The National Patient Safety Foundation’s Research Grants Program seeks to stimulate new, innovative projects directed toward enhancing patient safety in the United States. The program’s objective is to promote studies leading to the prevention of human errors, system errors, patient injuries and the consequences of such adverse events in the health care setting. In this first stage of a two-stage application process, Letters of Intent (LOIs) are solicited for research and development that is broadly related to identifying the causes of preventable injuries and errors and/or developing prevention strategies and methods to implement them. Based on these LOIs, a limited number of applicants will be invited to submit a full proposal.

In order to be eligible for consideration, LOIs must be delivered to NPSF no later than November 6, 2012. The number of grants to be awarded will depend on the nature and quality of applications received and the total funds available. A multidisciplinary team of experts will evaluate the LOIs. Investigators will be notified of the status of their LOIs no later than January 15, 2013.

In the second stage of the process, a limited number of applicants will be invited to submit a full proposal. Full proposals will be due on February 27, 2013. Finalists will be notified of acceptance or rejection for a grant award no later than April 15, 2013.

Please download the full request for LOIs for complete instructions and eligibility requirements or visit the Research Grants Program page.

For more information:
Call: 617.391.9900
E-mail: research@npsf.org

A recent article in Focus on Patient Safety highlights the work of the Centers for Education and Research on Therapeutics (CERTs), a network of research centers established in 1999 by the United States federal government to add to the evidence base on the safety and effectiveness of therapeutics—a broad category that includes drugs, medical devices, and biological products, such as vaccines. The article specifically focuses on recent CERTs research on the use of computerized information systems in health care settings.

Read or download the article.

Pharmacy Practice News

August 2012 | Volume 30

A research project, funded by a National Patient Safety Foundation Research Grant, sheds new light on the types of errors that can occur with computerized physician order entry. This article summarizes finding of Gordon Schiff, MD, principal investigator.

Read the article from Pharmacy Practice News.

BOSTON, MA (May 9, 2012) – The National Patient Safety Foundation (NPSF) today announced that it has awarded a total of $200,000 in grants for two innovative patient safety research projects. The grants are awarded through the NPSF Research Grants Program, which promotes studies leading to the prevention of human errors, system errors, patient injuries, and their consequences.

Mary Beth Happ, PhD, RN, FAAN

Principal investigator Mary Beth Happ, PhD, RN, FAAN, University of Pittsburgh Medical Center Health System Endowed Chair in Nursing Science and professor of nursing, critical care medicine, and clinical and translational science at the University of Pittsburgh School of Nursing, received the NPSF Board Research Grant in the amount of $100,000 for her study, “Management of Distractions and Interruptions During Nursing Care in the ICU.”

Prior research suggests that while distractions and interruptions in clinical settings are perhaps unavoidable, some such interruptions may actually be beneficial, and the key to maintaining a safe patient environment may be in adequately managing distractions. Dr. Happ’s project will utilize existing video recorded observations of bedside care in two intensive care units and a qualitative follow-up study consisting of real-time, semi-structured observations and nurse focus groups. The goals are to provide understanding of distractions and interruptions at the bedside; identify strategies for preventing and managing interruptions; and provide evidence to support the development of programs to help clinicians manage disruptions.

“Distractions and interruptions pose increasing threats to cognitive processing and safe, error-free patient care in critical care settings,” said Dr. Happ. “We aim to provide a more complete picture of the purpose and content of distractions and how they can be managed.”

The NPSF Board Research Grant is supported in part by generous contributions from NPSF board members.

Alicia I. Arbaje, MD, MPH

Principal investigator Alicia I. Arbaje, MD, MPH, assistant professor of medicine and associate director of transitional care research in the Division of Geriatric Medicine and Gerontology at Johns Hopkins University received the NPSF Research Grant in the amount of $100,000 for her project, “Identification and Validation of Risks to Patient Safety During Care Transitions of Older Adults Receiving Skilled Home Healthcare Services After Hospital Discharge.” This project seeks to identify factors that put seniors at risk after they leave the hospital for home and while they are under the care of skilled home health care workers. The study will look at a variety of parameters (for example, clinician and patient behaviors; home environment; technology; tools and tasks) and use direct observations of home health care intake as well as semi-structured interviews with patients, caregivers, and administrative staff to identify risks.

A secondary goal of the project is to develop and test an “index” of characteristics that will help home health care agencies identify older adults at increased risk in order to provide intervention during care transitions.

“Older adults who require skilled home health care services, such as nursing care or physical therapy, after being hospitalized are among those at highest risk of experiencing suboptimal outcomes, including rehospitalization,” said Dr. Arbaje. “We hope to not only identify risks, but also develop methods for care providers to prevent complications in this population. We believe this work can eventually help other populations with complex needs after leaving the hospital.”

The two grant recipients were selected from 80 submissions reviewed by an independent committee of 11 health care experts. That committee was chaired by Bruce Lambert, PhD, professor of Pharmacy Administration at the University of Illinois at Chicago.

“The NPSF Board of Directors joins me in congratulating these researchers,” said Diane C. Pinakiewicz, MBA, CPPS, president of NPSF. “We are committed to advancing the efforts of investigators focused on identifying the causes of preventable error and injuries and the strategies that reduce them.”

