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Marsh KM, Turrentine FE, Jin R, Schirmer BD, Hanks JB, Davis JP, Schenk WG, Jones RS. Judgment Errors in Surgical Care. J Am Coll Surg 2024; 238:874-879. [PMID: 38258825 PMCID: PMC11023767 DOI: 10.1097/xcs.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear. STUDY DESIGN The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression. RESULTS Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors. CONCLUSIONS Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.
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Affiliation(s)
- Katherine M. Marsh
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Ruyun Jin
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Bruce D. Schirmer
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - John B. Hanks
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - John P. Davis
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | | | - R. Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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2
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Lovett A, Vokes J, Loghides N, Johnstone L, Sykes B. Survival of formalin intoxication in a 13-year-old Thoroughbred gelding. Equine Vet J 2024; 56:494-502. [PMID: 37587652 DOI: 10.1111/evj.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Formalin intoxication via the gastrointestinal route has not been previously reported in the horse. Whereas ingestion of formalin in humans, although rare, is well documented. Majority of human cases are either accidental, suicidal or homicidal and often lead to fatality, with a reported lethal formaldehyde dose equating to 0.12 - 0.16 g/kg bwt. OBJECTIVES To describe a single case report of the clinical management of an adult horse referred to a veterinary teaching hospital following accidental administration of 10% formalin via nasogastric tube. METHODS A 13-year-old Thoroughbred gelding originally presented to the referring veterinarian for colic where 1.8 L of 10% formalin was accidentally administered instead of mineral oil via nasogastric intubation, a potentially lethal dose of formaldehyde (0.12 g/kg bwt). Approximately 20-hours following 10% formalin administration the horse was admitted to the referral hospital with moderate tachycardia, occasional ectopic beats, tacky and hyperaemic mucous membranes, delayed capillary refill time, reduced borborygmi, and pronounced digital pulses. Diagnostic investigations included laboratory blood analysis, urinalysis, electrocardiogram, abdominal ultrasound, palpation per rectum and gastroscopy. RESULTS Patient assessment found evidence of toxicity to the gastrointestinal tract, hypovolaemia and risk for laminitis. Intensive care included fluid and electrolyte therapy, anti-inflammatories and analgesia, continuous digital cryotherapy, gastro-protectants and other methods of gastrointestinal support. The horse was discharged from hospital on day 14 with no long-term complications and the client-veterinarian relationship was preserved. DISCUSSION In human cases of ingestion, gastrointestinal injury is typically accompanied by severe metabolic acidosis and multiple organ dysfunction syndrome due to toxicity of other body systems that can contribute to non-survival. Formaldehyde toxicity in the present case predominantly affected the gastrointestinal tract, most likely a direct result of the route of administration. Aside from gastrointestinal injury, primary toxicity of other body systems was not confirmed. To prevent this medical error recurring, the referring veterinary clinic revised their labelling and storage of 10% formalin. CONCLUSION This is the first report of systemic formalin intoxication in the horse. Following a high dose of 10% formalin (0.12 g/kg bwt formaldehyde) enterally, the horse survived having received intensive supportive care based on human guidelines for ingested formalin.
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Affiliation(s)
- Amy Lovett
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - Jessica Vokes
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - Natasha Loghides
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - Laura Johnstone
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - Benjamin Sykes
- Equine Veterinary Clinic, School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
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Hepworth-Warren KL, Maynard-Swift E, Prange T, Colwell C, Stallings O, Derks KG, Love K, Hepworth DA, Marks SL. Error reporting in a large animal veterinary teaching hospital identifies medication errors occur most often in the prescribing phase of therapy. J Am Vet Med Assoc 2024; 262:1-7. [PMID: 38134457 DOI: 10.2460/javma.23.10.0556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To identify the rate at which medication errors occurred over a 2-year period in a large animal veterinary teaching hospital and describe the types of errors that occurred. SAMPLE 226 medication errors over 6,155 large animal visits occurred during the study period. Multiple errors may have affected the same patient. METHODS Medication error reports from March 1, 2021, to March 31, 2023, were reviewed retrospectively and classified by species, type of drug, and month and day of the week the error occurred. Errors were categorized according to multiple previously developed systems to allow for comparison to other studies. RESULTS 226 medication errors occurred over 6,155 patient visits in a 2-year period: 57.5% (130/226) were identified by a dedicated large animal pharmacist, and 64.2% (145/226) of errors were identified and corrected before reaching the patient. Prescription/medication order errors (58.4% [132/226]) occurred significantly more often than errors in medication preparation (21.7% [49/226]; P < .001) and administration (19.6%; P < .001). Antibiotics (48.7% [110/226]) and NSAIDs (17.7% [40/226]) were the drug classes most involved in errors. CLINICAL RELEVANCE Most medication errors in this study occurred in the ordering/prescribing phase. This is similar to reports in human medicine, where standardized medication error reporting strategies exist. Developing and applying similar strategies in veterinary medicine may improve patient safety and outcome.
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Affiliation(s)
- Kate L Hepworth-Warren
- 1Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | | | - Timo Prange
- 1Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Curtis Colwell
- 2North Carolina State University Veterinary Hospital, Raleigh, NC
| | - Olivia Stallings
- 2North Carolina State University Veterinary Hospital, Raleigh, NC
| | - Kobi G Derks
- 2North Carolina State University Veterinary Hospital, Raleigh, NC
| | - Kim Love
- 3K. R. Love Quantitative Consulting and Collaboration, Athens, GA
| | | | - Steven L Marks
- 2North Carolina State University Veterinary Hospital, Raleigh, NC
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Hassinger AB, Velez C, Wang J, Mador MJ, Wilding GE, Mishra A. Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study. J Clin Sleep Med 2024; 20:221-227. [PMID: 37767811 PMCID: PMC10835772 DOI: 10.5664/jcsm.10820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
STUDY OBJECTIVES Reduced sleep duration and work hour variability contribute to medical error and physician burnout. This study assesses the relationships between physician performance, burnout, and the dimensions of sleep beyond hours slept. METHODS This was an ancillary analysis of 3 years of data from an international prospective cohort study: the Intern Health Study. Actigraphy data from 3,654 intern physicians capturing sleep timing, regularity, efficiency, and duration were used individually and combined as a composite sleep health index to measure the association of multidimensional sleep patterns on self-reported medical errors and burnout. RESULTS From 2017-2019, interns' work hours decreased by 4 hours per week and total sleep time also decreased (6.7 to 5.99 hours), and sleep efficiency, timing, and regularity all worsened (all P < .05). In the 21.2% of participants who committed an error, there was no difference in sleep duration, timing, or regularity. Lower sleep efficiency was associated with higher odds of committing an error (P = .003) and higher burnout scores (P < .001). Although overall sleep quality was poor in the entire cohort, interns in the lowest quintile of sleep duration, regularity, and efficiency had higher burnout scores than those in the best quintile. CONCLUSIONS Sleep efficiency, not duration, was associated with increased self-reported medical errors and burnout in intern physicians. Overall sleep quality and duration worsened despite fewer hours worked. Future studies on physician burnout should measure all aspects of sleep health. CITATION Hassinger AB, Velez C, Wang J, Mador MJ, Wilding GE, Mishra A. Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study. J Clin Sleep Med. 2024;20(2):221-227.
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Affiliation(s)
- Amanda B. Hassinger
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children’s Hospital, Buffalo, New York
| | - Chiara Velez
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jia Wang
- Department of Biostatistics, University at Buffalo, Buffalo, New York
| | - M. Jeffery Mador
- Department of Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Gregory E. Wilding
- Department of Biostatistics, University at Buffalo School of Public Health and Health Professions, Buffalo, New York
| | - Archana Mishra
- Department of Medicine, Division of Pulmonology, Critical Care and Sleep Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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Unoki Y, Ishizuka K, Hata T, Yoshimura F, Oshita T, Kunitomo K. How to overcome hurdles in holding mortality and morbidity conferences on diagnostic error cases in Japan. Diagnosis (Berl) 2024; 11:106-108. [PMID: 37545117 DOI: 10.1515/dx-2023-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/14/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Yuto Unoki
- Department of General Internal Medicine, Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Takuma Hata
- Department of Internal Medicine, Takahagi Kyodo General Hospital, Ibaraki, Japan
| | - Fumitaka Yoshimura
- Department of General Medicine, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Toshihiko Oshita
- Department of General Medicine, Kobe City Nishi-Kobe Medical Center, Kobe, Hyogo, Japan
| | - Kotaro Kunitomo
- Department of General Medicine, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
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Tomooka M, Matsumoto C, Maeda H. Effectiveness of a preceptors' social support program to aid novice nurses' error experience on preceptors' skill and novice nurses' perception of social support: A quasi-experimental study. Jpn J Nurs Sci 2024; 21:e12563. [PMID: 37749995 DOI: 10.1111/jjns.12563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/27/2023]
Abstract
AIM To evaluate the effectiveness of the preceptors' social support program (PSSP) on preceptors' social support skill-supportive relationships and post-error support-and novice nurses' perception of received social support. METHODS This study employed a quasi-experimental pretest-posttest design with a control group of a non-random assigned sample of 47 preceptors and novice nurses and an intervention group of 48 each. Intervention group preceptors received training in building supportive relationships skill and post-error support skills three times in the PSSP over 7 months. Preceptors' social support skill and novice nurses' perception of received social support were measured as primary outcomes. Data were collected at baseline (T0), 1 month after the second session (T1), and 1 month after the last session (T2) and analyzed. RESULTS No significant differences in demographics or scores were shown at baseline (T0). Preceptors in the intervention group showed significantly better supportive relationships (T2, 101.6 ± 9 vs. 96.9 ± 7.6, 95% CI [0.95, 8.42], p = .015) and better performance of post-error support (T2, 67.6 ± 5 vs. 62 ± 6.5, 95% CI [2.78, 8.32], p < .001). Intervention group preceptors' social support skill increased or remained stable, while it decreased over time in the control group. Novice nurses in the intervention group received significantly better supportive relationships and post-error support from preceptors (T2, median 112 vs. 101, p = .007; 70.5 vs. 65, p = .028, respectively). CONCLUSIONS The PSSP improved preceptors' supportive relationship skills and post-error support performance, leading to novice nurses' perceptions of better supportive relationships and receiving greater post-error support.
