Medical errors in primary care clinics--a cross sectional study

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study

BACKGROUND

There has been growing recognition that contextual factors influence the physician's cognitive processes. However, given that cognitive processes may depend on the physicians' specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians.

OBJECTIVE

This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy.

METHODS

We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis.

RESULTS

Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively.

CONCLUSION

Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.

Identifying factors in the provision of intravenous stroke thrombolysis in Malaysia: a multiple case study from the healthcare providers' perspective

BACKGROUND

Translation into clinical practice for use of intravenous thrombolysis (IVT) for the management of ischemic stroke remains a challenge especially across low- and middle-income countries, with regional inconsistencies in its rate. This study aimed at identifying factors that influenced the provision of IVT and the variation in its rates in Malaysia.

METHODS

A multiple case study underpinning the Tailored Implementation for Chronic Diseases framework was carried out in three public hospitals with differing rates of IVT using a multiple method design. Twenty-five in-depth interviews and 12 focus groups discussions were conducted among 89 healthcare providers, along with a survey on hospital resources and a medical records review to identify reasons for not receiving IVT. Qualitative data were analysed using reflective thematic method, before triangulated with quantitative findings.

RESULTS

Of five factors identified, three factors that distinctively influenced the variation of IVT across the hospitals were: 1) leadership through quality stroke champions, 2) team cohesiveness which entailed team dynamics and its degree of alignment and, 3) facilitative work process which included workflow simplification and familiarity with IVT. Two other factors that were consistently identified as barriers in these hospitals included patient factors which largely encompassed delayed presentation, and resource constraints. About 50.0 - 67.6% of ischemic stroke patients missed the opportunity to receive IVT due to delayed presentation.

CONCLUSIONS

In addition to the global effort to explore sustainable measures to improve patients' emergency response for stroke, attempts to improve the provision of IVT for stroke care should also consider the inclusion of interventions targeting on health systems perspectives such as promoting quality leadership, team cohesiveness and workflow optimisation.

Nurses' Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study

Background

Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated.

Objective

To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study.

Results

In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36-7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85-6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14-3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11-7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13-6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69-7.52]) were significantly associated with proper nursing care documentation practices.

Conclusion

Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.

Effects of Combinational Use of Additional Differential Diagnostic Generators on the Diagnostic Accuracy of the Differential Diagnosis List Developed by an Artificial Intelligence-Driven Automated History-Taking System: Pilot Cross-Sectional Study

BACKGROUND

Low diagnostic accuracy is a major concern in automated medical history-taking systems with differential diagnosis (DDx) generators. Extending the concept of collective intelligence to the field of DDx generators such that the accuracy of judgment becomes higher when accepting an integrated diagnosis list from multiple people than when accepting a diagnosis list from a single person may be a possible solution.

OBJECTIVE

The purpose of this study is to assess whether the combined use of several DDx generators improves the diagnostic accuracy of DDx lists.

METHODS

We used medical history data and the top 10 DDx lists (index DDx lists) generated by an artificial intelligence (AI)-driven automated medical history-taking system from 103 patients with confirmed diagnoses. Two research physicians independently created the other top 10 DDx lists (second and third DDx lists) per case by imputing key information into the other 2 DDx generators based on the medical history generated by the automated medical history-taking system without reading the index lists generated by the automated medical history-taking system. We used the McNemar test to assess the improvement in diagnostic accuracy from the index DDx lists to the three types of combined DDx lists: (1) simply combining DDx lists from the index, second, and third lists; (2) creating a new top 10 DDx list using a 1/n weighting rule; and (3) creating new lists with only shared diagnoses among DDx lists from the index, second, and third lists. We treated the data generated by 2 research physicians from the same patient as independent cases. Therefore, the number of cases included in analyses in the case using 2 additional lists was 206 (103 cases × 2 physicians' input).

RESULTS

The diagnostic accuracy of the index lists was 46% (47/103). Diagnostic accuracy was improved by simply combining the other 2 DDx lists (133/206, 65%, P<.001), whereas the other 2 combined DDx lists did not improve the diagnostic accuracy of the DDx lists (106/206, 52%, P=.05 in the collective list with the 1/n weighting rule and 29/206, 14%, P<.001 in the only shared diagnoses among the 3 DDx lists).

CONCLUSIONS

Simply adding each of the top 10 DDx lists from additional DDx generators increased the diagnostic accuracy of the DDx list by approximately 20%, suggesting that the combinational use of DDx generators early in the diagnostic process is beneficial.

Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions

OBJECTIVES

Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID.

PATIENTS AND METHODS

Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process.

RESULTS

MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID.

CONCLUSIONS

Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.

Ear, Nose and Throat (ENT) disease diagnostic error in low-resource health care: Observations from a hospital-based cross-sectional study

Although the global burden of ear, nose and throat (ENT) diseases is high, data relating to ENT disease epidemiology and diagnostic error in resource-limited settings remain scarce. We conducted a retrospective cross-sectional review of ENT patients' clinical records at a resource-limited tertiary hospital. We determined the diagnostic accuracy and appropriateness of patient referrals for ENT specialist care using descriptive statistics. Cohens kappa coefficient (κ) was calculated to determine the diagnostic agreement between non-ENT clinicians and the ENT specialist, and logistic regression applied to establish the likelihood of patient misdiagnosis by non-ENT clinicians. Of the 1543 patients studied [age 0-87 years, mean age 25(21) years (mean(SD)], non-ENT clinicians misdiagnosed 67.4% and inappropriately referred 50.4%. Compared to those aged 0-5 years, patients aged 51-87 years were 1.77 (95%CI: 1.03-3.04) fold more likely to have a referral misdiagnosis for specialist care. Patients with ear (aOR: 1.63; 95% CI: 1.14-2.33) and those with sinonasal diseases (aOR: 1.80; 95% CI: 1.14-2.45) had greater likelihood of referral misdiagnosis than those with head and neck diseases. Agreement in diagnosis between the ENT specialist and non-ENT clinicians was poor (κ = 0.0001). More effective, accelerated training of clinicians may improve diagnostic accuracy in low-resource settings.

Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021

Introduction

Medical documentation is an important part of the medical process as it is an essential way of communication within the health care system. However, medical documentation practice in the private sector is not well studied in Ethiopian context. The aim of this study was to assess the practice of medical documentation and its associated factors among health workers at private hospitals in the Amhara region, Ethiopia.

Method

An institution-based cross-sectional quantitative study supplemented with a qualitative design was conducted among 419 health workers at the private hospitals in the Amhara Region, Ethiopia from March 29 to April 29 /2021. Data were collected using both a self-administered questionnaire and interview guide for quantitative and qualitative respectively. Data were entered using Epi data version 3.1 and analyzed using SPSS version 20. Descriptive statistics, Bi-variable, and multivariable logistic regression analysis were performed. In-depth interviews were conducted using semi-structured questionnaires with eight respondents to explore the challenges related to the practice of medical documentation. Respondent’s response were analyzed using OpenCode version 4.03 thematically.

Results

Four hundred seven study participants returned the questionnaire. Nearly 50 % (47.2%) health workers had of good medical documentation practice. Health workers who received in-service training on medical documentation AOR = 2.77(95% CI: [1.49,5.14]), good knowledge AOR = 2.28 (95% CI: [1.34,3.89]), favorable attitude AOR = 1.78 (95%CI: [1.06,2.97]), strong motivation AOR = 3.49 (95% CI: [2.10,5.80]), available guide line formats AOR = 3.12 (95% CI: [1.41,6.84]), eHealth literacy AOR = 1.73(95% CI: [1.02,2.96]), younger age AOR = 2.64 (95% CI:[1.27,5.46]) were statistically associated with medical documentation.

Conclusion

More than half of the medical services provided were not registered. Therefore, it is important to put extra efforts to improve documentation practice by providing planed trainings on standards of documentation to all health workers, creating positive attitudes and enhancing their knowledge by motivating them to develop a culture of information.

Malignant Fungating Wounds of the Head and Neck: Management and Antibiotic Stewardship

Objective

Malignant fungating wounds (MFWs) are unfortunate and underreported manifestations of some advanced head and neck cancers. The management of MFWs is complex and challenging. MFWs are often mistaken for infectious processes/abscesses and treated indiscriminately with oral or intravenous antibiotics. Our aim is to promote awareness of MFWs and provide education on their management. We summarize their cost-effective and evidence-based therapies and highlight antibiotic stewardship with respect to their management.

Data Sources

A literature review was performed of PubMed, Cochrane Review, SCOPUS, Embase, and Google Scholar databases regarding topical and systemic treatments for MFWs.

Review Methods

Full-text articles were identified with the following terms: fungating, ulcerative, wound, tumor, malignancy, antibiotics, topical, dressings, radiotherapy, head, neck, scalp, face, lip, and ear. Treatment recommendations were extrapolated, categorically summarized, and retrospectively assigned with an evidence level based on the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation).

Conclusions

In the absence of systemic signs and symptoms of infections, MFWs should not be treated as conventional infections or abscesses, with prophylactic oral or intravenous antibiotics. Topical treatments such as ointments and wound dressings are the mainstay in terms of managing the unsightly appearance and fetid odor from these entities.

Implications for Practice

MFWs are most often not amenable to definitive/curative surgical or nonsurgical therapy, but consultation with a head and neck oncologic specialist will help to determine if the underlying malignancy requires surgery, radiation therapy, or palliative treatment.

Improvement of the Patient Safety Culture in the Primary Health Care Corporation - Qatar

OBJECTIVES

Primary Health Care Corporation (PHCC) is the public primary health care provider in Qatar. Having a patient safety culture (PSC) is the keystone to enabling a continuous process to improve the quality of services and to reduce errors. The objective of this study was to assess the impact of accreditation, quality improvement trainings, and patient safety (PS) trainings on the improvement of the PSC at the PHCC in Qatar.

METHODS

The Medical Office Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality was used in 2012 and 2015 to assess the culture of PS and health care quality in the 21 health centers. The results of the two surveys were compared using the χ2 test. A P value of less than 0.05 was considered significant.

RESULTS

Out of 2689 staff working in the 21 health centers, 1810 (67.3%) completed the survey in 2012, and 2616 (70.0%) of 3735 completed the survey in 2015. The comparison between 2012 and 2015 survey's results showed a statistically significant improvement for all the 10 dimensions (P < 0.05). Although a statistically significant difference was observed between 2012 and 2015 results for work pressure and pace, three of the four questions of the work pressure and pace dimension presented nonsignificant differences.

CONCLUSIONS

The survey was a good tool to raise awareness on PS and quality issues at PHCC. There is evidence that the implementation of accreditation program, the quality improvement trainings, and PS trainings helped the organization improve its PS culture.

Physician factors associated with medical errors in Norwegian primary care emergency services

OBJECTIVE

The aim of this study was to examine the associations between characteristics of physicians working in primary care emergency units (PCEUs) and the outcome of assessments of the medical records.

DESIGN

Data from a previous case-control study was used to evaluate factors related to medical errors.

SETTING

Ten Norwegian PCEUs were included.

SUBJECTS

Physicians that had evoked a patient complaint, and a random sample of three physicians from the same PCEU and time period as the physician who had evoked a complaint. Recorded physician characteristics were: gender, seniority, citizenship at, and years after authorization as a physician, specialty in general practice, and workload at the PCEU. Main outcome measures: Assessments of the medical records: errors that may have led to harm, no medical error, or inconclusive.

RESULTS

In the complaint group 77 physicians were included, and in the random sample group 217. In the first group, 53.2% of the medical records were assessed as revealing medical errors. In the random sample group, this percentage was 3.2. In the complaint group the percentages for no-error and inconclusive for the female physicians were 30.8 and 15.4; and for the male physicians 9.8 and 27.3, p = 0.027.

