Assessing patient safety in the United States: challenges and opportunities

First, Do No Harm (Gone Wrong): Total-Scale Analysis of Medical Errors Scientific Literature

Objective: Medical errors represent a leading cause of patient morbidity and mortality. The aim of this study was to quantitatively analyze the existing scientific literature on medical errors in order to gain new insights in this important medical research area. Study Design: Web of Science database was used to identify relevant publications, and bibliometric analysis was performed to quantitatively analyze the identified articles for prevailing research themes, contributing journals, institutions, countries, authors, and citation performance. Results: In total, 12,415 publications concerning medical errors were identified and quantitatively analyzed. The overall ratio of original research articles to reviews was 8.1:1, and temporal subset analysis revealed that the share of original research articles has been increasing over time. The United States contributed to nearly half (46.4%) of the total publications, and 8 of the top 10 most productive institutions were from the United States, with the remaining 2 located in Canada and the United Kingdom. Prevailing (frequently mentioned) and highly impactful (frequently cited) themes were errors related to drugs/medications, applications related to medicinal information technology, errors related to critical/intensive care units, to children, and mental conditions associated with medical errors (burnout, depression). Conclusions: The high prevalence of medical errors revealed from the existing literature indicates the high importance of future work invested in preventive approaches. Digital health technology applications are perceived to be of great promise to counteract medical errors, and further effort should be focused to study their optimal implementation in all medical areas, with special emphasis on critical areas such as intensive care and pediatric units.

Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands

OBJECTIVE

To prevent wrong surgery, the WHO 'Safe Surgery Checklist' was introduced in 2008. The checklist comprises a time-out procedure (TOP): the final step before the start of the surgical procedure where the patient, surgical procedure and side/site are reviewed by the surgical team. The aim of this study is to evaluate the extent to which hospitals carry out the TOP before anaesthesia in the operating room, whether compliance has changed over time, and to determine factors that are associated with compliance.

DESIGN

Evaluation study involving observations.

SETTING

Operating rooms of 2 academic, 4 teaching and 12 general Dutch hospitals.

PARTICIPANTS

A random selection was made from all adult patients scheduled for elective surgery on the day of the observation, preferably involving different surgeons and different procedures.

RESULTS

Mean compliance with the TOP was 71.3%. Large differences between hospitals were observed. No linear trend was found in compliance during the study period. Compliance at general and teaching hospitals was higher than at academic hospitals. Compliance decreased with the age of the patient, general surgery showed lower compliance in comparison with other specialties and compliance was higher when the team was focused on the TOP.

CONCLUSIONS

Large differences in compliance with the TOP were observed between participating hospitals which can be attributed at least in part to the type of hospital, surgical specialty and patient characteristics. Hospitals do not comply consistently with national guidelines to prevent wrong surgery and further implementation as well as further research into non-compliance is needed.

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study)

OBJECTIVE

To assess if the Agency for Healthcare Research and Quality  patient safety indictors (PSIs) could be used for case findings in the International Classification of Disease 10th revision (ICD-10) hospital discharge abstract data.

DESIGN

We identified and randomly selected 490 patients with a foreign body left during a procedure (PSI 5-foreign body), selected infections (IV site) due to medical care (PSI 7-infection), postoperative pulmonary embolism (PE) or deep vein thrombosis (DVT; PSI 12-PE/DVT), postoperative sepsis (PSI 13-sepsis)and accidental puncture or laceration (PSI 15-laceration) among patients discharged from three adult acute care hospitals in Calgary, Canada in 2007 and 2008. Their charts were reviewed for determining the presence of PSIs and used as the reference standard, positive predictive value (PPV) statistics were calculated to determine the proportion of positives in the administrative data representing 'true positives'.

RESULTS

The PPV for PSI 5-foreign body was 62.5% (95% CI 35.4% to 84.8%), PSI 7-infection was 79.1% (67.4% to 88.1%), PSI 12-PE/DVT was 89.5% (66.9% to 98.7%), PSI 13-sepsis was 12.5% (1.6% to 38.4%) and PSI 15-laceration was 86.4% (75.0% to 94.0%) after excluding those who presented to the hospital with the condition.

CONCLUSIONS

Several PSIs had high PPV in the ICD administrative data and are thus powerful tools for true positive case finding. The tools could be used to identify potential cases from the large volume of admissions for verification through chart reviews. In contrast, their sensitivity has not been well characterised and users of PSIs should be cautious if using them for 'quality of care reporting' presenting the rate of PSIs because under-coded data would generate falsely low PSI rates.