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Affiliation(s)
- Misa Tomooka
- Doctoral Program in Nursing, Graduate School of Health Science, Kumamoto University, Kumamoto, Japan
| | - Chiharu Matsumoto
- Department of Nursing, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hitomi Maeda
- Department of Nursing, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Schmude M, Adonizio T, Ellison HB, Shoemaker M. Fostering Students' Personal and Professional Growth: Responding to Error During the Internal Medicine Clerkship. J Med Educ Curric Dev 2024; 11:23821205241236594. [PMID: 38425719 PMCID: PMC10903198 DOI: 10.1177/23821205241236594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Developing professionalism is critical to medical education; accordingly, professionalism curricula may be implemented longitudinally throughout undergraduate medical education. Here we share our experiences addressing student response to medical error as a component of professionalism education during the core clerkship year. METHODS This pretest-posttest study reports medical students' knowledge regarding learning and growing in response to medical error. Students complete an online module, Beyond Recovery: Learning and Growing in the Wake of an Error, during the Internal Medicine Clerkship. We analyzed matched pre- and posttest responses using the Wilcoxon signed-rank test. RESULTS Pre- and posttest queries addressed 5 key elements during clinician assessment of medical error: self-expectations of perfection, long-term guilt following an error, likelihood of leaving the medical profession following an error, ability to address error with patients and families, and ability to grow in response to medical error. Results indicate students felt significantly more comfortable after completing the module in key components of managing emotions and responses in the wake of an error. CONCLUSION Benefits observed in medical students' perspectives include improved ability to move forward following medical error, ability to engage with affected patients and families, and capacity to learn from mistakes. Despite these positives, students' high self-expectations of perfectionism were unchanged.
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Affiliation(s)
- Michelle Schmude
- Department of Medical Education, Geisinger College of Health Sciences, Scranton, PA, USA
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Ghanian S, Wambier SPF, Wambier CG. Mitigation of risk of botulinum toxin A-induced blepharoptosis with hyperconcentrated glabellar injections. J Am Acad Dermatol 2023:S0190-9622(23)03398-4. [PMID: 38151057 DOI: 10.1016/j.jaad.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/06/2023] [Accepted: 12/16/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Soha Ghanian
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Division of Dermatology, College of Medicine, University of Arizona, Tucson, Arizona
| | - Sarah P F Wambier
- Ophthalmology and Oculoplastic Surgery, Wambier Center of Medical Specialties, Ponta Grossa, Brazil
| | - Carlos G Wambier
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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9
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Halpern J. What we owe patients when fear undermines autonomy: Concretized emotions and the incapacity to deliberate. J Eval Clin Pract 2023; 29:1251-1260. [PMID: 37259233 DOI: 10.1111/jep.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 06/02/2023]
Abstract
Fear and anxiety can interfere profoundly with a person's ability to deliberate. Patients sometimes face critical medical decisions while subject to intense emotions which involve catastrophic (or wishful) convictions about the future. Medical teams, and even psychiatrists and bioethicists, lack a model for what to do in such cases. Philosophical accounts of autonomy and the clinical criteria for decision-making capacity derived from them fail to address cases in which emotions do not merely skew judgment but rather block decision-making capacity itself. This paper provides an account of when emotions undermine a person's freedom to deliberate, which is the basis of the capacity for autonomy. People subject to what I call 'concretized emotions' meet the cognitive criteria for decision-making capacity. Yet their emotions dictate their views of reality and prevent them from meeting the basic conditions for deliberation. To deliberate one needs to be able to think through alternatives, and this thinking through alternatives needs to be responsive to evidence. With concretized fear, both the ability to think through alternatives and the ability to respond cognitively to evidence is undermined. The person can engage in apparent deliberation, but her thought processes regarding the feared matter are characterized by the rigid view that things are just as they seem from her emotional view. This paper develops a theoretical and clinical model for a more appropriate and nuanced approach to acting responsibly toward patients subject to intense fear and related emotional states that block their decision-making capacity.
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Affiliation(s)
- Jodi Halpern
- School of Public Health, University of California, Berkeley, California, USA
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Jalali M, Dehghan H, Habibi E, Khakzad N. Application of "Human Factor Analysis and Classification System" (HFACS) Model to the Prevention of Medical Errors and Adverse Events: A Systematic Review. Int J Prev Med 2023; 14:127. [PMID: 38264566 PMCID: PMC10803676 DOI: 10.4103/ijpvm.ijpvm_123_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/27/2022] [Indexed: 01/25/2024] Open
Abstract
Hospitals, as one of most important subsectors in human societies, are responsible for providing safe and effective medical services to clients. But sometimes these hospitals are the source of injury and death in patients by creating medical errors. In this systematic review study, the application of human factor analysis and classification system (HFACS) method in the classification of medical errors was investigated. Major electronic databases including Scopus, Web of Science, and MEDLINE were searched. All studies that investigated the application of HFACS method for coding, causation, and classification of medical errors and adverse events conducted from 2001 until February 2021 were included. A total of 108 articles were found. Due to duplication, 18 studies were removed from the review list. After reading the titles and abstracts, 50 of these publications were excluded because they had objectives different from this review. The remaining 40 publications were retrieved for further assessment. Of these, 28 publications were excluded because it did not meet the inclusion criteria. Finally, 12 articles remained for the final systematic review. We found that in 65% of the selected studies, preconditions for unsafe acts have been the major causal level of medical errors and adverse events. In the majority of the studies, communication and coordination, adverse mental states, physical environment, crew resource management, and technological environment have also been recognized as the most important causal categories in this study. As a result, to prevent medical errors and adverse events, the main focus should be on controlling the preconditions for unsafe acts including personnel factors, operator conditions, and environmental factors.
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Affiliation(s)
- Mahdi Jalali
- Department of Occupational Health Engineering, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Habibollah Dehghan
- Department of Occupational Health Engineering, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ehsanollah Habibi
- Department of Occupational Health Engineering, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nima Khakzad
- School of Occupational and Public Health, Ryerson University, Toronto, Canada
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11
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Nguyen ATN, Fisher RG, Valentine MJ, Kayastha A, Pham HM, Phu AT, Meimon SA, Newsome-Cuby TR, Parry CA, Kirila CE. Serotonergic Medication Error: A Case Report of Serotonin Syndrome. Cureus 2023; 15:e48161. [PMID: 38046758 PMCID: PMC10693256 DOI: 10.7759/cureus.48161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
Serotonin syndrome (SS) describes a life-threatening clinical condition that can develop within hours or days after taking serotonergic medication(s). Medication adverse reactions, overdose, or drug interactions can cause this syndrome. Patients often present with symptoms of hyperthermia, muscle rigidity, hyperreflexia, and clonus. Symptoms range broadly in severity, often influenced by polypharmacy and age. In this report, SS was diagnosed in an elderly patient who presented with diffuse urticaria and exacerbated tremor. These complaints were thought to be associated with Parkinson's disease due to a strong family history. Clinicians are encouraged to consider SS in their differential diagnosis when dealing with elderly patients with multiple medications, psychiatric diagnoses, conditions managed by other providers, and/or a strong family history of neurodegenerative diseases.
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Affiliation(s)
- Anh Thu N Nguyen
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Riley G Fisher
- College of Life Sciences, Brigham Young University, Provo, USA
| | | | - Ankur Kayastha
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Hanh M Pham
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
- Public Health, University of Nebraska Medical Center, Omaha, USA
| | - Alexander T Phu
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Saif A Meimon
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | | | - Conor A Parry
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Carol E Kirila
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
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12
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Arastehmanesh D, Mangino A, Eshraghi N, Wolfe RE, Grossman SA. Can Asking Emergency Physicians Whether or Not They Would Have Done Something Differently (WYHDSD) be a Useful Screening Tool to Identify Emergency Department Error? J Emerg Med 2023; 65:e250-e255. [PMID: 37689413 DOI: 10.1016/j.jemermed.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 05/08/2023] [Accepted: 05/26/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Error in emergency medicine remains common and difficult to identify. OBJECTIVE To evaluate if questioning emergency physician reviewers as to whether or not they would have done something differently (Would you have done something differently? [WYHDSD]) can be a useful marker to identify error. METHODS Prospective data were collected on all patients presenting to an academic emergency department (ED) between 2017 and 2021. All cases who met the following criteria were identified: 1) returned to ED within 72 h and admitted; 2) transferred to intensive care unit from floor within 24 h of admission; 3) expired within 24 h of arrival; or 4) patient or provider complaint. Cases were randomly assigned to emergency physicians and reviewed using an electronic tool to assess for error and adverse events. Reviewers were then mandated to answer WYHDSD in the management of the case. RESULTS During the study period, 6672 cases were reviewed. Of the 5857 cases where reviewers would not have done something differently, 5847 cases were found to have no error. The question WYHDSD had a sensitivity of 97.4% in predicting error and a negative predictive value of 99.8%. CONCLUSION There was a significantly higher rate of near misses, adverse events, and errors attributable to an adverse event in cases where the reviewer would have done something differently (WHDSD) compared with cases where they would not. Therefore, asking reviewers if they WHDSD could potentially be used as a marker to identify error and improve patient care in the ED.