CONCLUSION

In the group of complaints there was a higher percentage with no assessed medical error, and a lower percentage with inconclusive assessments of medical errors, among female physicians compared to their male colleagues. We found no other physician factors that were associated with assessed medical errors. Future research should focus on the underlying elements of these findings.Key pointsMedical errors are among the leading causes of death and they are essentially avoidable. Primary care emergency units are a vulnerable arena for committing medical errors.By assessing the medical records of a group of physicians who had evoked a complaint, no differences related to physician factors were revealed in the incidence of medical errors.In the group of female physicians, the proportion of no-errors, was higher, and the percentage of inconclusive medical records was lower than for their male colleagues.The Norwegian regulations on independent participation in PCEUs may have modulated these results.

A natural language processing pipeline to synthesize patient-generated notes toward improving remote care and chronic disease management: a cystic fibrosis case study

Objectives

Patient-generated health data (PGHD) are important for tracking and monitoring out of clinic health events and supporting shared clinical decisions. Unstructured text as PGHD (eg, medical diary notes and transcriptions) may encapsulate rich information through narratives which can be critical to better understand a patient’s condition. We propose a natural language processing (NLP) supported data synthesis pipeline for unstructured PGHD, focusing on children with special healthcare needs (CSHCN), and demonstrate it with a case study on cystic fibrosis (CF).

Materials and Methods

The proposed unstructured data synthesis and information extraction pipeline extract a broad range of health information by combining rule-based approaches with pretrained deep-learning models. Particularly, we build upon the scispaCy biomedical model suite, leveraging its named entity recognition capabilities to identify and link clinically relevant entities to established ontologies such as Systematized Nomenclature of Medicine (SNOMED) and RXNORM. We then use scispaCy’s syntax (grammar) parsing tools to retrieve phrases associated with the entities in medication, dose, therapies, symptoms, bowel movements, and nutrition ontological categories. The pipeline is illustrated and tested with simulated CF patient notes.

Results

The proposed hybrid deep-learning rule-based approach can operate over a variety of natural language note types and allow customization for a given patient or cohort. Viable information was successfully extracted from simulated CF notes. This hybrid pipeline is robust to misspellings and varied word representations and can be tailored to accommodate the needs of a specific patient, cohort, or clinician.

Discussion

The NLP pipeline can extract predefined or ontology-based entities from free-text PGHD, aiming to facilitate remote care and improve chronic disease management. Our implementation makes use of open source models, allowing for this solution to be easily replicated and integrated in different health systems. Outside of the clinic, the use of the NLP pipeline may increase the amount of clinical data recorded by families of CSHCN and ease the process to identify health events from the notes. Similarly, care coordinators, nurses and clinicians would be able to track adherence with medications, identify symptoms, and effectively intervene to improve clinical care. Furthermore, visualization tools can be applied to digest the structured data produced by the pipeline in support of the decision-making process for a patient, caregiver, or provider.

Conclusion

Our study demonstrated that an NLP pipeline can be used to create an automated analysis and reporting mechanism for unstructured PGHD. Further studies are suggested with real-world data to assess pipeline performance and further implications.

A survey of outpatient Internal Medicine clinician perceptions of diagnostic error

Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.

Diagnostic coding of chronic physical conditions in Irish general practice

Background

Chronic conditions are responsible for significant mortality and morbidity among the population in Ireland. It is estimated that almost one million people are affected by one of the four main categories of chronic disease (cardiovascular disease, chronic obstructive pulmonary disease, asthma, and diabetes). Primary healthcare is an essential cornerstone for individuals, families, and the community and, as such, should play a central role in all aspects of chronic disease management.

Aim

The aim of the project was to examine the extent of chronic disease coding of four chronic physical conditions in the general practice setting.

Methods

The design was a descriptive cross-sectional study with anonymous retrospective data extracted from practices.

Results

Overall, 8.8% of the adult population in the six participating practices were coded with at least one chronic condition. Only 0.7% of adult patients were coded with asthma, 0.3% with COPD, 3% with diabetes, and 3.3% with CVD. Male patients who visited their GP in the last year were more likely to be coded with any of the four chronic diseases in comparison with female patients. A significant relationship between gender and being coded with diabetes and CVD was found.

Conclusions

For a likely multitude of reasons, diagnostic coding in Irish general practice clinics in this study is low and insufficient for an accurate estimation of chronic disease prevalence. Monitoring of information provided through diagnostic coding is important for patients’ care and safety, and therefore appropriate training and reimbursement for these services is essential.

A Systematic Review of Measurement Tools for the Proactive Assessment of Patient Safety in General Practice

BACKGROUND

Primary care physicians have reported a difficulty in understanding how best to measure and improve patient safety in their practices.

OBJECTIVES

The aims of the study were to identify measures of patient safety suitable for use in primary care and to provide guidance on proactively monitoring and measuring safety.

METHODS

Searches were conducted using Medline, Embase, CINAHL and PsycInfo in February 2016. Studies that used a measure assessing levels of or attitudes toward patient safety in primary care were considered for inclusion. Only studies describing tools focused on the proactive assessment of safety were reviewed. Two independent reviewers extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

More than 2800 studies were screened, of which 56 were included. Most studies had used healthcare staff survey or interviews to assess patient safety (n = 34), followed by patient chart audit (n = 14) or use of a practice assessment checklist (n = 7). Survey or interview of patients, active monitoring systems, and simulated patients were used with less frequency.

CONCLUSIONS

A lack of appropriate measurement tools has been suggested to limit the ability to monitor patient safety in primary care and to improve patient care. There is no evident "best" method of measuring patient safety in primary care. However, many of the measures are readily available, quick to administer, do not require external involvement, and are inexpensive. This synthesis of the literature suggests that it is possible for primary care physicians to take a proactive approach to measuring and improving safety.

