Getting moving on patient safety--harnessing electronic data for safer care

Use of Triggers to Detect Adverse Events After Outpatient Orthopedic Surgery at a Single Ambulatory Surgery Center

Literature on adverse events (AEs) after outpatient orthopedic surgery is relatively sparse, and efforts to detect, measure, and track AEs after outpatient surgery lag behind those for the inpatient setting. Detection of AEs has traditionally relied on patient safety indicators (from billing data) and self-reporting, but these methods have been shown to have low sensitivity, missing up to 90% of AEs. There is growing recognition that the trigger method, which uses "triggers" as red flags to initiate more detailed chart audits, can serve as a more sensitive alternative to detect AEs. Moreover, the recent widespread adoption of electronic health records (EHRs) can provide faster automated methods for identifying triggers and estimating AE rates. This study evaluates the ability of 6 separate EHR-based triggers to predict AEs after outpatient orthopedic surgery and compares this trigger method with AE self-reporting. Triggers have the potential to decrease postoperative morbidity after outpatient orthopedic surgery and may lead to quality improvement. Further research is needed to qualify triggers as screening tools in the outpatient setting. [Orthopedics. 2022;45(2):116-121.].

Harmonization of the ICHOM Quality Measures to Enable Health Outcomes Measurement in Multimorbid Patients

Objectives: To update the sets of patient-centric outcomes measures (“standard-sets”) developed by the not-for-profit organization ICHOM to become more readily applicable in patients with multimorbidity and to facilitate their implementation in health information systems. To that end we set out to (i) harmonize measures previously defined separately for different conditions, (ii) create clinical information models from the measures, and (iii) restructure the annotation to make the sets machine-readable.

Materials and Methods: First, we harmonized the semantic meaning of individual measures across all the 28 standard-sets published to date, in a harmonized measure repository. Second, measures corresponding to four conditions (Breast cancer, Cataracts, Inflammatory bowel disease and Heart failure) were expressed as logical models and mapped to reference terminologies in a pilot study.

Results: The harmonization of semantic meaning resulted in a consolidation of measures used across the standard-sets by 15%, from 3,178 to 2,712. These were all converted into a machine-readable format. 61% of the measures in the 4 pilot sets were bound to existing concepts in either SNOMED CT or LOINC.

Discussion: The harmonization of ICHOM measures across conditions is expected to increase the applicability of ICHOM standard-sets to multi-morbid patients, as well as facilitate their implementation in health information systems.

Conclusion: Harmonizing the ICHOM measures and making them machine-readable is expected to expedite the global adoption of systematic and interoperable outcomes measurement. In turn, we hope that the improved transparency on health outcomes that follows will let health systems across the globe learn from each other to the ultimate benefit of patients.

Limited external reproducibility restricts the use of medical record review for benchmarking

Background

Medical record review (MRR) is used to assess the quality and safety in hospitals. It is increasingly used to compare institutions. Therefore, the external reproducibility should be high. In the current study, we evaluated this external reproducibility for the assessment of an adverse event (AE) in a sample of records from two university medical centres in the Netherlands, using the same review method.

Methods

From both hospitals, 40 medical records were randomly chosen from patient files of deceased patients that had been evaluated in the preceding years by the internal review committees. After reviewing by the external committees, we assessed the overall and kappa agreement by comparing the results of both review rounds (once by the own internal committee and once by the external committee). This was calculated for the presence of an AE, preventability and contribution to death.

Results

Kappa for the presence of AEs was moderate (k=0.47). For preventability, the agreement was fair (k=0.39) and poor for contribution to death (k=−0.109).

Conclusion

We still believe that MRR is suitable for the detection of general issues concerning patient safety. However, based on the outcomes of this study, we would advise to be careful when using MRR for benchmarking.