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Affiliation(s)
- David Arastehmanesh
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Alyssa Mangino
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Nadia Eshraghi
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Richard E Wolfe
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - Shamai A Grossman
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center Boston, Massachusetts
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13
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Usmanova EF, Tomilin OO. [The assuring of rights of of medical workers within the framework of modernization of primary health care legislation]. Probl Sotsialnoi Gig Zdravookhranenniiai Istor Med 2023; 31:951-959. [PMID: 37898883 DOI: 10.32687/0869-866x-2023-31-5-951-959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/13/2023] [Indexed: 10/31/2023]
Abstract
The more active implementation of innovative medical technologies, digital transformation in medical sphere, sanction restrictions resulted in complication of already existed problems in medical law and raised new questions. The necessity in improving medical legislation is obvious. The number of lawsuits concerning medical organizations and medical workers is invariably increasing. Hence request of adoption of normative legal regulations and decisions supporting effective functioning of industry and protection of rights and interests of medical organizations and medical workers. The purpose of the research is to study and to analyze current issues of ensuring rights of medical workers as one of the main aspects of modernization of modern medical law. The main normative legal acts of modern medical law were studied. The analysis, comparison, generalization and systematization of published statistical data, judicial practice, national and foreign sources of scientific publications, devoted to topical issues of modernization of legislation regulating health care and rights of health workers were implemented. The content analysis was applied to acts regulating legal responsibility and protection of rights of medical workers. The protection of rights of physicians in system of medical care of population at the present stage was investigated. A number of problems related to legal regulation of activities of health workers was established. The proposals for its improvement was summarized. The legal regulation of medical care support by multitude of normative acts makes actual issues of systematization of normative documentation. the assignment of independent sector of medical law where legal status of medical worker is to become its main institute.
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Affiliation(s)
- E F Usmanova
- The Federal State Budget Educational Institution of Higher Education "The N. P. Ogarev National Mordvinian State University", 430000, Saransk, Russia,
| | - O O Tomilin
- The Federal State Budget Educational Institution of Higher Education "The N. P. Ogarev National Mordvinian State University", 430000, Saransk, Russia
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Tansuwannarat P, Vichiensanth P, Sivarak O, Tongpoo A, Promrungsri P, Sriapha C, Wananukul W, Trakulsrichai S. A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes. Pharmacy (Basel) 2023; 11:138. [PMID: 37736910 PMCID: PMC10514797 DOI: 10.3390/pharmacy11050138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.
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Affiliation(s)
- Phantakan Tansuwannarat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Piraya Vichiensanth
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Ornlatcha Sivarak
- International College, Mahidol University, Nakhon Pathom 73170, Thailand;
| | - Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Puangpak Promrungsri
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Charuwan Sriapha
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
| | - Winai Wananukul
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Satariya Trakulsrichai
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (P.P.); (C.S.); (W.W.)
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
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Loncharich MF, Robbins RC, Durning SJ, Soh M, Merkebu J. Cognitive biases in internal medicine: a scoping review. Diagnosis (Berl) 2023; 10:205-214. [PMID: 37079281 DOI: 10.1515/dx-2022-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don't always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective. CONTENT We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of "bias", "clinical reasoning", and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants. SUMMARY Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy. OUTLOOK We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.
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Affiliation(s)
- Michael F Loncharich
- Rheumatology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Uniformed Services University, Bethesda, MD, USA
| | - Rachel C Robbins
- Rheumatology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Michael Soh
- Uniformed Services University, Bethesda, MD, USA
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16
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Pico M, Prado X, Guiñazú GG, Menéndez SD, Dvorkin J, López MV, Pascual C, Costa CE, Enríquez D. Communication of medical errors in a simulated clinical scenario. Experience with a pediatric residency group. Rev Paul Pediatr 2023; 42:e2022109. [PMID: 37436240 PMCID: PMC10332444 DOI: 10.1590/1984-0462/2024/42/2022109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/22/2022] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To determine the performance of groups of pediatric residents from a Buenos Aires hospital, in terms of correct recognition and communication of a medical error (ME), in a high-fidelity simulation scenario. To describe the reactions and communication attempts following the ME and the self-perception by the trainees before and after a debriefing. METHODS Quasi-experimental uncontrolled study conducted in a simulation center. First- and third-year pediatric residents participated. We designed a simulation case in which an ME occurred and the patient deteriorated. During the simulation, participants had to provide information on communicating the ME to the patient's father. We assessed communication performance and, additionally, participants completed a self-perception survey about ME management before and after a debriefing. RESULTS Eleven groups of residents participated. Ten (90.9%) identified the ME correctly, but only 27.3% (n=3) of them reported that a ME had occurred. None of the groups told the father they were going to give him important news concerning his son's health. All 18 residents who actively participated in this communication completed the self-perception survey, with an average score before and after debriefing of 5.00 and 5.05 (out of 10) (p=0.88). CONCLUSIONS We observed a high number of groups that recognized the presence of a ME, but the communication action was substantially low. Communication skills were insufficient and residents' self-perception of error management was regular and not modified by the debriefing.
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Teymourzadeh E, Mehdizadeh P, Yaghoubi M, Firoozjaie IT. Assessment and Reduction of Human Error using SHERPA Technique in Chemotherapy Department of a Large Military Hospital. Iran J Nurs Midwifery Res 2023; 28:426-429. [PMID: 37694207 PMCID: PMC10484388 DOI: 10.4103/ijnmr.ijnmr_382_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/04/2022] [Accepted: 01/08/2023] [Indexed: 09/12/2023]
Abstract
Background Medical errors are numerous in medical activities. Considering the sensitivity and importance of the medical group's professions, the emergence of an apparently simple error can cause the death of an individual or even a group of individuals. The present study aims the evaluation and reduction of human error using a system human error reduction and prediction approach System Human Error Reduction and Prediction Approach (SHERPA) in the nurses of Baqiyatallah hospital's chemotherapy ward in 2019. Materials and Methods A cross-sectional study was conducted in the chemotherapy ward using the SHERPA technique. Then, the duties were determined in detail using Hierarchical Task Analysis (HTA). The errors were identified using the SHERPA checklist, and the risk outcomes and intensities were finally evaluated. Results Based on the study findings, there are 109 possible errors for 48 sub-duties. The most frequent errors fall in the functional area (54%) and the least frequent errors pertain to the area of selection (3%). Conclusions In order to reduce the errors and increase the quality of the services and safety of the patients, errors can be identified by using the SHERPA technique; after identifying these errors, using this technique, it is possible to prevent the recurrence of the identified errors by careful planning. Considering the fact that the most frequent error was found in the functional domain, modern protocols can be codified in this area, and standards can be observed for putting the problems of this section atop of the priority list and reducing the errors and increasing safety of the patients.
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Affiliation(s)
- Ehsan Teymourzadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Parisa Mehdizadeh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Maryam Yaghoubi
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Iman Taghizadeh Firoozjaie
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Golestan University of Medical Sciences, Golestan, Iran
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Fryburg DA. Kindness Isn't Just about Being Nice: The Value Proposition of Kindness as Viewed through the Lens of Incivility in the Healthcare Workplace. Behav Sci (Basel) 2023; 13:457. [PMID: 37366709 DOI: 10.3390/bs13060457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviors, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modeling positive behaviors as well as the deterrence of negative behaviors, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.
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19
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Browne C, Crone L, O'Connor E. How Do We Learn About Error? A Cross-Sectional Study of Urology Trainees. J Surg Educ 2023; 80:864-872. [PMID: 37142489 DOI: 10.1016/j.jsurg.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE This qualitative descriptive study aims to explore trainees' experiences of error disclosure (ED) during their surgical postgraduate training and the factors influencing the intention-behavior gap for ED. DESIGN This study employs an interpretivist methodology and a qualitative descriptive research strategy. Data were collected using focus group interviews. Data coding was performed by the principal investigator using Braun and Clarke's reflexive thematic analysis. Themes were developed from the data in a deductive manner. Analysis was carried out using NVivo 12.6.1. SETTING All participants were at various stages of an 8-year specialist program under the auspices of the Royal College of Surgeons in Ireland. The training program involves clinical work in a teaching hospital under the supervision of senior doctors in their specialist field. Trainees attend mandatory communication skills training days throughout the program. PARTICIPANTS Study participants were recruited using purposive sampling from a sampling frame of 25 urology trainees on a national training scheme. Eleven trainees participated in the study. RESULTS Participants' stage of training ranged from first to final year. Seven key themes emerged from the data relating to the trainees' experiences of error disclosure and the intention-behavior gap for ED. These themes include observed positive and negative practice in the workplace, impact of stage of training, importance of interpersonal interactions, perceived blame/responsibility for multifactorial error or recognized complication, lack of formal training in ED, cultural aspects of the training environment and medicolegal issues around ED. CONCLUSIONS While trainees recognize the importance of ED, personal psychological factors, negative environmental culture, and medicolegal concerns are significant barriers to the practice of ED. A training environment that focuses on role-modelling and experiential learning with adequate time for reflection and debriefing is paramount. Areas for further research include broadening the scope of this study of ED across different medical and surgical subspecialties.
