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Bell SK, Amat MJ, Anderson TS, Aronson MD, Benneyan JC, Fernandez L, Ricci DA, Salant T, Schiff GD, Shafiq U, Singer SJ, Sternberg SB, Zhang C, Phillips RS. Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study. J Am Med Inform Assoc 2024; 31:622-630. [PMID: 38164964 PMCID: PMC10873783 DOI: 10.1093/jamia/ocad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVES The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. MATERIALS AND METHODS Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. RESULTS Among 12 849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). DISCUSSION AND CONCLUSION Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Maelys J Amat
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Timothy S Anderson
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Mark D Aronson
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - James C Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA 02115, United States
| | - Leonor Fernandez
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Dru A Ricci
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
| | - Talya Salant
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
- Bowdoin Street Health Center, Dorchester, MA 02122, United States
| | - Gordon D Schiff
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Umber Shafiq
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Sara J Singer
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Scot B Sternberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Cancan Zhang
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Russell S Phillips
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
- Center for Primary Care, Harvard Medical School, Boston, MA 02115, United States
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Scott IA, Crock C, Twining M. Too much versus too little: looking for the "sweet spot" in optimal use of diagnostic investigations. Med J Aust 2024; 220:67-70. [PMID: 38146617 DOI: 10.5694/mja2.52193] [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: 05/21/2023] [Accepted: 10/23/2023] [Indexed: 12/27/2023]
Affiliation(s)
- Ian A Scott
- Centre for Health Services Research, University of Queensland, Brisbane, QLD
- Princess Alexandra Hospital, Brisbane, QLD
| | - Carmel Crock
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC
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Boyle JG, Walters MR, Jamieson S, Durning SJ. Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159. MEDICAL TEACHER 2023; 45:1323-1333. [PMID: 37043405 DOI: 10.1080/0142159x.2023.2190479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.
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Affiliation(s)
- James G Boyle
- Undergraduate Medical School, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Matthew R Walters
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Susan Jamieson
- Health Professions Education Programme, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Steven J Durning
- Center for Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Marzo-Castillejo M, Vela-Vallespín C, Mascort Roca J, Guiriguet Capdevila C, Codern-Bové N, Borras JM. [Health professionals' perspective about women's experiences during the diagnostic process of ovarian cancer in Catalonia: Qualitative study]. Aten Primaria 2023; 55:102619. [PMID: 37043975 PMCID: PMC10119712 DOI: 10.1016/j.aprim.2023.102619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE To identify missed opportunities in the diagnosis of ovarian cancer (OC) in the public health system of Catalonia, through the analysis of the perceptions of health professionals on the stories's experiences of OC patients. DESIGN Qualitative exploratory-descriptive study, with two focus groups. SETTING Primary Care, November 2017. PARTICIPANTS Thirty-four professionals based on theoretical sampling: 21 family doctors, 8 professionals from sexual and reproductive health centres and 5 hospital gynaecologists. METHODS Participants discussed the different diagnostic pathways for women with OC through the presentation of flowcharts which were developed with three storie's and experiences of OC patients. RESULTS Three themes with various sub-themes were identified as follow: a)lack of cancer diagnostic suspicion (lack of knowledge of symptoms of OC, anamnesis and physical examination overlooked, fragmentation of patient's care and bias and prejudice); b)difficulties in activating the diagnostic process (limited access to tests, unequal accessibility to gynaecology and lack of follow-up); and c)absence of fast-track referral system. CONCLUSIONS The results offer insight into the difficulties of early diagnosis of OC in our setting. We believe that their identification will allow the development of strategies to improve diagnostic accuracy and quality of care for women with OC in our setting.
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Affiliation(s)
- Mercè Marzo-Castillejo
- Unitat Suport a la Recerca Metropolitana Sud, Institut Català de la Salut (ICS); Institut d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Hospitalet de Llobregat, Barcelona, España.
| | - Carmen Vela-Vallespín
- CAP Riu Nord i Riu Sud, Institut Català de la Salut (ICS), Santa Coloma de Gramenet, Barcelona; Unitat Suport a la Recerca Metropolitana Nord, Institut d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Mataró, Barcelona, España
| | - Juanjo Mascort Roca
- CAP Florida Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona; Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, España
| | - Carolina Guiriguet Capdevila
- Sistema d'Informació dels Serveis d'Atenció Primària (SISAP), Institut Català de la Salut (ICS), Universitat de Barcelona, Barcelona, España
| | - Núria Codern-Bové
- Escola Universitària d'Infermeria i Teràpia Ocupacional de Terrassa, Terrassa, Barcelona; Universitat Autònoma Barcelona. ÀreaQ (Evaluation and Qualitative Research), Barcelona, España
| | - Josep M Borras
- Departamento de Ciencias Clínicas, Universidad de Barcelona; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
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Savoy A, Patel H, Murphy DR, Meyer AND, Herout J, Singh H. Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review. HUMAN FACTORS 2023; 65:237-259. [PMID: 34033500 PMCID: PMC9969495 DOI: 10.1177/00187208211014300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making. METHOD We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers. RESULTS From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload. CONCLUSION Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.
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Affiliation(s)
- April Savoy
- Indiana University-Purdue University Indianapolis, USA
- Richard L. Roudebush Veterans Affairs Medical Center,
Indianapolis, Indiana, USA
- Regenstrief Institute, Inc.,
Indianapolis, Indiana, USA
| | - Himalaya Patel
- Richard L. Roudebush Veterans Affairs Medical Center,
Indianapolis, Indiana, USA
| | - Daniel R. Murphy
- Michael E. DeBakey Veterans Affairs Medical Center, Houston,
Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ashley N. D. Meyer
- Michael E. DeBakey Veterans Affairs Medical Center, Houston,
Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Herout
- Veterans Health Administration, Office of Health Informatics,
Washington, DC, USA
| | - Hardeep Singh
- Michael E. DeBakey Veterans Affairs Medical Center, Houston,
Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
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Hardy V, Usher-Smith J, Archer S, Barnes R, Lancaster J, Johnson M, Thompson M, Emery J, Singh H, Walter FM. Agreement between patient's description of abdominal symptoms of possible upper gastrointestinal cancer and general practitioner consultation notes: a qualitative analysis of video-recorded UK primary care consultation data. BMJ Open 2023; 13:e058766. [PMID: 36604136 PMCID: PMC9827246 DOI: 10.1136/bmjopen-2021-058766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Abdominal symptoms are common in primary care but infrequently might be due to an upper gastrointestinal (UGI) cancer. Patients' descriptions may differ from medical terminology used by general practitioners (GPs). This may affect how information about abdominal symptoms possibly due to an UGI cancer are documented, creating potential missed opportunities for timely investigation. OBJECTIVES To explore how abdominal symptoms are communicated during primary care consultations, and identify characteristics of patients' descriptions that underpin variation in the accuracy and completeness with which they are documented in medical records. METHODS AND ANALYSIS Primary care consultation video recordings, transcripts and medical records from an existing dataset were screened for adults reporting abdominal symptoms. We conducted a qualitative content analysis to capture alignments (medical record entries matching patient verbal and non-verbal descriptions) and misalignments (symptom information omitted or differing from patient descriptions). Categories were informed by the Calgary-Cambridge guide's 'gathering information' domains and patterns in descriptions explored. RESULTS Our sample included 28 consultations (28 patients with 18 GPs): 10 categories of different clinical features of abdominal symptoms were discussed. The information GPs documented about these features commonly did not match what patients described, with misalignments more common than alignments (67 vs 43 instances, respectively). Misalignments often featured patients using vague descriptors, figurative speech, lengthy explanations and broad hand gestures. Alignments were characterised by patients using well-defined terms, succinct descriptions and precise gestures for symptoms with an exact location. Abdominal sensations reported as 'pain' were almost always documented compared with expressions of 'discomfort'. CONCLUSIONS Abdominal symptoms that are well defined or communicated as 'pain' may be more salient to GPs than those expressed vaguely or as 'discomfort'. Variable documentation of abdominal symptoms in medical records may have implications for the development of clinical decision support systems and decisions to investigate possible UGI cancer.