Diagnostic Errors Induced by a Wrong a Priori Diagnosis: A Prospective Randomized Simulator-Based Trial

Preventive strategies against diagnostic errors require the knowledge of underlying mechanisms. We examined the effects of a wrong a priori diagnosis on diagnostic accuracy of a focussed assessment in an acute myocardial infarction scenario. One-hundred-and-fifty-six medical students (cohort 1) were randomized to three study arms differing in the a priori diagnosis revealed: no diagnosis (control group), myocardial infarction (correct diagnosis group), and pulmonary embolism (wrong diagnosis group). Forty-four physicians (cohort 2) were randomized to the control group and the wrong diagnosis group. Primary endpoint was the participants’ final presumptive diagnosis. Among students, the correct diagnosis of an acute myocardial infarction was made by 48/52 (92%) in the control group, 49/52 (94%) in the correct diagnosis group, and 14/52 (27%) in the wrong diagnosis group (p < 0.001 vs. both other groups). Among physicians, the correct diagnosis was made by 20/21 (95%) in the control group and 15/23 (65%) in the wrong diagnosis group (p = 0.023). In the wrong diagnosis group, 31/52 (60%) students and 6/23 (19%) physicians indicated their initially given wrong a priori diagnosis pulmonary embolism as final diagnosis. A wrong a priori diagnosis significantly increases the likelihood of a diagnostic error during a subsequent patient encounter.

Lifetime Prevalence and Correlates of Patient-Perceived Medical Errors Experienced in the U.S. Ambulatory Setting: A Population-Based Study

Background: The rate of safety harm self-perceived medical errors and harms reported in the U.S. ambulatory system is not well characterized.

Objectives: To determine the prevalence of U.S. adult ambulatory care patient self-perceived safety harms and to gauge the degree of association between harms with various patient characteristics and outcomes.

Methods: A large U.S. cross-sectional online survey of 9206 ambulatory care adults was assessed for their perception of medical errors and harms during care (misdiagnosis, mistakes in care, and wrong or delayed treatment) and also included patient demographics, health status, comorbidities, insurance status, income, barriers to care (affordability, transportation, and family and social support), number of visits to primary health care services in the past 12 months, and use of urgent or emergency care in the last 12 months.

Results: The overall rate of self-perceived medical errors and harms among adult patients in the ambulatory care setting was 36%. Female patients, independent of age, and those with multiple comorbidities or barriers to care, reported the highest number of medical errors. Utilization of multiple providers was associated with a greater number of reported medical errors, often resulting in changing health care providers. Patients who reported having trouble affording health care or navigating the system to receive care also reported higher levels of harm. They were cared for by multiple providers, often switch providers, and their care is associated with greater utilization of health care resources. Patients reporting the highest rates of harm had greater use of hospital and emergency room care.

Conclusions: This large U.S. adult ambulatory care study provides evidence that patient self-perceived medical errors and harms reported by patients are common. Patient self-perceived medical errors and harms occur most commonly in women, with poor health, limitation of activities, and who have three or more comorbidities.

Physician factors associated with increased risk for complaints in primary care emergency services: a case - control study

BACKGROUND

Patient safety incidents defined as any unintended or unexpected incident that could have or were judged to have led to patient harm, are reported as relatively common. In this study patient complaints have been used as an indicator to uncover the occurrence of patient safety incidents in primary care emergency units (PCEUs) in Norway.

METHODS

Ten PCEUs in major cities and rural parts of Norway participated. These units cover one third of the Norwegian population. A case-control design was applied. The case was the physician that evoked a complaint. The controls were three randomly chosen physicians from the same PCEU as the physician having evoked the complaint. The following variables regarding the physicians were chosen: gender, citizenship at, and years after authorization as physician, and specialty in general practice. The magnitude of patient contact was defined as the workload at the PCEU. The physicians' characteristics and workload were extracted from the medical records from the fourteen-day period prior to the consultation that elicited the complaint. The rest of the variables were then obtained from the Norwegian physician position register. Logistic regression was used to estimate odds ratio for complaints both unadjusted and adjusted for the independent variables. The data were analyzed using SPSS (Version25) and STATA.

RESULTS

A total of 78 cases and 217 controls were included during 18 months (September 1st 2015 till March 1st 2017). The risk of evoking a complaint was significantly higher for physicians without specialty in general practice, and lower for those with medium low and medium high workload compared to physicians with no duty during the fourteen-day period prior to the index consultation. The limited strength of the study did not make it possible to assess any correlation between workload and the other variables (physician's gender, seniority and citizenship at time of authorization).

CONCLUSIONS

Continuous medical training and achieving the specialty in general practice were decisively associated with a reduced risk for complaints in primary care emergency services. Future research should focus on elements promoting quality of care such as continuing education, duty rosters and other structural and organizational factors.

Development and Psychometric Validation of a Questionnaire to Evaluate Knowledge and Attitude Towards Medication Error Reporting Among Pharmacists

Purpose

Assessment of medication errors (ME) is crucial to improving the quality of health care. A questionnaire that can be used to explore pharmacists’ perspectives regarding ME would be very useful as part of an ongoing process of quality improvement in patient care. The aim of this study was to develop and validate a questionnaire to measure perceived causes of ME and attitude towards ME reporting among pharmacists.

Methods

The questionnaire was developed from the literature together with outcomes from focus group discussions. It was divided into two domains which are knowledge on ME and attitude towards ME reporting. Content validity index (I-CVI), exploratory factor analysis (EFA), Cronbach alpha and intraclass correlation coefficient (ICC) to assess test–retest reliability were obtained during the validation process.

Results

Overall Cronbach alpha for internal consistency was good (0.742), where subscale of the questionnaire demonstrated adequate internal consistency, with Cronbach alpha value 0.83 for knowledge and 0.70 for reporting behaviour attitude. The I-CVI showed good scores (knowledge=0.88) and (attitude=0.81), while ICC was moderately accepted with a value of 0.77. Two factors were extracted from the 16 items in EFA.

