Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients

What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving diagnosis

Diagnostic errors in health care are a global threat to patient safety. Researchers have traditionally focused diagnostic safety efforts on identifying errors and their causes with the goal of reducing diagnostic error rates. More recently, complementary approaches to diagnostic errors have focused on improving diagnostic performance drawn from the safety sciences. These approaches have been called Safety-II and Safety-III, which apply resilience engineering and system safety principles, respectively. This review explores the safety science paradigms and their implications for analyzing diagnostic errors, highlighting their distinct yet complementary perspectives. The integration of Safety-I, Safety-II, and Safety-III paradigms presents a promising pathway for improving diagnosis. Diagnostic researchers not yet familiar with the various approaches and potential paradigm shift in diagnostic safety research may use this review as a starting point for considering Safety-I, Safety-II, and Safety-III in their efforts to both reduce diagnostic errors and improve diagnostic performance.

Lessons from the COVID-19 pandemic in paediatric post-discharge care

The COVID-19 pandemic dictated rapid reform in outpatient paediatric services. To reduce ward footfall and its associated infection risk, a trainee-led outpatient clinic was established with the aim to provide children with continuity of care following discharge from hospital. The service was created as a safe alternative to the long-standing practice of ward attenders while reducing mounting pressures on appointments at consultant-led clinics. Several issues arose in its implementation. A retrospective analysis with insights from service users found significant communication issues at various stages in referral, booking and follow-up management. This project aimed to reduce clinic non-attendance rates and ensure timely outpatient review with effective communication to all parties.Quality improvement methods allowed the problem to be understood and defined. Through consultation with service users in the start-up phase of the project, four key criteria were determined as essential for improving communication: indication, lead consultant, patient attendance and outcome letter provision. The project aimed to achieve 100% compliance across the four criteria during the 6-month project period. A baseline measure was established and measurements collected while five interventions were tested using plan-do-study-act test cycles.Following the small-scale tests, the run chart illustrated process improvement leading to meaningful change in outcome at both patient and service level. During the project, performance increased from a baseline median of one to a minimum of three out of four criteria being met for every patient. Several patients and families had a change in management as a direct result of their timely review and communication of clinic outcomes. These interventions resulted in a 50% reduction in the clinic's did not attend rate.The initial pandemic response to facilitate post-discharge care for children and young people led to frustrations surrounding communication breakdown among service users. Targeted interventions led to the development of a safer, more efficient service. Ongoing feedback continues to guide strategies for change with future work in service development focusing on capturing patient experience and improving patient-centred outcomes.

Organizational Expectations Regarding Documentation Practices in Athletic Training

CONTEXT

Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor's role in creating policy and procedures, communicating expectations, and ensuring accountability has not been investigated.

OBJECTIVE

To investigate supervisor practices regarding support, hindrance, and enforcement of medical documentation standards at an individual organization level.

DESIGN

Mixed-methods study.

SETTING

Online surveys and follow-up interviews.

PATIENTS OR OTHER PARTICIPANTS

We criterion sampled supervising athletic trainers (n = 1107) in National Collegiate Athletic Association member schools. The survey collected responses from 64 participants (age = 43 ± 11 years; years of experience as a supervisor = 12 ± 10; access rate = 9.6%; completion rate = 66.7%), and 12 (age = 35 ± 6 years; years of experience as a supervisor = 8 ± 5) participated in a follow-up interview.

DATA COLLECTION AND ANALYSIS

We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multiphase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, and internal and external auditing.

RESULTS

Fewer than half of supervisors reported having formal written organization-level documentation policies (n = 45/93, 48%) and procedures (n = 32/93, 34%) and an expected timeline for completing documentation (n = 24/84, 29%). Participants described a framework relative to orienting new and existing employees, communicating policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality.

CONCLUSION

Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees' abilities to create complete and accurate records. This highlights a gap between supervisor and employee perceptions, as practicing athletic trainers have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization, and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.

Effect of Standardized Reminder Calls on Trauma Patient No-Show Rate

BACKGROUND

Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months.

STUDY DESIGN

The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models.

RESULTS

A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001).

CONCLUSIONS

Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.

Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers

Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.

Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies' Report Improving Diagnosis in Health Care

BACKGROUND

Standards for accurate and timely diagnosis are ill-defined. In 2015, the National Academies of Science, Engineering, and Medicine (NASEM) committee published a landmark report, Improving Diagnosis in Health Care , and proposed a new definition of diagnostic error, "the failure to ( a ) establish an accurate and timely explanation of the patient's health problem(s) or ( b ) communicate that explanation to the patient."

OBJECTIVE

This study aimed to explore how researchers operationalize the NASEM's definition of diagnostic error with relevance to accuracy, timeliness, and/or communication in peer-reviewed published literature.

METHODS

Using the Arskey and O'Malley's framework framework, we identified published literature from October 2015 to February 2021 using Medline and Google Scholar. We also conducted subject matter expert interviews with researchers.

RESULTS

Of 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by theme: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies indicated using the NASEM definition. Of those, 5 studies also operationalized with existing definitions proposed before the NASEM report. Four studies operationalized the components of the NASEM definition and did not cite existing definitions. Three studies operationalized error using existing definitions only. Subject matter experts indicated that the NASEM definition functions as foundation for researchers to conceptualize diagnostic error.