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Affiliation(s)
- Victoria Hardy
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rebecca Barnes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - John Lancaster
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Margaret Johnson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Jon Emery
- Centre for Cancer Research and General Practice and Primary Care Academic Centre, University of Melbourne Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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7
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Dixit RA, Boxley CL, Samuel S, Mohan V, Ratwani RM, Gold JA. Electronic Health Record Use Issues and Diagnostic Error: A Scoping Review and Framework. J Patient Saf 2023; 19:e25-e30. [PMID: 36538341 PMCID: PMC9983735 DOI: 10.1097/pts.0000000000001081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown. METHODS We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process. RESULTS We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process. DISCUSSION Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm. CONCLUSIONS The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.
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Affiliation(s)
- Ram A. Dixit
- National Center for Human Factors in Healthcare, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
| | - Christian L. Boxley
- National Center for Human Factors in Healthcare, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
| | - Sunil Samuel
- Oregon Health Sciences University, Department of Medical Informatics and Clinical Epidemiology, Portland, OR
| | - Vishnu Mohan
- Oregon Health Sciences University, Department of Medical Informatics and Clinical Epidemiology, Portland, OR
| | - Raj M. Ratwani
- National Center for Human Factors in Healthcare, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
- Georgetown University School of Medicine, Department of Emergency Medicine, Washington, DC
| | - Jeffrey A. Gold
- Oregon Health Sciences University, Department of Medicine, Portland, OR
- Oregon Health Sciences University, Department of Medical Informatics and Clinical Epidemiology, Portland, OR
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Yuan CT, Dy SM, Lai AY, Oberlander T, Hannum SM, Lasser EC, Heughan JA, Dukhanin V, Kharrazi H, Kim JM, Gurses AP, Bittle M, Scholle SH, Marsteller JA. Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study. Am J Med Qual 2022; 37:379-387. [PMID: 35404306 PMCID: PMC9700196 DOI: 10.1097/jmq.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.
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Affiliation(s)
- Christina T. Yuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | | | | | - Susan M. Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
| | - Elyse C. Lasser
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health
| | - JaAlah-Ai Heughan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Vadim Dukhanin
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | - Hadi Kharrazi
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
- Johns Hopkins Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health
| | - Julia M. Kim
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
- Department of Pediatrics, Johns Hopkins School of Medicine
| | - Ayse P. Gurses
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
| | - Mark Bittle
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
| | | | - Jill A. Marsteller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine
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Hunter J, Porter M, Cody P, Williams B. Can a targeted educational approach improve situational awareness in paramedicine during 911 emergency calls? Int Emerg Nurs 2022; 63:101174. [PMID: 35594762 DOI: 10.1016/j.ienj.2022.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/23/2022] [Accepted: 04/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paramedics must be situationally aware in order to avoid human error and protect themselves, their partner, their patient, and the public. Previous research has suggested that paramedics lack situational awareness (SA), possibly due to a lack of an organized approach, distraction, and a poor understanding of SA. There is no educational approach provided to paramedics that is known to improve their levels of SA. If such an approach were provided, it could possibly reduce human error and lead to improved outcomes. OBJECTIVE The aim of this study is to determine whether providing paramedics with a targeted educational approach, including aspects from crew resource management (CRM) such as sterile cockpit and Endsley's model for SA, can improve overall SA during emergency calls. METHODS A prospective, quasi-experimental before-and-after study was used, in which out-of hospital paramedics were observed during 911 emergency calls. Baseline SA was measured using the situational awareness global assessment technique (SAGAT). Paramedics were then given a targeted educational lesson focusing on elements of SA and CRM as well as a novel quick reference tool to utilize during 911 calls. Post intervention SA was then measured again, and before-and-after results were compared for difference of mean scores. RESULTS The overall baseline SA was 62% increasing to 86% following the educational intervention. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between mean SA performance in the same group of paramedics before and after the intervention. The increase in SA was found to be statistically significant where p = 0.011. CONCLUSIONS A targeted educational approach focusing on CRM and a novel quick reference tool may increase SA levels of paramedics during 911 emergency calls. Further studies are needed with bigger cohorts. Paramedicine educational institutions and out-of-hospital agencies should consider implementing this targeted approach with their students and currently practicing providers.
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Affiliation(s)
- Justin Hunter
- Department of Paramedicine, Monash University, Australia; Oklahoma State University - Oklahoma City, Paramedicine Program, USA; Norman Regional Hospital - EMSStat, USA; EMS Success, Inc, USA.
| | - Michael Porter
- Department of Paramedicine, Monash University, Australia; Norman Regional Hospital - EMSStat, USA; Oklahoma State University Center for Health Sciences, Emergency Medicine Residency Program, USA; EMS Success, Inc, USA
| | - Patrick Cody
- Oklahoma State University - Oklahoma City, Paramedicine Program, USA; Norman Regional Hospital - EMSStat, USA; Oklahoma State University Center for Health Sciences, Emergency Medicine Residency Program, USA.
| | - Brett Williams
- Department of Paramedicine, Monash University, Australia.
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10
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Lewis K, O V, Garber AM, Sweet M, Novoa-Takara K, McConville J, Readlynn JK, Alweis R. AAIM Recommendations to Improve Learner Transitions. Am J Med 2022; 135:536-542. [PMID: 35038408 DOI: 10.1016/j.amjmed.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Kristen Lewis
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Valerie O
- Alliance for Academic Internal Medicine, Alexandria, Virginia
| | - Adam M Garber
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Michelle Sweet
- Rush Medical College of Rush University, Chicago, Illinois
| | | | | | - Jennifer K Readlynn
- University of Rochester School of Medicine and Dentistry,Rochester, New York
| | - Richard Alweis
- Rochester Regional Health, Lake Eric College of Osteopathic Medicine, Rochester, New York.
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Svelato A, Carabaneanu A, Sergiampietri C, Mannella P, D'Avino S, De Luca C, Bartolone M, Angioli R, Ragusa A. "To get the baby out off the hook": a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery. BMC Pregnancy Childbirth 2022; 22:128. [PMID: 35172781 PMCID: PMC8848824 DOI: 10.1186/s12884-022-04440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 01/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure. This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled. Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure. Results Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable. Conclusion Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation. Tweetable abstract Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.