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Affiliation(s)
- Clíodhna Browne
- School of Health Sciences, National University of Ireland, Galway, Ireland; Royal College of Surgeons, Dublin, Ireland.
| | | | - Enda O'Connor
- School of Medicine, Trinity College Dublin, Dublin, Ireland; Department of Anaesthetics, St James' Hospital, Dublin, Ireland
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20
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Fidalgo M, Cabral J, Soares I, Oliveira M. From Testicle to Brain: A Case of Disseminated Tuberculosis. Cureus 2023; 15:e38526. [PMID: 37273294 PMCID: PMC10239069 DOI: 10.7759/cureus.38526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Tuberculosis remains a major cause of death by infection in the world. Disseminated tuberculosis occurs most frequently in the context of reactivation of a previously latent infection and is invariably lethal if untreated. Age, late presentation, and serious underlying disease are strong death predictors. We report the case of a 72-year-old male patient who presented to the emergency room with sudden onset hemiparesis and aphasia, with no acute lesions on contrast CT. Two months prior to the current event, the patient had undergone surgery for a testicular abscess in a different hospital. Since the surgery, he had progressive and unexplained weight loss and dysphagia. The medical team reviewed patient records from this hospital and the one where the surgery took place and concluded that the histopathology results from the surgery were not reviewed in the post-surgery follow-up consult and that the diagnosis of genitourinary tuberculosis was never made. This disease, untreated, evolved into disseminated tuberculosis with central nervous system involvement, causing the neurological deficits the patient presented and leading to his death. Surveillance and notification systems exist for individual and public health safeguarding. In the present case, failure to review the pathology report after surgery, coupled with the absence of notification from the laboratory, delayed the diagnosis and led to patient death. This report suggests a need for continuous system improvement, with integrated healthcare records and interinstitutional communication channels, in order to minimize information loss, diagnostic delays, and public health risks.
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Affiliation(s)
- Mariana Fidalgo
- Internal Medicine, Centro Hospitalar Vila Nova Gaia/Espinho, Vila Nova Gaia, PRT
| | - Joana Cabral
- Internal Medicine, Centro Hospitalar Vila Nova Gaia Espinho, Vila Nova Gaia, PRT
| | - Inês Soares
- Internal Medicine, Centro Hospitalar Vila Nova Gaia/Espinho, Vila Nova Gaia, PRT
| | - Marta Oliveira
- Internal Medicine, Centro Hospitalar Vila Nova Gaia/Espinho, Vila Nova Gaia, PRT
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Kalywis AL, Samuel R, Scholtes F, Reuter G, Stienen MN, Seifritz E, Surbeck W. Distribution of psychological instability among surgeons. World Neurosurg 2023:S1878-8750(23)00461-8. [PMID: 37028482 DOI: 10.1016/j.wneu.2023.03.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND High emotional instability, i.e. neuroticism, is associated with poor mental health. Conversely, traumatic experiences may increase neuroticism. Stressful experiences such as complications are common in the surgical profession, with neurosurgeons being particularly affected. We compared the personality trait neuroticism between physicians in a prospective cross-sectional study. METHODS We used an online survey using the Ten-Item Personality Inventory, an internationally validated measure of the five-factor model of personality dimensions. It was distributed to board-certified physicians, residents, and medical students in several European countries and Canada (n = 5,148). Multivariate linear regression was used to model differences between surgeons, non-surgeons and specialties with occasional surgical interventions with respect to neuroticism, adjusting for gender, age, age squared and their interactions, then testing equality of parameters of adjusted predictions separately and jointly using Wald tests. RESULTS With an expected variability within disciplines, average levels of neuroticism are lower in surgeons than non-surgeons, especially in the first part of their career. However, the course of neuroticism across age follows a quadratic pattern, i.e., an increase after the initial decrease. The acceleration of neuroticism with age is specifically significant in surgeons. Levels of neuroticism are lowest towards mid-career, but exhibit a strong secondary increase towards the end of the surgeons' career. This pattern seems driven by neurosurgeons. CONCLUSION Despite initially lower levels of neuroticism, surgeons suffer a stronger increase of neuroticism together with age. Since, beyond well-being, neuroticism influences professional performance and healthcare systems costs, explanatory studies are mandatory to enlighten causes of this burden.
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Affiliation(s)
- Anna L Kalywis
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland; Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital, Zurich, University of Zurich, Zurich, Switzerland
| | - Robin Samuel
- Department of Social Sciences, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Felix Scholtes
- Department of Neuroanatomy, Faculty of Medicine, Université de Liège, Liège, Belgium
| | - Gilles Reuter
- Department of Neurosurgery, Faculty of Medicine, Université de Liège, Liège, Belgium
| | - Martin N Stienen
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Werner Surbeck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland.
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Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Curr Opin Anaesthesiol 2023; 36:240-245. [PMID: 36700459 PMCID: PMC9973433 DOI: 10.1097/aco.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Despite healthcare workers' best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement? RECENT FINDINGS The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk. SUMMARY Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.
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Affiliation(s)
- Guttorm Brattebø
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital
- Department of Clinical Medicine, University of Bergen
- Norwegian National Advisory Unit on Emergency Medical Communication, Haukeland University Hospital
| | - Hans Kristian Flaatten
- Department of Clinical Medicine, University of Bergen
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
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Najafi Ghezeljeh T, Farahani MA, Kafami Ladani F. "Attempting to protect self and patient:" A grounded theory study of error recovery by intensive care nurses. Nurs Open 2023. [PMID: 36915234 DOI: 10.1002/nop2.1719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 08/23/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
AIM The aim of this study was to explore the process of error recovery (ER) by nurses in intensive care unit (ICU). DESIGN This qualitative study was conducted in 2018-2020 using the grounded theory methodology. METHODS Participants were 20 staff nurses, head nurses and nursing managers recruited from the ICUs. Sampling was started purposively and continued theoretically. Data were collected using semi-structured interviews and were analysed using the approach proposed by Corbin and Strauss. RESULTS The findings indicated that nurses' primary concern was for the patient and their own personal/professional identity. Five strategies were found including evaluating situation, identifying error, analysing error and situation, determining the agent for error correction, and reducing error effects. Contextual factors were also highlighted as being important in the error recovery. Attempting to protect self and patient" was the core category of the study. Nurses' concern about protecting patient life and their own personal/professional identity make them use unprofessional approaches for ER.
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Affiliation(s)
- Tahereh Najafi Ghezeljeh
- Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Mansoureh Ashghali Farahani
- Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kafami Ladani
- Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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Moore AJ, Webster-Edge S. 5S solutions to promote medication efficiency and safety. Br J Anaesth 2023; 130:e416-e418. [PMID: 36609059 PMCID: PMC9811378 DOI: 10.1016/j.bja.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 01/06/2023] Open
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Marung H, Strametz R, Roesner H, Reifferscheid F, Petzina R, Klemm V, Trifunovic-Koenig M, Bushuven S. Second Victims among German Emergency Medical Services Physicians (SeViD-III-Study). Int J Environ Res Public Health 2023; 20:4267. [PMID: 36901278 PMCID: PMC10001835 DOI: 10.3390/ijerph20054267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Patient care in the prehospital emergency setting is error-prone. Wu's publications on the second victim syndrome made very clear that medical errors may lead to severe emotional injury on the caregiver's part. So far, little is known about the extent of the problem within the field of prehospital emergency care. Our study aimed at identifying the prevalence of the Second Victim Phenomenon among Emergency Medical Services (EMS) physicians in Germany. METHODS Web-based distribution of the SeViD questionnaire among n = 12.000 members of the German Prehospital Emergency Physician Association (BAND) to assess general experience, symptoms and support strategies associated with the Second Victim Phenomenon. RESULTS In total, 401 participants fully completed the survey, 69.1% were male and the majority (91.2%) were board-certified in prehospital emergency medicine. The median length of experience in this field of medicine was 11 years. Out of 401 participants, 213 (53.1%) had experienced at least one second victim incident. Self-perceived time to full recovery was up to one month according to 57.7% (123) and more than one month to 31.0% (66) of the participants. A total of 11.3% (24) had not fully recovered by the time of the survey. Overall, 12-month prevalence was 13.7% (55/401). The COVID-19 pandemic had little effect on SVP prevalence within this specific sample. CONCLUSIONS Our data indicate that the Second Victim Phenomenon is very frequent among prehospital emergency physicians in Germany. However, four out of ten caregivers affected did not seek or receive any assistance in coping with this stressful situation. One out of nine respondents had not yet fully recovered by the time of the survey. Effective support networks, e.g., easy access to psychological and legal counseling as well as the opportunity to discuss ethical issues, are urgently required in order to prevent employees from further harm, to keep healthcare professionals from leaving this field of medical care and to maintain a high level of system safety and well-being of subsequent patients.
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Affiliation(s)
- Hartwig Marung
- Department Health Sciences, MSH Medical School Hamburg, 20457 Hamburg, Germany
| | - Reinhard Strametz
- Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany
| | - Hannah Roesner
- Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany
| | - Florian Reifferscheid
- Department of Anaesthesiology and Intensive Care, Universitätsklinikum Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
- Bundesvereinigung der Arbeitsgemeinschaften der Notaerzte Deutschlands (BAND), 10969 Berlin, Germany
| | - Rainer Petzina
- Department Health Sciences, MSH Medical School Hamburg, 20457 Hamburg, Germany
| | - Victoria Klemm
- Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany
| | | | - Stefan Bushuven
- Institute for Infection Control and Infection Prevention, Hegau-Jugendwerk Gailingen, Health Care Association District of Constance, 78315 Radolfzell, Germany
- Institute for Medical Education, University Hospital, LMU Munich, 80539 Munich, Germany
- Department of Anesthesiology and Critical Care, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg im Breisgau, Germany
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Krvavac S, Bystad M, Wynn R, Bukholm IRK, Jansson B. Characteristics of Patients Who Complete Suicide and Suicide Attempts While Undergoing Treatment in Norway: Findings from Compensation Claims Records. Int J Environ Res Public Health 2023; 20:4083. [PMID: 36901092 PMCID: PMC10002346 DOI: 10.3390/ijerph20054083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/19/2023] [Accepted: 02/22/2023] [Indexed: 06/18/2023]
Abstract
The aim of this study was to identify characteristics that differentiate patients who complete suicide (SC) from patients with suicide attempts (SA) while undergoing treatment in Norway. We examined data from the Norwegian System of Patient Injury Compensation (Norsk Pasientskade Erstatning-NPE). Data were extracted from NPE case records from a 10-year period (2009-2019) for 356 individuals who attempted (n = 78) or died by (n = 278) suicide. The two groups differed significantly in the types of medical errors identified by experts. Inadequate suicide risk assessment tended to be proportionally and significantly more prevalent among SC compared to SA. There was a weak but significant trend that SA had received medication only, whereas SC had received both medication and psychotherapy. There were no significant differences with respect to age group, gender, diagnostic category, number of previous suicide attempts, inpatient/outpatient status, or category of responsible clinic. We conclude that suicide attempters and suicide completers differed in terms of identified medical errors. Focusing on the prevention of these and other types of errors could help to reduce the number of suicides of patients in treatment.