Daily Electronic Health Record Reports Meet Meaningful Use Requirements, Improve Care Efficiency, and Provide a Layer of Safety for Trauma Patients

The electronic health record (EHR) is frequently viewed as a government-mandated charting system. As simply a replacement for the paper record, however, it was also frequently found to be inconvenient and a distraction to patient care. Broader use of the technology inherent in the EHR in the form of daily reports focused on key information that allows trauma clinical teams to efficiently monitor important information such as specific laboratory results or medications that might be missed or overlooked. In addition, other clinical personnel can monitor and assist in the care of trauma patients from remote locations such as an administrative office. Implementation of EHR reports is feasible, can be easily adopted by the clinical team, and has the potential to promote quality, safety, and efficiency. In addition, this innovation satisfies many of the requirements for meaningful use.

Challenges in patient safety improvement research in the era of electronic health records

Electronic health record (EHR) data repositories contain large volumes of aggregated, longitudinal clinical data that could allow patient safety researchers to identify important safety issues and conduct comprehensive evaluations of health care delivery outcomes. However, few health systems have successfully converted this abundance of data into useful information or knowledge for safety improvement. In this paper, we use a case study involving a project on missed/delayed follow-up of test results to discuss real-world challenges in using EHR data for patient safety research. We identify three types of challenges that pose as barriers to advance patient safety improvement research: 1) gaining approval to access/review EHR data; 2) interpreting EHR data; 3) working with local IT/EHR personnel. We discuss the complexity of these challenges, all of which are unlikely to be unique to this project, and outline some key next steps that must be taken to support research that uses EHR data to improve safety. We recognize that all organizations face competing priorities between clinical operations and research. However, to leverage EHRs and their abundant data for patient safety improvement research, many current data access and security policies and procedures must be rewritten and standardized across health care organizations. These efforts are essential to help make EHRs and EHR data useful for progress in our journey to safer health care.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings

Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.

Adverse events in healthcare: learning from mistakes

Large national reviews of patient charts estimate that approximately 10% of hospital admissions are associated with an adverse event (defined as an injury resulting in prolonged hospitalization, disability or death, caused by healthcare management). Apart from having a significant impact on patient morbidity and mortality, adverse events also result in increased healthcare costs due to longer hospital stays. Furthermore, a substantial proportion of adverse events are preventable. Through identifying the nature and rate of adverse events, initiatives to improve care can be developed. A variety of methods exist to gather adverse event data both retrospectively and prospectively but these do not necessarily capture the same events and there is variability in the definition of an adverse event. For example, hospital incident reporting collects only a very small fraction of the adverse events found in retrospective chart reviews. Until there are systematic methods to identify adverse events, progress in patient safety cannot be reliably measured. This review aims to discuss the need for a safety culture that can learn from adverse events, describe ways to measure adverse events, and comment on why current adverse event monitoring is unable to demonstrate trends in patient safety.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval

OBJECTIVE

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

STUDY SETTING

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

STUDY DESIGN

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

DATA COLLECTION

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

PRINCIPAL FINDINGS

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

CONCLUSIONS

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Resilient Practices in Maintaining Safety of Health Information Technologies

Electronic health record systems (EHRs) can improve safety and reliability of health care, but they can also introduce new vulnerabilities by failing to accommodate changes within a dynamic EHR-enabled health care system. Continuous assessment and improvement is thus essential for achieving resilience in EHR-enabled health care systems. Given the rapid adoption of EHRs by many organizations that are still early in their experiences with EHR safety, it is important to understand practices for maintaining resilience used by organizations with a track record of success in EHR use. We conducted interviews about safety practices with 56 key informants (including information technology managers, chief medical information officers, physicians, and patient safety officers) at two large health care systems recognized as leaders in EHR use. We identified 156 references to resilience-related practices from 41 informants. Framework analysis generated five categories of resilient practices: (a) sensitivity to dynamics and interdependencies affecting risks, (b) basic monitoring and responding practices, (c) management of practices and resources for monitoring and responding, (d) sensitivity to risks beyond the horizon, and (e) reflecting on risks with the safety and quality control process itself. The categories reflect three functions that facilitate resilience: reflection, transcending boundaries, and involving sharp-end practitioners in safety management.

