A survey of mindset theories of intelligence and medical error self-reporting among pediatric housestaff and faculty

BACKGROUND

Intelligence theory research has illustrated that people hold either "fixed" (intelligence is immutable) or "growth" (intelligence can be improved) mindsets and that these views may affect how people learn throughout their lifetime. Little is known about the mindsets of physicians, and how mindset may affect their lifetime learning and integration of feedback. Our objective was to determine if pediatric physicians are of the "fixed" or "growth" mindset and whether individual mindset affects perception of medical error reporting. 

METHODS

We sent an anonymous electronic survey to pediatric residents and attending pediatricians at a tertiary care pediatric hospital. Respondents completed the "Theories of Intelligence Inventory" which classifies individuals on a 6-point scale ranging from 1 (Fixed Mindset) to 6 (Growth Mindset). Subsequent questions collected data on respondents' recall of medical errors by self or others.

RESULTS

We received 176/349 responses (50 %). Participants were equally distributed between mindsets with 84 (49 %) classified as "fixed" and 86 (51 %) as "growth". Residents, fellows and attendings did not differ in terms of mindset. Mindset did not correlate with the small number of reported medical errors.

CONCLUSIONS

There is no dominant theory of intelligence (mindset) amongst pediatric physicians. The distribution is similar to that seen in the general population. Mindset did not correlate with error reports.

Mentoring and supervising clinical pharmacist students at patients' bedside: which benefits?

RATIONALE, AIMS AND OBJECTIVES

 Hospital clinical pharmacists are involved in teaching students during professional internship. Organization between the unit care and the pharmacy place is complicated. This study evaluated the effectiveness of two pharmaceutical teams: an experienced pharmacist in the pharmacy place, reachable by phone (team 1) or an experienced pharmacist in the ward, near patients and students (team 2).

METHODS

Pharmaceutical interventions were collected during two successive time periods, each of 6 months in a 15-bed unit (neurology). During the first time period, prescriptions were analyzed by the student (resident) in the ward and experienced pharmacist in the pharmacy place. During the second time period, prescriptions were analyzed by both experienced pharmacist and the resident in the ward. We compared the number, the type, the approval of pharmaceutical interventions and the medication reconciliation activities. Proportions were compared by a chisquared test (or Fisher exact test) as well as the quantitative value was calculated by a Student test.

RESULTS

'Mentoring and supervising' students in the ward increased significantly the number of pharmaceutical interventions (PI; 104 interventions for 1408 analyzed prescriptions (7.4%) by the students in the ward and 317 interventions for 1391 (22.8%) by both the experienced pharmacist and the students in the ward (P = 0.002). Furthermore, specific interventions from medication reconciliation were significantly increased by the presence of experienced pharmacist in the ward (0.96% vs. 8.83% P = 0.018).

CONCLUSION

Effectiveness of clinical pharmacists can be improved by the presence of experienced pharmacist at patients' bedside, near students.

The role of emotion in patient safety: Are we brave enough to scratch beneath the surface?

Healthcare professionals work in emotionally charged settings; yet, little is known about the role of emotion in ensuring safe patient care. This article presents current knowledge in this field, drawing upon psychological approaches and evidence from clinical settings. We explore the emotions that health professionals experience in relation to making a medical error and describe the impact on healthcare professionals and on their professional and patient relationships. We also explore how positive and negative emotions can contribute to clinical decision making and affect responses to clinical situations. Evidence to date suggests that emotion plays an integral role in patient safety. Implications for training, practice and research are discussed in addition to strategies to facilitate health services to understand and respond to the influence of emotion in clinical practice.

Relationship Between Patients' Perceptions of Care Quality and Health Care Errors in 11 Countries: A Secondary Data Analysis

Patients may be the most reliable reporters of some aspects of the health care process; their perspectives should be considered when pursuing changes to improve patient safety. The authors evaluated the association between patients' perceived health care quality and self-reported medical, medication, and laboratory errors in a multinational sample. The analysis was conducted using the 2010 Commonwealth Fund International Health Policy Survey, a multinational consumer survey conducted in 11 countries. Quality of care was measured by a multifaceted construct developed using Rasch techniques. After adjusting for potentially important confounding variables, an increase in respondents' perceptions of care coordination decreased the odds of self-reporting medical errors, medication errors, and laboratory errors (P < .001). As health care stakeholders continue to search for initiatives that improve care experiences and outcomes, this study's results emphasize the importance of guaranteeing integrated care.

The Efficacy of Patients' Wristband Bar-code on Prevention of Medical Errors: A Meta-analysis Study

BACKGROUND

Patient misidentification, as a major patient safety issue, occurs in any healthcare setting and leads to inappropriate medical procedures, diagnosis or treatment, with serious outcomes.

OBJECTIVES

The study aimed to investigate the effectiveness of wristband bar-code medication scanning to reduce medical errors (ME).

METHODS

A meta-analysis study was conducted. The relevant studies were searched in PubMed, Embase, Cochrane Library, Web of Science and Scopus from 1990 to March 2015. Thereafter, the studies retrieved were screened based on predefined inclusion and exclusion criteria. Data were extracted, and the quality of the included studies was evaluated using the STROBE checklist.

RESULTS

In total, 14 articles involving 483 cases were included. The meta-analysis indicated that the use of wristband bar-code medication scanning can reduce the ME around 57.5% (OR=0.425, 95% CI: 0.28-0.65, P<0.001). The study results showed a marked heterogeneity in the subgroup analysis (I-squared=98%). This was I(2)=70.35, P-value=0.018 for the type of samples and I(2)=99%, P-value<0.001 for years and countries.

CONCLUSION

Wristband bar-code medication scanning can decrease the ME in hospital setting. Since the patient's safety is the main goal of the World Health Organization, it is recommended that a unique patient identification barcode should be used with name, medical record number, and bar-coded financial number.

An analysis of closed medical litigations against the obstetrics departments in Taiwan from 2003 to 2012†

OBJECTIVE

To examine the epidemiologic data of closed medical claims from Taiwanese civil courts against obstetric departments and identify high-risk diseases.

DESIGN

A retrospective descriptive study.

SETTING/STUDY PARTICIPANTS

The verdicts from the national database of the Taiwan judicial system that pertained to obstetric departments were reviewed. Between 2003 and 2012, a total of 79 closed medical claims were included.

