Transparent and open discussion of errors does not increase malpractice risk in trauma patients

Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study

BACKGROUND

Morbidity and mortality conferences (MMCs) are quality improvement mechanisms during which adverse events are reviewed, often by physicians within a single discipline. There is a growing desire to include nonphysicians and physicians from other disciplines in team-based morbidity and mortality conferences (TBMMs). This mixed methods study investigates perioperative perspectives on MMCs generally and TBMMs specifically.

METHODS

A national survey of perioperative health care professionals, including surgeons, anesthesiologists, and nurses, was used to explore opinions about MMCs and TBMMs. Semistructured qualitative interviews and focus groups were conducted with health care professionals and leaders at a single study site. Quantitative data were compared using a Kruskal-Wallis test. Interview transcripts were inductively analyzed. Data were analyzed using a concurrent mixed methods approach, triangulating both sources of data.

RESULTS

Survey respondents (N = 1,466) were generally positive about both MMCs and TBMMs, agreeing that conferences were respectful, affected practice, and were educational. Nurses, compared to surgeons and anesthesiologists, were more likely to find conferences educational (p = 0.004) and were less comfortable speaking up in conferences (p < 0.001). Attendees who had more experience with TBMMs rated conferences as having significantly higher utility in achieving educational and safety goals. Qualitative data from 14 participants identified barriers and facilitators at the micro, meso, and macro level. Barriers include negative personal interactions, unsupportive leadership, and legal and regulatory issues. Facilitators include interpersonal relationships between professionals, buy-in from leadership, and external motivators.

CONCLUSION

Perceptions of TBMMs were overall positive, but significant barriers to implementation remain. Team members may be invited to the table, but more effort is needed to make the entire team feel included in the discussion and optimize the value of these conferences. Strategies for overcoming identified barriers remains an open area of research.

Assessing psychiatric risk with a focus on optimizing patient satisfaction with penile prosthesis placement-a narrative review

Background and Objective

Treatment for medication-refractory erectile dysfunction (ED) is based on a shared decision-making model. The gold standard treatment for medication refractory ED is penile prosthesis (PP) placement. Patient satisfaction rates with PP are high with adequate counseling and expectation-setting. However, as with any elective surgery, patient selection is key to minimizing complications and ultimately patient dissatisfaction. Psychological well-being is an important consideration in the preoperative evaluation and postoperative management of patients undergoing PP placement.

Methods

We performed a PubMed literature review to identify pertinent studies for this narrative review. Specifically, we sought describe preoperative evaluation including appropriate counseling and patient selection as well relevant intraoperative and postoperative factors for patients undergoing PP placement with a specific focus on optimizing preoperative psychiatric factors and treatment-related patient satisfaction to identify pertinent articles describing ways to optimize patient satisfaction with PP.

Key Content and Findings

A patient's psychological state can influence the degree of understanding of their condition, affect perception of their treatment team, and limit their ability to cope with complications. All patients should undergo a thorough medical history and physical examination to screen for psychiatric health disorders, substance abuse, and chronic pain conditions. Establishing patient expectations with regards to treatment-related outcomes during the preoperative consultation will ensure congruency between the patient and performing surgeon. Patients with a more significant psychiatric distress related to their underlying sexual dysfunction may require additional evaluation and counseling preoperatively.

Conclusions

PP placement is associated with high levels of overall satisfaction in appropriately screened patients. Specific considerations during preoperative counseling and careful patient selection, intraoperative decision making to avoid or anticipate possible complications, and postoperative cares are necessary to ensure the best result for an individual patient.

In their own words: Safety and quality perspectives from families of hospitalized children with medical complexity

BACKGROUND

Children with medical complexity (CMC) experience adverse events due to multiorgan impairment, frequent hospitalizations, subspecialty care, and dependence on multiple medications/equipment. Their families are well-versed in care and can help identify safety/quality gaps to inform improvements. Although previous studies have shown families identify important safety/quality gaps in hospitals, studies of inpatient safety/quality experience of CMC and their families are limited. To address this gap and identify otherwise unrecognized, family-prioritized areas for improving safety/quality of CMC, we conducted a secondary qualitative analysis of safety reporting surveys among families of CMC.

OBJECTIVE

Explore safety reports from families of hospitalized CMC to identify areas to improve safety/quality.

DESIGNS, SETTINGS AND PARTICIPANTS

We analyzed free-text responses from predischarge safety reporting surveys administered to families of CMC at a quaternary children's hospital from April 2018 to November 2020. Using a qualitative descriptive approach, we categorized responses into standard clinical categories. Three team members inductively generated an initial codebook to apply iteratively to responses. Reviewers coded responses collaboratively, resolved discrepancies through consensus, and generated themes.