Since 1998, NPSF has supported 38 research projects with more than $3.8 million in grant funding. For a compendium of research supported by the NPSF Research Grants Program, see the 2012 Research Program Summary of Progress report.

About the National Patient Safety Foundation

NPSF has been pursuing one mission since its founding in 1997 – to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, and the NPSF Research Grants Program and its application process, visit www.npsf.org.

Contact: Patricia McTiernan
pmctiernan@npsf.org
617.391.9922

A hospitalized patient receiving opioids for pain may have little in common with a patient in a primary care clinic who is struggling to control diabetes mellitus. Yet these vastly different clinical scenarios are similar in one significant way: In both cases, there is a strong risk that medication is not being optimally prescribed or taken, with the result being less-than-optimal outcomes and, perhaps, gaps in patient safety.

These problems are also part of the focus of a $4.25 million, five-year contract awarded last fall by the Agency for Healthcare Research and Quality as part of the Centers for Education and Research on Therapeutics (CERTs) program. Led by Bruce Lambert, PhD, professor of pharmacy administration and director of the CERT at the University of Illinois at Chicago, the Tools for Optimizing Medication Safety (TOP-MEDS) project has broad goals for improving the prescribing of opioids; reducing drug name confusion; enhancing post-marketing surveillance of adverse drug events; and improving patients’ understanding of and compliance with drug regimens.

Bruce Lambert, PhD

“We set out to address unambiguously big, important problems,” Lambert said recently during a discussion of the project’s start-up and progress to date. “We wanted to work on projects that had a very high likelihood of success in five years.”

The CERTs program was started as part of the Food and Drug Administration Modernization Act of 1997. Its mission is to “increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics.” That includes medications, medical devices, and biological products. The TOP-MEDS CERT is one of six research centers in the country to receive funding in the latest round and the only one focused exclusively upon patient safety. The others are at Duke University Medical Center (cardiovascular therapeutics), Rutgers University (mental health therapeutics), Brigham and Women’s Hospital (health information technology), University of Alabama at Birmingham (musculoskeletal disorders), and Cincinnati Hospital Children’s Medical Center (pediatric therapeutics). There is also a coordinating center, the CERTs Scientific Forum, to lead scientific collaborations of all six CERTs Research Centers; it is based at the Kaiser Foundation Center for Health Research in Portland, OR.

Lambert said that the current projects grew from prior research in these areas. For example, Lambert himself first began researching drug-name confusion in 1998 with a grant from the National Patient Safety Foundation. “This current project is a direct continuation of that line of research,” he said. “If you look at data on medication errors, wrong drug errors account for about 8 percent. Even when we know which names are likely to be confused, the errors just keep happening.”

Yet, beyond adding to the pool of knowledge, the TOP-MEDS program also plans to deliver tools that can be applied in practice. For example, Robert Gibbons, PhD, statistical director for the program, whom Lambert calls “one of the foremost biostatisticians in the world,” is involved in a project to develop a new statistical model for analyzing large observational databases of adverse drug events. “We aim to have a statistics program that we can give away for free,” Lambert said. “We’ll produce good research papers, but we will embody the methods in tools that others can put to use.”

TOP-MEDS has four main areas of research:

1. Developing a model for large-scale adverse drug event screening that will surpass spontaneous reporting and detect ADEs not noted in pre-approval clinical trials.
2. Developing a web-based simulation program to train clinicians in the proper selection and dosing of opioids to improve the safety and effectiveness of acute pain control in inpatients.
3. Developing and testing methods of preventing and detecting drug-name confusion both pre-approval and post-approval.
4. Evaluating low-literacy materials and the use of electronic health records to promote safe and effective use of medications among English and Spanish-speaking patients in an urban primary care practice.

“We hope to make a meaningful, incremental contribution in these areas,” Lambert said. “We’re modest about the impact we can have, but we hold ourselves accountable to make a contribution. We owe the public a substantial return on their investment.”

Also collaborating on the project are Dr. Bill Galanter, clinical director, and a number of co-investigators from Rush University Medical Center; Northwestern University; University of Chicago; and Brigham and Women’s Hospital, Boston. The Institute for Safe Medication Practices, Horsham, Penn.; and the National Patient Safety Foundation, Boston, are subcontractors and partners in dissemination of results and findings.

“We are proud to be a partner in such a rigorous program that is also characterized by innovative uses of technology and a focus on patient-centeredness,” said Diane C. Pinakiewicz, MBA, president of NPSF.

Lambert will be among the faculty at the NPSF Patient Safety Congress this coming May, presenting a breakout session that will focus on the CERTs patient safety work. As the TOP-MEDS project progresses, he and his team plan subsequent presentations at the annual Congress.

This is the first in a series of articles about the TOP-MEDS projects and the patient safety work being done by the other Centers for Education and Research on Therapeutics. NPSF will report on the progress of these projects periodically.

—Patricia McTiernan

“Handoff” is not the friendliest word, yet in healthcare, it has come to define the delicate transfer of information when a patient is discharged from one care setting to another, or when staff members change shifts.  Much has been written about the safety gaps that can occur during these transitions, but this topic is still ripe for research—as Emily Patterson, PhD, well knows.