Are doctors the structural weakness in the e-health building?

Progressive evaluations by the Organization for Economic Co-operation and Development (OECD) demonstrate that health care is now or becoming unaffordable. This means nations must change the way they manage health care. The costly nature of health care in most nations, as a percentage of Gross Domestic Product (GDP) seems independent of the national funding models. Increasing evidence is demonstrating that the lack of involvement by clinicians (doctors, nurses, pharmacists, ancillary care and patients) in e-health projects is a major factor for the costly failures of many of these projects. The essential change in focus required to improve healthcare delivery using e-health technologies has to be on clinical care. To achieve this change clinicians must be involved at all stages of e-health implementations. From a clinicians perspective medicine is not a business. Our business is clinical medicine and e-health must be focussed on clinical decision making. This paper views the roles of physicians in e-health structural reforms.

Approaches to recording drug allergies in electronic health records: qualitative study

BACKGROUND

Drug allergy represent an important subset of adverse drug reactions that is worthy of attention because many of these reactions are potentially preventable with use of computerised decision support systems. This is however dependent on the accurate and comprehensive recording of these reactions in the electronic health record. The objectives of this study were to understand approaches to the recording of drug allergies in electronic health record systems.

MATERIALS AND METHODS

We undertook a case study comprising of 21 in-depth interviews with a purposefully selected group of primary and secondary care clinicians, academics, and members of the informatics and drug regulatory communities, observations in four General Practices and an expert group discussion with 15 participants from the Allergy and Respiratory Expert Resource Group of the Royal College of General Practitioners.

RESULTS

There was widespread acceptance among healthcare professionals of the need for accurate recording of drug allergies and adverse drug reactions. Most drug reactions were however likely to go unreported to and/or unrecognised by healthcare professionals and, even when recognised and reported, not all reactions were accurately recorded. The process of recording these reactions was not standardised.

CONCLUSIONS

There is considerable variation in the way drug allergies are recorded in electronic health records. This limits the potential of computerised decision support systems to help alert clinicians to the risk of further reactions. Inaccurate recording of information may in some instances introduce new problems as patients are denied treatments that they are erroneously believed to be allergic to.

How to improve the performance of intraoperative risk models: an example with vital signs using the surgical apgar score

BACKGROUND

Computerized reviews of patient data promise to improve patient care through early and accurate identification of at-risk and well patients. The significance of sampling strategy for patient vital signs data is not known. In the instance of the surgical Apgar score (SAS), we hypothesized that larger sampling intervals would improve the specificity and overall predictive ability of this tool.

METHODS

We used electronic intraoperative data from general and vascular surgical patients in a single-institution registry of the American College of Surgeons National Surgical Quality Improvement Program. The SAS, consisting of lowest heart rate, lowest mean arterial blood pressure, and estimated blood loss between incision and skin closure, was calculated using 5 methods: instantaneously and using intervals of of 5 and 10 minutes with and without interval overlap. Major complications including death were assessed at 30 days postoperatively.

RESULTS

Among 3000 patients, 272 (9.1%) experienced major complications or death. As the sampling interval increased from instantaneous (shortest) to 10 minutes without overlap (largest), the sensitivity, positive predictive value, and negative predictive value did not change significantly, but significant improvements were noted for specificity (79.5% to 82.9% across methods, P for trend <0.001) and accuracy (76.0% to 79.3% across methods, P for trend <0.01). In multivariate modeling, the predictive utility of the SAS as measured by the c-statistic nearly increased from Δc = +0.012 (P = 0.038) to Δc = +0.021 (P < 0.002) between the shortest and largest sampling intervals, respectively. Compared with a preoperative risk model, the net reclassification improvement and integrated discrimination improvement for the shortest versus largest sampling intervals of the SAS were net reclassification improvement 0.01 (P = 0.8) vs 0.06 (P = 0.02), and for integrated discrimination improvement, they were 0.008 (P < 0.01) vs 0.015 (P < 0.001).