CONCLUSIONS

The NASEM report produced a common understanding of diagnostic error that includes accuracy, timeliness, and communication. In recent peer-reviewed literature, most researchers continue to use pre-NASEM report definitions to operationalize accuracy and timeliness. The report catalyzed the use of patient-centered concepts in the definition, resulting in emerging studies focused on examining errors related to communicating diagnosis to patients.

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy

Solving diagnostic errors is difficult and progress on preventing those errors has been slow since the 2015 National Academy of Medicine report. There are several methods used to improve diagnostic and other errors including voluntary reporting; malpractice claims; patient complaints; physician surveys, random quality reviews and audits, and peer review data which usually evaluates single cases and not the systems that allowed the error. Additionally, manual review of charts is often labor intensive and reviewer dependent. In 2010 we developed an e-Autopsy/e-Biopsy (eA/eB) methodology to aggregate cases with quality/safety/diagnostic issues, focusing on a specific population of patients and conditions. By performing a hybrid review process (cases are first filtered using administrative data followed by standardized manual chart reviews) we can efficiently identify patterns of medical and diagnostic error leading to opportunities for system improvements that have improved care for future patients. We present a detailed methodology for eA/eB studies and describe results from three successful studies on different diagnoses (ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer) that illustrate our eA/eB process and how it reveals insights into creating systems that reduce diagnostic and other errors. The eA/eB process is innovative and transferable to other healthcare organizations and settings to identify trends in diagnostic error and other quality issues resulting in improved systems of care.

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement

OBJECTIVES

Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care.

METHODS

The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics.

RESULTS

During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings.

CONCLUSIONS

Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.

Interprofessional teamwork in healthcare: Observations and the road ahead

In this effort we draw from the literature on interprofessional teamwork in high reliability organizations from different fields of study, including healthcare, industrial/organizational psychology, and management. We combine this literature with our collective experience to offer five observations on future needs for the field of team science research and practice. These themes include: (1) exploration of nonclinical teams, (2) evaluation of multi-team systems in healthcare, (3) the study of dyad leadership of teams, (4) the proliferation of virtual healthcare teams, and (5) the continuing integration of organizational and team science into the study of interprofessional teams. By presenting these observations, we argue why each is critical to the overall understanding of interprofessional teamwork in healthcare and provide areas for future scholarly advancement that will inform healthcare practice.

Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis

OBJECTIVES

The aims of the study were to assess a system-based approach to event investigation and analysis-collaborative case reviews (CCRs)-and to measure impact of clinical specialty on strength of action items prescribed.

METHODS

A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes. This institutional review board-approved study describes the program, including percentage of CCR from an institutional Electronic Safety Reporting System, percentage of CCR per specialty, and action item completion rates and strength (e.g., stronger) based on a Veterans Administration-designed hierarchy. χ2 analysis assessed impact of clinical specialty on strength of action prescribed.

RESULTS

Seventy-three CCR in 2018 generated 260 action items from 10 specialties. Seventy percent (51/73) were adverse events identified through Electronic Safety Reporting System. The specialty most frequently associated with CCR was radiology (16/73, 22%). Most action items (204/260, 78%) were completed in 1 year; stronger action items were completed in 71 (27%) of 260. Radiology was responsible for 61 action items; 25 (41%) of 61 were strong versus all other specialties with strong action items in 46 (23%) of 199 (P < 0.01).

CONCLUSIONS

An integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments. Active engagement in CCR can provide insights into addressing adverse events and promote patient safety.

Technology-Based Closed-Loop Tracking for Improving Communication and Follow-up of Pathology Results

OBJECTIVE

Failure to follow-up on laboratory test results can lead to missed diagnoses, diagnostic delays, patient harm, and potential malpractice claims against providers. State-of-the-art tracking technologies such as the radio frequency identification (RFID) can potentially improve laboratory order processing and test result communication. We conducted a comparative evaluation of differences in completion rates for 5 testing process milestones and time to reach these process milestones, with and without RFID order tracking for skin biopsy orders.

METHODS

This observational study analyzed 48,515 orders from 20 dermatology providers, sent to 8 pathology laboratories in 2016 to 2017. Descriptive t tests and multiple Cox proportional hazard regressions were used to examine the differences in completion rates and times to the 5 testing process milestones, namely, (1) provider receipt of results, (2) provider review of results, (3) patient notification, (4) follow-up scheduling, and (5) order case closure, for orders processed with and without RFID order tracking.

RESULTS

Descriptive statistics illustrated that all 5 testing process milestone completion rates were statistically higher for RFID tracked orders compared with non-RFID tracked orders, and RFID tracked orders took 3 to 5 days lesser than non-RFID tracked orders to reach the 5 testing process milestones. Multiple cox proportional hazard regressions showed that the process milestones were achieved faster if orders were RFID tracked versus not (hazard ratios ranged from 1.3 to 4.9).

CONCLUSIONS

The RFID tracking technology considerably improved test result communication timeliness and reliability. Such technologies can be beneficial for laboratory order processing, and their effectiveness should be explored in other practice settings.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem

OBJECTIVES

The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention.

METHODS

The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken.

