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McLaren JTT, Bhate TD, Taher AK, Chartier LB. Return visit audits, quality improvement infrastructure, and a culture of safety: a theoretical model and practical assessment tool. CAN J EMERG MED 2023; 25:649-652. [PMID: 37318705 PMCID: PMC10425292 DOI: 10.1007/s43678-023-00539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/28/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Jesse T. T. McLaren
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
- Toronto General Hospital, Toronto, ON Canada
| | - Tahara D. Bhate
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Ahmed K. Taher
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Lucas B. Chartier
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
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Hussain B, Kannikeswaran N, Mathew R, Arora R. Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes. Am J Emerg Med 2021; 52:174-178. [PMID: 34942426 DOI: 10.1016/j.ajem.2021.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED. METHODS We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major. RESULTS Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these. CONCLUSIONS APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.
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Affiliation(s)
- Batool Hussain
- Pediatric Emergency Medicine Fellow, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Nirupama Kannikeswaran
- Pediatrics and Emergency Medicine, Central Michigan University, Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Michigan, MI, United States of America.
| | - Reny Mathew
- Pediatric Resident, Children's Hospital of Michigan, MI, United States of America.
| | - Rajan Arora
- Pediatrics and Emergency Medicine, Central Michigan University, Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Michigan, MI, United States of America.
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Sawicki JG, Nystrom D, Purtell R, Good B, Chaulk D. Diagnostic error in the pediatric hospital: a narrative review. Hosp Pract (1995) 2021; 49:437-444. [PMID: 34743667 DOI: 10.1080/21548331.2021.2004040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Diagnostic error is a prevalent type of medical error that is associated with considerable patient harm and increased medical costs. The majority of literature guiding the current understanding of diagnostic error in the hospital setting is from adult studies. However, there is research to suggest this type of error is also prevalent in the pediatric specialty. OBJECTIVES The primary objective of this study was to define the current understanding of diagnostic error in the pediatric hospital through a structured literature review. METHODS We searched PubMed and identified studies focusing on three aspects of diagnostic error in pediatric hospitals: the incidence or prevalence, contributing factors, and related interventions. We used a tiered review, and a standardized electronic form to extract data from included articles. RESULTS Fifty-nine abstracts were screened and 23 full-text studies were included in the final review. Seventeen of the 23 studies focused on the incidence or prevalence, with only 3 studies investigating the utility of interventions. Most studies took place in an intensive care unit or emergency department with very few studies including only patients on the general wards. Overall, the prevalence of diagnostic error in pediatric hospitals varied greatly and depended on the measurement technique and specific hospital setting. Both healthcare system factors and individual cognitive factors were found to contribute to diagnostic error, with there being limited evidence to guide how best to mitigate the influence of these factors on the diagnostic process. CONCLUSION The general knowledge of diagnostic error in pediatric hospital settings is limited. Future work should incorporate structured frameworks to measure diagnostic errors and examine clinicians' diagnostic processes in real-time to help guide effective hospital-wide interventions.
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Affiliation(s)
- Jonathan G Sawicki
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel Nystrom
- Clinical Risk Management, Intermountain Healthcare, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Rebecca Purtell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Brian Good
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David Chaulk
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Chartier LB, Ovens H, Hayes E, Davis B, Calder L, Schull M, Dreyer J, Ostrow O. Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program. Ann Emerg Med 2020; 77:193-202. [PMID: 33199045 DOI: 10.1016/j.annemergmed.2020.09.449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/31/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.
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Affiliation(s)
- Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Howard Ovens
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Sinai Health System, Toronto, Ontario, Canada
| | - Emily Hayes
- Health Quality Ontario, Toronto, Ontario, Canada
| | | | - Lisa Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Schull
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada; ICES and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan Dreyer
- London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Olivia Ostrow
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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