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Affiliation(s)
- Sanja Krvavac
- Department of Psychiatry, Helgeland Hospital Trust, 8802 Sandnessjøen, Norway
- Department of Health and Care Sciences, UiT The Arctic University of Tromsø, 9037 Tromsø, Norway
| | - Martin Bystad
- Division of Substance Use and Mental Health, University Hospital of North Norway, 9019 Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, UiT The Arctic University of Tromsø, 9038 Tromsø, Norway
- Department of Education, ICT and Learning, Østfold University College, 1757 Halden, Norway
| | - Ida Rashida Khan Bukholm
- The Norwegian System of Patient Injury Compensation, 0130 Oslo, Norway
- Faculty of Landscape and Society, The Norwegian University of Life Sciences, 1430 Ås, Norway
| | - Billy Jansson
- Department of Psychology and Social Work, Mid Sweden University, 831 25 Ostersund, Sweden
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Mavragani A, Lyons PG, Harris E, McCune EK, Rojas JC, Santhosh L. Improving Communication in Intensive Care Unit to Ward Transitions: Protocol for Multisite National Implementation of the ICU-PAUSE Handoff Tool. JMIR Res Protoc 2023; 12:e40918. [PMID: 36745494 PMCID: PMC9941899 DOI: 10.2196/40918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The intensive care unit (ICU)-ward transfer poses a particularly high-risk period for patients. The period after transfer has been associated with adverse events and additional work for care teams related to miscommunication or omission of information. Standardized handoff processes have been found to reduce communication errors and adverse patient events in other clinical environments but are understudied at the ICU-ward interface. We previously developed an electronic ICU-ward transfer tool, ICU-PAUSE, which embeds the key elements and diagnostic reasoning to facilitate a safe transfer of care at ICU discharge. OBJECTIVE The aim of this study is to evaluate the implementation process of the ICU-PAUSE handoff tool across 10 academic medical centers, including the rate of adoption and acceptability, as perceived by clinical care teams. METHODS ICU-PAUSE will be implemented in the medical ICU across 10 academic hospitals, with each site customizing the tool to their institution's needs. Our mixed methods study will include a combination of a chart review, quantitative surveys, and qualitative interviews. After a 90-day implementation period, we will conduct a retrospective chart review to evaluate the rate of uptake of ICU-PAUSE. We will also conduct postimplementation surveys of providers to assess perceptions of the tool and its impact on the frequency of communication errors and adverse events during ICU-ward transfers. Lastly, we will conduct semistructured interviews of faculty stakeholders with subsequent thematic analysis with the goal of identifying benefits and barriers in implementing and using ICU-PAUSE. RESULTS ICU-PAUSE was piloted in the medical ICU at Barnes-Jewish Hospital, the teaching hospital of Washington University School of Medicine in St. Louis, in 2019. As of July 2022, implementation of ICU-PAUSE is ongoing at 6 of 10 participating sites. Our results will be published in 2023. CONCLUSIONS Our process of ICU-PAUSE implementation embeds each step of template design, uptake, and customization in the needs of users and key stakeholders. Here, we introduce our approach to evaluate its acceptability, usability, and impact on communication errors according to the tenets of sociotechnical theory. We anticipate that ICU-PAUSE will offer an effective handoff tool for the ICU-ward transition that can be generalized to other institutions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/40918.
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Affiliation(s)
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, John T Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St Louis, MO, United States.,Healthcare Innovation Lab, BJC HealthCare, St Louis, MO, United States
| | - Emily Harris
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Emma K McCune
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Juan C Rojas
- Department of Internal Medicine, Rush University, Chicago, IL, United States
| | - Lekshmi Santhosh
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Krommer E, Ablöscher M, Klemm V, Gatterer C, Rösner H, Strametz R, Huf W, Ettl B. Second Victim Phenomenon in an Austrian Hospital before the Implementation of the Systematic Collegial Help Program KoHi: A Descriptive Study. Int J Environ Res Public Health 2023; 20:1913. [PMID: 36767279 PMCID: PMC9915153 DOI: 10.3390/ijerph20031913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
(1) Background: The Second Victim Phenomenon (SVP) is widespread throughout health care institutions worldwide. Second Victims not only suffer emotional stress themselves; the SVP can also have a great financial and reputational impact on health care institutions. Therefore, we conducted a study (Kollegiale Hilfe I/KoHi I) in the Hietzing Clinic (KHI), located in Vienna, Austria, to find out how widespread the SVP was there. (2) Methods: The SeViD (Second Victims in Deutschland) questionnaire was used and given to 2800 employees of KHI, of which 966 filled it in anonymously. (3) Results: The SVP is prevalent at KHI (43% of the participants stated they at least once suffered from SVP), although less prevalent and pronounced than expected when compared to other studies conducted in German-speaking countries. There is still a need for action, however, to ensure a psychologically safer workspace and to further prevent health care workers at KHI from becoming psychologically traumatized.
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Affiliation(s)
- Elisabeth Krommer
- Karl Landsteiner Institute for Clinical Risk Management, Wolkersbergenstraße 1, 1130 Vienna, Austria
| | - Miriam Ablöscher
- Karl Landsteiner Institute for Clinical Risk Management, Wolkersbergenstraße 1, 1130 Vienna, Austria
| | - Victoria Klemm
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain UAS, Bleichstr. 44, 65183 Wiesbaden, Germany
| | - Christian Gatterer
- Karl Landsteiner Institute for Clinical Risk Management, Wolkersbergenstraße 1, 1130 Vienna, Austria
| | - Hannah Rösner
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain UAS, Bleichstr. 44, 65183 Wiesbaden, Germany
| | - Reinhard Strametz
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain UAS, Bleichstr. 44, 65183 Wiesbaden, Germany
| | - Wolfgang Huf
- Karl Landsteiner Institute for Clinical Risk Management, Wolkersbergenstraße 1, 1130 Vienna, Austria
| | - Brigitte Ettl
- Karl Landsteiner Institute for Clinical Risk Management, Wolkersbergenstraße 1, 1130 Vienna, Austria
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29
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Albreiki S, Alqaryuti A, Alameri T, Aljneibi A, Simsekler MCE, Anwar S, Lentine KL. A Systematic Literature Review of Safety Culture in Hemodialysis Settings. J Multidiscip Healthc 2023; 16:1011-1022. [PMID: 37069892 PMCID: PMC10105578 DOI: 10.2147/jmdh.s407409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
Background Safety culture is an important aspect of quality in healthcare settings. There are many risks that patients can encounter in hemodialysis settings one of which is the infection risks due to the regular need to access bloodstreams using catheters and needles. Implementation of prevention guidelines, protocols and strategies that reinforce safety culture excellence are essential to mitigate risks. The objective of this study was to identify and characterize the main strategies that enhance and improve patient safety culture in hemodialysis settings. Methods Medline (via PubMed) and Scopus were searched from 2010 to 2020 in English. Terms defining safety culture, patient safety were combined with the term hemodialysis during the search. The studies were chosen based on inclusion criteria. Results A total of 17 articles reporting on six countries were identified that met inclusion criteria following the PRISMA statement. From the 17 papers, practices that were successfully applied to improve safety culture in hemodialysis settings included (i) training of nurses on the technologies used in hemodialysis treatment, (ii) proactive risk identification tools to prevent infections (iii) root cause analysis in evaluating the errors, (iv) hemodialysis checklist to be used by the dialysis nurses to reduce the adverse events, and (v) effective communication and mutual trust between the employee and leadership to support no-blame environment, and improve the safety culture. Conclusion This systematic review provided significant insights on the strategies that healthcare safety managers and policy makers can implement to enhance safety culture in hemodialysis settings.
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Affiliation(s)
- Salma Albreiki
- Department of Industrial and Systems Engineering, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
| | - Alaa Alqaryuti
- Department of Industrial and Systems Engineering, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
| | - Tareq Alameri
- Department of Industrial and Systems Engineering, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
| | - Amani Aljneibi
- Department of Industrial and Systems Engineering, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
| | - Mecit Can Emre Simsekler
- Department of Industrial and Systems Engineering, Khalifa University of Science and Technology, Abu Dhabi, 127788, United Arab Emirates
- Correspondence: Mecit Can Emre Simsekler, Khalifa University of Science and Technology, Department of Industrial and Systems Engineering, P.O. Box 127788, Abu Dhabi, United Arab Emirates, Tel +9712 501 8410, Fax +971 2 447 2442, Email
| | - Siddiq Anwar
- Sheikh Shakhbout Medical City, Abu Dhabi, 10001, United Arab Emirates
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO, USA
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30
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Jia JL, Lester JC. Anchoring bias and heuristics can perpetuate disparities in dermatology. J Am Acad Dermatol 2023; 88:265-266. [PMID: 35671884 DOI: 10.1016/j.jaad.2022.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Justin L Jia
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Jenna C Lester
- Department of Dermatology, University of California San Francisco, San Francisco, California.