MAIN OUTCOME MEASURES

The epidemiologic data of litigations including the results of adjudication and the disease and outcome of the alleged injury.

RESULTS

A majority of the disputes (65.9%) were fetus-related. Four disease categories accounted for 78.5% of all claims including (i) perinatal maternal complications (25.3%); (ii) errors in antenatal screening or ultrasound diagnoses (21.5%); (iii) fetal hypoxemic-ischemia encephalopathy (16.5%); and (iv) brachial plexus injury (15.2%). Six cases (7.6%) resulted in an indemnity payment with a mean amount of $109 205. Fifty-one cases (64.6%) were closed in the district court. The mean incident-to-litigation closure time was 52.9 ± 29.3 months. All cases with indemnity payments were deemed negligent or were at least determined to be controversial by a medical appraisal, while all defendants whose care was judged as appropriate by a medical appraisal won their lawsuits.

CONCLUSIONS

Almost 93% of clinicians win their cases but spend 4.5 years waiting for final adjudication. The court ruled against the clinician only if there was no appropriate response during a complication or if there was no follow-up or further testing for potential critical diseases.

How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study

OBJECTIVE

Surgical trainees are often subject to the negative consequences of medical error, and it is therefore important to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur. This article examines how trainees interpret catastrophic surgical outcomes and ways to provide support for trainees who have experienced catastrophic events.

DESIGN

Totally 23 semistructured interviews were conducted with surgical trainees. Interviews were conducted in English and subjected to modified thematic analysis.

SETTING

A tertiary care hospital in Toronto, Canada.

PARTICIPANTS

Interviews were completed with 23 surgery residents. Potential participants were recruited through communications via the Department of Surgery and volunteered to take part in the study.

RESULTS

Totally 5 themes emerged: (1) catastrophic errors usually represent system deficiencies; (2) catastrophic events provide lessons for future practice; (3) many trainees did not feel comfortable speaking with the surgical staff; (4) counseling services should be offered to help a subset of trainees; and (5) the culture of surgery may act as a barrier to trainees seeking help.

CONCLUSIONS

This study demonstrates the importance of providing support for the emotional needs of surgical trainees who have experienced catastrophic surgical errors and the continued need for mentoring by staff surgeons.

Making health care safer: What is the contribution of health psychology?

While health care brings great benefits, all treatments, and many investigations, carry some risk. As patients, we should be told of the risks of specific treatments but we are also at risk from failings in the health care system itself. We suggest that, while there are many examples of individual health psychologists who have made important contributions, this has not yet translated into a broader disciplinary engagement. Health psychologists have devoted much more attention to patients and devoted much less attention to the potentially huge impact of studying and intervening with staff, clinical practice, and organizations. We believe that there are considerable opportunities for health psychology to engage more closely with patient safety and, more importantly, that this would be of great benefit to both patients and staff. Statement of contribution What is already known on this subject? While health care brings great benefits, all treatments, and many investigations, carry some risk. Patients are also at risk from failings in the health care system itself. Studies using review of medical records in many countries have found that between 8% and 12% of patients in hospital suffer an unintended harm due to health care. What does this study add? There are many examples of individual psychologists who have made important contributions, but this has not yet translated into a broader disciplinary engagement. There are considerable opportunities for health psychology to engage more closely with patient safety. These include health behaviour change, teamwork, communication after medical error, diagnosis and decision making, organisational culture, and improving compliance with rules and standards. Psychologists providing a clinical service to specialist services in any area could expand their remit from supporting patients to a more general support and engagement with safety and quality initiatives. Health psychologists have models to understand the behaviour of people, and recent developments in changing behaviour should be applicable to health professionals in addition to their patients.

Barriers to Medical Error Reporting

BACKGROUND

This study was conducted to explore the prevalence of medical error underreporting and associated barriers.

METHODS

This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan, Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments.

RESULTS

Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%), lack of proper reporting form (51.8%), lack of peer supporting a person who has committed an error (56.0%), and lack of personal attention to the importance of medical errors (62.9%). The rate of committing medical errors was higher in men (71.4%), age of 50-40 years (67.6%), less-experienced personnel (58.7%), educational level of MSc (87.5%), and staff of radiology department (88.9%).

CONCLUSIONS

This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.

The missing evidence: a systematic review of patients' experiences of adverse events in health care

PURPOSE

Preventable patient harm due to adverse events (AEs) is a significant health problem today facing contemporary health care. Knowledge of patients' experiences of AEs is critical to improving health care safety and quality. A systematic review of studies of patients' experiences of AEs was conducted to report their experiences, knowledge gaps and any challenges encountered when capturing patient experience data.

DATA SOURCES

Key words, synonyms and subject headings were used to search eight electronic databases from January 2000 to February 2015, in addition to hand-searching of reference lists and relevant journals.

STUDY SELECTION

Titles and abstracts of publications were screened by two reviewers and checked by a third. Full-text articles were screened against the eligibility criteria.

DATA EXTRACTION

Data on design, methods and key findings were extracted and collated.

RESULTS

Thirty-three publications demonstrated patients identifying a range of problems in their care; most commonly identified were medication errors, communication and coordination of care problems. Patients' income, education, health burden and marital status influence likelihood of reporting. Patients report distress after an AE, often exacerbated by receiving inadequate information about the cause. Investigating patients' experiences is hampered by the lack of large representative patient samples, data over sufficient time periods and varying definitions of an AE.

CONCLUSION

Despite the emergence of policy initiatives to enhance patient engagement, few studies report patients' experiences of AEs. This information must be routinely captured and utilized to develop effective, patient-centred and system-wide policies to minimize and manage AEs.

Varieties of clinical reasoning

RATIONALE, AIMS AND OBJECTIVES

Clinical reasoning comprises a variety of different modes of inference. The modes that are practiced will be influenced by the sociological characteristics of the clinical settings and the tasks to be performed by the clinician.

METHODS

This article presents C.S. Peirce's typology of modes of inference: deduction, induction and abduction. It describes their differences and their roles as stages in scientific argument. The article applies the typology to reasoning in clinical settings.

RESULTS

The article describes their differences, and their roles as stages in scientific argument. It then applies the typology to reasoning in typical clinical settings.