CONCLUSIONS

When vital signs data are recorded in compliance with American Society of Anesthesiologists' standards, the sampling strategy for vital signs significantly influences performance of the SAS. Computerized reviews of patient data are subject to the choice of sampling methods for vital signs and may have the potential to be optimized for safe, efficient patient care.

The global burden of unsafe medical care: analytic modelling of observational studies

OBJECTIVE

To contextualise the degree of harm that comes from unsafe medical care compared with individual health conditions using the global burden of disease (GBD), a metric to determine how much suffering is caused by individual diseases.

DESIGN

Analytic modelling of observational studies investigating unsafe medical care in countries' inpatient care settings, stratified by national income, to identify incidence of seven adverse events for GBD modelling. Observational studies were generated through a comprehensive search of over 16 000 articles written in English after 1976, of which over 4000 were appropriate for full text review.

RESULTS

The incidence, clinical outcomes, demographics and costs for each of the seven adverse events were collected from each publication when available. We used disability-adjusted life years (DALYs) lost as a standardised metric to measure morbidity and mortality due to specific adverse events. We estimate that there are 421 million hospitalisations in the world annually, and approximately 42.7 million adverse events. These adverse events result in 23 million DALYs lost per year. Approximately two-thirds of all adverse events, and the DALYs lost from them, occurred in low-income and middle-income countries.

CONCLUSIONS

This study provides early evidence that adverse events due to medical care represent a major source of morbidity and mortality globally. Though suffering related to the lack of access to care in many countries remains, these findings suggest the importance of critically evaluating the quality and safety of the care provided once a person accesses health services. While further refinements of the estimates are needed, these data should be a call to global health policymakers to make patient safety an international priority.

Electronic health record-based triggers to detect potential delays in cancer diagnosis

BACKGROUND

Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis.

METHODS

We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV).

RESULTS

The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.

CONCLUSIONS

EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

Why don't we know whether care is safe?

Reliable data are essential to ensuring that health care is delivered safely and appropriately. Yet the availability of reliable data on safety remains surprisingly poor, as does our knowledge of what it costs (and should cost) to generate such data. The authors suggest the following as priorities: (1) develop valid and reliable measures of the common causes of preventable deaths; (2) evaluate whether a global measure of safety is valid, feasible, and useful; (3) explore the incremental value of collecting data for each patient safety measure; (4) evaluate if/how patient safety reporting systems can be used to influence outcomes at all levels; (5) explore the value-and the unintended consequences-of creating a list of reportable events; (6) evaluate the infrastructure required to monitor patient safety; and (7) explore the validity and usefulness of measurements of patient safety climate.

Electronic health records and national patient-safety goals

Hospitals and clinics are adapting to new technologies and implementing electronic health records, but the efforts need to be aligned explicitly with goals for patient safety. EHRs bring the risks of both technical failures and inappropriate use, but they can also help to monitor and improve patient safety.

Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians

A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients.

National patient safety initiatives: Moving beyond what is necessary

Ilan and Donchin have compared Israel and Canada's experiences in setting a national patient safety agenda. We broaden this comparison to include the U.S. experience, and suggest that there are three additional key steps which will be important in any national patient safety agenda, and which Israel in particular should consider. These are 1) using health information technology (HIT) to directly improve patient safety, 2) dissemination and broad use of checklists, and 3) measuring patient safety over time at the national level. Especially because of its already substantial commitment to HIT and well-developed HIT sector, Israel has a major opportunity to move forward rapidly in this area and to achieve broad impact on the safety front.This is a commentary on http://www.ijhpr.org/content/1/1/19/

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.