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31
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Mertens M, King OC, van Putten MJAM, Boenink M. Can we learn from hidden mistakes? Self-fulfilling prophecy and responsible neuroprognostic innovation. J Med Ethics 2022; 48:922-928. [PMID: 34253620 PMCID: PMC9626909 DOI: 10.1136/medethics-2020-106636] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 05/22/2021] [Indexed: 05/24/2023]
Abstract
A self-fulfilling prophecy (SFP) in neuroprognostication occurs when a patient in coma is predicted to have a poor outcome, and life-sustaining treatment is withdrawn on the basis of that prediction, thus directly bringing about a poor outcome (viz. death) for that patient. In contrast to the predominant emphasis in the bioethics literature, we look beyond the moral issues raised by the possibility that an erroneous prediction might lead to the death of a patient who otherwise would have lived. Instead, we focus on the problematic epistemic consequences of neuroprognostic SFPs in settings where research and practice intersect. When this sort of SFP occurs, the problem is that physicians and researchers are never in a position to notice whether their original prognosis was correct or incorrect, since the patient dies anyway. Thus, SFPs keep us from discerning false positives from true positives, inhibiting proper assessment of novel prognostic tests. This epistemic problem of SFPs thus impedes learning, but ethical obligations of patient care make it difficult to avoid SFPs. We then show how the impediment to catching false positive indicators of poor outcome distorts research on novel techniques for neuroprognostication, allowing biases to persist in prognostic tests. We finally highlight a particular risk that a precautionary bias towards early withdrawal of life-sustaining treatment may be amplified. We conclude with guidelines about how researchers can mitigate the epistemic problems of SFPs, to achieve more responsible innovation of neuroprognostication for patients in coma.
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Affiliation(s)
- Mayli Mertens
- Center for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
| | - Owen C King
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
| | - Michel J A M van Putten
- MIRA-Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, Overijssel, The Netherlands
- Department of Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Overijssel, The Netherlands
| | - Marianne Boenink
- Department of Philosophy, University of Twente, Enschede, Overijssel, The Netherlands
- Department IQ Healthcare, RadboudUMC - Radboud University, Nijmegen, Gelderland, the Netherlands
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32
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Schulz JS. Reforming clinical negligence in England: lessons about patients' and providers' values from medical injury resolution in New Zealand and the United States of America. Future Healthc J 2022; 9:230-237. [PMID: 36561808 PMCID: PMC9761461 DOI: 10.7861/fhj.2022-0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
England's current review of clinical negligence and consideration of alternatives (such as no-fault compensation) should be welcomed. Valuing what patients and families want, and need, after harm in healthcare necessitates a system that enables their needs to be met. Medical negligence litigation is misaligned with patients' needs after harm events. By contrast, alternatives (such as no-fault and communication-and-resolution programmes) offer opportunities to place patients', families' and providers' values at the forefront of resolution efforts. This article offers empirical insights and lessons from two alternative systems for resolving medical injuries: New Zealand's (NZ's) administrative compensation scheme, and the US communication-and-resolution programmes (CRPs). The review in England presents an exciting opportunity to design a system for responding to medical injuries that harnesses the strengths of alternative approaches for resolving medical injuries, while also improving on the challenges with treatment injury in NZ.
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Affiliation(s)
- Jennifer S Schulz
- University of New South Wales, Sydney, Australia and adjunct associate professor, Auckland University of Technology, Auckland, New Zealand,Address for correspondence: Dr Jennifer S Schulz, University of New South Wales Faculty of Law, Law Building Kensington, Sydney, New South Wales 2052, Australia. Twitter: @jensarahmoore
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Mahmudah NA, Im D, Pyo J, Ock M. Occurrence of patient safety incidents during cancer screening: A cross-sectional investigation of the general public. Medicine (Baltimore) 2022; 101:e31284. [PMID: 36316891 PMCID: PMC9622598 DOI: 10.1097/md.0000000000031284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This study aimed to explore the various types and frequency of patient safety incidents (PSIs) during a cancer screening health examination for the general public of Ulsan Metropolitan City, South Korea. Furthermore, the associated elements and responses to PSIs during a cancer screening were examined. The survey, conducted in the five districts of Ulsan, was completed by residents aged 19 years and older who agreed to participate. Descriptive analysis, Chi-square or Fisher exact test, and multivariable logistic regression were performed to analyze the data. A total of 620 participants completed the survey, with 11 (1.8%) individuals who experienced PSIs themselves and 11 (1.8%) by their family members. The highest type of PSIs was those related to procedures. The multivariable logistic regression analysis showed no significant variables associated with experiencing PSIs during cancer screening. However, there was a significant association between the judgment of medical error occurrence and level of patient harm both in experience by family members and total experience of PSIs (P < .05). There was also a significant difference between with and without an experience of PSIs disclosure (P < .001). This study comprehensively analyzed the types and extent of PSIs experienced by Korean individuals and their family members in Ulsan. These findings suggest that patient safety issues during cancer screening should not be overlooked. Furthermore, an investigation system to regularly monitor PSIs in cancer screening should be developed and established.
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Affiliation(s)
- Noor Afif Mahmudah
- Department of Family and Community Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Dasom Im
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jeehee Pyo
- Task Forces to Support Public Health and Medical Services in Ulsan Metropolitan City, Ulsan, Republic of Korea
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
- Task Forces to Support Public Health and Medical Services in Ulsan Metropolitan City, Ulsan, Republic of Korea
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * Correspondence: Minsu Ock, Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan 44033, Republic of Korea (e-mail: )
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Schmidt M, Lambert SI, Klasen M, Sandmeyer B, Lazarovici M, Jahns F, Trefz LC, Hempel G, Sopka S. Safety management in times of crisis: Lessons learned from a nationwide status-analysis on German intensive care units during the COVID-19 pandemic. Front Med (Lausanne) 2022; 9:988746. [PMID: 36275792 PMCID: PMC9583873 DOI: 10.3389/fmed.2022.988746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/02/2022] [Indexed: 01/08/2023] Open
Abstract
Background The status of Safety Management is highly relevant to evaluate an organization's ability to deal with unexpected events or errors, especially in times of crisis. However, it remains unclear to what extent Safety Management was developed and sufficiently implemented within the healthcare system during the COVID-19 pandemic. Providing insights of potential for improvement is expected to be directional for ongoing Safety Management efforts, in times of crisis and beyond. Method A nationwide survey study was conducted among healthcare professionals and auxiliary staff on German Intensive Care Units (ICUs) evaluating their experiences during the first wave of the COVID-19 pandemic. Error Management and Patient Safety Culture (PSC) measures served to operationalize Safety Management. Data were analyzed descriptively and by using quantitative content analysis (QCA). Results Results for n = 588 participants from 53 hospitals show that there is a gap between errors occurred, reported, documented, and addressed. QCA revealed that low quality of safety culture (27.8%) was the most mentioned reason for errors not being addressed. Overall, ratings of PSC ranged from 26.7 to 57.9% positive response with Staffing being the worst and Teamwork Within Units being the best rated dimension. While assessments showed a similar pattern, medical staff rated PSC on ICUs more positively in comparison to nursing staff. Conclusion The status-analysis of Safety Management in times of crisis revealed relevant potential for improvement. Human Factor plays a crucial role in the occurrence and the way errors are dealt with on ICUs, but systemic factors should not be underestimated. Further intensified efforts specifically in the fields of staffing and error reporting, documentation and communication are needed to improve Safety Management on ICUs. These findings might also be applicable across nations and sectors beyond the medical field.
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Affiliation(s)
- Michelle Schmidt
- AIXTRA — Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Aachen, Germany,Department of Anaesthesiology, University Hospital RWTH Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany,*Correspondence: Michelle Schmidt
| | - Sophie Isabelle Lambert
- AIXTRA — Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Aachen, Germany,Department of Anaesthesiology, University Hospital RWTH Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Martin Klasen
- AIXTRA — Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Aachen, Germany,Department of Anaesthesiology, University Hospital RWTH Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Benedikt Sandmeyer
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, München, Germany
| | - Marc Lazarovici
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, München, Germany
| | - Franziska Jahns
- Department of Anaesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Lara Charlott Trefz
- Department of Anaesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Gunther Hempel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Leipzig, Germany
| | - Saša Sopka
- AIXTRA — Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Aachen, Germany,Department of Anaesthesiology, University Hospital RWTH Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany
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McMillan MW, Lehnus K. Application of systems analysis to safety incident investigations in a single centre using anaesthesia as an example. Vet Rec 2022; 191:e2237. [PMID: 36195981 DOI: 10.1002/vetr.2237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Systems analysis is widely recommended for patient safety investigations in medicine, but the method is poorly described in the veterinary literature. METHODS Anaesthetic safety incidents were discussed in debriefs and then reported on standardised forms. Investigators performed informal interviews with team members involved in case management and interrogated clinical records. Finally, incidents were discussed during morbidity and mortality conferences. Systems analysis involved developing a timeline for the case, identifying any care delivery problems (CDPs) that occurred and contributing factors associated with them, and developing control measures to reduce system weaknesses. RESULTS From 15 incidents, 32 CDPs were identified. These were categorised into 11 thematic groups. Misdiagnosis (n = 8), human resource allocation (n = 8), failure in planning (n = 6) and technical error (n = 5) were most frequent. Individual factors were identified in 15 (100%), team factors in 12 (80.0%), animal and owner factors in 11 (73.3%), organisation factors in 10 (66.7%), work environmental factors in 10 (66.7%) and task and technology factors in four (26.7%) investigations. Numerous immediate and longer term recommendations were made regarding how to manage systems weaknesses. LIMITATIONS Investigations were limited to pre-procedural anaesthetic safety incidents. CONCLUSIONS Systems analysis applied to incident investigations can highlight areas for improvement within veterinary healthcare systems.