CONCLUSIONS

Abduction is less commonly taught or discussed than induction and deduction. However, it is a common mode of inference in clinical settings, especially when the clinician must try to make sense of a surprising phenomenon. Whether abduction is followed up with deductive and inductive verification is strongly influenced by situational constraints and the cognitive and psychological stamina of the clinician. Recognizing the inevitability of abduction in clinical practice and its value to discovery is important to an accurate understanding of clinical reasoning.

Staphylococcus-related glomerulonephritis and poststreptococcal glomerulonephritis: why defining "post" is important in understanding and treating infection-related glomerulonephritis

A spate of recent publications describes a newly recognized form of glomerulonephritis associated with active staphylococcal infection. The key kidney biopsy findings, glomerular immunoglobulin A (IgA) deposits dominant or codominant with IgG deposits, resemble those of IgA nephritis. Many authors describe this condition as "postinfectious" and have termed it "poststaphylococcal glomerulonephritis." However, viewed through the prism of poststreptococcal glomerulonephritis, the prefix "post" in poststaphylococcal glomerulonephritis is historically incorrect, illogical, and misleading with regard to choosing therapy. There are numerous reports describing the use of high-dose steroids to treat poststaphylococcal glomerulonephritis. The decision to use steroid therapy suggests that the treating physician believed that the dominant problem was a postinfectious glomerulonephritis, not the infection itself. Unfortunately, steroid therapy in staphylococcus-related glomerulonephritis can precipitate severe staphylococcal sepsis and even death and provides no observable benefits. Poststreptococcal glomerulonephritis is an authentic postinfectious glomerulonephritis; poststaphylococcal glomerulonephritis is not. Making this distinction is important from the perspective of history, pathogenesis, and clinical management.

Reducing risk of overdose with midazolam injection in adults: an evaluation of change in clinical practice to improve patient safety in England

RATIONALE AIMS AND OBJECTIVES

This study sought to evaluate potential reductions in risk associated with midazolam injection, a sedating medication, following a UK National Patient Safety Alert. This alert, 'Reducing risk of overdose with midazolam injection in adults', was sent to all National Health Service organizations as a Rapid Response Report detailing actions services should take to minimize risks.

METHOD

To evaluate any potential changes arising from this alert, a number of data sources were explored including reported incidents to a national reporting system for health care error, clinician survey and audit data, pharmaceutical purchasing patterns and feedback from National Health Service managers.

RESULTS

Prior to the Rapid Response Report, 498 incidents were received by the National Patient Safety Agency including three deaths. Post-implementation of the Rapid Response Report (June 2009), no incidents resulting in death or severe harm had been received. All organizations reported having completed the Rapid Response Report actions. Purchase and use of risk-prone, high-strength sedating midazolam by health care organizations decreased significantly as did the increased use of safer, lower strength doses (as recommended in the Rapid Response Report).

CONCLUSIONS

Organizations can achieve safer medication practices, better knowledge, awareness and implementation of national safer practice recommendations. Risks from inadvertent overdose of midazolam injection were reduced post-implementation of national recommendations. Ongoing monitoring of this particular adverse event will be required with a sustained patient safety message to health services to maintain awareness of the issue and reduction in the number of midazolam-related errors.

Incidence of intravenous drug incompatibilities in intensive care units

AIMS

Drug incompatibilities are relatively common in inpatients and this may result in increased morbidity/mortality as well as add to costs. The aim of this 12 month study was to identify real incidences of drug incompatibilities in intravenous lines in critically ill patients in two intensive care units (ICUs).

METHODS

A prospective cross sectional study of 82 patients in 2 ICUs, one medical and one surgical in a 1500-bed university hospital. One monitor carried out observations during busy hours with frequent drug administration. Patients included in both ICUs were those receiving at least two different intravenous drugs.

RESULTS

6.82% and 2.16% of drug pairs were found to be incompatible in the two ICUs respectively. Among the most frequent incompatible drugs found were insulin, ranitidine and furosemide.

CONCLUSIONS

The study showed that a significant number of drug incompatibilities occur in both medical and surgical ICUs. It follows that the incidence of incompatibilities could be diminished by adhering to a few simple rules for medication administration, following by recommendations for multiple lumen catheter use. Future prospective studies should demonstrate the effect of applying these policies in practice.

Evaluating the PRASE patient safety intervention - a multi-centre, cluster trial with a qualitative process evaluation: study protocol for a randomised controlled trial

BACKGROUND

Estimates show that as many as one in 10 patients are harmed while receiving hospital care. Previous strategies to improve safety have focused on developing incident reporting systems and changing systems of care and professional behaviour, with little involvement of patients. The need to engage with patients about the quality and safety of their care has never been more evident with recent high profile reviews of poor hospital care all emphasising the need to develop and support better systems for capturing and responding to the patient perspective on their care. Over the past 3 years, our research team have developed, tested and refined the PRASE (Patient Reporting and Action for a Safe Environment) intervention, which gains patient feedback about quality and safety on hospital wards.

METHODS/DESIGN

A multi-centre, cluster, wait list design, randomised controlled trial with an embedded qualitative process evaluation. The aim is to assess the efficacy of the PRASE intervention, in achieving patient safety improvements over a 12-month period.The trial will take place across 32 hospital wards in three NHS Hospital Trusts in the North of England. The PRASE intervention comprises two tools: (1) a 44-item questionnaire which asks patients about safety concerns and issues; and (2) a proforma for patients to report (a) any specific patient safety incidents they have been involved in or witnessed and (b) any positive experiences. These two tools then provide data which are fed back to wards in a structured feedback report. Using this report, ward staff are asked to hold action planning meetings (APMs) in order to action plan, then implement their plans in line with the issues raised by patients in order to improve patient safety and the patient experience.The trial will be subjected to a rigorous qualitative process evaluation which will enable interpretation of the trial results.

METHODS

fieldworker diaries, ethnographic observation of APMs, structured interviews with APM lead and collection of key data about intervention wards. Intervention fidelity will be assessed primarily by adherence to the intervention via scoring based on an adapted framework.

