First Appeared Thursday, 13 February '03

Web-Based Journal Will Draw Patient Safety Lessons from Actual Cases

The Agency for Healthcare Research and Quality (AHRQ) and UCSF announced yesterday (February 12) the launch of a web-based medical journal designed to improve patient safety and health care quality.

Titled AHRQ WebM&M (Morbidity and Mortality Rounds on the Web), the journal presents actual cases of medical errors -- along with commentaries from national experts.

"The AHRQ website offers the medical community a unique opportunity to learn about patient safety from the experiences of their colleagues across the country and around the world," according to Carolyn M. Clancy, MD, AHRQ's director. The anonymity safeguards will enable physicians to share their experiences without fear of reprisal, she said.

Editors Robert Wachter, MD, UCSF professor and associate chairman of the department of medicine, and Kaveh Shojania, MD, UCSF assistant professor of medicine, aim to educate a broad audience of health care providers about patient safety and medical mistakes.

"We have been thrilled with the initial response to the site," said Wachter. He noted that more than 1500 individuals have registered as users even before the official launch. "We're finding that physicians and other health care providers are eager to share their experiences — even their errors — with their colleagues because they want to make health care safer for patients."

"To make real progress in patient safety, we have to break down the shame and silence surrounding errors," added Lucian Leape, MD, the leader of the modern patient safety movement and a member of the AHRQ WebM&M advisory panel. "By presenting real-life cases and dynamic commentaries, the journal is an ideal way for physicians to learn more about, and ultimately improve, patient safety."

The web-based journal uses a case-based approach that emphasizes changes that can be made in health care systems - such as teamwork training, checklists, and computerization of medical records and prescriptions. Each month, five cases are published -- in medicine, surgery/anesthesia, obstetrics/gynecology, pediatrics, and other specialties including psychiatry, radiology and emergency medicine. Cases are submitted anonymously by providers, and the most interesting and instructive are posted on the site, accompanied by short, evidence-based commentaries written by the nation's top experts in patient safety. One case each month is expanded into an interactive learning module -- called the "Spotlight Case" -- and features readers' polls, quizzes, and other multi-media elements, said Wachter.

This month, the site features cases on a patient mix-up; a mistaken drug administration causing a patient to stop breathing unexpectedly; a procedural mishap requiring emergency vascular surgery; an infusion pump flying into an MRI, narrowly missing a child; and a misdiagnosis of delusions in a man later found to have metastatic brain and spine cancer.

AHRQ WebM&M features forums for online discussion, free continuing medical education for practicing physicians, certification for trainees, and downloadable slide presentations for educational use. In addition, the site provides links to other resources on patient safety, medical errors and health care quality.

Wachter, a leader of the hospitalist movement, is editor of the textbook, Hospital Medicine. Shojania was lead editor of the 2001 AHRQ report Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Commentators, editorial board members, and advisors for the journal include many of the world's experts in patient safety. The site contains no advertisements, and the editors can be reached by email.

All technology design, development and support to the AHRQ WebM&M journal is provided by DoctorQuality. Founded with a mission for patient safety, DoctorQuality, Inc. provides health care organizations with an integrated suite of products that enables proactive implementation of best practices, benchmarking and improvements in health care safety overall. Together with its more than 150 clients, DoctorQuality has built the largest known database of medical adverse events and near misses for hospitals and health care facilities. For further information regarding DoctorQuality, visit the website.

AHRQ is the nation's lead federal agency for research on health care quality, costs, outcomes, and patient safety. Agency research provides evidence-based information on health care outcomes; quality; and cost, use and access. The research also helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

Links:

WebM&M

DoctorQuality