RESULTS

There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%).

CONCLUSIONS

The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.

Assessments of heart failure and frailty-related health instability provide complementary and useful information for home care planning and prognosis

BACKGROUND

Health instability, measured with the Changes in Health and End-stage disease Signs and Symptoms (CHESS) scale, predicts hospitalizations and mortality in home care clients. Heart failure (HF) is also common among home care clients. We seek to understand how HF contributes to the odds of death, hospitalization or worsening health among new home care clients depending on admission health instability.

METHODS

We undertook a retrospective cohort study of home care clients aged 65 years and older between January 1st 2010 and March 31st 2015 from Alberta, British Columbia, Ontario, and the Yukon, Canada. We used multistate Markov models to derive adjusted odds ratios (OR) for transitions to different health instability states, hospitalization, and death. We examined the role of HF and CHESS at 6 months after home care admission.

RESULTS

The sample included 286,232 clients. Those with HF had greater odds of worsening health instability than those without HF. At low-moderate admission health instability (CHESS 0-2), clients with HF had greater odds of hospitalization and death than those without HF. Clients with HF and high health instability (CHESS≥3) had slightly greater odds of hospitalization (OR 1.08, 95% Confidence Interval 1.02-1.13) but similar odds of death (OR 1.024, 95% CI 0.937-1.120) compared to clients without HF.

CONCLUSIONS

Among new home care clients, a HF diagnosis predicts death, hospitalization and worsening health, predominantly among those with low-moderate admission health instability. A HF diagnosis and admission CHESS score provide complementary information to support care planning in this population.

The jaw-dropping costs of oral cavity cancer malpractice

BACKGROUND

Medical litigation is different than it was 20 years ago due to changes in health care. This study provides an updated analysis of oral cavity malpractice litigation from the past two decades (2000-2010 and 2011-2019).

METHODS

Verdict reviews from the Westlaw database were analyzed from January 2000 to August 2019. Data were collected and analyzed with the Statistical Package for the Social Sciences.

RESULTS

Sixty-five lawsuits were evaluated across 24 states. Failure to diagnose was the most common allegation in both decades. Adjusting for inflation, the average amount awarded from 2000 to 2010 was $1 721 068 and $3 925 504 from 2011 to 2019.

CONCLUSIONS

There has been a significant rise in allegations of failure to biopsy and failure to refer (p < 0.05). In addition, while award amounts appear different between decades, the difference is not statistically significant (p = 0.248). Education should focus on early diagnosis, biopsy, and referral to physicians who routinely care for this patient population.

A Quality Improvement Intervention Leveraging a Safety Net Model for Surveillance Colonoscopy Completion

Systems to address follow-up testing of clinically positive surveillance colonoscopy results are lacking. The impact of an ambulatory safety net (ASN) intervention on rates of colonoscopy completion was assessed. The ASN team identified patients using an electronic registry, conducted patient outreach, coordinated care, and tracked colonoscopy completion. In all, 701 patients were captured in the ASN program: 58.1% (407/701) had possible barriers to follow-up colonoscopy completion, with rates of 80.1% (236/294) if no barrier, and 40.9% (287/701) overall. Colonoscopy completion likelihood increased with prior polypectomy (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.3), and decreased with White race (OR, 0.5; 95% CI, 0.3-0.9), increased inpatient visits (OR, 0.6; 95% CI, 0.4-0.9), more outreach attempts (OR, 0.6; 95% CI, 0.5-0.7), and fair/poor/inadequate preparation (OR, 0.4; 95% CI, 0.2-0.7) in logistic regression models. An ASN model for quality improvement promotes colonoscopy completion rates and identifies patient barriers.

Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims

OBJECTIVE

Diagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.

SETTING/PARTICIPANTS

1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 'index' outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).

OUTCOME MEASURES

90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.

DESIGN

Using retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.

RESULTS

Rates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI -5.0 to -0.7, p=0.008), 4.1 fewer hospitalisations (95% CI -6.9 to -1.2, p=0.006) and 4.9 fewer ED visits (95% CI -8.1% to -1.6%, p=0.003) per 1000 visits.

CONCLUSION

Higher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

A Narrative Review of Methods for Causal Inference and Associated Educational Resources

BACKGROUND AND OBJECTIVES

Root cause analysis involves evaluation of causal relationships between exposures (or interventions) and adverse outcomes, such as identification of direct (eg, medication orders missed) and root causes (eg, clinician's fatigue and workload) of adverse rare events. To assess causality requires either randomization or sophisticated methods applied to carefully designed observational studies. In most cases, randomized trials are not feasible in the context of root cause analysis. Using observational data for causal inference, however, presents many challenges in both the design and analysis stages. Methods for observational causal inference often fall outside the toolbox of even well-trained statisticians, thus necessitating workforce training.

METHODS

This article synthesizes the key concepts and statistical perspectives for causal inference, and describes available educational resources, with a focus on observational clinical data. The target audience for this review is clinical researchers with training in fundamental statistics or epidemiology, and statisticians collaborating with those researchers.