DISCUSSION

This study will be one of the largest patient safety trials ever conducted, involving 32 hospital wards. The results will further understanding about how patient feedback on the safety of care can be used to improve safety at a ward level. Incorporating the 'patient voice' is critical if patient feedback is to be situated as an integral part of patient safety improvements.

TRIAL REGISTRATION

ISRCTN07689702, 16 Aug 2013.

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports

An increasing number of healthcare providers are adopting patient safety event reporting systems, yet leveraging these data to improve safety remains a challenge, particularly with large datasets composed of thousands of event reports. A MedStar Health research team, with expertise in data analytics and human factors, developed intuitive visualization dashboards to facilitate data exploration and trend analysis. Dashboards were developed using an iterative design and development process that was end-user focused. A system level dashboard, representing data from multiple hospitals, and a hospital level dashboard were developed. The dashboards allowed users to directly manipulate the data, provided coordinated displays in different formats, and allowed users to quickly zoom in on specific variables of interest. Overall feedback was incredibly positive with nearly all users wanting to adopt the system immediately. Several improvements were suggested and are discussed. The success of this approach highlights the need for more intuitive data analysis tools.

Medical errors in neurosurgery

Background:

Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified.

Methods:

Here, we provide a systematic review of the neurosurgical literature describing medical errors at the departmental level. Eligible articles were identified from the PubMed database, and restricted to reports of recognizable errors across neurosurgical practices. We limited this analysis to cross-sectional studies of errors in order to better match systems-level concerns, rather than reviewing the literature for individually selected errors like wrong-sided or wrong-level surgery.

Results:

Only a small number of articles met these criteria, highlighting the paucity of data on this topic. From these studies, errors were documented in anywhere from 12% to 88.7% of cases. These errors had many sources, of which only 23.7-27.8% were technical, related to the execution of the surgery itself, highlighting the importance of systems-level approaches to protecting patients and reducing errors.

Conclusions:

Overall, the magnitude of medical errors in neurosurgery and the lack of focused research emphasize the need for prospective categorization of morbidity with judicious attribution. Ultimately, we must raise awareness of the impact of medical errors in neurosurgery, reduce the occurrence of medical errors, and mitigate their detrimental effects.

A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum

BACKGROUND

Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error.

DISCUSSION

To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the month's case reviews are presented, learning points discussed, and corrective actions are proposed.

CONCLUSION

By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.

[jeder-fehler-zaehlt.de: Content of and prospective benefits from a critical incident reporting and learning system (CIRS) for primary care]

Critical incident reporting and learning systems (CIRS) have been recommended as an instrument to promote patient safety for a long time. However, both their scientific value and their actual impact have been disputed. The nationwide German CIRS for primary care has been in operation since September 2004. Incident reports are available online, and the question is how to make use of this large database to promote patient safety. A descriptive analysis of the content was performed, classifying, in particular, types of error and contributing factors. Its usage is presented for the period from 2004 to 2013 where a total of 483 complete reports have been recorded. Their severity ranges from 35.6 % with no tangible harm to patients to 14.6 % with important harm (or errors contributing to mortality). The majority of them (74.2 %) were process errors, compared to 25.8 % knowledge/skills errors. The main areas involved were treatment/medication (54.2 %) and diagnosis/tests (16.4 %). The results of the analysis of the CIRS cannot be used as an epidemiological data source. And yet they will generate hypotheses for further research in the field of patient safety. Moreover, they will enable practice teams to make themselves familiar with and learn from critical incident analysis. In spite of the specific difficulties in ambulatory care, CIRS should be promoted in this sector to enable learning. Participation in CIRS can be increased by enhanced feedback.

Validity of and interrater agreement on the LINNEAUS Euro-PC medication safety incident classification system in primary care in Poland

INTRODUCTION

Medication safety incidents occur in all health care sectors and cause considerable morbidity and mortality, with 8.5% of all related incidents reported estimated to occur in primary care. A common incident classification system could facilitate collective learning from the analysis of medication-related errors and improve patient safety

OBJECTIVE

The objective of this study was to assess the validity of a new classification system of medication safety incidents in primary care in Poland.

METHODS

Analysis of data from a descriptive, cross-sectional, self-reported survey on the Learning from International Networks about Errors and Understanding Safety in Primary Care (LINNEAUS Euro-PC) medication safety incident classification for primary care with assessment of 10 case-based clinical scenarios done by doctors and pharmacists form community-based family medicine clinics and pharmacies in Lodz.

MAIN OUTCOME MEASURES

The percentages of overall agreement on judgements and a fixed-marginal multirater kappa (κ) coefficient as statistical measures of interrater agreement for categorical items.

RESULTS

The overall agreement levels were: category 1 - 86.3%; category 2 - 85.6%; category 3 - 72.1%; category 4 - 71.8%; and category 5 - 70.4%. The interrater agreement between the 15 evaluators varied as follows: category 1 fixed-marginal κ = 0.144; category 5 fixed-marginal κ = 0.565; category 3 fixed-marginal κ = 0.607; category 4 fixed-marginal κ = 0.634; and category 2 fixed-marginal κ = 0.807.

CONCLUSIONS

This is the first known study on levels of agreement on the perception of medication safety incidents and assessment of the validity of a related classification system in primary health care in Poland. Interrater agreement in this study was surprisingly high, but still leaves room for improvement.

Literature review on clinical decision support system reducing medical error

OBJECTIVES

Quite a number of studies on clinical decision support systems (CDSS) have been published in recent years to assess the characteristics and architecture of CDSS and evaluate the effects of CDSS on clinical work. However, until now there have been no relevant studies to investigate the quantity of these, and their contribution to present day thinking. The aim of this study was to explore the areas of theme, and the study design of research on CDSS in literature published in English and Chinese-language journals.

METHODS

We searched the major database including MEDLINE, EMbase, Cochrane Library and four Chinese databases including Chinese Biomedical Literature Database (CBM), Wanfang Data, Chinese Scientific Journal Database (VIP), and Chinese Journals Full-text Database (CNKI) and to analyze the publication years, research themes, authors' affiliations and methodologies of studies. Quality and statistical method were only appraised by classification of study designs.