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Affiliation(s)
- Alessandro Svelato
- Department of Obstetrics and Gynecology, San Giovanni Calibita Fatebenefratelli Hospital, Isola Tiberina, Via di Ponte Quattro capi, 39, 00186, Rome, Italy.
| | - Alis Carabaneanu
- Department of Obstetrics and Gynecology, Prato General Hospital, Prato, Italy
| | | | - Paolo Mannella
- Department of Reproductive Medicine and Child Development, University of Pisa, Pisa, Italy
| | - Sara D'Avino
- Department of Obstetrics and Gynecology, San Giovanni Calibita Fatebenefratelli Hospital, Isola Tiberina, Via di Ponte Quattro capi, 39, 00186, Rome, Italy
| | - Caterina De Luca
- Department of Obstetrics and Gynecology, San Giovanni Calibita Fatebenefratelli Hospital, Isola Tiberina, Via di Ponte Quattro capi, 39, 00186, Rome, Italy
| | - Martina Bartolone
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Roberto Angioli
- Department of Gynecology, University Campus Biomedico, Rome, Italy
| | - Antonio Ragusa
- Department of Obstetrics and Gynecology, San Giovanni Calibita Fatebenefratelli Hospital, Isola Tiberina, Via di Ponte Quattro capi, 39, 00186, Rome, Italy
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Schiff GD, Volodarskaya M, Ruan E, Lim A, Wright A, Singh H, Reyes Nieva H. Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study. JAMA Netw Open 2022; 5:e2144531. [PMID: 35061037 PMCID: PMC8783262 DOI: 10.1001/jamanetworkopen.2021.44531] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Progress in understanding and preventing diagnostic errors has been modest. New approaches are needed to help clinicians anticipate and prevent such errors. Delineating recurring diagnostic pitfalls holds potential for conceptual and practical ways for improvement. OBJECTIVES To develop the construct and collect examples of "diagnostic pitfalls," defined as clinical situations and scenarios vulnerable to errors that may lead to missed, delayed, or wrong diagnoses. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used data from January 1, 2004, to December 31, 2016, from retrospective analysis of diagnosis-related patient safety incident reports, closed malpractice claims, and ambulatory morbidity and mortality conferences, as well as specialty focus groups. Data analyses were conducted between January 1, 2017, and December 31, 2019. MAIN OUTCOMES AND MEASURES From each data source, potential diagnostic error cases were identified, and the following information was extracted: erroneous and correct diagnoses, presenting signs and symptoms, and areas of breakdowns in the diagnostic process (using Diagnosis Error Evaluation and Research and Reliable Diagnosis Challenges taxonomies). From this compilation, examples were collected of disease-specific pitfalls; this list was used to conduct a qualitative analysis of emerging themes to derive a generic taxonomy of diagnostic pitfalls. RESULTS A total of 836 relevant cases were identified among 4325 patient safety incident reports, 403 closed malpractice claims, 24 ambulatory morbidity and mortality conferences, and 355 focus groups responses. From these, 661 disease-specific diagnostic pitfalls were identified. A qualitative review of these disease-specific pitfalls identified 21 generic diagnostic pitfalls categories, which included mistaking one disease for another disease (eg, aortic dissection is misdiagnosed as acute myocardial infarction), failure to appreciate test result limitations, and atypical disease presentations. CONCLUSIONS AND RELEVANCE Recurring types of pitfalls were identified and collected from diagnostic error cases. Clinicians could benefit from knowledge of both disease-specific and generic cross-cutting pitfalls. Study findings can potentially inform educational and quality improvement efforts to anticipate and prevent future errors.
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Affiliation(s)
- Gordon D. Schiff
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts
| | - Mayya Volodarskaya
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Elise Ruan
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Andrea Lim
- Department of Internal Medicine, Kaiser Permanente, San Francisco, California
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Biomedical Informatics, Columbia University, New York, New York
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13
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Murphy RE, Ibekwe JC, Ibekwe SI, Refuerzo JS. A Structural, Cognitive, and Behavioral Model for Error Analysis of Group B Streptococcus Prophylaxis in Pregnancy. AJP Rep 2022; 12:e17-e26. [PMID: 35141031 PMCID: PMC8816629 DOI: 10.1055/s-0041-1742235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to develop a structural-cognitive-behavioral model for error analysis of group B streptococcus (GBS) prophylaxis failure, classify delivery cases into this model, and examine compliance with treatment guidelines. A retrospective, cohort study was conducted of women with liveborn pregnancies greater than 24 weeks in April 2018 at a single hospital. We created a structural-cognitive-behavioral model of five assessments for adherence to GBS prophylaxis guidelines and then classified these into four distinct error stages. A descriptive analysis was performed to determine if the pregnancy had a perfect process, a GBS prophylaxis failure, or a fortuitous outcome. There were 313 women who met the study criteria. The rate of GBS positive was 12.8%, negative 37.4%, and unknown 49.8%. The most common errors were cognitive perception errors related to incorrectly documenting GBS status, 57.7% ( N = 79). Of these errors, 15.2% ( N = 12) led to GBS prophylaxis failure. Perfect outcomes occurred in 62.7% ( N = 196) women, GBS prophylaxis failure occurred in 13.7% ( N = 43), and fortuitous outcomes occurred in 23.6% ( N = 74). In our study, we were able to identify structural, cognitive, and behavioral errors that contribute to GBS prophylaxis failures. In other cases, these errors may contribute to fortuitous outcomes.
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Affiliation(s)
- Robert E Murphy
- School of Biomedical Informatics, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Jane C Ibekwe
- School of Biomedical Informatics, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Stella I Ibekwe
- School of Biomedical Informatics, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Jerrie S Refuerzo
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health-McGovern Medical School, Houston, Texas
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14
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Savoy A, Saleem JJ, Barker BC, Patel H, Kara A. Mobile technology for hospitalists: Clinician perspectives and unmet needs from a workflow analysis. JMIR Hum Factors 2021; 9:e28783. [PMID: 34643530 PMCID: PMC8767475 DOI: 10.2196/28783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/01/2021] [Accepted: 10/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background The hospitalist workday is cognitively demanding and dominated by activities away from patients’ bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. Objective The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists’ workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists’ perspectives on mobile technology and apps. Methods We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. Results Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. Conclusions Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists’ workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists’ memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.
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Affiliation(s)
- April Savoy
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US.,Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indianapolis, US.,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, US
| | - Jason J Saleem
- Department of Industrial Engineering, J.B. Speed School of Engineering, University of Louisville, Louisville, US
| | - Barry C Barker
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Himalaya Patel
- Center for Health Information and Communication, Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, US
| | - Areeba Kara
- Indiana University Health Physicians, Indianapolis, US.,Indiana University School of Medicine, Indianapolis, US
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15
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Read AJ, Waljee AK, Sussman JB, Singh H, Chen GY, Vijan S, Saini SD. Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians. JAMA Netw Open 2021; 4:e2127827. [PMID: 34596670 PMCID: PMC8486982 DOI: 10.1001/jamanetworkopen.2021.27827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. OBJECTIVE To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. DESIGN, SETTING, AND PARTICIPANTS This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. MAIN OUTCOMES AND MEASURES Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. RESULTS Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. CONCLUSIONS AND RELEVANCE In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.
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Affiliation(s)
- Andrew J. Read
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Jeremy B. Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Grace Y. Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sandeep Vijan
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Health Services Research and Development, Center for Clinical Management Research, Ann Arbor, Michigan
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16
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Studying Institutional Situational Awareness Through Anonymous Incident Reporting. Qual Manag Health Care 2021; 29:164-168. [PMID: 32590492 DOI: 10.1097/qmh.0000000000000257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries. We present a straightforward method using statistical process control to study the progression and efficacy of AIR. METHODS This study represents a retrospective review of all anonymous incident reports and surgical critical events from 2012 to 2017 at a single-institution, 500-bed, university-based, metropolitan Veterans Affairs Administration Medical Center located in Texas. This work was approved by the Veterans Administration Quality Board and deemed to be an appropriate quality improvement project. This project did not require institutional review board approval. RESULTS There was an exponential increase in AIRs in the first 15 months from 1 report per month to 168 reports in the ninth month (1425% increase). The results then plateaued over time (first year: 1017, second year: 1634, and third year: 1938-common-cause variation). A logarithmic regression was performed for progression of AIRs per month yielding the equation y = -7E-13ln(x) + 142.92, Pearson Correlation Coefficient = 0.55, where y represents number of reports and x time by month. The highest number of Critical Incident Tracking Notification System (CITNS) reports was observed early in the self-reporting process and decreased over time (first year: 5, second year: 2, third year: 1, fourth year: 1, and fifth year: 0). The numbers of AIR and CITNS reports were found to be inversely related with a Pearson correlation coefficient of -0.4. CONCLUSIONS Statistical process control can be applied to an institution's AIR program to study progression and situational awareness.