Emily Patterson, PhD

As principal investigator of a research grant funded by Hospira and awarded through the NPSF Research Grants Program, Patterson and her team are surveying the strategies employed by clinical staff during shift changes in two intensive care units at Ohio State University Medical Center. They are also exploring whether a change of shift influences a change in primary diagnosis and whether a change of leadership makes the staff more or less likely to bring up a safety concern.

Patterson’s project grew out of prior research that seems to indicate positive effects of shift changes. James O’Brien, MD, her co-investigator, recently published a study of intensivists who work a five-days-on and two-days-off schedule—essentially they get a “weekend.” The issue being studied was burnout, not handoffs, Patterson explains. But while burnout was found to be lower among those working the five/two schedule, other factors also may have improved as a result—including mortality.

“Our theory is that handoffs allow a fresh perspective coming onto the case,” she says.  “Critical care is a good place to study this, because everyone needs to act so quickly. There is a rapidly changing treatment plan.”

An industrial and systems engineer, Patterson began studying handoffs in 1994, while working on her master’s thesis at Johnson Space Center in Houston. “At NASA-Johnson they trained people very well,” Patterson says. “There were no written procedures, but everyone did them [handoffs] exactly the same way. “

That said, she admits that “At NASA a change of shift took anywhere from five to 15 minutes. In an ICU, I’ve seen nursing shift changes that took an hour and a half.”

Still, her subjects have so far been keen to participate. “The staff are intellectually curious and more than willing to support it. They like to hear good things,” she says.

One goal of the project is to develop training materials. “We’re really hoping to find a few ideas that can make handoffs safer, at least for the ICU setting,” Patterson says.

Patterson calls it “a real honor” to have received the Hospira grant. “NPSF stands out as a driving force in positive activities in support of patient safety.”

For more information about the NPSF research grants or to read about recent grants, visit our Research Grants Program page.

—Patricia McTiernan

Grant Recipients from Beth Israel Deaconess Medical Center and Ohio State University Medical Center Chosen from Field of 125 Submissions

BOSTON, MA (May 9, 2011) – The National Patient Safety Foundation (NPSF) today announced that it has awarded $200,000 in grants to two researchers at leading medical centers. The grants are awarded through the NPSF Research Grants Program, which promotes studies leading to the prevention of human errors, system errors, patient injuries and their consequences.

• The NPSF Board Research Grant has been awarded to James Gray, MD, Beth Israel Deaconess Medical Center, Boston, for his project, Trigger Events as a Burst-like Phenomena: Understanding the Role of Care Team Structure and Designing Solutions.  This project will study the transmissible nature of patient events requiring intervention by a rapid response team (RRT)—a multidisciplinary medical team that provides critical care to patients who experience sudden clinical deterioration. The investigator’s previous work on RRTs suggests that the occurrence of an RRT event appears to influence or predict the risk of future deterioration in other patients. Using a large data set (more than 100,000 admissions), Dr. Gray and his team will explore whether an individual patient’s risk of decline is affected by the complex set of connections that exist between patients, their care, and the teams providing that care.

The NPSF Board Research Grant is supported in part by generous contributions from NPSF Board members.

• The Hospira Research Grant has been awarded to Emily Patterson, PhD, Ohio State University Medical Center, for her study, Patient Handoffs: the Impact of a Fresh Perspective on Patient Mortality in Critical Care Settings. Dr. Patterson’s project will use targeted ethnographic observations in two intensive care units to explore multiple questions related to changes in diagnoses after handoffs; strategies employed by staff during handoffs to increase patient safety; and team members’ willingness to speak up about safety concerns. This two-year study also aims to develop training materials related to patient handoffs.

This grant is funded by Hospira, the global specialty pharmaceutical and medication delivery company that provides solutions to help improve the safety, cost, and productivity of patient care.

The two grant recipients were selected from 125 submissions reviewed by an independent committee of 11 healthcare experts. That committee was chaired by Bruce Lambert, PhD, Professor of Pharmacy Administration at the University of Illinois at Chicago.

“The only way to truly transform the body of patient safety knowledge is to support original research,” said Diane C. Pinakiewicz, MBA, President of NPSF. “We are committed to advancing the efforts of investigators focused on identifying the causes of preventable injuries and the strategies that reduce them.”

“Our partnership with NPSF to advance research addressing medical errors reinforces the shared commitment of NPSF and Hospira to enhance patient safety in hospitals,” said Kathryn J. McDonagh, PhD, RN, vice president, Hospira.

“The number and quality of this year’s submissions were extraordinary,” Ms. Pinakiewicz added. “NPSF is most grateful to Hospira for its generous funding support of the research grants program and to our Board members, for their continual commitment to advancing research in patient safety.”

Since 1998, NPSF has supported 36 research projects with more than $3.6 million in grant funding.

The National Patient Safety Foundation

(NPSF) has been pursuing one mission since its founding in 1997 – to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, inclusive, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, and the NPSF Research Grants Program and its application process, visit www.npsf.org.