RESULTS

The available literature includes a number of textbooks and thousands of review articles. However, using this literature for independent study or clinical training programs is extremely challenging for numerous reasons. First, the published articles often assume an advanced technical background with different notations and terminology. Second, they may be written from any number of perspectives across statistics, epidemiology, computer science, or philosophy. Third, the methods are rapidly expanding and thus difficult to capture within traditional publications. Fourth, even the most fundamental aspects of causal inference (eg, framing the causal question as a target trial) often receive little or no coverage. This review presents an overview of (1) key concepts and frameworks for causal inference and (2) online documents that are publicly available for better assisting researchers to gain the necessary perspectives for functioning effectively within a multidisciplinary team.

CONCLUSION

A familiarity with causal inference methods can help risk managers empirically verify, from observed events, the true causes of adverse sentinel events.

Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data

IMPORTANCE

Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged.

OBJECTIVE

To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018.

MAIN OUTCOMES AND MEASURES

Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved.

RESULTS

Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.

CONCLUSIONS AND RELEVANCE

This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.

Health Care Provider Factors Associated with Patient-Reported Adverse Events and Harm

BACKGROUND

Patients can provide valuable information missing from traditional sources of safety data, thus adding new insights about factors that lead to preventable harm. In this study, researchers determined associations between patient-reported contributory factors and patient-reported harms experienced after an adverse event (AE).

METHODS

A secondary analysis was conducted of a national sample of patient-reported AEs (surgical, medication, diagnostic, and hospital-acquired infection) gathered through an online questionnaire between January 2010 and February 2016. Generalized logit multivariable regression was used to assess the association between patient-reported contributory factors and patient-reported harms (grouped as nonphysical harm only, physical harm only, physical harm and emotional or financial harm, and all three harms) and adjusted for patient and AE characteristics.

RESULTS

One third of patients (32.6%) reported experiencing all three harms, 27.3% reported physical harms and one additional harm, 25.5% reported physical harms only, and 14.7% reported nonphysical harms only. Patients reporting all three harms were 2.5 times more likely to have filed a report with a responsible authority (95% confidence interval [CI] = 1.23-5.01) and 3.3 times more likely to have also experienced a surgical complication (95% CI = 1.42-7.51). Odds of reporting problems related to communication between clinician and patients/families or clinician-related behavioral issues was 13% higher in those experiencing all three harm types (95% CI = 1.07-1.19).

CONCLUSION

Patients' experiences are important to identify safety issues and reduce harm and should be included in patient safety measurement and improvement activities. These findings underscore the need for policy and practice changes to identify, address, and support harmed patients.

Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE

BACKGROUND

Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors.

METHODS

Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts.

RESULTS

Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2-9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors.

CONCLUSIONS

EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.

Unscheduled Radiologic Examination Orders in the Electronic Health Record: A Novel Resource for Targeting Ambulatory Diagnostic Errors in Radiology

PURPOSE

The aim of this study was to assess the prevalence of unscheduled radiologic examination orders in an electronic health record, and the proportion of unscheduled orders that are clinically necessary, by modality.

METHODS

This retrospective study was conducted from January to October 2016 at an academic institution. All unscheduled radiologic examination orders were retrieved for seven modalities (CT, MR, ultrasound, obstetric ultrasound, bone densitometry, mammography, and fluoroscopy). After excluding duplicates, 100 randomly selected orders from each modality were assigned to two physician reviewers who classified their clinical necessity, with 10% overlap. Interannotator agreement was assessed using κ statistics, the percentage of clinically necessary unscheduled orders was compared, and χ² analysis was used to assess differences by modality.

RESULTS

A total 494,503 radiologic examination orders were placed during the study period. After exclusions, 33,546 unscheduled orders were identified, 7% of all radiologic examination orders. Among 700 reviewed unscheduled orders, agreement was substantial (κ = 0.63). Eighty-seven percent of bone densitometric examinations and sixty-five percent of mammographic studies were considered clinically necessary, primarily for follow-up management. The majority of orders in each modality were clinically necessary, except for CT, obstetric ultrasound, and fluoroscopy (P < .0001).

CONCLUSIONS

Large numbers of radiologic examination orders remain unscheduled in the electronic health record. A substantial portion are clinically necessary, representing potential delays in executing documented provider care plans. Clinically unnecessary unscheduled orders may inadvertently be scheduled and performed. Identifying and performing clinically necessary unscheduled radiologic examination orders may help reduce diagnostic errors related to diagnosis and treatment delays and enhance patient safety, while eliminating clinically unnecessary unscheduled orders will help avoid unneeded testing.

How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

OBJECTIVES

The aim of this systematic review was to consolidate studies to determine whether root cause analysis (RCA) is an adequate method to decrease recurrence of avoidable adverse events (AAEs).

METHODS

A systematic search of databases from creation until December 2018 was performed using PubMed, Scopus and EMBASE. We included articles published in scientific journals describing the practical usefulness in and impact of RCA on the reduction of AAEs and whether professionals consider it feasible. The Mixed Methods Appraisal Tool was used to assess the quality of studies.

RESULTS

Twenty-one articles met the inclusion criteria. Samples included in these studies ranged from 20 to 1,707 analyses of RCAs, AAEs, recommendations, audits or interviews with professionals. The most common setting was hospitals (86%; n = 18), and the type of incident most analysed was AAEs, in 71% (n = 15) of the cases; 47% (n = 10) of the studies stated that the main weakness of RCA is its recommendations. The most common causes involved in the occurrence of AEs were communication problems among professionals, human error and faults in the organisation of the health care process. Despite the widespread implementation of RCA in the past decades, only 2 studies could to some extent establish an improvement in patient safety due to RCAs.