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White AA, King AM, D'Addario AE, Brigham KB, Dintzis S, Fay EE, Gallagher TH, Mazor KM. Effects of Practicing With and Obtaining Crowdsourced Feedback From the Video-Based Communication Assessment App on Resident Physicians' Adverse Event Communication Skills: Pre-post Trial. JMIR Med Educ 2022; 8:e40758. [PMID: 36190751 PMCID: PMC9577713 DOI: 10.2196/40758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND US residents require practice and feedback to meet Accreditation Council for Graduate Medical Education mandates and patient expectations for effective communication after harmful errors. Current instructional approaches rely heavily on lectures, rarely provide individualized feedback to residents about communication skills, and may not assure that residents acquire the skills desired by patients. The Video-based Communication Assessment (VCA) app is a novel tool for simulating communication scenarios for practice and obtaining crowdsourced assessments and feedback on physicians' communication skills. We previously established that crowdsourced laypeople can reliably assess residents' error disclosure skills with the VCA app. However, its efficacy for error disclosure training has not been tested. OBJECTIVE We aimed to evaluate the efficacy of using VCA practice and feedback as a stand-alone intervention for the development of residents' error disclosure skills. METHODS We conducted a pre-post study in 2020 with pathology, obstetrics and gynecology, and internal medicine residents at an academic medical center in the United States. At baseline, residents each completed 2 specialty-specific VCA cases depicting medical errors. Audio responses were rated by at least 8 crowdsourced laypeople using 6 items on a 5-point scale. At 4 weeks, residents received numerical and written feedback derived from layperson ratings and then completed 2 additional cases. Residents were randomly assigned cases at baseline and after feedback assessments to avoid ordinal effects. Ratings were aggregated to create overall assessment scores for each resident at baseline and after feedback. Residents completed a survey of demographic characteristics. We used a 2×3 split-plot ANOVA to test the effects of time (pre-post) and specialty on communication ratings. RESULTS In total, 48 residents completed 2 cases at time 1, received a feedback report at 4 weeks, and completed 2 more cases. The mean ratings of residents' communication were higher at time 2 versus time 1 (3.75 vs 3.53; P<.001). Residents with prior error disclosure experience performed better at time 1 compared to those without such experience (ratings: mean 3.63 vs mean 3.46; P=.02). No differences in communication ratings based on specialty or years in training were detected. Residents' communication was rated higher for angry cases versus sad cases (mean 3.69 vs mean 3.58; P=.01). Less than half of all residents (27/62, 44%) reported prior experience with disclosing medical harm to patients; experience differed significantly among specialties (P<.001) and was lowest for pathology (1/17, 6%). CONCLUSIONS Residents at all training levels can potentially improve error disclosure skills with VCA practice and feedback. Error disclosure curricula should prepare residents for responding to various patient affects. Simulated error disclosure may particularly benefit trainees in diagnostic specialties, such as pathology, with infrequent real-life error disclosure practice opportunities. Future research should examine the effectiveness, feasibility, and acceptability of VCA within a longitudinal error disclosure curriculum.
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Affiliation(s)
- Andrew A White
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Ann M King
- National Board of Medical Examiners, Philadelphia, PA, United States
| | | | - Karen Berg Brigham
- Collaborative for Accountability and Improvement, University of Washington, Seattle, WA, United States
| | - Suzanne Dintzis
- Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
| | - Emily E Fay
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States
| | - Thomas H Gallagher
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Kathleen M Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, United States
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Dolev T, Zubedat S, Manor I, Bloch B, Blondheim O, Avital A. Differential Impact of Work Overload on Physicians' Attention: A Comparison Between Residential Fields. J Patient Saf 2022; 18:e971-e978. [PMID: 35323137 PMCID: PMC9422770 DOI: 10.1097/pts.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Medical errors cause tens of thousands of deaths annually and have a major impact on quality of care and management; however, it receives scant research and public awareness. This study aimed to examine the relation between workload-induced lack of sleep and attention failure, as indications for medical errors risk, among young residents. METHODS We performed an evaluation of young physicians by the Test of Variables of Attention, before and after a 24-hour shift. RESULTS Workload was manifested by 13% overall attention impairment at baseline, which increased to 34% with deficiencies below the normal range after the shift. Attention measures differed between physicians of each residential field at baseline, but to greater extent after the shift. CONCLUSIONS Traditional working schedule is strongly associated with attention failure. Based on the literature linking attention failures to medical errors, we suggest a regulatory change regarding residents' shift duration to decrease preventable errors.
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Affiliation(s)
- Talya Dolev
- From the Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Salman Zubedat
- From the Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Iris Manor
- Department of Psychiatry, Geha Mental Health Center, Petah Tikva, Israel
| | | | | | - Avi Avital
- From the Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Emek Medical Center, Afula, Israel
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Harrison R, Johnson J, McMullan RD, Pervaz-Iqbal M, Chitkara U, Mears S, Shapiro J, Lawton R. Toward Constructive Change After Making a Medical Error: Recovery From Situations of Error Theory as a Psychosocial Model for Clinician Recovery. J Patient Saf 2022; 18:587-604. [PMID: 35617626 PMCID: PMC9422758 DOI: 10.1097/pts.0000000000001038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Making a medical error is a uniquely challenging psychosocial experience for clinicians. Feelings of personal responsibility, coupled with distress regarding potential or actual patient harm resulting from a mistake, create a dual burden. Over the past 20 years, experiential accounts of making an error have provided evidence of the associated distress and impacts. However, theory-based psychosocial support interventions to improve both individual outcomes for the involved clinicians and system-level outcomes, such as patient safety and workforce retention, are lacking. There is a need for evidence-based ways to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts. Such interventions play a role within wider programs of health professional support. We sought to address this by developing a testable, psychosocial model of clinician recovery after error based on recent evidence. METHODS Systematic review methodology was used to identify studies published between January 2010 and June 2021 reporting experiences of direct involvement in medical errors and/or subsequent recovery. A narrative synthesis was produced from the resulting articles and used as the basis for a team-based qualitative approach to model building. RESULTS We identified 25 studies eligible for inclusion, reporting evidence primarily from experiences of doctors and nurses. The identified evidence indicates that coping approach, conversations (whether they occur and whether they are perceived to be helpful or unhelpful), and learning or development activities (helpful, unhelpful or absent) may influence the relationship between making an error and both individual clinician outcomes of emotional impact and resultant practice change. Our findings led to the development of the Recovery from Situations of Error Theory model, which provides a preliminary theoretical basis for intervention development and testing. CONCLUSIONS The Recovery from Situations of Error Theory model is the first testable psychosocial model of clinician recovery after making a medical error. Applying this model provides a basis to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts and to support the replication of interventions that work across services and health systems toward constructive change. Such interventions may be embedded into the growing body of peer support and employee support programs internationally that address a diverse range of stressful workplace experiences.
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Affiliation(s)
- Reema Harrison
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Judith Johnson
- School of Psychology, University of Leeds, Leeds
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, United Kingdom
| | - Ryan D. McMullan
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Maha Pervaz-Iqbal
- From the Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Upma Chitkara
- Hunter New England Medical Libraya, New Lambton, Australia
| | - Steve Mears
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Jo Shapiro
- Department of Anesthesia, Pain and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, United Kingdom
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Rai A, Keil M, Choi H, Mindel V. Understanding how physician perceptions of job demand and process benefits evolve during CPOE implementation. Health Syst (Basingstoke) 2022; 12:98-122. [PMID: 36926371 PMCID: PMC10013386 DOI: 10.1080/20476965.2022.2113343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 08/03/2022] [Indexed: 10/14/2022] Open
Abstract
We examine how physicians' perceptions of two computerized provider order entry (CPOE) capabilities, standardisation of care protocols and documentation quality, are associated with their perceptions of turnaround time, medical error, and job demand at three phases of CPOE implementation: pre-go-live, initial use, and continued use. Through a longitudinal study at a large urban hospital, we find standardisation of care protocols is positively associated with turnaround time reduction in all phases but positively associated with job demand increase only in the initial use phase. Standardisation also has a positive association with medical error reduction in the initial use phase, but later this effect becomes fully mediated through turnaround time reduction in the continued use phase. Documentation quality has a positive association with medical error reduction in the initial use phase and this association strengthens in the continued use phase. Our findings provide insights to effectively manage physicians' response to CPOE implementation.
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Affiliation(s)
- Arun Rai
- Georgia State University, Atlanta, Georgia, United States
| | - Mark Keil
- Georgia State University, Atlanta, Georgia, United States
| | - Hyoungyong Choi
- Hankuk University of Foreign Studies, Dongdaemun-gu, Seoul, Korea
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40
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Kim MJ, Seo HJ, Koo HM, Ock M, Hwang JI, Lee SI. The Korea National Patient Safety Incidents Inquiry Survey: Characteristics of Adverse Events Identified Through Medical Records Review in Regional Public Hospitals. J Patient Saf 2022; 18:382-388. [PMID: 35948288 PMCID: PMC9329043 DOI: 10.1097/pts.0000000000000944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In 2019, the Korean National Patient Safety Incidents Inquiry was conducted in the Republic of Korea to identify the national-level incidence of adverse events. This study determined the incidence and detailed the characteristics of adverse events at 15 regional public hospitals in the Republic of Korea. METHODS Medical records data of 500 randomly selected patients (discharged in 2016) were extracted from each of the 15 studied hospitals and reviewed in 3 stages. First, for each hospital, 2 nurses independently reviewed the medical records, using 41 screening criteria. Second, 2 physicians independently reviewed the records of those patients with at least 1 screening criterion from the first stage for adverse events occurrence and their characteristics. Third, a 9-member committee conducted a final review and compiled the final adverse event report. RESULTS Among 7500 patients, 4159 (55.5%) had at least 1 screening criterion; 745 (9.9%) experienced 901 adverse events (incidence, 12.0%). By type of institution, adverse event incidence varied widely from 1.2% to 45.6%. In 1032 adverse events, the majority (33.5%) were "patient care-related." By severity, the majority (638; 70.8%) were temporary, requiring intervention, whereas 38 (4.2%) resulted in death. The preventability score was high for "patient care-related" and "diagnosis-related" adverse events. Duration of hospitalization was extended for 463 (44.9%) adverse events, with "diagnosis-related" (30.8%) and "surgery/procedural-related" (30.1%) types extended by at least 21 days. CONCLUSIONS A review of medical records aids in identifying adverse events in medical institutions with varying characteristics, thus helping prioritize interventions to reduce their incidence.
