Patient safety in ambulatory care

What's the harm? Results of an active surveillance adverse event reporting system for chiropractors and physiotherapists

This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017. Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T0] and 2-7 days post-treatment [T2]) and one completed by the provider immediately post-treatment [T1]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious. From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T0 and T1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care. From the patients visits with a complete T2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which: 7.9% were mild, 6.2% moderate, 3.7% severe, 1.5% serious, and 2.0% had missing severity rating. The most common symptoms reported with moderate or higher severity were discomfort/pain, stiffness, difficulty walking and headache. This study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.

Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children

Purpose of review

Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children.

Recent findings

Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship.

Summary

The principles of stewardship and parsimonious care can improve patient safety for children.

Patient Safety in Ambulatory Pediatrics

Purpose of Review

The majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.

Recent Findings

The majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.

Summary

There is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

Assessing Adverse Events After Chiropractic Care at a Chiropractic Teaching Clinic: An Active-Surveillance Pilot Study

OBJECTIVE

This study aimed to assess the feasibility of implementing an active-surveillance reporting system within a chiropractic teaching clinic and subsequently determining the frequency of adverse events (AEs) after treatment administered by chiropractic interns.

METHODS

Interns were invited to collect data from patients using 3 questionnaires that recorded patient symptom change: 2 completed by the patient (before and 7 days after treatment) and 1 completed by the intern (immediately after treatment). Worsened and new symptoms were considered AEs. Qualitative interviews were conducted with clinicians and interns to assess the feasibility of implementing the reporting system, with resulting data categorized under 4 domains: acceptability, implementation, practicality, and integration.

RESULTS

Of the 174 eligible interns, 80 (46.0%) collected data from 364 patient encounters, with 119 (32.7%) returning their posttreatment form. Of the 89 unique patients (mean age = 39.5 years; 58.4% female, 41.6% male), 40.1% presented with low back pain and 31.1% with neck pain. After treatment, 25 symptoms (8.9%) were identified as AEs, mostly reported by patients as worsening discomfort or pain. Data from qualitative interviews suggest that the AE reporting system was well accepted; however, proposed specific modifications include use of longitudinal electronic surveys.

CONCLUSION

Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research.

Desarrollo e implementación de un modelo de auditoría médica basado en el aseguramiento de la calidad y la supervisión participativa en Ecuador

Objetivos: Este estudio es una descripción del desarrollo de una estrategia de Auditoría Médica basada en el Aseguramiento de la Calidad de la prestación utilizando herramientas de supervisión participativa en un intento de generar cooperación entre el auditor y el auditado en servicios de salud del primer nivel de atención del Ministerio de Salud Pública de Ecuador. Métodos: Se desarrolló y se implementó una metodología la cual se probó en el terreno, basados en una descripción de los resultados (corte transversal). Resultados: Al inicio del proceso, las puntuaciones de pertinencia clínica, de manera global, no superaban el 45% y respecto al riesgo legal no superan el 65%. Progresivamente se observa un aumento de la puntuación, adicionalmente se obtuvieron resultados propios de la percepción de este proceso por parte de los auditados, teniendo resistencia en menos del 5% de los casos, quizás debido al carácter participativo del proceso. Conclusión: El proceso de auditoría Médica es indispensable para la identificación de problemas, pero también es necesario que sea un proceso activo con intervención y resolución de los mismos. Auditoría Médica identifica problemas ocultos para los tomadores de decisiones y disminuye la resistencia en la inclusión de estrategias de mejoramiento de la calidad.

Disclosure of Adverse Events in Pediatrics

Despite increasing attention to issues of patient safety, preventable adverse events (AEs) continue to occur, causing direct and consequential injuries to patients, families, and health care providers. Pediatricians generally agree that there is an ethical obligation to inform patients and families about preventable AEs and medical errors. Nonetheless, barriers, such as fear of liability, interfere with disclosure regarding preventable AEs. Changes to the legal system, improved communications skills, and carefully developed disclosure policies and programs can improve the quality and frequency of appropriate AE disclosure communications.

Enhancing Patient Safety in Pediatric Primary Care: Implementing a Patient Safety Curriculum

OBJECTIVE

We developed and implemented a patient safety (PS) curriculum targeted at clinicians and nonclinical office practice staff within a large primary care pediatric network.

METHODS

Curricular content was informed by medical literature, local PS experts, and malpractice claims data. Sessions were centered on illustrative closed malpractice cases or informed by identified safety events. Participants provided subjective responses to the postsession evaluations.

RESULTS

Invited participants from 12 practices included both clinical and nonclinical practice staff (up to 24 attendees per session). Participants reported that they were confident in their knowledge and skills. Several participants engaged in improvement projects that included active surveillance of high-risk patients, improvements in referral and test result management processes, and the distribution of patient educational materials.

CONCLUSIONS

We successfully developed and implemented a multifaceted PS curriculum for pediatric providers. Participants enjoyed the sessions and several engaged in new PS projects as a result of the program.

Patient Safety and Quality Improvement: Reducing Risk of Harm

Most medical errors and preventable adverse events represent failures of complex systems. Pediatric clinicians must ensure a safe environment for health-care delivery to children. To do so, they must recognize risk factors for errors and adverse events; ensure effective communication with patients, parents, and colleagues; heighten situation awareness; develop high-functioning, high-reliability teams; implement and employ technology carefully; and provide integrated, ongoing education to trainees.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension

BACKGROUND

Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans.

OBJECTIVE

To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence.

MAIN OUTCOME MEASURES

Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime.

RESULTS

Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57).

CONCLUSIONS

Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.