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AHRQ Releases Annual Reports
Last month, the Agency for Healthcare Research and Quality (AHRQ) released its annual National Healthcare Quality Report and National Healthcare Disparities Report. The quality report found that the overall quality of care for all Americans improved at a rate of 2.8 percent. However, there has been more rapid improvement in measures for which there are focused efforts to improve care. It found, for example, a 10.2 percent annual improvement in the five core measures of patient safety. Although the disparities report found that there has been improvement in both quality of care and access to care for low-income people overall, regardless of race and ethnicity, disparities have widened for the Hispanic population. "It is clear that the need for action to improve quality of care for all Americans continues to be great," says Carolyn Clancy, M.D., AHRQ director. Yet, AHRQ's budget will remain essentially flat this year, with $319 million in funds, almost $50 million of which is allocated for information technology initiatives.

JCAHO Issues Drug Reconciliation Alert
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), prompted by the fact that medication reconciliation errors continue to occur despite repeated warnings and rigorous standards, issued a Sentinel Event Alert Jan. 25 outlining the processes that health care organizations should follow to avoid such errors. Failure to compare a patient's medication orders to all of the medications that the patient has been taking when transitioning patients from one care location to another can result in duplicative medications, incompatible drugs, wrong dosages, or wrong dosage forms. United States Pharmacopeia received more than 2,000 voluntary reports of medication reconciliation errors last year, and JCAHO's Sentinel Event Database shows that 63 percent of reported medication errors resulting in death or serious injury were due to breakdowns in communication. Further, half of these errors could have been avoided through effective medication reconciliation. The alert recommends that detailed medication lists be put in a highly visible place on patients' charts, medications be reconciled at each interface of care, and patients be provided with a list of medications upon discharge.

ACP Report Pushes Quality, Warns of Crisis
The American College of Physicians (ACP), in its annual report on the State of the Nation's Health Care, called on Congress and the Centers for Medicare and Medicaid Services to "provide sustained and sufficient financial incentives for physicians to participate in programs to continuously improve, measure, and report on the quality and efficiency of care provided to patients." Further, the report, released Jan. 30, recommends that financial incentives under Medicare pay-for-performance be non-punitive and sufficient to offset doctors' investment in health information technology and other office redesigns necessary to measure and report on quality. The group also calls for changes in the way primary care is delivered and financed by Medicare and other payers—reforms that ACP believes are necessary to attract young physicians to primary care medicine and ultimately prevent the system's collapse. "The consequences of failing to act will be higher costs, greater inefficiency, lower quality, more uninsured persons, and growing patient and physician dissatisfaction," says Vineet Arora, M.D., M.A., chair of the ACP Council of Associates.

High Drug Error Rate in Hospital Radiology
Medication errors that harm patients are seven times more likely to occur in a hospital's radiology department than in other settings of the health care organization, according to a United States Pharmacopeia (USP) report released Jan. 18. The sixth annual MEDMARX Data Report found that 12 percent of the 2,032 medication errors reported in radiological services from 2000 to 2004 resulted in patient harm, and that radiological services were more likely than other hospital services to result in the need for additional care and resources. Radiological services include complex procedures that use high-risk drugs and, with patients circulating quickly through hospital departments, breakdowns in communication between radiology staff and patients' physicians and nurses may lead to patients receiving the wrong drug, wrong dose of a drug, or not getting the drug at all. To prevent errors, USP recommends that patients carry an up-to-date list of medications; inform health care providers, including radiological services staff, of all allergies; inquire about transfers within the hospital; and ensure that their patient charts accompany them. In a statement responding to the study's findings, the American College of Radiology maintains that the data obtained by USP were voluntarily submitted and not representative of all U.S. radiology facilities.

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