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Pollack AH, Mishra SR, Apodaca C, Khelifi M, Haldar S, Pratt W. Different roles with different goals: Designing to support shared situational awareness between patients and clinicians in the hospital. J Am Med Inform Assoc 2021; 28:222-231. [PMID: 33150394 PMCID: PMC7883969 DOI: 10.1093/jamia/ocaa198] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Team situational awareness helps to ensure high-quality care and prevent errors in the complex hospital environment. Although extensive work has examined factors that contribute to breakdowns in situational awareness among clinicians, patients’ and caregivers’ roles have been neglected. To address this gap, we studied team-based situational awareness from the perspective of patients and their caregivers. Materials and Methods We utilized a mixed-methods approach, including card sorting and semi-structured interviews with hospitalized patients and their caregivers at a pediatric hospital and an adult hospital. We analyzed the results utilizing the situational awareness (SA) theoretical framework, which identifies 3 distinct stages: (1) perception of a signal, (2) comprehension of what the signal means, and (3) projection of what will happen as a result of the signal. Results A total of 28 patients and 19 caregivers across the 2 sites participated in the study. Our analysis uncovered how team SA helps patients and caregivers ensure that their values are heard, their autonomy is supported, and their clinical outcomes are the best possible. In addition, our participants described both barriers—such as challenges with communication—and enablers to facilitating shared SA in the hospital. Discussion Patients and caregivers possess critical knowledge, expertise, and values required to ensure successful and accurate team SA. Therefore, hospitals need to incorporate tools that facilitate patients and caregivers as key team members for effective SA. Conclusions Elevating patients and caregivers from passive recipients to equal contributors and members of the healthcare team will improve SA and ensure the best possible outcomes.
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Affiliation(s)
- Ari H Pollack
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Sonali R Mishra
- Information School, University of Washington, Seattle, Washington, USA
| | - Calvin Apodaca
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Maher Khelifi
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Shefali Haldar
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Wanda Pratt
- Information School, University of Washington, Seattle, Washington, USA
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18
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Kowalski L, Krusen NE. Lung Cancer Screening Policy in Alaska and Occupational Therapy. Am J Occup Ther 2021; 75:12496. [PMID: 34781340 DOI: 10.5014/ajot.2021.048231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lung cancer claims more lives than any other cancer in the world and remains difficult to diagnose in the early stages. This article examines the current state of lung cancer detection and screening via low-dose computed tomography (LDCT) in Alaska and considers potential opportunities for occupational therapy practitioners in primary care settings. Medicare requires at least one documented shared decision-making encounter between provider and patient before LDCT lung cancer screening occurs. As a result of time constraints, documentation requirements, and the plethora of preventive health services they provide, primary care physicians often lack the time and training to conduct this essential service. This provides an opportunity for occupational therapy practitioners to perform these services as part of their practice and to play a role in this area as patient educators and prevention specialists in primary care settings. What This Article Adds: This article explores the national health crisis of lung cancer and describes how occupational therapists can participate in providing care in primary care settings.
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Affiliation(s)
- Lesleigh Kowalski
- Lesleigh Kowalski, PhD, MOT, OTR/L, ATP, is Research Scientist, Department of Family Medicine, University of Washington, Seattle; . At the time of the research, Kowalski was Doctoral Student, College of Health of Professions, Pacific University, Forest Grove, OR
| | - Nancy E Krusen
- Nancy E. Krusen, PhD, MA, OTR/L, is Program Director and Associate Professor, Division of Occupational Therapy Education, University of Nebraska Medical Center, Omaha
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19
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Fischer M, Schijven MP, Kennedy KM, Durning S, Kropmans TJB. Evaluation of Consecutive Guided Training to Improve Interrater Agreement in Identifying Elements of Situation Awareness in Objective Structured Clinical Examination Assessments. MEDEDPUBLISH 2021; 10:106. [PMID: 38486551 PMCID: PMC10939566 DOI: 10.15694/mep.2021.000106.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. Introduction: Little is known about the medical student's cognitive ability in diagnostic and therapeutic accuracy. Literature does not suggest a methodology to quantify students' cognitive processing. Situation Awareness (SA) is described as having the proficiency to obtain awareness of the surrounding and to integrate this consciousness into the situational context and potential forthcoming development. OSCEs might be a suitable instrument to evaluate students' awareness of the situation. Methods: Consecutive guided training was provided to obtain a consistent comprehension of the model of SA. 4 independent researchers consecutively examined 6 randomised OSCE forms in a qualitative and quantitative method. Final interrater agreement was expressed as Cohens kappa. Generalisability theory determined the impact of the main facets on the variation in disagreement. Results: Evaluation of identifying and categorising elements of SA within OSCE forms demonstrated a moderate to very good interrater agreement. The G-Theory revealed key facets for variance: OSCE forms, Levels of SA, Items embedded in the Levels, Interaction between Forms and Levels and Forms and Items embedded within Levels. Conclusion: Consecutive guided training improved the identification of elements of SA within OSCE assessments. Further research is necessary to improve the assessment of SA in undergraduate medical curricula.
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20
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Pfoh ER, Engineer L, Singh H, Hall LL, Fried ED, Berger Z, Wu AW. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf 2021; 17:e121-e127. [PMID: 28248748 DOI: 10.1097/pts.0000000000000317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents. METHODS This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development. RESULTS Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)-related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology. CONCLUSIONS Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.
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Affiliation(s)
| | | | | | - Laura Lee Hall
- American College of Physicians, Washington, District of Columbia
| | - Ethan D Fried
- Hofstra Northwell School of Medicine at Lenox Hill Hospital, New York, New York
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21
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Walshe NC, Crowley CM, OʼBrien S, Browne JP, Hegarty JM. Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis. Simul Healthc 2020; 14:398-408. [PMID: 31116171 DOI: 10.1097/sih.0000000000000376] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
STATEMENT We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.
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Affiliation(s)
- Nuala C Walshe
- From the Clinical Skills Simulation Resource Centre (N.C.W., C.M.C., SO'B), School of Nursing and Midwifery (J.M.H.); and School of Public Health (J.P.B.), University College Cork, Cork, Ireland
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22
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Chapman LR, Molloy L, Wright F, Oswald C, Adnum K, O'Brien TA, Mitchell R. Implementation of Situational Awareness in the Pediatric Oncology Setting. Does a 'huddle' Work and Is it Sustainable? J Pediatr Nurs 2020; 50:75-80. [PMID: 31770680 DOI: 10.1016/j.pedn.2019.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Huddles are short, regular debriefings that are designed to engage clinical staff in discussions about existing or emerging safety issues. They allow a brief conversation to take place creating a 'situational awareness' about the complexities of the healthcare environment for that day. METHODS The huddle was implemented in a pediatric oncology service as an intervention aimed at improving patient safety and staff communication to enhance situational awareness. To ensure an efficient format for each huddle a huddle observational tool (HOT) was developed. An initial electronic anonymous survey focusing on safety and situational awareness was distributed to all of the multi-disciplinary (MDT) team. A second survey was disseminated 18 months post huddle introduction to scrutinize its effectiveness. Sustainability was assessed using staff attendance and huddle numbers. RESULTS Four key areas demonstrated high situational awareness; safety awareness, incident management, communication and teamwork. Positive/negative pooled responses from both survey time points demonstrated a high percentage of positive responses, particularly relating to teamwork enhancement. The overwhelming finding was sustainability of the intervention of the huddle. The pediatric oncology services have now conducted over 700 huddles events over a three-year period. CONCLUSION The initiation of the huddle has led to increased situational awareness and promotion of safety. It has been shown to be sustainable in the pediatric oncology setting, with durability and attendance of the huddle being the most significant outcome.