RESULTS

A total of 616 studies published from 1990 to 2013 were included in our research. In the year of 2011 the number of studies reached its peak with 96 studies accounting for 15.58% of the years' publication. We grouped the included studies into six major topic areas of which computerized clinical decision support systems dominated the included studies accounting for 51.46% of all studies. Commentary reviews and cross-sectional studies which took up approximately 46.10% of the included studies, with 30.52% (188 studies) and 15.58% (96 studies) respectively. Most included studies on CDSS were conducted in the following four institutions: universities, hospitals, research institutions and companies.

CONCLUSIONS

There is a growing change trend in the number of studies on CDSS research in recent two decades, most of which are non-comparative studies (46.10%) . Only 21 systematic reviews and 22 randomized controlled trails were published with the percentage of 3.41% and 3.57% of the included studies. More methodologically rigorous designs are needed to improve the research quality on CDSS.

Medical errors and uncertainty in primary healthcare: a comparative study of coping strategies among young and experienced GPs

OBJECTIVE

To study coping differences between young and experienced GPs in primary care who experience medical errors and uncertainty.

DESIGN

Questionnaire-based survey (self-assessment) conducted in 2011.

SETTING

Finnish primary practice offices in Southern Finland.

SUBJECTS

Finnish GPs engaged in primary health care from two different respondent groups: young (working experience ≤ 5 years, n = 85) and experienced (working experience > 5 years, n = 80).

MAIN OUTCOME MEASURES

Outcome measures included experiences and attitudes expressed by the included participants towards medical errors and tolerance of uncertainty, their coping strategies, and factors that may influence (positively or negatively) sources of errors.

RESULTS

In total, 165/244 GPs responded (response rate: 68%). Young GPs expressed significantly more often fear of committing a medical error (70.2% vs. 48.1%, p = 0.004) and admitted more often than experienced GPs that they had committed a medical error during the past year (83.5% vs. 68.8%, p = 0.026). Young GPs were less prone to apologize to a patient for an error (44.7% vs. 65.0%, p = 0.009) and found, more often than their more experienced colleagues, on-site consultations and electronic databases useful for avoiding mistakes.

CONCLUSION

Experienced GPs seem to better tolerate uncertainty and also seem to fear medical errors less than their young colleagues. Young and more experienced GPs use different coping strategies for dealing with medical errors.

IMPLICATIONS

When GPs become more experienced, they seem to get better at coping with medical errors. Means to support these skills should be studied in future research.

What is the profile of patients thinking of litigation? Results from the hospitalized and outpatients' profile and expectations study

BACKGROUND

Patients vary considerably in their intentions to pursue legal action following a medical error. The aim of this study was to explore predictors of litigious intentions in both hospitalized patients and outpatients, determining the relative influences of patients' characteristics, help-seeking behavior, information-seeking attitudes and general health status factors.

METHODS

A representative cross-section of the urologic clinic of a general academic hospital and the associated outpatient clinic was used (a total of 226 patients, 145 outpatients). Data were gathered using in-person interviews conducted by trained psychologists. Attitudes were assessed by "General statements about medical errors", while expectations for information by "Krantz's Health Opinion Survey" (KHOS).

RESULTS

A single multivariate model explained 21.5% of the variance of litigious intentions. Younger age (explained 7.6% of the variation, p=0.04), weaker relationship with religion (4%, p=0.02), less than 15 visits/year to any physician (7.2%, p=0.001), outpatient status (2.4%, p=0.02), and higher expectations for information were associated with higher possibility to consider suing their physician (7.6%, p=0.002). Patients' desire for disclosure of a medical error (agreement in 82.2%) exceeded their expectations for financial compensation, particularly in less severe cases (agreement in 24.1%).

CONCLUSIONS

This is the first report on the profile of patients with high potential for malpractice suits as predicted by patients' age, relationship with religion, health-seeking and information-seeking behavior. Respecting patients' need for information during clinical consultations and proceeding to disclosure of medical errors, when they occur, seems to be not only the more patient-centered approach, but also the best way to lessen the likelihood of a claim. Hippokratia 2014; 18 (2):139-143.

We're not there yet

Patient injury due to medical error continues to plague health care delivery. Efforts to eliminate errors or mitigate their effects have largely been thwarted, despite enormous investments of human and financial resources. A survey published in this issue of Otolaryngology-Head and Neck Surgery on the status of medical error in otolaryngology finds that the specialty is not exempt. The authors report that relatively little has changed since the original report by the senior authors published a decade ago. Despite this lack of apparent progress, there is growing awareness that improvements in patient safety will be incremental rather than transformational. The author of this commentary identifies a number of fundamental cultural changes that will be required to achieve transformational change.

Predictors of health care professionals' attitudes towards involvement in safety-relevant behaviours

BACKGROUND

Patients can make valuable contributions towards promoting the safety of their health care. Health care professionals (HCPs) could play an important role in encouraging patient involvement in safety-relevant behaviours. However, to date factors that determine HCPs' attitudes towards patient participation in this area remain largely unexplored.

OBJECTIVE

To investigate predictors of HCPs' attitudes towards patient involvement in safety-relevant behaviours.

DESIGN

A 22-item cross-sectional fractional factorial survey that assessed HCPs' attitudes towards patient involvement in relation to two error scenarios relating to hand hygiene and medication safety.

SETTING

Four hospitals in London

PARTICIPANTS

  Two hundred sixteen HCPs (116 doctors; 100 nurses) aged between 21 and 60 years (mean: 32): 129 female.

OUTCOME MEASURES

Approval of patient's behaviour, HCP response to the patient, anticipated effects on the patient-HCP relationship, support for being asked as a HCP, affective rating response to the vignettes.

RESULTS

HCPs elicited more favourable attitudes towards patients intervening about a medication error than about hand sanitation. Across vignettes and error scenarios, the strongest predictors of attitudes were how the patient intervened and how the HCP responded to the patient's behaviour. With regard to HCP characteristics, doctors viewed patients intervening less favourably than nurses.

CONCLUSIONS

HCPs perceive patients intervening about a potential error less favourably if the patient's behaviour is confrontational in nature or if the HCP responds to the patient intervening in a discouraging manner. In particular, if a HCP responds negatively to the patient (irrespective of whether an error actually occurred), this is perceived as having negative effects on the HCP-patient relationship.