A pilot study on record reviewing with a priori patient selection

OBJECTIVES

To investigate whether a priori selection of patient records using unexpectedly long length of stay (UL-LOS) leads to detection of more records with adverse events (AEs) compared to non-UL-LOS.

DESIGN

To investigate the opportunities of the UL-LOS, we looked for AEs in all records of patients with colorectal cancer. Within this group, we compared the number of AEs found in records of patients with a UL-LOS with the number found in records of patients who did not have a UL-LOS.

SETTING

Our study was done at a general hospital in The Netherlands. The hospital is medium sized with approximately 30 000 admissions on an annual basis. The hospital has two major locations in different cities where both primary and secondary care is provided.

PARTICIPANTS

The patient records of 191 patients with colorectal cancer were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of triggers and adverse events were the primary outcome measures.

RESULTS

In the records of patients with colorectal cancer who had a UL-LOS, 51% of the records contained one or more AEs compared with 9% in the reference group of non-UL-LOS patients. By reviewing only the UL-LOS group with at least one trigger, we found in 84% (43 out of 51) of these records at least one adverse event.

CONCLUSIONS

A priori selection of patient records using the UL-LOS indicator appears to be a powerful selection method which could be an effective way for healthcare professionals to identify opportunities to improve patient safety in their day-to-day work.

Safety outcomes in the United States: trends and challenges in measurement

OBJECTIVE

To prepare Agency for Healthcare Research and Quality (AHRQ) for monitoring the impact of its own patient safety initiative, by exploring available outcomes data, assessing usability of measures, and estimating national trends in patient outcomes.

DATA SOURCES

Annual summary data on incidence of Joint Commission Sentinel Events, MEDMARX medication error events, and MDS measures of falls and pressure ulcers in nursing home residents. HCUP National Inpatient Sample (NIS) administrative claims data.

METHODS

Description and assessment of published summary data on selected safety measures. Analysis of selected Patient Safety Indicators (PSIs) and Utah–Missouri adverse event measures using HCUP NIS claims data (1994–2003).

PRINCIPAL FINDINGS

Interpretation of safety outcome trends requires close attention to the characteristics of underlying data sources and measures. Encounter-based measures have been affected by changes in definitions and ICD-9 coding, as well as by changes in the structure of administrative datasets like HCUP NIS. Historical trends are mixed for the safety outcome measures reviewed, with some measures showing improvement, others deterioration, and still others remaining fairly stable.

CONCLUSIONS

Constructing national trends of safety outcomes is difficult because of limitations in available data sources and measures. Tracking growth in the adoption of safe practices could offer an important strategy for complementing existing safety measurement capabilities.

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality? Evidence from survey data

BACKGROUND

Although strongly favored by patients and ethically imperative for providers, the disclosure of medical errors to patients remains rare because providers fear that it will trigger lawsuits and jeopardize their reputation. To date little is known how patients might respond to their providers' disclosure of a medical error even when paired with an offer of remediation.

RESEARCH DESIGN

A representative sample of Illinois residents was surveyed in 2008 about their knowledge about medical errors, their confidence that their providers would disclose medical errors to them, and their propensity to sue and recommend providers that disclose medical errors and offer to remedy them. We report the response patterns to these questions. As robustness checks, we also estimate the covariate-adjusted distributions and test the associations among these dimensions of medical-error disclosure.

RESULTS

Of the 1018 respondents, 27% would sue and 38% would recommend the hospital after medical error disclosure with an accompanying offer of remediation. Compared with the least confident respondents, those who were more confident in their providers' commitment to disclose were not likely to sue but significantly and substantially more likely to recommend their provider.

CONCLUSIONS

Patients who are confident in their providers' commitment to disclose medical errors are not more litigious and far more forgiving than patients who have no faith in their providers' commitment to disclose.

CKD as an underrecognized threat to patient safety

Chronic kidney disease (CKD) is common, but underrecognized, in patients in the health care system, where improving patient safety is a high priority. Poor disease recognition and several other features of CKD make it a high-risk condition for adverse safety events. In this review, we discuss the unique attributes of CKD that make it a high-risk condition for patient safety mishaps. We point out that adverse safety events in this disease have the potential to contribute to disease progression; namely, accelerated loss of kidney function and increased incidence of end-stage renal disease. We also propose a framework in which to consider patient safety in CKD, highlighting the need for disease-specific safety indicators that reflect unsafe practices in the treatment of this disease. Finally, we discuss the hypothesis that increased recognition of CKD will reduce disease-specific safety events and in this way decrease the likelihood of adverse outcomes, including an accelerated rate of kidney function loss and increased incidence of end-stage renal disease.