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Affiliation(s)
- Laura Rm Chapman
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia.
| | - Luke Molloy
- The University of Wollongong, Wollongong, NSW, Australia.
| | - Felicity Wright
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia; Graduate School of Health, University of Technology Sydney, Australia.
| | - Cecilia Oswald
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia.
| | - Kirsten Adnum
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia.
| | - Tracey A O'Brien
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia.
| | - Richard Mitchell
- Kids Cancer Center, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia.
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23
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Murphy DR, Giardina TD, Satterly T, Sittig DF, Singh H. An Exploration of Barriers, Facilitators, and Suggestions for Improving Electronic Health Record Inbox-Related Usability: A Qualitative Analysis. JAMA Netw Open 2019; 2:e1912638. [PMID: 31584683 PMCID: PMC6784746 DOI: 10.1001/jamanetworkopen.2019.12638] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Managing messages in the electronic health record (EHR) inbox consumes substantial amounts of physician time. Certain factors associated with inbox management, such as poor usability and excessive and unnecessary inbox messages, have been associated with physician burnout. Additionally, inbox design, usability, and workflows are associated with physicians' situational awareness (ie, perception, comprehension, and projection of clinical status) and efficiency of processing EHR inbox messages. Understanding factors associated with inbox usability could improve future EHR inbox designs and workflows, thus reducing risk of burnout while improving patient safety. OBJECTIVE To determine barriers, facilitators, and suggestions associated with EHR inbox-related usability. DESIGN, SETTING, AND PARTICIPANTS This qualitative study included cognitive walkthroughs of EHR inbox management with 25 physicians (17 primary care physicians and 8 specialists) at 6 large health care organizations using 4 different EHR systems between May 6, 2015, and September 19, 2016. While processing EHR inbox messages, participants identified facilitators and barriers associated with EHR inbox situational awareness and processing efficiency and potential interventions to address such barriers. A qualitative analysis was performed on transcribed recordings using an inductive thematic approach with an 8-dimension sociotechnical model as a theoretical lens from May 6, 2015, to August 15, 2019. RESULTS The cognitive walkthroughs identified 60 barriers, 32 facilitators, and 28 suggestions for improving the EHR inbox. Emergent data fit within 5 major themes: message processing complexity, inbox interface design, cognitive load, team communication, and inbox message content. Within these themes, similar barriers were identified across sites, such as poor usability due the high numbers of clicks needed to accomplish actions. In certain instances, an identified facilitator at one site provided the exact solution needed to address a barrier identified at another site. CONCLUSIONS AND RELEVANCE This qualitative study found that usability of the EHR inbox is often suboptimal and variable across sites, suggesting lack of shared best practices related to information management. Implementation of optimized design features and workflows will require EHR developers and health care organizations to collectively share this responsibility. Development of regional or national consortia to support collaborative sharing and implementation of EHR system best practices across EHR developers and health care organizations could also improve safety and efficiency and reduce physician burnout.
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Affiliation(s)
- Daniel R. Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Traber D. Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Tyler Satterly
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dean F. Sittig
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston
- Center for Healthcare Quality and Safety, University of Texas Health Science Center at Houston, Houston
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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Murphy DR, Satterly T, Giardina TD, Sittig DF, Singh H. Practicing Clinicians' Recommendations to Reduce Burden from the Electronic Health Record Inbox: a Mixed-Methods Study. J Gen Intern Med 2019; 34:1825-1832. [PMID: 31292905 PMCID: PMC6712240 DOI: 10.1007/s11606-019-05112-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/25/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Workload from electronic health record (EHR) inbox notifications leads to information overload and contributes to job dissatisfaction and physician burnout. Better understanding of physicians' inbox requirements and workflows could optimize inbox designs, enhance efficiency, and reduce safety risks from information overload. DESIGN We conducted a mixed-methods study to identify strategies to enhance EHR inbox design and workflow. First, we performed a secondary analysis of national survey data of all Department of Veterans Affairs (VA) primary care practitioners (PCP) to identify major themes in responses to a free-text question soliciting suggestions to improve EHR inbox design and workflows. We then conducted expert interviews of clinicians at five health care systems (1 VA and 4 non-VA settings using 4 different EHRs) to understand existing optimal strategies to improve efficiency and situational awareness related to EHR inbox use. Themes from survey data were cross-validated with interview findings. RESULTS We analyzed responses from 2104 PCPs who completed the free-text inbox question (of 5001 PCPs who responded to survey) and used an inductive approach to identify five themes: (1) Inbox notification content should be actionable for patient care and relevant to recipient clinician, (2) Inboxes should reduce risk of losing messages, (3) Inbox functionality should be optimized to improve efficiency of processing notifications, (4) Team support should be leveraged to help with EHR inbox notification burden, (5) Sufficient time should be provided to all clinicians to process EHR inbox notifications. We subsequently interviewed 15 VA and non-VA clinicians and identified 11 unique strategies, each corresponding directly with one of these five themes. CONCLUSION Feedback from practicing end-user clinicians provides robust evidence to improve content and design of the EHR inbox and related clinical workflows and organizational policies. Several strategies we identified could improve clinicians' EHR efficiency and satisfaction as well as empower them to work with their local administrators, health IT personnel, and EHR developers to improve these systems.
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Affiliation(s)
- Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), 2002 Holcombe Boulevard, Houston, TX, 77030, USA.
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Tyler Satterly
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), 2002 Holcombe Boulevard, Houston, TX, 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), 2002 Holcombe Boulevard, Houston, TX, 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dean F Sittig
- University of Texas Health Science Center at Houston's School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (152), Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), 2002 Holcombe Boulevard, Houston, TX, 77030, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Zhu X, Tu SP, Sewell D, Yao NA, Mishra V, Dow A, Banas C. Measuring electronic communication networks in virtual care teams using electronic health records access-log data. Int J Med Inform 2019; 128:46-52. [PMID: 31160011 DOI: 10.1016/j.ijmedinf.2019.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/01/2019] [Accepted: 05/11/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop methods for measuring electronic communication networks in virtual care teams using electronic health records (EHR) access-log data. METHODS For a convenient sample of 100 surgical colorectal cancer patients, we used time-stamped EHR access-log data extracted from an academic medical center's EHR system to construct communication networks among healthcare professionals (HCPs) in each patient's virtual care team. We measured communication linkages between HCPs using the inverse of the average time between access events in which the source HCPs sent information to and the destination HCPs retrieved information from the EHR system. Social network analysis was used to examine and visualize communication network structures, identify principal care teams, and detect meaningful structural differences across networks. We conducted a non-parametric multivariate analysis of variance (MANOVA) to test the association between care teams' communication network structures and patients' cancer stage and site. RESULTS The 100 communication networks showed substantial variations in size and structures. Principal care teams, the subset of HCPs who formed the core of the communication networks, had higher proportions of nurses, physicians, and pharmacists and a lower proportion of laboratory medical technologists than the overall networks. The distributions of conditional uniform graph quantiles suggested that our network-construction technique captured meaningful underlying structures that were different from random unstructured networks. MANOVA results found that the networks' topologies were associated with patients' cancer stage and site. CONCLUSIONS This study demonstrates that it is feasible to use EHR access-log data to measure and examine communication networks in virtual care teams. The proposed methods captured salient communication patterns in care teams that were associated with patients' clinical differences.