CONCLUSIONS

RCA is a useful tool for the identification of the remote and immediate causes of safety incidents, but not for implementing effective measures to prevent their recurrence.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

BACKGROUND

An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management.

METHODS

Two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer. Data from electronic registries and chart reviews were used to evaluate the effectiveness of the ASNs, which were defined as follows: colon cancer-the proportion of patients who were scheduled for or completed a colonoscopy following safety net team outreach to the patient; lung cancer-the proportion of patients for whom the safety net was able to identify and implement appropriate follow-up, as defined by scheduled or completed chest CT.

RESULTS

The effectiveness of the colon cancer ASN was 44.0%, and the effectiveness of the lung cancer ASN was 56.9%. The ASNs led to the development of registries to address patient safety, fostered collaboration among interdisciplinary teams of clinicians and administrative staff, and created new work flows for patient outreach and tracking.

CONCLUSION

Two ASNs were successfully implemented at an academic medical center to address missed and delayed recognition of abnormal test results related to colon cancer and lung cancer. The ASNs are providing a framework for development of additional safety nets in the organization.

Discordance in Information Exchange Between Providers During Care Transitions for Surgical Patients

BACKGROUND

The exchange of health information between primary care providers (PCPs) and surgeons is critical during transitions of care for older patients with multiple comorbidities; however, it is unknown to what extent this process occurs. This study was designed to characterize the extent to which factors associated with older patient's recovery, such as functional status, cognitive status, social status, and emotional factors, are shared among PCPs and surgical providers during care transitions.

MATERIALS AND METHODS

We prospectively identified 15 patients aged over 60 y with ≥3 comorbidities referred for general and vascular surgery procedures at a Veterans Administrative and academic medical center. Semistructured Critical Decision Method interviews were conducted with patients along with their surgical providers and referring PCPs. Thematic content analysis was performed independently by five reviewers on the cognitive processes associated with functional status, cognitive status, social status, and emotional factors. Interrater reliability between providers and patients was assessed using Cohen's kappa.

RESULTS

Forty-seven Critical Decision Method interviews were conducted, which included 20 paired interviews between a PCP and a surgeon and 16 paired interviews that involved a patient and a provider. The majority of patients reported experiencing poor information exchange between their PCP and surgeon (58%) and feeling they were primarily responsible for communicating their own health information during care transitions (67%). In paired interviews between PCPs and surgeons, there was nearly perfect agreement for the shared knowledge of cognitive (kappa: 0.83) and emotional (kappa 1) factors. In contrast, there was only minimal agreement for shared knowledge of functional status (kappa 0.38) and social status (kappa: 0.34).

CONCLUSIONS

Information exchange between PCPs and surgical providers is often discordant during transitions of surgical care for medically complex older patients, particularly when it pertains to communicating their functional or social status.

Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety

The Institute of Medicine's To Err Is Human, published in 1999, represented a watershed moment for the US health care system. The report dramatically raised the profile of patient safety and stimulated dedicated research funding to this essential aspect of patient care. Highly effective interventions have since been developed and adopted for hospital-acquired infections and medication safety, although the impact of these interventions varies because of their inconsistent implementation and practice. Progress in addressing other hospital-acquired adverse events has been variable. In the past two decades additional areas of safety risk have been identified and targeted for intervention, such as outpatient care, diagnostic errors, and the use of health information technology. In sum, the frequency of preventable harm remains high, and new scientific and policy approaches to address both prior and emerging risk areas are imperative. With the increasing availability of electronic data, investments must now be made in developing and testing methods to routinely and continuously measure the frequency and types of patient harm and even predict risk of harm for specific patients. This progress could lead us from a Bronze Age of rudimentary tool development to a Golden Era of vast improvement in patient safety.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care

BACKGROUND

Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care.

METHODS

Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended.

RESULTS

A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third.

LESSONS LEARNED AND LIMITATIONS

Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success.

CONCLUSION

Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Timely Interventions for Children with ADHD through Web-Based Monitoring Algorithms

The aim of this study was to evaluate an automated trigger algorithm designed to detect potentially adverse events in children with Attention-Deficit/Hyperactivity Disorder (ADHD), who were monitored remotely between visits. We embedded a trigger algorithm derived from parent-reported ADHD rating scales within an electronic patient monitoring system. We categorized clinicians’ alert resolution outcomes and compared Vanderbilt ADHD rating scale scores between patients who did or did not have triggered alerts. A total of 146 out of 1738 parent reports (8%) triggered alerts for 98 patients. One hundred and eleven alerts (76%) required immediate clinician review. Nurses successfully contacted parents for 68 (61%) of actionable alerts; 46% (31/68) led to a change in care plan prior to the next scheduled appointment. Compared to patients without alerts, patients with alerts demonstrated worsened ADHD severity (β = 5.8, 95% CI: 3.5–8.1 [p < 0.001] within 90 days prior to an alert. The trigger algorithm facilitated timely changes in the care plan in between face-to-face visits.