Conclusion

The questionnaire to assess knowledge on ME and attitude towards ME reporting among pharmacists is valid and reliable. It demonstrates good psychometric properties.

Regret among primary care physicians: a survey of diagnostic decisions

BACKGROUND

Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care.

METHODS

In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016.

RESULTS

29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret.

CONCLUSION

Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.

Usability and Utility of a Mobile App to Improve Medication Adherence Among Ambulatory Care Patients in Malaysia: Qualitative Study

BACKGROUND

To date, several medication adherence apps have been developed. However, the existing apps have been developed without involving relevant stakeholders and were not subjected to mobile health app guidelines. In addition, the usability and utility of these apps have not been tested with end users.

OBJECTIVE

This study aimed to describe the usability and utility testing of a newly developed medication adherence app-Med Assist-among ambulatory care patients in Malaysia.

METHODS

The Med Assist app was developed based on the Theory of Planned Behavior and the Nielson usability model. Beta testing was conducted from March to May 2016 at a primary care clinic in Kuala Lumpur. Ambulatory care patients who scored ≥40% on the electronic health literacy scale, were aged ≥21 years, and were taking two or more long-term medications were recruited. Two rounds of in-depth interviews were conducted with each participant. The first interview, which was conducted upon participant recruitment, was to assess the usability of Med Assist. Participants were asked to download Med Assist on their phone and perform two tasks (register themselves on Med Assist and enter at least one medication). Participants were encouraged to "concurrently think aloud" when using Med Assist, while nonverbal cues were observed and recorded. The participants were then invited for a second interview (conducted ≥7 days after the first interview) to assess the utility of Med Assist after using the app for 1 week. This was done using "retrospective probing" based on a topic guide developed for utilities that could improve medication adherence.

RESULTS

Usability and utility testing was performed for the Med Assist app (version P4). A total of 13 participants were recruited (6 men, 7 women) for beta testing. Three themes emerged from the usability testing, while three themes emerged from the utility testing. From the usability testing, participants found Med Assist easy to use and user friendly, as they were able to complete the tasks given to them. However, the details required when adding a new medication were found to be confusing despite displaying information in a hierarchical order. Participants who were caregivers as well as patients found the multiple-user support and pill buddy utility useful. This suggests that Med Assist may improve the medication adherence of patients on multiple long-term medications.

CONCLUSIONS

The usability and utility testing of Med Assist with end users made the app more patient centered in ambulatory care. From the usability testing, the overall design and layout of Med Assist were simple and user friendly enough for participants to navigate through the app and add a new medication. From the participants' perspectives, Med Assist was a useful and reliable tool with the potential to improve medication adherence. In addition, utilities such as multiple user support and a medication refill reminder encouraged improved medication management.

Determining the optimal human reliability analysis (HRA) method in healthcare systems using Fuzzy ANP and Fuzzy TOPSIS

Purpose

As one of the leading causes of deaths and injuries, medical errors constitute a veritable threat to patient safety. Despite this fact, no unique method has yet been established to identify and evaluate medical errors. This study was conducted to select an optimal human reliability analysis method compatible with healthcare systems from available methods. Design/methodology/approach: In order to select the optimal method for the identification and evaluation of medical errors, different criteria and sub-criteria were determined by reviewing the literature and based on experts’ opinions. Next, weights of criteria and sub-criteria were specified by using the fuzzy analytical network process (ANP). Finally, fuzzy technique for order preference by similarity to ideal solution method was used to prioritize the methods.

Findings

Six criteria and 21 sub-criteria for choosing the optimal method were determined. The utility, usability, and structure of a method had the highest influence with weights of 0.262, 0.191, and 0.187, respectively. Based on the results of fuzzy technique for order preference by similarity to ideal solution, the Human Error Assessment and Reduction Technique method with a closeness coefficient of 0.576 was selected as the optimal method for identifying medical errors. The Human Factors Analysis and Classification System and Systematic Human Error Reduction and Prediction Approach methods ranked second and third, respectively. Originality/value: To date, no studies have attempted to determine the optimal methods for identification and assessment of medical errors. This paper aimed to fill this gap by using fuzzy analytical network process and fuzzy technique for order preference by similarity to ideal solution techniques.

Accuracy of the medication list in the electronic health record-implications for care, research, and improvement

Objective

Electronic medication lists may be useful in clinical decision support and research, but their accuracy is not well described. Our aim was to assess the completeness of the medication list compared to the clinical narrative in the electronic health record.

Methods

We reviewed charts of 30 patients with inflammatory bowel disease (IBD) from each of 6 gastroenterology centers. Centers compared IBD medications from the medication list to the clinical narrative.

Results

We reviewed 379 IBD medications among 180 patients. There was variation by center, from 90% patients with complete agreement between the medication list and clinical narrative to 50% agreement.

Conclusions

There was a range in the accuracy of the medication list compared to the clinical narrative. This information may be helpful for sites seeking to improve data quality and those seeking to use medication list data for research or clinical decision support.

Potential value of patient record review to assess and improve patient safety in general practice: A systematic review

Background: There is limited research, and guidance, on how to address safety in general practice proactively.

Objectives: This review aimed to synthesize the literature describing the use of patient record review (PRR) to measure and improve patient safety in primary care. The PRR methodologies utilized and the resulting outcomes were examined.

Methods: Searches were conducted using Medline, Embase, CINAHL and PsycINFO in February 2017. Reference lists of included studies and existing review papers were also screened. English language, peer-reviewed studies that utilized PRR to identify patient safety incidents (PSIs) occurring in general practice were included. Two researchers independently extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs.

Results: A total of 3265 studies were screened, with 15 included. Trigger tools were the most frequent method used for the PRRs (n = 6). The mean number of safety incidents per 100 records was 12.6. Within studies, a mean of 30.6% of incidents were associated with severe harm (range 8.6–50%), and a mean of 55.6% of incidents was considered preventable (range 32.7–93.5%). The most commonly identified types of PSIs related to medication and prescribing, diagnosis, communication and treatment. Three studies reported on improvement actions taken after the PRRs.