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Affiliation(s)
- Xi Zhu
- University of Iowa, Department of Health Management and Policy, 145 N Riverside Dr, N222, Iowa City, IA 52242, United States.
| | - Shin-Ping Tu
- University of California Davis, Department of Internal Medicine, Davis, CA, United States
| | - Daniel Sewell
- University of Iowa, Department of Biostatistics, Iowa City, IA, United States
| | - Nengliang Aaron Yao
- University of Virginia, Department of Public Health Sciences, Charlottesville, VA, United States
| | - Vimal Mishra
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
| | - Alan Dow
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
| | - Colin Banas
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States
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Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events. J Gen Intern Med 2018; 33:1187-1191. [PMID: 29380218 PMCID: PMC6025685 DOI: 10.1007/s11606-018-4304-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/21/2017] [Accepted: 12/20/2017] [Indexed: 12/30/2022]
Abstract
Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying "undesirable diagnostic events" (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.
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Smith MW, Hughes AM, Brown C, Russo E, Giardina TD, Mehta P, Singh H. Test results management and distributed cognition in electronic health record-enabled primary care. Health Informatics J 2018; 25:1549-1562. [PMID: 29905084 DOI: 10.1177/1460458218779114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.
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Affiliation(s)
| | | | | | | | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, USA
| | - Praveen Mehta
- VA Great Lakes Health Care System, USA; Loyola University Chicago Stritch School of Medicine, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, USA
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Veinot TC, Senteio CR, Hanauer D, Lowery JC. Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis. J Am Med Inform Assoc 2018; 25:746-758. [PMID: 29025114 PMCID: PMC7646963 DOI: 10.1093/jamia/ocx085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/18/2017] [Accepted: 08/01/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research. Materials and Methods We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research. Results The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process. Discussion The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations. Conclusion The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.
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Affiliation(s)
- Tiffany C Veinot
- School of Information and School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Charles R Senteio
- Department of Library and Information Science, School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - David Hanauer
- Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Julie C Lowery
- Center for Clinical Management, Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
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O’Neill TA, White J, Delaloye N, Gilfoyle E. A taxonomy and rating system to measure situation awareness in resuscitation teams. PLoS One 2018; 13:e0196825. [PMID: 29758042 PMCID: PMC5951547 DOI: 10.1371/journal.pone.0196825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/21/2018] [Indexed: 01/11/2023] Open
Abstract
Team SA involves a common perspective between two or more individuals regarding current environmental events, their meaning, and projected future status. Team SA has been theorized to be important for resuscitation team effectiveness. Accordingly, multidimensional frameworks of observable behaviors relevant to resuscitation teams are needed to understand more deeply the nature of team SA, its implications for team effectiveness, and whether it can be trained. A seven-dimension team resuscitation SA framework was developed following a literature review and consensus process using a modified Delphi approach with a group of content experts. We applied a pre-post design within a day-long team training program involving four video-recorded simulated resuscitation events and 42 teams across Canada. The first and fourth events represented “pre” and “post” training events, respectively. Teams were scored on SA five times within each 15-minute event. Distractions were introduced to investigate whether SA scores would be affected. The current study provides initial construct validity evidence for a new measure of SA and explicates SA's role in resuscitation teams.
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Affiliation(s)
- Thomas A. O’Neill
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Jesse White
- Faculty of Law, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Delaloye
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elaine Gilfoyle
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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Nicholson BD, Goyder CR, Bankhead CR, Toftegaard BS, Rose PW, Thulesius H, Vedsted P, Perera R. Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data. Br J Gen Pract 2018; 68:e323-e332. [PMID: 29686134 PMCID: PMC5916079 DOI: 10.3399/bjgp18x695813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/05/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained. AIM To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions. DESIGN AND SETTING A secondary analysis of survey data from the International Cancer Benchmarking Partnership. METHOD The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach. RESULTS PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility. CONCLUSION The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Goyder
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Peter W Rose
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Växjö, Sweden
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Peabody J, Saldivar JS, Swagel E, Fugaro S, Paculdo D, Tran M. Primary care variability in patients at higher risk for colorectal cancer: evaluation of screening and preventive care practices. Curr Med Res Opin 2018; 34:851-856. [PMID: 29239679 DOI: 10.1080/03007995.2017.1417244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Sub-optimal colorectal cancer (CRC) evaluations have been attributed to both physician and patient factors. The primary objective of this study was to evaluate physician practice variation in patients with a higher risk of CRC. We wanted to identify the physician characteristics and the types of patients that were associated with missed screening opportunities; we also explored whether screening for CRC served as a proxy for better preventive care practices. METHODS A total of 213 board-certified family and internal medicine physicians participated in the study, conducted between September and December 2016. We used Clinical Performance and Value (CPV®) vignettes, simulated patients, to collect data on CRC screening. The CPV patients presented with a typical range of signs and symptoms of potential CRC. The care provided to the simulated patients was scored against explicit evidence-based criteria. The main outcome measure was rate a diagnostic CRC workup was ordered. This data quantified the clinical practice variability for CRC screening in high risk patients and other preventive and screening practices. RESULTS A total of 81% of participants ordered appropriate CRC workup in patients at risk for CRC, with a majority (71%) selecting diagnostic colonoscopy over FIT/FOBT. Only 6% of physicians ordering CRC workup, however, counseled patients on their higher risk for CRC. The most commonly recognized symptoms prompting testing were unexplained weight loss or inadequate screening history, while the least recognized symptoms of CRC risk were abdominal discomfort found on review of systems. CONCLUSION This study shows that primary care physician screening of CRC varies widely. Those physicians who successfully screened for CRC were more likely to complete other prevention and screening practices.
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Affiliation(s)
- John Peabody
- a QURE Healthcare , San Francisco , CA , USA
- b University of California , San Francisco , CA , USA
- c University of California , Los Angeles , CA , USA
| | | | - Eric Swagel
- e Private Medical Services Inc. , San Francisco , CA , USA
| | - Steven Fugaro
- b University of California , San Francisco , CA , USA
| | | | - Mary Tran
- a QURE Healthcare , San Francisco , CA , USA
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Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol 2018; 15:287-295. [PMID: 29102539 DOI: 10.1016/j.jacr.2017.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE We previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography. METHODS An algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger's performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed. RESULTS Of 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result. CONCLUSIONS Care delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.
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Comparison between Simulation-based Training and Lecture-based Education in Teaching Situation Awareness. A Randomized Controlled Study. Ann Am Thorac Soc 2018; 14:529-535. [PMID: 28362531 DOI: 10.1513/annalsats.201612-950oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Situation awareness has been defined as the perception of the elements in the environment within volumes of time and space, the comprehension of their meaning, and the projection of their status in the near future. Intensivists often make time-sensitive critical decisions, and loss of situation awareness can lead to errors. It has been shown that simulation-based training is superior to lecture-based training for some critical scenarios. Because the methods of training to improve situation awareness have not been well studied in the medical field, we compared the impact of simulation vs. lecture training using the Situation Awareness Global Assessment Technique (SAGAT) score. OBJECTIVES To identify an effective method for teaching situation awareness. METHODS We randomly assigned 17 critical care fellows to simulation vs. lecture training. Training consisted of eight cases on airway management, including topics such as elevated intracranial pressure, difficult airway, arrhythmia, and shock. During the testing scenario, at random times between 4 and 6 minutes into the simulation, the scenario was frozen, and the screens were blanked. Respondents then completed the 28 questions on the SAGAT scale. Sample items were categorized as Perception, Projection, and Comprehension of the situation. Results were analyzed using SPSS Version 21. RESULTS Eight fellows from the simulation group and nine from the lecture group underwent simulation testing. Sixty-four SAGAT scores were recorded for the simulation group and 48 scores were recorded for the lecture group. The mean simulation vs. lecture group SAGAT score was 64.3 ± 10.1 (SD) vs. 59.7 ± 10.8 (SD) (P = 0.02). There was also a difference in the median Perception ability between the simulation vs. lecture groups (61.1 vs. 55.5, P = 0.01). There was no difference in the median Projection and Comprehension scores between the two groups (50.0 vs. 50.0, P = 0.92, and 83.3 vs. 83.3, P = 0.27). CONCLUSIONS We found a significant, albeit modest, difference between simulation training and lecture training on the total SAGAT score of situation awareness mainly because of the improvement in perception ability. Simulation may be a superior method of teaching situation awareness.