Comparative usability evaluation of consultation order templates in a simulated primary care environment

Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.

Test results management and distributed cognition in electronic health record-enabled primary care

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.

Patient and caregiver perspectives on care coordination during transitions of surgical care

Care coordination for patients with chronic disease commonly involves multiple transitions between primary care and surgical providers. These transitions often cross healthcare settings, providers, and information systems. We performed a cross-sectional qualitative study to gain a better understanding of the factors that influence how patients and caregivers perceive care coordination during transitions of surgical care. Eight focus groups were conducted among individuals from three different U.S. states who had experienced an episode of surgical care within the past year. We included patients who had undergone major surgery for a chronic condition, as well as caregivers. We used Atlas.ti qualitative software and engaged in an iterative process of thematic analysis of focus group transcripts. After five-rounds of review, five main themes emerged that define chronic care coordination for surgical patients and caregivers: (a) Care coordination is embedded in the unwritten social con tract patients share with their surgical providers; (b) Patients expect all surgical and nonsurgical healthcare providers to be "on the same page"; (c) Patients are frightened and vulnerable during surgical care transitions; (d) Patients need to have accurate expectations of the processes associated with care coordination; and (e) Care coordination relies upon establishing patient trust with their surgical team and needs to be continually reaffirmed. Surgical patients and caregivers expect care coordination processes to involve informatics infrastructure, patient education, and information exchange between providers. Unfortunately, these aspects of care coordination are often lacking during transitions. These findings have implications for designing patient-centered interventions to improve coordination of chronic care.

Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care

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.

Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System

BACKGROUND

Missed or delayed follow-up of abnormal subcritical tests (tests that do not require immediate medical attention) can lead to poor patient outcomes. Safety-net health systems with limited resources and socially complex patients are vulnerable to safety gaps resulting from delayed management. Clinician perspectives to identify system challenges, vulnerable situations, and potential solutions were sought in focus groups.

METHODS

Five semistructured focus groups were conducted in 2015 with purposefully sampled clinicians from radiology, hospital medicine, emergency medicine, risk management, and ambulatory care from an urban, academic, integrated, safety-net health system. Thematic analysis identified challenges of current management of abnormal subcritical tests, vulnerable situations, and solution characteristics. A total of 43 clinicians participated.

RESULTS

Clinicians cited challenges in assigning responsibility for follow-up and identified tests pending at discharge and tests requiring delayed follow-up as vulnerable situations. The lack of tracking systems and missing contact information for patients and providers exacerbated these challenges. Proposed solution characteristics involved protocols to aid in assigning responsibility, reliable paths of communication, and systems to track the status of tests. Clinicians noted a strong desire for integration of the work flow and technology solutions into existing structures.

CONCLUSION

In an urban safety-net setting, clinicians recommended outlining clear chains of responsibility and communication in the management of subcritical test results, and employing simple, integrated technological solutions that allow for tracking and management of tests. Existing test management solutions should be adapted to work within safety-net systems, which often have fewer resources and more complex patients and may function in the absence of integrated technology systems.

Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration

BACKGROUND

ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions.

METHODS

This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured.

RESULTS

Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better."

CONCLUSION

ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.

Finding Diagnostic Errors in Children Admitted to the PICU

OBJECTIVES

To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU.

DESIGN AND SETTING

The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four "high-risk" patient cohorts admitted to the PICU between June 2013 and December 2013.

PATIENTS

High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours.

INTERVENTIONS

Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians.

MEASUREMENTS AND MAIN RESULTS

Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2-17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% (κ, 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26).

CONCLUSIONS

The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children.

Effect size of contributory factors on adverse events: an analysis of RCA series in a teaching hospital

BACKGROUND

One of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective.

METHODS

This study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event.

RESULTS

Having the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %).

CONCLUSIONS

RCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.

Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care

IMPORTANCE

Diagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement.

OBJECTIVES

We aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews.

DESIGN

We gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (n = 389), with and without previously identified diagnostic errors (n = 129 and n = 260, respectively).

RESULTS

The final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient-provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84 %, sensitivity of 71 %, specificity of 90 %, negative predictive value of 86 %, and positive predictive value of 78 %. All 11 items correlated significantly with the instrument's error outcome question (all p values ≤ 0.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach's alpha coefficients 0.93, 0.92, and 0.38, respectively).

CONCLUSIONS

The Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.

Effective strategies for reducing maternal mortality in Isfahan University of Medical Sciences, 2014

Background:

Maternal mortality rate is among the most important health indicators. This indicator is a function of factors that are related to pregnant women; these factors include economic status, social and family life of the pregnant woman, human resources, structure of the hospitals and health centers, and management factors. Strategic planning, with a comprehensive analysis and coverage of all causes of maternal mortality, can be helpful in improving this indicator.

Materials and Methods:

This research is a descriptive exploratory study. After needs assessment and review of the current situation through eight expert panel meetings and evaluating the organization's internal and external environment, the strengths, weaknesses, threats, and opportunities of maternal mortality reduction were determined. Then, through mutual comparison of strengths/opportunities, strengths/threats, weaknesses/opportunities, and weaknesses/threats, WT, WO, ST, and SO strategies and suggested activities of the researchers for reducing maternal mortality were developed and dedicated to the areas of education, research, treatment, and health, as well as food and drug administration to be implemented.