Effective notification of important non-urgent radiology results: a qualitative study of challenges and potential solutions

INTRODUCTION

We report on the implementation of a Radiology Notification System (RNS), set up by the medical imaging department of a major Sydney teaching hospital in March 2010. This study aimed to investigate the views of the medical imaging department staff about: (i) the results follow-up problem encountered by the medical imaging department prior to the implementation of the RNS; (ii) what changes occurred following implementation of the RNS; and (iii) suggestions for improving the RNS.

METHODS

This is a cross-sectional qualitative study incorporating semi-structured interviews with 16 staff (15 radiologists and 1 clerk) after the implementation of the RNS. Interviews were conducted in August/September 2011.

RESULTS

The reasons behind the development of the RNS were related to: (i) major existing problems with the communication of results between the imaging department and hospital wards; (ii) cumbersome and inefficient paper-based notification systems; and (iii) the absence of standardised guidelines and procedures for radiology test notification and follow-up. The RNS managed to free up a significant proportion of radiologist time, resulting in greater efficiencies. Study participants also highlighted a number of areas for improvement, including the need for a 24-h service, feedback and acknowledgement of test results by clinicians and the standardisation of test management definitions and procedures.

CONCLUSION

Test management systems can play an important part in enhancing safe and effective communications between wards and hospital departments. However, their uptake and sustainability will require the establishment of a multidisciplinary and hospital-wide collaboration that includes clinicians.

Outcome of adverse events and medical errors in the intensive care unit: a systematic review and meta-analysis

Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially eligible studies were identified from 4 major databases. Of 902 studies screened, 12 met the inclusion criteria, 10 of which are included in the quantitative analysis. Patients with 1 or more MEs/AEs (vs no MEs/AEs) had a nonsignificant increase in mortality (odds ratio = 1.5; 95% confidence interval [CI] = 0.98-2.14) but significantly longer hospital and ICU stays; the mean difference (95% CI) was 8.9 (3.3-14.7) days for hospital stay and 6.8 (0.2-13.4) days for ICU. The ICU environment is associated with a substantial incidence of MEs/AEs, and patients with MEs/AEs have worse outcomes than those with no MEs/AEs.

Can eye-tracking technology improve situational awareness in paramedic clinical education?

Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one’s surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.

Hospital patients' reports of medical errors and undesirable events in their health care

OBJECTIVE

To investigate hospital patients' reports of undesirable events in their health care.

DESIGN

Cross-sectional mixed methods design.

PARTICIPANTS

A total of 80 medical and surgical patients (mean age 58, 56 male).

INTERVENTION

Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed.

MAIN OUTCOME MEASURES

Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care.

RESULTS

In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system.

CONCLUSION

Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.

Comparison of Administrative Data Versus Infection Control Data in Identifying Central Line-Associated Bloodstream Infections in Children's Hospitals

OBJECTIVE

As of July 2012, the Centers for Medicare and Medicaid Services prohibited state Medicaid programs from paying for medical care related to certain provider-preventable conditions. The most prevalent provider-preventable condition in pediatrics is central line-associated bloodstream infections (CLABSIs), which cause significant morbidity and mortality. The objective of this study was to compare the uses of administrative data and infection control data in measuring CLABSIs.

METHODS

Retrospective chart reviews were performed in 3 children's hospitals to compare CLABSIs identified according to administrative data diagnostic coding versus infections identified by hospital infection control departments. Clinical criteria from the Centers for Disease Control and Prevention and reported to the National Healthcare Safety Network were used.

RESULTS

A total of 166 CLABSIs were identified in 35 698 discharges in the 3 children's hospitals in 2010. Using the Centers for Disease Control and Prevention criteria as the standard, administrative data had 34.78% sensitivity and 99.92% specificity. The positive predictive value was 63.16% whereas the negative predictive value was 99.75%.

CONCLUSIONS

Administrative data and National Healthcare Safety Network criteria identify discordant numbers of CLABSIs.

Does the Maslach Burnout Inventory correlate with cognitive performance in anesthesia practitioners? A pilot study

Background:

Chronic stress is a common condition among health-care operators, anesthetists in particular. It is known to cause cognitive weakening and pathological outcomes, as the Burnout syndrome. Nevertheless, the impact of clinicians’ health on their performance has received limited attention thus far. Our pilot study, aims at evaluating the influence of burnout on the cognitive performance in a population of anesthesia practitioners.

Methods:

In 18 practitioners we assessed attention by means of reaction times (RTs), pre- and post-shift, with a five-subtest computerized neuropsychological battery. RTs were controlled for the situational anxiety with the State-Trait Anxiety Inventory X1. The burnout level was evaluated with the Maslach Burnout Inventory (MBI). The three MBI sub-scores (emotional exhaustion, depersonalization and professional achievement) were combined to obtain two groups according to the burnout score (high and low).

Results:

Anesthetists showed a significantly worse performance in the fifth test post-shift (P=0.041) than pre-shift. The high-score burnout group reacted slower than the low-score burnout group in three of the five cognitive subtests, without reaching a statistical significance. Nevertheless, our effect size, which is independent from the sample size, is very large (d=1.165).

Conclusion:

We found that in a population of health-care operators, burnout may affect the cognitive and potentially, the working performance. Qualitative and quantitative measurements should be integrated to ensure a better management of burnout and its consequences in workplaces.

Reducing the risk of harm from medication errors in children

MEDICATION ERRORS AFFECT THE PEDIATRIC AGE GROUP IN ALL SETTINGS

outpatient, inpatient, emergency department, and at home. Children may be at special risk due to size and physiologic variability, limited communication ability, and treatment by nonpediatric health care providers. Those with chronic illnesses and on multiple medications may be at higher risk of experiencing adverse drug events. Some strategies that have been employed to reduce harm from pediatric medication errors include e-prescribing and computerized provider order entry with decision support, medication reconciliation, barcode systems, clinical pharmacists in medical settings, medical staff training, package changes to reduce look-alike/sound-alike confusion, standardization of labeling and measurement devices for home administration, and quality improvement interventions to promote nonpunitive reporting of medication errors coupled with changes in systems and cultures. Future research is needed to measure the effectiveness of these preventive strategies.

Wrong site surgery in otolaryngology-head and neck surgery

OBJECTIVES/HYPOTHESIS

Wrong site surgery has received high public awareness this past decade, yet discussion specific to otolaryngology is limited.