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Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care. J Pediatr Health Care 2018; 32:53-62. [PMID: 28916249 DOI: 10.1016/j.pedhc.2017.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/11/2017] [Accepted: 07/17/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies. METHODS A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records. RESULTS Knowledge related to diagnostic errors statistically improved from the pretest to posttest scores with sustained 60-day differences (p < .025). Although there was a decline in the proportion of patients returning with the same chief complaint within 14 days, this was not statistically significant (p < .15). When providers were confronted with an unrecognizable clinical presentation, they reported an increased use of a "diagnostic timeout" (p < .038). DISCUSSION Providers developed an increased awareness of the presence of diagnostic errors in the primary care setting, the contributing risk factors for a diagnostic error, and possible strategies to reduce diagnostic errors. These factors had an unexpected impact on changing the primary care practice model to enhance the continuity of patient care.
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Murphy DR, Meyer AND, Vaghani V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Development and Validation of Trigger Algorithms to Identify Delays in Diagnostic Evaluation of Gastroenterological Cancer. Clin Gastroenterol Hepatol 2018; 16:90-98. [PMID: 28804030 DOI: 10.1016/j.cgh.2017.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/11/2017] [Accepted: 08/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) and hepatocellular cancer (HCC) are common causes of death and morbidity, and patients benefit from early detection. However, delays in follow-up of suspicious findings are common, and methods to efficiently detect such delays are needed. We developed, refined, and tested trigger algorithms that identify patients with delayed follow-up evaluation of findings suspicious of CRC or HCC. METHODS We developed and validated two trigger algorithms that detect delays in diagnostic evaluation of CRC and HCC using laboratory, diagnosis, procedure, and referral codes from the Department of Veteran Affairs National Corporate Data Warehouse. The algorithm initially identified patients with positive test results for iron deficiency anemia or fecal immunochemical test (for CRC) and elevated α-fetoprotein results (for HCC). Our algorithm then excluded patients for whom follow-up evaluation was unnecessary, such as patients with a terminal illness or those who had already completed a follow-up evaluation within 60 days. Clinicians reviewed samples of both delayed and nondelayed records, and review data were used to calculate trigger performance. RESULTS We applied the algorithm for CRC to 245,158 patients seen from January 1, 2013, through December 31, 2013 and identified 1073 patients with delayed follow up. In a review of 400 randomly selected records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 56.0% (95% CI, 51.0%-61.0%). We applied the algorithm for HCC to 333,828 patients seen from January 1, 2011 through December 31, 2014, and identified 130 patients with delayed follow-up. During manual review of all 130 records, we found that our algorithm identified patients with delayed follow-up with a positive predictive value of 82.3% (95% CI, 74.4%-88.2%). When we extrapolated the findings to all patients with abnormal results, the algorithm identified patients with delayed follow-up evaluation for CRC with 68.6% sensitivity (95% CI, 65.4%-71.6%) and 81.1% specificity (95% CI, 79.5%-82.6%); it identified patients with delayed follow-up evaluation for HCC with 89.1% sensitivity (95% CI, 81.8%-93.8%) and 96.5% specificity (95% CI, 94.8%-97.7%). Compared to nonselective methods, use of the algorithm reduced the number of records required for review to identify a delay by more than 99%. CONCLUSIONS Using data from the Veterans Affairs electronic health record database, we developed an algorithm that greatly reduces the number of record reviews necessary to identify delays in follow-up evaluations for patients with suspected CRC or HCC. This approach offers a more efficient method to identify delayed diagnostic evaluation of gastroenterological cancers.
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Affiliation(s)
- Daniel R Murphy
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas.
| | - Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Viralkumar Vaghani
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Elise Russo
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dean F Sittig
- University of Texas Health Science Center, University of Texas-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas
| | - Li Wei
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Louis Wu
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Baylor College of Medicine, Houston, Texas
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Fischer MA, Kennedy KM, Durning S, Schijven MP, Ker J, O’Connor P, Doherty E, Kropmans TJB. Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search. BMC MEDICAL EDUCATION 2017; 17:262. [PMID: 29268744 PMCID: PMC5740962 DOI: 10.1186/s12909-017-1105-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/12/2017] [Indexed: 05/30/2023]
Abstract
BACKGROUND Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. METHODS A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. RESULTS The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. DISCUSSION Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. CONCLUSION Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.
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Affiliation(s)
- Markus A. Fischer
- National University Ireland Galway, School of Medicine, University Road, Galway, H91TK33 Ireland
| | - Kieran M. Kennedy
- National University Ireland Galway, School of Medicine, University Road, Galway, H91TK33 Ireland
| | - Steven Durning
- Department of Internal Medicine, University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 USA
| | - Marlies P. Schijven
- Department of Surgery, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam-Zuidoost, The Netherlands
| | - Jean Ker
- University of Dundee. Clinical Skills Centre Level 6, Ninewells Hospital & Medical School, Dundee, UK
| | - Paul O’Connor
- National University Galway Ireland, Discipline of General Practice, Distillery Road, Galway, H91TK33 Ireland
| | - Eva Doherty
- Royal College of Surgeons in Ireland, 123 St Stephen’s Green, Dublin 2, Ireland
| | - Thomas J. B. Kropmans
- National University Ireland Galway, School of Medicine, University Road, Galway, H91TK33 Ireland
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Situational Awareness in Critical Care: An Aviation Approach to Reduce Error. J Perianesth Nurs 2017; 32:650-652. [PMID: 29157771 DOI: 10.1016/j.jopan.2017.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/10/2017] [Indexed: 11/24/2022]
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Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis. Anesthesiology 2017; 127:326-337. [PMID: 28459735 DOI: 10.1097/aln.0000000000001661] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors. METHODS Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013. RESULTS Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common. CONCLUSIONS Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.
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Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017; 26:484-494. [PMID: 27530239 PMCID: PMC5502242 DOI: 10.1136/bmjqs-2016-005401] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/15/2016] [Accepted: 07/13/2016] [Indexed: 12/20/2022]
Abstract
Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.