MAIN OUTCOME AND MEASURES

Outcomes: family-reported areas of safety/quality improvement.

MEASURES

pre-discharge family surveys.

RESULTS

Two hundred and eight/two hundred and thirty-seven (88%) families completed surveys; 83 families offered 138 free-text safety responses about medications, feeds, cares, and other categories. Themes included unmet expectations of hospital care/environment, lack of consistency, provider-patient communication lapses, families' expertise about care, and the value of transparency.

CONCLUSION

To improve care of CMC and their families, hospitals can manage expectations about hospital limitations, improve consistency of care/communication, acknowledge family expertise, and recognize that family-observed quality concerns can have safety implications. Soliciting family input can help hospitals improve care in meaningful, otherwise unrecognized ways.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance

Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.

Objective

To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.

Design, Setting, and Participants

We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.

Main Outcomes and Measures

Error and AE rates.

Results

Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.

Conclusions and Relevance

Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Fatal surgical or procedure-related complications: a Finnish registry-based study

INTRODUCTION

In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010.

MATERIALS AND METHODS

In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry.

RESULTS

Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors.

CONCLUSION

Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

Malpractice risk: trauma care versus other surgical and medical specialties

BACKGROUND

Medical malpractice has been noted to play an important role in physicians' decisions to pursue or remain in certain presumed high-risk specialties such as trauma surgery, despite little evidence suggesting an elevated malpractice risk. The objective of this study was to compare the malpractice experience for trauma care and other medical and surgical specialties at an academic medical center.

METHODS

Information regarding all potentially compensable medical events (hereafter "events") and actual lawsuits that occurred between 2003 and 2006 at one academic medical institution, including the department or service primarily involved, the current medical-legal disposition of the event, and the actual or expected expenses was obtained. The number of patients admitted to each service and the time they spent in the hospital was also obtained, and the number of events per capita and length of stay was calculated.

RESULTS

Among the 13 medical and surgical specialties considered, there were 194 total events, 183,392 patients seen, and 757,880 days of hospitalization. The trauma service had the fewest events and lawsuits per 10,000 patient-days and ranked 10th (11th for lawsuits) on a per capita basis, and 9th in total estimated cost.

CONCLUSIONS

With the fewest events and lawsuits per patient days and a relatively low amount set aside for claims, trauma care has better claim experience than almost every other clinical service line. Although these results have some limitations, they refute the perception that trauma care is a higher medicolegal risk. This observation should not be cited as a disincentive for surgeons to provide trauma care.

Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace, older face

BACKGROUND

The epidemiology of trauma deaths in Europe is less than well investigated. Thus, our goal was to study the contemporary patterns of trauma deaths within a defined population with an exceptionally high trauma autopsy rate.

METHODS

This was a retrospective evaluation of 260 consecutive trauma autopsies for which we collected demographic, pre-hospital and in-hospital data. Patients were analyzed for injury severity by standard scoring systems (Abbreviated Injury Scale [AIS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]), and the Trauma and Injury Severity Scale [TRISS] methodology.

RESULTS

The fatal trauma incidence was 10.0 per 100,000 inhabitants (17.4 per 100,000 age-adjusted > or = 55 years). Blunt mechanism (87%), male gender (75%), and pre-hospital deaths (52%) predominated. Median ISS was 38 (range: 4-75). Younger patients (<55 years) who died in the hospital were more often hypotensive (SBP < 90 mmHg; p = 0.001), in respiratory distress (RR < 10/min, or > 29/min; p < 0.0001), and had deranged neurology on admission (Glasgow Coma Score [GCS] < or = 8; p < 0.0001), compared to those > or = 55 years. Causes of death were central nervous system (CNS) injuries (67%), exsanguination (25%), and multiorgan failure (8%). The temporal death distribution is model-dependent and can be visualized in unimodal, bimodal, or trimodal patterns. Age increased (r = 0.43) and ISS decreased (r = -0.52) with longer time from injury to death (p < 0.001). Mean age of the trauma patients who died increased by almost a decade during the study period (from mean 41.7 +/- 24.2 years to mean 50.5 +/- 25.4 years; p = 0.04). The pre-hospital:in-hospital death ratio shifted from 1.5 to 0.75 (p < 0.007).

CONCLUSIONS

While pre-hospital and early deaths still predominate, an increasing proportion succumb after arrival in hospital. Focus on injury prevention is imperative, particularly for brain injuries. Although hemorrhage and multiorgan failure deaths have decreased, they do still occur. Redirected attention and focus on the geriatric trauma population is mandated.