Chronic kidney disease adversely influences patient safety

Reducing medical errors and improving patient safety have become a national priority. Patients with chronic kidney disease (CKD) may be at higher risk for adverse consequences of medical care, but few studies have evaluated this question. Here, data for patients hospitalized in the Veteran's Health Administration during 2004 to 2005 was analyzed to conduct a cross-sectional study of CKD and adverse safety events. Outcomes included 13 patient safety indicators (PSI) defined by the Agency for Healthcare Research and Quality and six experimental PSI relevant to CKD. The 71,666 (29%) hospitalized veterans with CKD had a higher risk for several PSI, even after case-mix adjustment. Among surgical hospitalizations, CKD was associated with increased risk for hip fracture, physiologic/metabolic derangements, and complications of anesthesia. Among all acute hospitalizations, the PSI with the highest risk in patients with CKD were infection as a result of medical care and death among those in diagnosis-related groups normally associated with low mortality. Furthermore, as preadmission estimated GFR decreased, a significant trend of increasing risk for all PSI was observed (P = 0.001). In conclusion, hospitalized patients with CKD are at increased risk for adverse safety events, measured by established PSI. Further investigation is needed to develop and test interventions to reduce this risk.

Impact of date stamping on patient safety measurement in patients undergoing CABG: experience with the AHRQ Patient Safety Indicators

Background

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) provide information on hospital risk-adjusted rates for potentially preventable adverse events. Although designed to work with routine administrative data, it is unknown whether the PSIs can accurately distinguish between complications and pre-existing conditions. The objective of this study is to examine whether the AHRQ PSIs accurately measure hospital complication rates, using the data with present-on-admission (POA) codes to distinguish between complications and pre-existing conditions

Methods

Retrospective cohort study of patients undergoing isolated CABG surgery in California conducted using the 1998–2000 California State Inpatient Database. We calculated the positive predictive value of selected AHRQ PSIs using information from the POA as the gold standard, and the intra-class correlation coefficient to assess the level of agreement between the hospital risk-adjusted PSI rates with and without the information contained in the POA modifier.

Results

The false positive error rate, defined as one minus the positive predictive value, was greater than or equal to 20% for four of the eight PSIs examined: decubitus ulcer, failure-to-rescue, postoperative physiologic and metabolic derangement, and postoperative pulmonary embolism or deep venous thrombosis. Pairwise comparison of the hospital risk-adjusted PSI rates, with and without POA information, demonstrated almost perfect agreement for five of the eight PSI's. For decubitus ulcer, failure-to-rescue, and postoperative pulmonary embolism or DVT, the intraclass-correlation coefficient ranged between 0.63 to 0.79.

Conclusion

For some of the AHRQ Patient Safety Indicators, there are significant differences in the risk-adjusted rates of adverse events depending on whether the POA indicator is used to distinguish between pre-existing conditions and complications. The use of the POA indicator will increase the accuracy of the AHRQ PSIs as measures of adverse outcomes.

Can patient safety be measured by surveys of patient experiences?

BACKGROUND

A study was conducted to test whether patient reports of medical errors via surveys could produce sufficiently accurate information to be used as a measure of patient safety.

METHODS

A survey mailed regularly by a large multispecialty medical group to recent patients to assess their satisfaction and error experiences was expanded to collect more details about the patient-perceived errors. Following an initial mailing to 3,109 patients and parents of child patients soon after they had office visits in June 2005, usable mailed or phone follow-up responses were obtained from 1,998 respondents (65.1% adjusted). Responses were reviewed through a two-stage process that included chart audits and implicit physician reviewer judgments. The analysis categorized the review results and compared patient-reported errors with satisfaction.

RESULTS

Of the 1,998 respondents, 219 (11.0%) reported 247 separate incidents, for a rate of 12.4 errors per 100 patients. After complete review, only 5 (2.0%) of these incidents were judged to be real clinician errors. Most appeared to represent misunderstandings or behavior/communication problems, but 15.4% lacked sufficient information to categorize. Women, Hispanics, and those aged 41-60 years were most likely to report errors. Those respondents making error reports were much more likely to report visit dissatisfaction than those not reporting them (odds ratio [OR] = 13.8, p < .001).

DISCUSSION

Although patient reports of perceived errors might be useful to improve the patient experience of care, they cannot be used to measure technical medical errors and patient safety reliably without added evaluation. This study's findings need to be replicated elsewhere before generalizing from one metropolitan region and a patient population that is about two-thirds members of one health plan.

