the quality of teamwork and communication among physicians, nurses, and ancillary
patient care staff. Two hundred twenty-nine surveys were completed, forty-one of those
were from operating room (OR) staff members. Results were drawn from a total
response rate of 68% and showed that that overall job satisfaction was high, and
physicians perceived there was better teamwork than all other staff, among other
findings.

NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 7 2006 Update on Consumers’ Views of Patient Safety and Quality Information.
No Author.
The Kaiser Family Foundation/Agency for Healthcare Research and Quality. 2006 (Sep).
A Health Poll Report Survey was conducted by telephone interview by the Princeton
Survey Research Associates from August 3-8, 2006 among a randomly selected nationally
representative sample of 1,216 respondents eighteen years of age or older. The purpose
of this study was to assess consumers’ views and overall perception of health care quality
in the United States. Several graphs and charts are used to illustrate the data collected
and also to compare it with previously collected data showing trends in consumer views
in past years.

U.S. Health System Performance: A National Scorecard.
Schoen C., Davis K., How S.K.H., Schoenbaum S.C.
Health Affairs. 2006 (Sep 20):w457-w475.
This article presents a detailed report on the findings of the scorecard developed by the
Commonwealth Fund Commission on a High Performance Health System, also discussed
in Article no. 17 in this issue of Current Awareness. The scorecard indicator was devised
by the Commonwealth Fund Commission on a High Performance Health System and with
input from leading experts. National and international data is used to identify
performance benchmarks and to compute scores from 51 to 71 spanning multiple
domains, including health outcomes, quality, access, equity and efficiency. The results
placed the United States health system is behind other countries on indicators of
mortality and healthy life expectancy. While there is room for improvement, the authors
point out that this is the first year of the performance record and is a starting point for
discussion. Several tables and a graph are included.

NPSF Current Awareness Literature Alert Archives can be accessed at: NPSF Bibliography Materials selected from the collection of the NPSF Clearinghouse Contents 1998-2006 National Patient Safety Foundation. All Rights Reserved. Page 8

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