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Affiliation(s)
- Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Gordon D Schiff
- General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark L Graber
- RTI International, Research Triangle Park, North Carolina, USA
- SUNY Stony Brook School of Medicine, Stony Brook, New York, USA
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Dhurjati R, Salas E, Profit J. If Health Care Teams Had to Win Championships: Insights From High-Performance Sports. Am J Med Qual 2017; 32:336-337. [DOI: 10.1177/1062860616686684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ravi Dhurjati
- Stanford Cancer Center, Stanford Health Care, Stanford CA
| | | | - Jochen Profit
- Lucille Salter Packard Children’s Hospital, Stanford University, Stanford, CA
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Improving Diagnostic Safety in Primary Care by Unlocking Digital Data. Jt Comm J Qual Patient Saf 2017; 43:29-31. [PMID: 28334582 DOI: 10.1016/j.jcjq.2016.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Lenert LA. Toward Medical Documentation That Enhances Situational Awareness Learning. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2017; 2016:763-771. [PMID: 28269872 PMCID: PMC5333306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of writing medical notes in a computer system goes beyond documentation for medical-legal purposes or billing. The structure of documentation is a checklist that serves as a cognitive aid and a potential index to retrieve information for learning from the record. For the past 50 years, one of the primary organizing structures for physicians' clinical documentation have been the SOAP note (Subjective, Objective, Assessment, Plan). The cognitive check list is well-suited to differential diagnosis but may not support detection of changes in systems and/or learning from cases. We describe an alternative cognitive checklist called the OODA Loop (Observe, Orient, Decide, Act. Through incorporation of projections of anticipated course events with and without treatment and by making "Decisions" an explicit category of documentation in the medical record in the context of a variable temporal cycle for observations, OODA may enhance opportunities to learn from clinical care.
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Affiliation(s)
- Leslie A Lenert
- Biomedical Informatics Center, Medical University of South Carolina, Charleston, SC, USA
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Meyer AND, Singh H. Calibrating how doctors think and seek information to minimise errors in diagnosis. BMJ Qual Saf 2016; 26:436-438. [PMID: 27672123 DOI: 10.1136/bmjqs-2016-006071] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 11/03/2022]
Affiliation(s)
- Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Murphy DR, Meyer AN, Bhise V, Russo E, Sittig DF, Wei L, Wu L, Singh H. Computerized Triggers of Big Data to Detect Delays in Follow-up of Chest Imaging Results. Chest 2016; 150:613-20. [PMID: 27178786 DOI: 10.1016/j.chest.2016.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/14/2016] [Accepted: 05/02/2016] [Indexed: 02/08/2023] Open
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Cemalovic N, Scoccimarro A, Arslan A, Fraser R, Kanter M, Caputo N. Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate? Emerg Med Australas 2016; 28:295-9. [DOI: 10.1111/1742-6723.12575] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/13/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Nail Cemalovic
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
| | - Anthony Scoccimarro
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
| | - Albert Arslan
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
| | - Robert Fraser
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
| | - Marc Kanter
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
| | - Nicholas Caputo
- Department of Emergency Medicine; Lincoln Medical and Mental Health Center; Bronx New York USA
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Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiol 2016; 16:4. [PMID: 26772179 PMCID: PMC4715310 DOI: 10.1186/s12871-016-0172-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 01/14/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS). METHODS Two experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making. RESULTS SA errors were identified in 81.5%. Predominantly, errors occurred on the levels of perception (38.0%) and comprehension (31.5%). Errors on the level of projection played a minor role (12.0%). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance. CONCLUSIONS SA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.
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Affiliation(s)
- Christian M Schulz
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany.
| | - Veronika Krautheim
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Annika Hackemann
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Matthias Kreuzer
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Eberhard F Kochs
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Klaus J Wagner
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
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Morineau T, Chapelain P, Quinio P. Task management skills and their deficiencies during care delivery in simulated medical emergency situation: A classification. Intensive Crit Care Nurs 2016; 34:34-42. [PMID: 26764210 DOI: 10.1016/j.iccn.2015.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/13/2015] [Accepted: 11/08/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Our objective was to develop the analysis of task management skills by proposing a framework classifying task management stages and deficiencies. Few studies of non-technical skills have detailed the components of task management skills through behavioural markers, despite their central role in care delivery. RESEARCH METHODOLOGY/DESIGN A post hoc qualitative behavioural analysis was performed of recordings made of professional training sessions based upon simulated scenarios. SETTING Four recorded sessions in a high-fidelity simulation setting were observed and recorded. Two scenarios were used (cardiac arrest and respiratory failure), and there were two training sessions per scenario. MAIN OUTCOMES MEASURES Four types of task management deficiencies were identified with regards to task constraints: constraint relaxation, unsatisfied constraints, additional constraints and constraint transgression. Both equipment and space constraints were also identified. RESULTS The lack of prerequisite actions when preparing the environment, corequisite actions for equipment and protocol monitoring, or postrequisite actions to restore the environment were associated with task management deficiencies. CONCLUSION Deficiencies in task management behaviours can be identified in simulated as well as actual medical emergency settings. This framework opens perspectives for both training caregivers and designing ergonomic work situations.
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Affiliation(s)
- Thierry Morineau
- Université Bretagne-Sud, Centre de Recherches en Psychologie, Cognition, Communication, Lorient, France.
| | - Pascal Chapelain
- Centre de Simulation en Santé du Scorff, IFPS, Scorff Hospital, Lorient, France
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Carayon P, Kianfar S, Li Y, Xie A, Alyousef B, Wooldridge A. A systematic review of mixed methods research on human factors and ergonomics in health care. APPLIED ERGONOMICS 2015; 51:291-321. [PMID: 26154228 PMCID: PMC4725322 DOI: 10.1016/j.apergo.2015.06.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 05/20/2023]
Abstract
This systematic literature review provides information on the use of mixed methods research in human factors and ergonomics (HFE) research in health care. Using the PRISMA methodology, we searched four databases (PubMed, PsycInfo, Web of Science, and Engineering Village) for studies that met the following inclusion criteria: (1) field study in health care, (2) mixing of qualitative and quantitative data, (3) HFE issues, and (4) empirical evidence. Using an iterative and collaborative process supported by a structured data collection form, the six authors identified a total of 58 studies that primarily address HFE issues in health information technology (e.g., usability) and in the work of healthcare workers. About two-thirds of the mixed methods studies used the convergent parallel study design where quantitative and qualitative data were collected simultaneously. A variety of methods were used for collecting data, including interview, survey and observation. The most frequent combination involved interview for qualitative data and survey for quantitative data. The use of mixed methods in healthcare HFE research has increased over time. However, increasing attention should be paid to the formal literature on mixed methods research to enhance the depth and breadth of this research.
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Affiliation(s)
- Pascale Carayon
- Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA.
| | - Sarah Kianfar
- Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA
| | - Yaqiong Li
- Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA
| | - Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, USA
| | | | - Abigail Wooldridge
- Center for Quality and Productivity Improvement and Department of Industrial and Systems Engineering, University of Wisconsin-Madison, USA
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Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial. J Clin Oncol 2015; 33:3560-7. [PMID: 26304875 PMCID: PMC4622097 DOI: 10.1200/jco.2015.61.1301] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer. METHODS We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months. RESULTS We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58). CONCLUSION Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.
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Affiliation(s)
- Daniel R Murphy
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Louis Wu
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Eric J Thomas
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Samuel N Forjuoh
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Ashley N D Meyer
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Hardeep Singh
- Daniel R. Murphy, Louis Wu, Ashley N.D. Meyer, and Hardeep Singh, Houston Veterans Affairs Health Services Research and Development, Michael E. DeBakey Veterans Affairs Medical Center, and Section of Health Services Research, Baylor College of Medicine; Eric J. Thomas, University of Texas Houston Medical School and University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston; and Samuel N. Forjuoh, Scott and White Healthcare, Texas A&M Health Science Center, College of Medicine, Temple, TX.
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Murphy DR, Thomas EJ, Meyer AND, Singh H. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings. Radiology 2015; 277:81-7. [PMID: 25961634 DOI: 10.1148/radiol.2015142530] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Daniel R Murphy
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Eric J Thomas
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Ashley N D Meyer
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
| | - Hardeep Singh
- From the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (D.R.M., A.N.D.M., H.S.); Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Tex (D.R.M., A.N.D.M., H.S.); Department of Internal Medicine, University of Texas Houston Medical School, Houston, Tex (E.J.T.); and UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Tex (E.J.T.)
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