Conclusion: This review suggests that PRR may be a promising means of proactively identifying patient safety incidents and informing improvements.

Exploration of Nurses' Knowledge, Attitudes, and Perceived Barriers towards Medication Error Reporting in a Tertiary Health Care Facility: A Qualitative Approach

Medication error reporting (MER) is an effective way used to identify the causes of Medication Errors (MEs) and to prevent repeating them in future. The underreporting of MEs is a challenge generally in all MER systems. The current research aimed to explore nurses' knowledge on MER by determining their attitudes towards reporting and studying the implicated barriers and facilitators. A total of 23 nurses were interviewed using a semi-structured interview guide. The saturation point was attained after 21 interviews. All the interviews were tape-recorded and transcribed verbatim, and analysed using inductive thematic analysis. Four major themes and 17 sub-themes were identified. Almost all the interviewees were aware about the existence of the MER system. They showed a positive attitude towards MER. The main barriers for MER were the impacts of time and workload, fear of investigation, impacts on the job, and negative reactions from the person in charge. The nurses were knowledgeable about MER but there was uncertainty towards reporting harmless MEs, thus indicating the need for an educational program to highlight the benefits of near-miss reporting. To improve participation strategies, a blameless reporting culture, reporting anonymously, and a simplified MER process should be considered.

The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics: a cluster randomised trial

BACKGROUND

To evaluate the effectiveness of a structured prescription review and prescriber feedback program in reducing prescribing errors in government primary care clinics within an administrative region in Malaysia.

METHODS

This was a three group, pragmatic, cluster randomised trial. In phase 1, we randomised 51 clinics to a full intervention group (prescription review and league tables plus authorised feedback letter), a partial intervention group (prescription review and league tables), and a control group (prescription review only). Prescribers in these clinics were the target of our intervention. Prescription reviews were performed by pharmacists; 20 handwritten prescriptions per prescriber were consecutively screened on a random day each month, and errors identified were recorded in a standardised data collection form. Prescribing performance feedback was conducted at the completion of each prescription review cycle. League tables benchmark prescribing errors across clinics and individual prescribers, while the authorised feedback letter detailed prescribing performance based on a rating scale. In phase 2, all clinics received the full intervention. Pharmacists were trained on data collection, and all data were audited by researchers as an implementation fidelity strategy. The primary outcome, percentage of prescriptions with at least one error, was displayed in p-charts to enable group comparison.

RESULTS

A total of 32,200 prescriptions were reviewed. In the full intervention group, error reduction occurred gradually and was sustained throughout the 8-month study period. The process mean error rate of 40.7% (95% CI 27.4, 29.5%) in phase 1 reduced to 28.4% (95% CI 27.4, 29.5%) in phase 2. In the partial intervention group, error reduction was not well sustained and showed a seasonal pattern with larger process variability. The phase 1 error rate averaging 57.9% (95% CI 56.5, 59.3%) reduced to 44.8% (95% CI 43.3, 46.4%) in phase 2. There was no evidence of improvement in the control group, with phase 1 and phase 2 error rates averaging 41.1% (95% CI 39.6, 42.6%) and 39.3% (95% CI 37.8, 40.9%) respectively.

CONCLUSIONS

The rate of prescribing errors in primary care settings is high, and routine prescriber feedback comprising league tables and a feedback letter can effectively reduce prescribing errors.

TRIAL REGISTRATION

National Medical Research Register: NMRR-12-108-11,289 (5th March 2012).

Variation of polypharmacy in older primary care attenders occurs at prescriber level

BACKGROUND

Polypharmacy is particularly important in older persons as they are more likely to experience adverse events compared to the rest of the population. Despite the relevance, there is a lack of studies on the possible association of patient, prescriber and practice characteristics with polypharmacy. Thus, the aim of this study was to determine the rate of polypharmacy among older persons attending public and private primary care clinics, and its association with patient, prescriber and practice characteristics.

METHODS

We used data from The National Medical Care Survey (NMCS), a national cross-sectional survey of patients' visits to primary care clinics in Malaysia. A weighted total of 22,832 encounters of patients aged ≥65 years were analysed. Polypharmacy was defined as concomitant use of five medications and above. Multilevel logistic regression was performed to examine the association of polypharmacy with patient, prescriber and practice characteristics.

RESULTS

A total of 20.3% of the older primary care attenders experienced polypharmacy (26.7%% in public and 11.0% in private practice). The adjusted odds ratio (OR) of polypharmacy were 6.37 times greater in public practices. Polypharmacy was associated with patients of female gender (OR 1.49), primary education level (OR 1.61) and multimorbidity (OR 14.21). The variation in rate of polypharmacy was mainly found at prescriber level.

CONCLUSION

Polypharmacy is common among older persons visiting primary care practices. Given the possible adverse outcomes, interventions to reduce the burden of polypharmacy are best to be directed at individual prescribers.

The global burden of diagnostic errors in primary care

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.

Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital

INTRODUCTION

Even though nursing care documentation is an important part of nursing practice, it is commonly left undone. The objective of this study was to assess nursing care documentation practice and the associated factors among nurses who are working at the University of Gondar Hospital.

METHODS

An institution-based cross-sectional study was conducted among 220 nurses working at the University of Gondar Hospital inpatient wards from March 20 to April 30, 2014. Data were collected using a structured and pre-tested self-administered questionnaire. Data were entered into Epi Info version 7 and analyzed with SPSS version 20. Descriptive statistics, bivariate, and multivariate logistic regression analyses were carried out.

RESULTS

Two hundred and six nurses returned the questionnaire. Good nursing care documentation practice among nurses was 37.4%. A low nurse-to-patient ratio AOR = 2.15 (95%CI [1.155, 4.020]), in-service training on standard nursing process AOR = 2.6 (95%CI[1.326, 5.052]), good knowledge AOR = 2.156(95% CI [1.092, 4.254]), and good attitude toward nursing care documentation AOR = 2.22 (95% CI [1.105, 4.471] were significantly associated with nursing care documentation practice.