Results:

In the expert panel meetings, seven opportunity and strength strategies, eight strength and threat strategies, five weakness and threat strategies, and seven weakness and opportunity strategies were determined and a strategic plan was developed.

Conclusions:

Dedication of the developed strategies to the areas of education, research, treatment, and health, as well as food and drug administration has coordinated these areas to develop Ministry of Health indicators. In particular, it emphasizes the key role of university management in improving the processes related to maternal health.

PREDICTORS OF NONATTENDANCE AT AN ENDOCRINOLOGY OUTPATIENT CLINIC

OBJECTIVE

To identify predictors potentially contributing to patients' nonattendance or to same-day cancellation of scheduled appointments at an adult endocrinology office practice.

METHODS

A retrospective, records-based, cross-sectional study was conducted using data from 9,305 electronic medical records of patients presenting at a U.S. metropolitan adult endocrinology clinic in 2013. Statistical analyses included multivariate regression, calculated odds ratios, and posttest probabilities.

RESULTS

Of 29,178 total patient visits analyzed, 68% were attended by patients. Of total scheduled appointments, 7% resulted in nonattendance and 5% in same-day cancellation. The most significant predictors of nonatten-dance were a previous history of nonattendance (P<.001), uncontrolled diabetes (P<.001), and new patients to the practice (P<.001). Long lead-time to appointment (P = .001), younger age (P<.001), and certain insurance carriers (P<.001) also were significant predictors.

CONCLUSION

Specific predictors of nonattendance at scheduled appointments were identified using statistical analysis of electronic medical record data. Previous history of nonattendance and having uncontrolled diabetes (especially in patients newly referred to the practice) are among these significant predictors. Identifying specific predictors for nonattendance enables targeted strategies to be developed.

ABBREVIATIONS

APRN = Advanced Practice Registered Nurse CI = confidence interval DM = diabetes mellitus EMR = electronic medical record HbA1c = glycated hemoglobin NS = no-show OR = odds ratio SDC = same-day cancellation.

A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure

The objective of this review was to evaluate existing transition-of-care models and identify common themes that may minimize exacerbation and rehospitalization, and improve quality of life for patients with heart failure (HF). HF is a significant burden in the United States and a common reason for recurrent hospitalizations. When multidisciplinary health care providers function as liaisons and educators during transition from hospital to home, they help prepare patients for life with chronic HF and mitigate the need for readmission. Systematic literature searches were performed to identify research papers relevant to transition-of-care themes in HF. Eight common themes were identified that can be applied to patients with HF to improve long-term outcomes. This paper emphasizes ways in which health care providers can implement theme-based transitional care, including providing patients and caregivers with practical skills and services that promote knowledge and engagement in self-care and stimulate active communication with health care providers.

Investigating the Challenges and Opportunities in Home Care to Facilitate Effective Information Technology Adoption

BACKGROUND

As home care utilization increases, information technology (IT) becomes a critical tool for providing quality home care. However, most home health agencies (HHAs) in the United States are in a position to adopt and leverage IT solutions in budget-constrained settings, where it is crucial to address important and pressing challenges and opportunities for achieving effectiveness in IT adoption.

OBJECTIVES

(1) Explore HHAs' challenges and opportunities related to delivering home care as well as performing administrative functions and conducting business, (2) learn about current IT implementation levels and activities in home care, and (3) make recommendations to facilitate efforts and initiatives designed for adopting IT in home care effectively.

METHODS

Semistructured interviews were conducted to elicit rich contextual information from the participants recruited from 13 local HHAs in one of the states in the United States. Established systems analysis techniques were used to ask questions during the interviews. Framework, a qualitative research method, was used to analyze the qualitative data obtained from the interviews.

RESULTS

Coordinating clinical and administrative workflows was an important challenge. Inadequate access to patients' medical history and difficulties with medication reconciliation detracted from the quality of care. Hiring, training, scheduling, and retaining qualified personnel constituted another important challenge. Training and educating patients, caregivers, and families hold important opportunities for improving the quality of care. All except one HHA adopted electronic health records (EHR) but many continued to struggle considerably in their day-to-day functions. Health information exchange (HIE) seems to be the most needed technology. Telehealth solutions were perceived to be promising but their added value and financial viability in the long run were questioned.

CONCLUSIONS

The recommendations for effective IT adoption include keeping a quality improvement focus, keeping a holistic organizational perspective, considering potential information exchange problems, addressing education and training needs, experimentation with telehealth if resources permit, considering organization size, and reducing lengthy procedures and excessive documentation requirements. The relevant stakeholders, such as home care professionals, IT vendors, and policy makers, should consider the recommendations from this study to facilitate success in future IT efforts and initiatives in home care.

Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial

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.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings

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.