STUDY DESIGN

Literature review.

METHODS

We searched the MEDLINE database on PubMed from 1980 to 2013 and pursued the citations of key references further. We conducted a review of the literature and public patient safety reports on the scope, root causes, and prevention of wrong site surgery with emphasis on otolaryngology.

RESULTS

A review of the literature reveals that otolaryngology procedures constitute 0.3% to 4.5% of all wrong site surgery events, and wrong site surgery accounts for 4% to 6% of all medical errors in otolaryngology. A significant proportion (9% to 21%) of otolaryngologists reported experiences with wrong site surgery over their career, and the events most frequently resulted in temporary injuries to the patient with few cases of permanent disability or death. Although otolaryngology procedures have similar root causes for wrong site events as other specialties, inverted imaging and ambiguity in site marking are particular challenges. Site-marking practices are variable among otolaryngologists, as it is not applicable to many otolaryngology procedures, yet these are common procedures that also constitute the majority of wrong site cases reported in otolaryngology.

CONCLUSIONS

Future interventions to address these challenges related to otolaryngology-head and neck surgery might involve a standardized protocol to confirm imaging accuracy, a specialty- or procedure-specific checklist, a standardized alternative to site marking when marking is impractical, and other innovations. Evaluation of these interventions is becoming easier given the increasing mandatory reporting of these events that provides more reliable incidence data.

"Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention"

BACKGROUND

We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers.

METHODS

The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011.

RESULTS

Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year.

CONCLUSIONS

The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision.

Preventable errors in organ transplantation: an emerging patient safety issue?

Several widely publicized errors in transplantation including a death due to ABO incompatibility, two HIV transmissions and two hepatitis C virus (HCV) transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the OPTN/UNOS Disease Transmission Advisory Committee (DTAC) and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research is critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities.

Judging whether a patient is actually improving: more pitfalls from the science of human perception

Fallible human judgment may lead clinicians to make mistakes when assessing whether a patient is improving following treatment. This article provides a narrative review of selected studies in psychology that describe errors that potentially apply when a physician assesses a patient's response to treatment. Comprehension may be distorted by subjective preconceptions (lack of double blinding). Recall may fail through memory lapses (unwanted forgetfulness) and tacit assumptions (automatic imputation). Evaluations may be further compromised due to the effects of random chance (regression to the mean). Expression may be swayed by unjustified overconfidence following conformist groupthink (group polarization). An awareness of these five pitfalls may help clinicians avoid some errors in medical care when determining whether a patient is improving.

Medical errors - not only patients' problem

INTRODUCTION

Medical error is often a traumatic experience not only for patients but also for doctors. However, patients as victims get much more publicity than those responsible for actual errors. The authors of the study conducted research to learn about Polish doctors' opinions on and reactions to medical errors and how they affect their further professional activity and psychological status. The aim of this study was to evaluate the impact of involvement in medical errors of doctors of different specialties and different age.

MATERIAL AND METHODS

The research was conducted in a group of 100 doctors of different specialties. Respondents anonymously completed an experimental survey comprising 6 groups of multiple choice questions concerning such issues as awareness of the nature of medical error, legal liability of the perpetrator, consequences of medical error for further professional activity, the function of the Patients' Rights Representative and consequences of publishing the problem.

RESULTS

The results indicate many negative effects of medical errors on physicians, such as common fear of making an error (82%), increased caution (52%), disadvantageous security measures while performing one's duties (57%), worsening of doctor-patient relations (67%), loss of social trust (62%) and increased treatment costs (40%). Forty five percent of the surveyed doctors declared that patients need the Patients' Rights Representative and 39% claimed it does not affect their work.

CONCLUSIONS

Given the significant burden on physicians' health, well-being and performance associated with medical errors, health care institutions should take this into account and provide physicians with formal systems of support.

Estrogen receptor testing and 10-year mortality from breast cancer: A model for determining testing strategy

Background:

The use of adjuvant tamoxifen therapy in the treatment of estrogen receptor (ER) expressing breast carcinomas represents a major advance in personalized cancer treatment. Because there is no benefit (and indeed there is increased morbidity and mortality) associated with the use of tamoxifen therapy in ER-negative breast cancer, its use is restricted to women with ER expressing cancers. However, correctly classifying cancers as ER positive or negative has been challenging given the high reported false negative test rates for ER expression in surgical specimens. In this paper I model practice recommendations using published information from clinical trials to address the question of whether there is a false negative test rate above which it is more efficacious to forgo ER testing and instead treat all patients with tamoxifen regardless of ER test results.

Methods:

I used data from randomized clinical trials to model two different hypothetical treatment strategies: (1) the current strategy of treating only ER positive women with tamoxifen and (2) an alternative strategy where all women are treated with tamoxifen regardless of ER test results. The variables used in the model are literature-derived survival rates of the different combinations of ER positivity and treatment with tamoxifen, varying true ER positivity rates and varying false negative ER testing rates. The outcome variable was hypothetical 10-year survival.

Results:

The model predicted that there will be a range of true ER rates and false negative test rates above which it would be more efficacious to treat all women with breast cancer with tamoxifen and forgo ER testing. This situation occurred with high true positive ER rates and false negative ER test rates in the range of 20-30%.

Conclusions:

It is hoped that this model will provide an example of the potential importance of diagnostic error on clinical outcomes and furthermore will give an example of how the effect of that error could be modeled using real-world data from clinical trials.

Determining whether a patient is feeling better: pitfalls from the science of human perception

Human perception is fallible and may lead patients to be inaccurate when judging whether their symptoms are improving with treatment. This article provides a narrative review of studies in psychology that describe misconceptions related to a patient's comprehension, recall, evaluation and expression. The specific misconceptions include the power of suggestion (placebo effects), desire for peace-of-mind (cognitive dissonance reduction), inconsistent standards (loss aversion), a flawed sense of time (duration neglect), limited perception (measurement error), declining sensitivity (Weber's law), an eagerness to please (social desirability bias), and subtle affirmation (personal control). An awareness of specific pitfalls might help clinicians avoid some mistakes when providing follow-up and interpreting changes in patient symptoms.

Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety

CONTEXT

Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives.

METHODS

This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature.

FINDINGS

The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions.