CONCLUSION

Most of the nursing care provided remains undocumented. Nurse-to-patient ratio, in-service training, knowledge, and attitude of nurses toward nursing care documentation were factors associated with nursing care documentation practice.

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia

Objective

To explore and understand participants’ perceptions and attitudes towards the reporting of medication errors (MEs).

Methods

A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach.

Results

Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter’s burden and benefit of reporting also were identified.

Conclusions

Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

Cognitive biases associated with medical decisions: a systematic review

Background

Cognitive biases and personality traits (aversion to risk or ambiguity) may lead to diagnostic inaccuracies and medical errors resulting in mismanagement or inadequate utilization of resources. We conducted a systematic review with four objectives: 1) to identify the most common cognitive biases, 2) to evaluate the influence of cognitive biases on diagnostic accuracy or management errors, 3) to determine their impact on patient outcomes, and 4) to identify literature gaps.

Methods

We searched MEDLINE and the Cochrane Library databases for relevant articles on cognitive biases from 1980 to May 2015. We included studies conducted in physicians that evaluated at least one cognitive factor using case-vignettes or real scenarios and reported an associated outcome written in English. Data quality was assessed by the Newcastle-Ottawa scale. Among 114 publications, 20 studies comprising 6810 physicians met the inclusion criteria. Nineteen cognitive biases were identified.

Results

All studies found at least one cognitive bias or personality trait to affect physicians. Overconfidence, lower tolerance to risk, the anchoring effect, and information and availability biases were associated with diagnostic inaccuracies in 36.5 to 77 % of case-scenarios. Five out of seven (71.4 %) studies showed an association between cognitive biases and therapeutic or management errors. Of two (10 %) studies evaluating the impact of cognitive biases or personality traits on patient outcomes, only one showed that higher tolerance to ambiguity was associated with increased medical complications (9.7 % vs 6.5 %; p = .004). Most studies (60 %) targeted cognitive biases in diagnostic tasks, fewer focused on treatment or management (35 %) and on prognosis (10 %). Literature gaps include potentially relevant biases (e.g. aggregate bias, feedback sanction, hindsight bias) not investigated in the included studies. Moreover, only five (25 %) studies used clinical guidelines as the framework to determine diagnostic or treatment errors. Most studies (n = 12, 60 %) were classified as low quality.

Conclusions

Overconfidence, the anchoring effect, information and availability bias, and tolerance to risk may be associated with diagnostic inaccuracies or suboptimal management. More comprehensive studies are needed to determine the prevalence of cognitive biases and personality traits and their potential impact on physicians’ decisions, medical errors, and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0377-1) contains supplementary material, which is available to authorized users.

Separation of prescribing and dispensing in Malaysia: the history and challenges

This article serves as an update to the work by Shafie et al. (2012) which previously reviewed the benefits of policies separating prescribing and dispensing in various countries to advocate its implementation in Malaysia. This article seeks to strengthen the argument by highlighting not only the weaknesses of the Malaysian health care system from the historical, professional and economic viewpoints but also the shortcomings of both medical and pharmacy professions in the absence of separation of dispensing. It also provides a detailed insight into the ongoing initiatives taken to consolidate the role of pharmacists in the health care system in the advent of separation of dispensing. Under the two tier system in Malaysia at present, the separation of prescribing and dispensing is implemented only in government hospitals. The absence of this separation in the private practices has led to possible profit-oriented medical and pharmacy practices which hinder safe and cost-effective delivery of health services. The call for separation of dispensing has gained traction over the years despite various hurdles ranging from the formidable resistance from the medical fraternity to the public's scepticism towards the new policy. With historical testament and present evidence pointing towards the merits of a system in which doctors prescribe and pharmacists dispense, the implementation of this health care model is justified.

Productivity and performance improvement in the medical records department of a hospital

Purpose

– The purpose of this paper is to illustrate how Lean Six Sigma (LSS) methodology was applied to a medical records department (MRD) of a hospital in India to reduce the Turn-Around-Time (TAT) of medical records preparation process and thus to improve the productivity and performance of the department.

Design/methodology/approach

– The research reported in this paper is based on a case study carried out using LSS approach and in improving the medical records preparation process.

Findings

– The root causes for the problem were identified and validated through data-based analysis from LSS tool box, at different stages in the project. As a result of this project, the TAT was reduced from average 19 minutes to eight minutes and the standard deviation was reduced by one-tenth, which was a remarkable achievement for department under study. This was resulted in the reduction in the work-in-process inventory of medical records from 40 units to 0 at the end of the day. Project in-turn reduced the staffing level from the earlier level of six to a current level of four.

Research limitations/implications

– The paper is based on a single case study executed in IP-MRD of a single hospital and hence there is limitation in generalizing the specific results from the study. But the approach adopted and the learning from this study can be generalized.

Originality/value

– This paper will be helpful for those professionals who are interested in implementing LSS to healthcare organization to improve the productivity and performance.

Weaving together peer assessment, audios and medical vignettes in teaching medical terms

OBJECTIVE

The current study aims at exploring the possibility of aligning peer assessment, audiovisuals, and medical case-report extracts (vignettes) in medical terminology teaching. In addition, the study wishes to highlight the effectiveness of audio materials and medical history vignettes in preventing medical students' comprehension, listening, writing, and pronunciation errors. The study also aims at reflecting the medical students' attitudes towards the teaching and learning process.

METHODS

The study involved 161 medical students who received an intensive medical terminology course through audio and medical history extracts. Peer assessment and formative assessment platforms were applied through fake quizzes in a pre- and post-test manner. An 18-item survey was distributed amongst students to investigate their attitudes and feedback towards the teaching and learning process. Quantitative and qualitative data were analysed using the SPSS software.