A vision for using online portals for surveillance of patient-centered communication in cancer care

The Veterans Health Administration (VHA) is charged with providing high-quality health care, not only in terms of technical competence but also with regard to patient-centered care experiences. Patient-centered coordination of care and communication are especially important in cancer care, as deficiencies in these areas have been implicated in many cases of delayed cancer diagnosis and treatment. Additionally, because cancer care facilities are concentrated within the VHA system, geographical and system-level barriers may present prominent obstacles to quality care. Systematic assessment of patient-centered communication (PCC) may help identify both individual veterans who are at risk of suboptimal care and opportunities for quality improvement initiatives at the service, facility, or system-wide level. In this manuscript, we describe our vision to implement an assessment of PCC through patient self-report to improve the quality of cancer care and other health services in the VHA. We outline a possible strategy to assess PCC that leverages the VHA's existing initiative to promote use of an online personal health record for veterans (MyHealtheVet). Questionnaires administered periodically or following specific episodes of care can be targeted to assess PCC in cancer care. Assessment of PCC can also be tied to clinical and administrative data for more robust analysis of patient outcomes. Ultimately, the goal of any assessment of PCC is to gather valid, actionable data that can assist VHA clinicians and staff with providing the best possible care for veterans with cancer.

Investigation of the causes of maternal mortality using root cause analysis in Isfahan, Iran in 2013-2014

BACKGROUND

Many maternal deaths caused are due to preventable causes during pregnancy and childbirth. Therefore, the detailed analysis of the root causes provides developing a plan and appropriate interventions to prevent these deaths occurring in the health system. This study aims to determine the causes of maternal mortality using root cause analysis (RCA) method.

MATERIALS AND METHODS

This research is a descriptive explorative study. The data were collected from the files in the maternal health center and the interviews conducted with relevant personnel. The causes of maternal mortality and related reasons were determined by experts' team opinions and through a standard checklist of RCA. Causes consisted of the factors related to health services (human factors and structural factors), maternal family and social status, and maternal disease status. For each of these factors, analysis was performed to determine the root. In the end, interventional suggestions were developed to prevent the recurrence of similar deaths.

RESULTS

Causes were classified into human factors, and structural factors in the area of planning and management and social status of mothers. The results showed that human factors were composed of lack of knowledge and skills in the medical team, unfamiliarity with their duties, lack of health care-based on protocols, etc. Structural factors included lack of follow-up after discharge and inadequate supervision of inspectors on academic qualified doctors. Maternal social and family status factor included lack of referral the mothers' to the health care center.

CONCLUSIONS

Based on the RCA process, the most fundamental factor in creating these deaths was management errors at the level of universities and the Ministry of Health. These errors included inadequate supervision of medical education, failure to identify and introduce the instructions and guidelines related to the care of pregnant mothers by the health workers and experts, and lack of collective strategies to inform the public about the type and model of self-care in health centers. Based on the obtained results, the solutions proposed for elimination of root causes of maternal death are organizing sequential training courses tailored for the staff taking care of pregnant women, sending guidelines related to maternal health care to all private and public institutions, and informing the community to receive health care services by health centers and mass media.

Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports?

RATIONALE AND OBJECTIVES

To understand the reasons leading to potentially inappropriate management of imaging findings concerning for malignancy and identify optimal methods for communicating these findings to providers.

MATERIALS AND METHODS

We identified all abdominal imaging examinations with findings of possible cancer performed on six randomly selected days in August to December 2013. Electronic medical records (EMR) of one patient group were reviewed 3 months after the index examination to determine whether management was appropriate (completed follow-up or documented reason for no follow-up) or potentially inappropriate (no follow-up or no documented reason). Providers of a second patient group were contacted 5-6 days after imaging examinations to determine notification preferences.

RESULTS

Among 43 patients in the first group, five (12%) received potentially inappropriate management. Reasons included patient loss to follow-up and provider failure to review imaging results, document known imaging findings, or communicate findings to providers outside the health system. Among 16 providers caring for patients in the second group, 33% were unaware of the findings, 75% preferred to be notified of abnormal findings via e-mail or EMR, 56% wanted an embedded hyperlink enabling immediate follow-up order entry, and only 25% had a system to monitor whether patients had completed ordered testing.

CONCLUSIONS

One in eight patients did not receive potentially necessary follow-up care within 3 months of imaging findings of possible cancer. Automated notification of imaging findings and follow-up monitoring not only is desired by providers but can also address many of the reasons we found for inappropriate management.

Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records

On September 30th, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first travel-associated case of US Ebola in Dallas, TX. This case exposed two of the greatest concerns in patient safety in the US outpatient health care system: misdiagnosis and ineffective use of electronic health records (EHRs). The case received widespread media attention highlighting failures in disaster management, infectious disease control, national security, and emergency department (ED) care. In addition, an error in making a correct and timely Ebola diagnosis on initial ED presentation brought diagnostic decision-making vulnerabilities in the EHR era into the public eye. In this paper, we use this defining "teachable moment" to highlight the public health challenge of diagnostic errors and discuss the effective use of EHRs in the diagnostic process. We analyze the case to discuss several missed opportunities and outline key challenges and opportunities facing diagnostic decision-making in EHR-enabled health care. It is important to recognize the reality that EHRs suffer from major usability and inter-operability issues, but also to acknowledge that they are only tools and not a replacement for basic history-taking, examination skills, and critical thinking. While physicians and health care organizations ultimately need to own the responsibility for addressing diagnostic errors, several national-level initiatives can help, including working with software developers to improve EHR usability. Multifaceted approaches that account for both technical and non-technical factors will be needed. Ebola US Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health.