NPSF Awards Four Grants For Patient Safety Research

December 22, 1998

Chicago, IL, December 22, 1998 -- The National Patient Safety Foundation at the AMA (NPSF) Research Program announces four grant awards totaling $350,000 for the purpose of understanding the mechanisms that lead to patient injuries and creating widely applicable solutions to reducing preventable health care errors. One of the objectives of the NPSF is to promote patient safety as a distinct field of research in health care quality. This is the first year of operation of the NSPF grant award program.

One of the grants will be awarded in the memory of James S. Todd, MD, who as Executive Vice President of the American Medical Association (AMA), was instrumental in developing and launching the NPSF. "We are thrilled to see James Todd's name associated with this emerging field in health care research," said Timothy Flaherty, MD, a member of the NPSF Board and Trustee of the AMA.

The four newly awarded grants are described below. The principal investigator's name and institution are in parentheses.

"Quantitative Measurement of the Progression of Clinical Expertise"
This project - the recipient of the James S. Todd Memorial Award for Patient Safety Research - will study how physicians acquire clinical expertise, using anesthesia as the domain of study. This is a potentially widely applicable research project that gets at the underlying mechanisms of how clinicians learn how to do the right thing at the right time. The work will involve real time observations in clinical settings and analysis of videotapes of clinician performance. Researchers will generate a "cognitive map" of one clinical process that will be used to compare the decision-making processes of providers of different levels of training and experience. The methods get to the heart of understanding technical work, which is a critical precursor to improving patient safety. (Matthew B. Weinger, MD, of the University of California at San Diego)

"Auditory Warning Signals in Critical Care Settings"
A team of researchers from the University of Maryland and the University of Illinois will examine the fundamental question of the value of audio alarms as information-providing technologies. While audio alarms may seem to have inherent value, their actual utility is not well understood and they are known to be problematic in clinical settings. The team will use cognitive engineering techniques to examine how providers use the information in audio alarms and will develop new design principles, re-evaluating the role of audio alarms in acute care settings. (Yan Xiao, PhD of the University of Maryland, Baltimore)

"Theory and Methods for Minimizing Name Confusion Errors"
The two-year project will focus on what are called Look-Alike-Sound-Alike (LASA) drug names. One primary objective is to create an improved computer algorithm to identify drug names that look and sound alike when new drug names are being assigned. Using psycholinguistic theory and practice, this project will produce a more systematic approach to identify LASA names, prevent new similar names from being introduced, and thus help prevent the errors associated with drugs that have similar names. (Bruce L. Lambert, Ph.D., of the University of Illinois at Chicago)

"Looking for Trouble in All the Right Places: Electronic Decision Support for Error Reduction in a Large HMO"
The objective of this project is to develop a computer program that will search clinical information systems to identify cases that should be more carefully examined for errors and system problems. Using a database of obstetrical cases, investigators will seek "signatures" of cases that should be more carefully examined. This would greatly improve the identification of such cases, which now are found mainly by manual chart reviews without correlation with other hospital data. The methodology should be widely applicable to other patient cohorts. This is another two-year project involving a multi-disciplinary team, including co-investigators from Cornell University. (Gabriel J. Escobar, MD of the Kaiser Permanente Medical Care Program, Oakland, CA)
Founded in 1997, the National Patient Safety Foundation is an independent, nonprofit research and education organization. The NPSF is dedicated to the measurable improvement of patient safety in the delivery of health care. For more information about the NPSF, visit

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