RESULTS

The students did better in the posttests than on the pretests for both the quizzes of audios and medical vignettes showing a t-test of -12.09 and -13.60 respectively. Moreover, out of the 133 students, 120 students (90.22%) responded to the survey questions. The students gave positive attitudes towards the application of audios and vignettes in the teaching and learning of medical terminology and towards the learning process.

CONCLUSIONS

The current study revealed that the teaching and learning of medical terminology have more room for the application of advanced technologies, effective assessment platforms, and active learning strategies in higher education. It also highlights that students are capable of carrying more responsibilities of assessment, feedback, and e-learning.

Medication incidents in primary care medicine: protocol of a study by the Swiss Federal Sentinel Reporting System

BACKGROUND/RATIONALE

Patient safety is a major concern in healthcare systems worldwide. Although most safety research has been conducted in the inpatient setting, evidence indicates that medical errors and adverse events are a threat to patients in the primary care setting as well. Since information about the frequency and outcomes of safety incidents in primary care is required, the goals of this study are to describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents.

STUDY DESIGN AND SETTING

We will conduct a prospective surveillance study to identify cases of medication incidents among primary care patients in Switzerland over the course of the year 2015.

PARTICIPANTS

Patients undergoing drug treatment by 167 general practitioners or paediatricians reporting to the Swiss Federal Sentinel Reporting System.

INCLUSION CRITERIA

Any erroneous event, as defined by the physician, related to the medication process and interfering with normal treatment course.

EXCLUSION CRITERIA

Lack of treatment effect, adverse drug reactions or drug-drug or drug-disease interactions without detectable treatment error.

PRIMARY OUTCOME

Medication incidents.

RISK FACTORS

Age, gender, polymedication, morbidity, care dependency, hospitalisation.

STATISTICAL ANALYSIS

Descriptive statistics to assess type, frequency, seasonal and regional distribution of medication incidents and logistic regression to assess their association with potential risk factors. Estimated sample size: 500 medication incidents.

LIMITATIONS

We will take into account under-reporting and selective reporting among others as potential sources of bias or imprecision when interpreting the results.

ETHICS AND DISSEMINATION

No formal request was necessary because of fully anonymised data. The results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT0229537.

Investigating an outbreak of acute fever in Chuuk, Federated States of Micronesia

OBJECTIVE

In September 2012, there was an unexpected increase of acute febrile illness (AFI) in Chuuk State of the Federated States of Micronesia. At the same time, dengue outbreaks were occurring in two of the Federated States of Micronesia's other three states. The cause of AFI was suspected to be dengue; however, by the end of October, only one of 39 samples was positive for dengue. The objective of the investigation was to establish the cause of the outbreak.

METHODS

A line list was created and data analysed by time, place, person and clinical features. Reported symptoms were compared with the published symptoms of several diagnoses and laboratory testing undertaken.

RESULTS

Of the 168 suspected cases, 62% were less than 20 years of age and 60% were male. The clinical features of the cases were not typical for dengue but suggestive of respiratory illness. Nasopharyngeal swabs were subsequently collected and found to be positive for influenza. Public health measures were undertaken and the AFI returned to expected levels.

DISCUSSION

Clinical diagnosis of acute febrile illness (AFI) can often be difficult and misleading. This can mean that opportunities for preventive measures early on in an outbreak are missed. In any outbreak, descriptive epidemiological analyses are valuable in helping to ascertain the cause of the outbreak.

Reducing Medical Errors in Primary Care Using a Pragmatic Complex Intervention

This study aimed to develop an intervention to reduce medical errors and to determine if the intervention can reduce medical errors in public funded primary care clinics. A controlled interventional trial was conducted in 12 conveniently selected primary care clinics. Random samples of outpatient medical records were selected and reviewed by family physicians for documentation, diagnostic, and management errors at baseline and 3 months post intervention. The intervention package comprised educational training, structured process change, review methods, and patient education. A significant reduction was found in overall documentation error rates between intervention (Pre 98.3% [CI 97.1-99.6]; Post 76.1% [CI 68.1-84.1]) and control groups (Pre 97.4% [CI 95.1-99.8]; Post 89.5% [85.3-93.6]). Within the intervention group, overall management errors reduced from 54.0% (CI 49.9-58.0) to 36.6% (CI 30.2-43.1) and medication error from 43.2% (CI 39.2-47.1) to 25.2% (CI 19.9-30.5). This low-cost intervention was useful to reduce medical errors in resource-constrained settings.

Why are chemotherapy administration errors not reported? Perceptions of oncology nurses in a Nigerian tertiary health institution

OBJECTIVE

The administration of chemotherapy forms a major part of the clinical role of oncology nurses. When a mistake is made during chemotherapy administration, admitting and reporting the error timely could save the lives of cancer patients. The main objective of this study was to assess the perceptions of oncology nurses about why chemotherapy administration errors are not reported.

METHODS

This is a descriptive study that surveyed a convenient sample of 128 oncology nurses currently practicing in the Ogun State University Teaching Hospital, Nigeria. The tool for data collection was a structured questionnaire that consisted of two sections. The first section was for the demographic data of participants and the second section consisted of questions constructed based on the Medication Administration Error (MAE) reporting survey developed by Wakefield and his team.

RESULTS

Findings showed that majority of the nurses (89.8%) have made at least one MAE in the course of their professional practice. Fear (mean = 3.63) and managerial response (mean = 2.87) were the two major barriers to MAE reporting perceived among oncology nurses.

CONCLUSION

Critically analyzing why medication errors are not reported among oncology nurses is crucial to identifying strategic interventions that would promote reporting of all errors, especially those related to chemotherapy administration. It is therefore recommended that nurse managers and health care administrators should create a favorable atmosphere that does not only prevent medication errors but also supports nurses' voluntary reporting of MAEs. Education, information and communication strategies should also be put in place to train nurses on the need to report, if possible prevent, all medication errors.