James S. Todd Memorial Award for Patient Safety Research of 2002

This award has been co-sponsored by the NPSF, AMA, and the Commonwealth Fund and named in the memory of James S. Todd, MD. Transitions in Care: Emergency Department Sign-overs University of Florida, Health Science Center in Jacksonville
Investigators:
Shawna Perry, MD, FACEP (Principal Investigator), P.G. Croskerry, MD, PhD, M. Shapiro, MD, C. Beach, MD, R.L Wears, MD, M. Vanderhoef, RN, MSN, R. Behara, PhD, A. Murphy, PhD, and E. Eisenberg, PhD The necessary division of labor in healthcare organizations makes transitions in care inevitable. Although such transitions are typically thought of as problems in communication and coordination, they are much more complex than that, and also involve problems related to transfer of authority and responsibility. Transitions in care are generally felt to rich sources of safety problems. A recent JCAHO review of sentinel event reports identified 55 cases of serious delays in care due to poor transitions, generally poor communication among physicians. Over 50% of these cases came from the emergency department. This project will study a specific instance of transitions in care- shift changes ("turnovers") in the emergency department. These turnovers have been found to be both sources of failure and of recovery from failure, and could provide insight into other transitions in care as well. The investigators will use the information to develop approaches to turnover processes that meet the clinicians needs for information and lower the opportunity for failures.

Talking to Patients about Medical Errors
This grant has been co-sponsored by the National Patient Safety Foundation and the Commonwealth Fund.
The Meyers Primary Care Institute
Investigators:
Kathleen Mazor, EdD (Principal Investigator), Jerry Gurwitz, MD and George Reed, PhD
The goal of this study is to bring a patient-focused, evidence-based approach to discussions of disclosure of medical error. It will examine the impact of several factors likely to affect patients responses to errors and to disclosure of errors. The primary analysis of this project will focus on the impact of error type, error outcome, and level of communication on patient responses. The resulting information on patient preferences, the impact of specific communication strategies, and attitudes and beliefs about medical error will guide providers in informing patients of medical errors and will help to reduce the barriers to openly discussing errors and preventable injuries.

Clinical Decision Support to Reduce Adverse Drug Events in High Risk Home Care Patients
In its efforts to enhance patient safety in the state of Connecticut, the Donaghue Foundation joined NPSF in co-sponsoring this study. Masonicare, Connecticut
Investigators:
James O. Judge, MD (Prinicipal Investigator), Jane LaPrino, Barbara Banning, Pharm D, Kathy White, RPh, Donna Galluzo, Cheryl Leslie, RN, MPH and Cora Zombrzuski, RN, MS
Poor transfer of critical clinical data during the transition from the hospital or post-acute care center to home care characterizes usual care for older patients with complex medical conditions. The proposed pilot project will extend the concept of a Computerized Physician Order Entry (CPOE) system from a Physician Order Entry with Clinical Decision Support (CDS) in the hospital into a new setting-homecare, and a population at high risk- patients requiring home care following a hospitalization. The working group will also determine what components of disease guidelines (CHF, Coronary Artery Disease, chronic pain, and osteoporosis guidelines) will be included in the CDS and how the CDS report will be communicated to primary care offices. The results of this project will determine the effect size for a larger randomized clinical trial of efficacy and cost-effectiveness in reducing Adverse Drug Events and reducing rates of hospitalization following discharge to home care.