CONCLUSIONS

This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation.

Novel Representation of Clinical Information in the ICU: Developing User Interfaces which Reduce Information Overload

The introduction of electronic medical records (EMR) and computerized physician order entry (CPOE) into the intensive care unit (ICU) is transforming the way health care providers currently work. The challenge facing developers of EMR's is to create products which add value to systems of health care delivery. As EMR's become more prevalent, the potential impact they have on the quality and safety, both negative and positive, will be amplified. In this paper we outline the key barriers to effective use of EMR and describe the methodology, using a worked example of the output. AWARE (Ambient Warning and Response Evaluation), is a physician led, electronic-environment enhancement program in an academic, tertiary care institution's ICU. The development process is focused on reducing information overload, improving efficiency and eliminating medical error in the ICU.

Disclosing medical errors to patients: it's not what you say, it's what they hear

BACKGROUND

There is consensus that patients should be told if they are injured by medical care. However, there is little information on how they react to different methods of disclosure.

OBJECTIVE

To determine if volunteers' reactions to videos of physicians disclosing adverse events are related to the physician apologizing and accepting responsibility.

DESIGN

Survey of viewers randomized to watch videos of disclosures of three adverse events (missed mammogram, chemotherapy overdose, delay in surgical therapy) with designed variations in extent of apology (full, non-specific, none) and acceptance of responsibility (full, none).

PARTICIPANTS

Adult volunteer sample from the general community in Baltimore.

MEASUREMENTS

Viewer evaluations of physicians in the videos using standardized scales.

RESULTS

Of 200 volunteers, 50% were <40 years, 25% were female, 80% were African American, and 50% had completed high school. For designed variations, scores were non-significantly higher for full apology/responsibility, and lower for no apology/no responsibility. Perceived apology or responsibility was related to significantly higher ratings (chi-square, 81% vs. 38% trusted; 56% vs. 27% would refer, p < 0.05), but inclination to sue was unchanged (43% vs. 47%). In logistic regression analyses adjusting for age, gender, race and education, perceived apology and perceived responsibility were independently related to higher ratings for all measures. Inclination to sue was reduced non-significantly.

CONCLUSIONS

Patients will probably respond more favorably to physicians who apologize and accept responsibility for medical errors than those who do not apologize or give ambiguous responses. Patient perceptions of what is said may be more important than what is actually said. Desire to sue may not be affected despite a full apology and acceptance of responsibility.

The nomenclature of safety and quality of care for patients with congenital cardiac disease: a report of the Society of Thoracic Surgeons Congenital Database Taskforce Subcommittee on Patient Safety

A large body of literature devoted to "patient safety" and error prevention exists and utilizes a nomenclature that can be applied specifically to the field of congenital cardiac disease and aid in the goals of increasing the safety of patients, decreasing medical error, minimizing mortality and morbidity, and evaluating quality of care. The purpose of this manuscript is to suggest and document a quality of health care taxonomy and the appropriate application of this nomenclature of "patient safety" to the specialty of congenital cardiac disease, with special emphasis on the following ten terms: morbidity, complication, medical error, adverse event, harm, near miss, iatrogenesis, iatrogenic complication, medical injury, and sentinel event. Each of these terms is commonly utilized in the medical literature without universal agreement on their meaning and relationship. It is our hope that the standardization of the definitions of these terms, as they are applied to the analysis of outcomes of the treatments applied to patients with congenital and paediatric cardiac disease, will facilitate improved methodologies to assess and improve quality of care in our profession.

Using risk management files to identify and address causative factors associated with adverse events in pediatrics

We report a retrospective analysis of 84 consecutive pediatrics-related internal review files opened by a medical center's risk managers between 1996 and 2001. The aims were to identify common causative factors associated with adverse events/adverse outcomes (AEs) in a Pediatrics Department, then suggest ways to improve care. The main outcome was identification of any patterns of factors that contributed to AEs so that interventions could be designed to address them. Cases were noted to have at least one apparent contributing problem; the most common were with communication (44% of cases), diagnosis and treatment (37%), medication errors (20%), and IV/Central line issues (17%). 45% of files involved a child with an underlying diagnosis putting her/him at high risk for an adverse outcome. All Pediatrics Departments face multiple challenges in assuring consistent quality care. The extent to which the data generalize to other institutions is unknown. However, the data suggest that systematic analysis of aggregated claims files may help identify and drive opportunities for improvement in care.

Role of medical students in preventing patient harm and enhancing patient safety

BACKGROUND

Substantial efforts are focused on the high prevalence of patient harm due to medical errors and the mechanisms to prevent them. The potential role of the medical student as a valuable member of the team in preventing patient harm has, however, often been overlooked.

METHODS

Four cases are presented from two US academic health centers in which medical students prevented or were in a position to prevent patient harm from occurring. The authors directly participated in each case.

RESULTS

The types of harm prevented included averting non-sterile conditions, missing medications, mitigating exposure to highly contagious patients, and respecting patients' "do not resuscitate" requests.

CONCLUSION

Medical students are often overlooked as valuable participants in ensuring patient safety. These cases show that medical students may be an untapped resource for medical error prevention. Medical students should be trained to recognize errors and to speak up when errors occur. Those supervising students should welcome and encourage students to actively communicate observed errors and near misses and should work to eliminate all intimidation by medical hierarchy that can prevent students from being safety advocates.

Sensemaking of patient safety risks and hazards

In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. True sensemaking in patient safety must use both retrospective and prospective approach to learning. Sensemaking is as an essential part of the design process leading to risk informed design. Sensemaking serves as a conceptual framework to bring together well established approaches to assessment of risk and hazards: (1) at the single event level using root cause analysis (RCA), (2) at the processes level using failure modes effects analysis (FMEA) and (3) at the system level using probabilistic risk assessment (PRA). The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards. Without ownership engendered by such conversations, the possibility of effective action to eliminate or minimize them is greatly reduced.

Disclosure of medical errors: what factors influence how patients respond?

BACKGROUND

Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited.

OBJECTIVE

This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors.

PARTICIPANTS

Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure.

DESIGN

Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome.

MEASURES

Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response.

RESULTS

Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact.

CONCLUSIONS

This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain.

Toward a theoretical approach to medical error reporting system research and design

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.