Designing healthcare organizations to reduce medical errors and enhance patient safety

Medical errors and patient safety are urgent healthcare management challenges. To date, not enough has occurred to provide a systematic organizational design framework for reducing medical errors and improving patient safety. The authors offer such a framework by integrating multiple organizational factors and using well-accepted organization theory, citing relevant empirical research studies of medical errors and patient safety to support specific organizational factors. They discuss organizational design implications and recommendations for healthcare executives.

What do family physicians consider an error? A comparison of definitions and physician perception

Background

Physicians are being asked to report errors from primary care, but little is known about how they apply the term "error." This study qualitatively assesses the relationship between the variety of error definitions found in the medical literature and physicians' assessments of whether an error occurred in a series of clinical scenarios.

Methods

A systematic literature review and pilot survey results were analyzed qualitatively to search for insights into what may affect the use of the term error. The National Library of Medicine was systematically searched for medical error definitions. Survey participants were a random sample of active members of the American Academy of Family Physicians (AAFP) and a selected sample of family physician patient safety "experts." A survey consisting of 5 clinical scenarios with problems (wrong test performed, abnormal result not followed-up, abnormal result overlooked, blood tube broken and missing scan results) was sent by mail to AAFP members and by e-mail to the experts. Physicians were asked to judge if an error occurred. A qualitative analysis was performed via "immersion and crystallization" of emergent insights from the collected data.

Results

While one definition, that originated by James Reason, predominated the literature search, we found 25 different definitions for error in the medical literature. Surveys were returned by 28.5% of 1000 AAFP members and 92% of 25 experts. Of the 5 scenarios, 100% felt overlooking an abnormal result was an error. For other scenarios there was less agreement (experts and AAFP members, respectively agreeing an error occurred): 100 and 87% when the wrong test was performed, 96 and 87% when an abnormal test was not followed up, 74 and 62% when scan results were not available during a patient visit, and 57 and 47% when a blood tube was broken. Through qualitative analysis, we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility

Conclusion

There is a lack of consensus about what constitutes an error both in the medical literature and in decision making by family physicians. These potential areas of confusion need further study.

Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction?

OBJECTIVE

To assess the potential contribution of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to organizational learning for patient safety improvement.

PRINCIPAL FINDINGS

Patient safety improvement requires organizational learning at the system level, which entails changes in organizational routines that cut across divisions, professions, and levels of hierarchy. This learning depends on data that are varied along a number of dimensions, including structure-process-outcome and from granular to high-level; and it depends on integration of those varied data. PSIs are inexpensive, easy to use, less subject to bias than some other sources of patient safety data, and they provide reliable estimates of rates of preventable adverse events.

CONCLUSIONS

From an organizational learning perspective, PSIs have both limitations and potential contributions as sources of patient safety data. While they are not detailed or timely enough when used alone, their simplicity and reliability make them valuable as a higher-level safety performance measure. They offer one means for coordination and integration of patient safety data and activity within and across organizations.

Potentially Inappropriate Drug Use and Health-Related Quality of Life in the Elderly

STUDY OBJECTIVE

To investigate the relationship between two widely used, generic health-related quality of life (HRQOL) measures, Short Form-12 (SF-12) and EuroQol's EQ-5D, and potentially inappropriate drug use in an elderly cohort.

DESIGN

Longitudinal retrospective cohort study.

DATA SOURCE

Medical Expenditure Panel Survey, panel 5.

PARTICIPANTS

Respondents aged 65 years or older.

MEASUREMENTS AND MAIN RESULTS

Participants with potentially inappropriate drug use were identified by using National Drug Codes based on the Beers updated criteria. The dependent variable, HRQOL, was measured by using self-reported scores on the SF-12 (physical component summary, mental component summary, and global rating of health) and the EQ-5D (index and visual analog scale). The HRQOL data were regressed onto scores for potentially inappropriate drug, age, sex, number of prescriptions, race, comorbidity, and previous HRQOL. Regression analysis revealed statistically significant models for all five HRQOL equations (adjusted R2=26.50-53.83%, p<0.0001). However, potentially inappropriate drug use was not a significant predictor of HRQOL in any of the models tested. Previous HRQOL, as measured by using the SF-12 (global, physical component summary, and mental component summary) and the EQ-5D (index and visual analog scale), was a significant predictor of HRQOL; number of prescriptions was also a significant predictor of HRQOL, as measured by using the SF-12 (global and physical component summary) and the EQ-5D (index and visual analog scale).

CONCLUSION

The results supported others showing that a significant proportion of the elderly receive care that is potentially harmful and not supported by evidence-based practice. Use of a disease-specific HRQOL scale may be more responsive to measuring the impact of potentially inappropriate drugs on patients' HRQOL.