Successful remediation of patient safety incidents: a tale of two medication errors

Disclosure of medical errors to patients by medical professionals: a protocol for a qualitative systematic review

INTRODUCTION

Although the disclosure of medical errors is an integral component of medical ethics, it remains inconsistent in practice worldwide. Despite various explanations of why healthcare professionals reveal their mistakes to patients, comprehensive comparisons and evaluations of this topic remain lacking. The objective of this review is to evaluate the experience of medical error disclosure among medical professionals who have been involved in such errors.

METHODS AND ANALYSIS

This work will focus on studies involving medical professionals from various countries who work in hospital settings and have obtained an understanding of and firsthand experience with medical error disclosure. This review will include qualitative studies. Studies published in databases such as PubMed, Embase, EBSCO, OVID, Web of Science, ScienceDirect, China National Knowledge Infrastructure, Wanfang Data and Cochrane Library from 1 January 2000 to 30 April 2024 will be searched as part of this research. Additionally, OpenGrey will be searched manually to obtain supplementary information. The search will be conducted starting in May 2024 and will include both Chinese-language and English-language literature. The systematic review will follow the Joanna Briggs Institute's (JBI) methodology for systematic reviews of qualitative evidence and use the JBI System for the Unified Management, Assessment and Review of Information online program. Study authenticity will be investigated via the Qualitative Research Authenticity Evaluation Tool provided by the JBI Evidence-Based Health Care Centre, and data extraction will be performed via the Qualitative Assessment and Review Instrument data extraction tool. The results will be integrated via a pooled integration methodology and evaluated in terms of reliability via the ConQual qualitative systematic evaluation evidence grading tool.

ETHICS AND DISSEMINATION

Ethical approval is not required for the study because the review will be based on pre-existing data available in the literature. The results of this systematic review will be submitted to peer-reviewed journals and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42024494360.

Long-Term Impacts Faced by Patients and Families After Harmful Healthcare Events

BACKGROUND

Patients and families report experiencing a multitude of harms from medical errors resulting in physical, emotional, and financial hardships. Little is known about the duration and nature of these harms and the type of support needed to promote patient and family healing after such events. We sought to describe the long-term impacts (LTIs) reported by patients and family members who experienced harmful medical events 5 or more years ago.

METHODS

We performed a content analysis on 32 interviews originally conducted with 72 patients or family members about their views of the factors contributing to their self-reported harmful event. Interviews selected occurred 5 or more years after the harmful event and were grouped by time since event, 5 to 9 years (22 interviews) or 10 or more years (10 interviews) for analysis. We analyzed these interviews targeting spontaneous references of ongoing impacts experienced by the participants.

RESULTS

Participants collectively described the following four LTIs: psychological, social/behavioral, physical, and financial. Most cited psychological impacts with half-reporting ongoing anger and vivid memories. More than half reported ongoing physical impacts and one-third experienced ongoing financial impacts. Long-term social and behavioral impacts such as alterations in lifestyle, self-identity, and healthcare seeking behaviors were the most highly reported.

CONCLUSIONS

These patients and families experienced many profound LTIs after their harmful medical event. For some, these impacts evolved into secondary harms ongoing 10 years and more after the event. Our results draw attention to the persistent impacts patients and families may experience long after harmful events and the need for future research to understand and support affected patients and families.

Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program

OBJECTIVE

To test if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories.

DATA SOURCE

Records of patients discharged with a principal diagnosis of chest pain from 44 nonfederal general hospitals in Cook County, Illinois, between January 2002 and December 2009.

STUDY DESIGN

Propensity-score matched discharges from the intervention and comparison hospitals before computing difference-in-differences estimates of quarterly growth rates.

DATA COLLECTION METHODS

We used discharge records submitted to a central statewide repository.

PRINCIPAL FINDINGS

Relative to the comparison hospitals and to pre-implementation trends, and consistent with reduced testing at presentation, the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.

CONCLUSIONS

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

The "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes

OBJECTIVE

To determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.

DATA SOURCES/STUDY SETTING

Administrative, safety, and risk management data from the University of Illinois Hospital and Health Sciences System, from 2002 to 2014.

STUDY DESIGN

Single health system, interrupted time series design. Using Mann-Whitney U tests and segmented regression models, we compared means and trends in incident reports, claims, event analyses, patient communication consults, legal fees, costs per claim, settlements, and self-insurance expenses before and after the implementation of the "Seven Pillars" communication and resolution intervention.

DATA COLLECTION METHODS

Queried databases maintained by Department of Safety and Risk Management and the Department of Administrative Services at UIH. Extracted data from risk module of the Midas incident reporting system.

PRINCIPAL FINDINGS

The intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs.

CONCLUSIONS

A communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.

Designing highly reliable adverse-event detection systems to predict subsequent claims

BACKGROUND

To respond proactively to patient safety events, many healthcare organizations have been enhancing and customizing their event reporting systems. Yet an indiscriminate expansion of the range and number of event reports may reduce, rather than raise, risk managers' ability to detect events that warrant a response. To avoid becoming overwhelmed by too many event reports that have little immediate operational value, risk managers therefore require a concurrent and complementary refinement of their data-processing capabilities.

OBJECTIVE

To examine the extent to which adverse event reports can predict subsequent claims.

DATA AND METHODS

The study sample included all adverse event reports and all records of closed claims that related to patient care episodes between July 1, 2006, and May 31, 2009, at a large hospital system in northern Virginia. After matching closed claims to event reports, we fitted multivariate predictive models to identify event report entries that predict future claims.

RESULTS

During the period under study, 20 151 event reports and 94 claims were filed across the health system. We were able to match 60 claims (63.8%) to at least 1 preceding event report, implying that only 0.3% of event reports preceded a subsequent matching claim. The superior prediction model identified 90% of eventual matched claims by retaining only 20% of all event reports.

CONCLUSION

Simple prediction algorithms can supplement expert judgment by screening for reports that are likely to result in a claim, thereby enabling risk managers to evaluate adverse event reports more expeditiously and to identify, and ultimately prevent, serious safety lapses more reliably.