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Affiliation(s)
- Min Ji Kim
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hee Jung Seo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Hong Mo Koo
- From the Korea Institute for Healthcare Accreditation, Seoul
| | - Minsu Ock
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
- Department of Preventive Medicine, University of Ulsan College of Medicine
| | - Jee-In Hwang
- Department of Nursing Management, College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine
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Abstract
Following the tumultuous times of a pandemic, members of the healthcare disciplines, including nursing, face mounting priorities and ethical straight-thinking questions for policy development. The processes for developing ethical policies must acknowledge others' health priorities and what matters to them instead of political agendas that dominate global thinking. An example of doing harm in healthcare is examined here as a priority leadership policy opportunity from a humanbecoming ethos understanding.
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Wolfe JM, Lyu W, Dong J, Wu CC. What eye tracking can tell us about how radiologists use automated breast ultrasound. J Med Imaging (Bellingham) 2022; 9:045502. [PMID: 35911209 PMCID: PMC9315059 DOI: 10.1117/1.jmi.9.4.045502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Purpose: Automated breast ultrasound (ABUS) presents three-dimensional (3D) representations of the breast in the form of stacks of coronal and transverse plane images. ABUS is especially useful for the assessment of dense breasts. Here, we present the first eye tracking data showing how radiologists search and evaluate ABUS cases. Approach: Twelve readers evaluated single-breast cases in 20-min sessions. Positive findings were present in 56% of the evaluated cases. Eye position and the currently visible coronal and transverse slice were tracked, allowing for reconstruction of 3D "scanpaths." Results: Individual readers had consistent search strategies. Most readers had strategies that involved examination of all available images. Overall accuracy was 0.74 (sensitivity = 0.66 and specificity = 0.84). The 20 false negative errors across all readers can be classified using Kundel's (1978) taxonomy: 17 are "decision" errors (readers found the target but misclassified it as normal or benign). There was one recognition error and two "search" errors. This is an unusually high proportion of decision errors. Readers spent essentially the same proportion of time viewing coronal and transverse images, regardless of whether the case was positive or negative, correct or incorrect. Readers tended to use a "scanner" strategy when viewing coronal images and a "driller" strategy when viewing transverse images. Conclusions: These results suggest that ABUS errors are more likely to be errors of interpretation than of search. Further research could determine if readers' exploration of all images is useful or if, in some negative cases, search of transverse images is redundant following a search of coronal images.
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Affiliation(s)
- Jeremy M Wolfe
- Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States
| | - Wanyi Lyu
- Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jeffrey Dong
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Chia-Chien Wu
- Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Boston, Massachusetts, United States
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Odoeme CV, Ugwuja D, Onah CS. Medical Error Litigation in Nigeria: A Proposal for Change. J Leg Med 2022; 42:111-121. [PMID: 37594366 DOI: 10.1080/01947648.2023.2238564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Negligence actions are the most important and dynamic of all torts because they are the principal means of compensating victims of accidents, including medical errors. Unfortunately, victims of medical error in Nigeria have not historically been able to enjoy the relief available through negligence suits. This article explores the Nigerian legal and regulatory framework for addressing medical errors and offers suggestions that could help improve such medical error response.
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Ortiz-López N, Ponce-Arancibia S, Olea-Gangas C, Chacano-Muñoz R, Arancibia-Carvajal S, Solis I. Determinants of the intention to speak up about medical error in primary healthcare settings in Chile. Health Soc Care Community 2022; 30:e1202-e1211. [PMID: 34431150 DOI: 10.1111/hsc.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 06/29/2021] [Accepted: 07/21/2021] [Indexed: 06/13/2023]
Abstract
Medical error frequently occurs in ambulatory care, and healthcare professionals may encounter situations in which they need to speak up to ensure better practice. This study aims to investigate the factors that influenced the intention to speak up about medical errors among healthcare professionals in primary care settings. Data were generated through a national cross-sectional survey of primary healthcare centres in the Republic of Chile. A research instrument was designed using the constructs of the theory of planned behaviour and was analysed using the structural equation model technique. In total, 203 healthcare professionals were recruited between March and May 2020. The model showed that the intention to speak up was directly and positively influenced by attitudes towards speaking up and perceived control (standard deviation [SD] = 0.284 and 0.576, respectively). Subjective norms indirectly and negatively influenced the intention to speak up through attitudes towards speaking up and perceived control (total effect SD = -0.303). The exploratory construct of willingness to change self-behaviour positively influenced the attitude towards behaviour. The intention to speak up strongly influenced the speaking up behaviour (total effect SD = 0.631). The proposed model explained 40% of the variance in behaviour. Based on this model, it was concluded that the intention to speak up strongly influenced the speaking up behaviour and predicted it by 40%. Factors that modify the intention to speak up are expected to influence the occurrence of this behaviour. This knowledge will inform strategies to enhance communication among healthcare professionals, improve speaking up behaviour and improve patient care.
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Affiliation(s)
| | | | | | | | - Sara Arancibia-Carvajal
- Institute of Basic Sciences, Faculty of Engineering and Sciences, Diego Portales University, Santiago, Chile
| | - Ivan Solis
- University of Chile School of Medicine, Santiago, Chile
- Department of Medicine, University of Chile Clinical Hospital, Santiago, Chile
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45
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Lou SS, Kim S, Harford D, Warner BC, Payne PRO, Abraham J, Kannampallil T. Effect of clinician attention switching on workload and wrong-patient errors. Br J Anaesth 2022; 129:e22-e24. [PMID: 35568509 DOI: 10.1016/j.bja.2022.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Sunny S Lou
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, MO, USA; Institute for Informatics, School of Medicine, Washington University in St Louis, MO, USA
| | - Seunghwan Kim
- Institute for Informatics, School of Medicine, Washington University in St Louis, MO, USA; Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Derek Harford
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Benjamin C Warner
- Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Philip R O Payne
- Institute for Informatics, School of Medicine, Washington University in St Louis, MO, USA; Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St Louis, St Louis, MO, USA; Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, MO, USA; Department of Medicine, School of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, MO, USA; Institute for Informatics, School of Medicine, Washington University in St Louis, MO, USA; Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St Louis, St Louis, MO, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis, MO, USA; Institute for Informatics, School of Medicine, Washington University in St Louis, MO, USA; Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St Louis, St Louis, MO, USA; Department of Computer Science and Engineering, McKelvey School of Engineering, Washington University in St Louis, St Louis, MO, USA.
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Derese M, Agegnehu W. Challenges of Medical Error Reporting in Mizan-Tepi University Teaching Hospital: A Qualitative Exploratory Study. Drug Healthc Patient Saf 2022; 14:51-59. [PMID: 35502287 PMCID: PMC9056101 DOI: 10.2147/dhps.s347738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Medical error is defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”. It is a serious public health problem that can pose a threat to patient safety and if managed it can be an opportunity to an organizational learning. This study aimed to assess the challenges of error reporting. Methods Explorative qualitative cross-sectional study was conducted. The study was conducted among healthcare providers in Mizan-Tepi University Teaching Hospital. The study participants were selected purposely based on the patient contact hour and had served in this hospital for long period of time. Twenty-one in-depth interviews were undertaken. From each wards, three in-depth interviews were held. Case team leaders and other healthcare providers were identified and interviewed. The data were analyzed thematically. Results Twenty-one healthcare providers were recruited for this study. Majority of the participants, 12 (57.1%) were nurses and midwives and as to marital status, 18 (85.7%) were married. Challenges for reporting medical errors were identified as perceived lack of confidentiality of the medical errors, perceived punitive measures, lack of good reporting system, perceived fear of losing acceptance, lack of learning culture from errors, information asymmetry, mass-media publication of medical errors, avoidance of conflict and attitude of health professionals. Conclusion There were system and individual related challenges for reporting of medical errors. Healthcare managers should enhance medical error reporting for organizational learning by addressing these system and individual factors.
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Affiliation(s)
- Msganaw Derese
- Department of Nursing, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Wubetu Agegnehu
- Department of Public Health, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
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47
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White AA, King AM, D'Addario AE, Brigham KB, Dintzis S, Fay EE, Gallagher TH, Mazor KM. Video-Based Communication Assessment of Physician Error Disclosure Skills by Crowdsourced Laypeople and Patient Advocates Who Experienced Medical Harm: Reliability Assessment With Generalizability Theory. JMIR Med Educ 2022; 8:e30988. [PMID: 35486423 PMCID: PMC9107044 DOI: 10.2196/30988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 02/19/2022] [Accepted: 03/31/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Residents may benefit from simulated practice with personalized feedback to prepare for high-stakes disclosure conversations with patients after harmful errors and to meet American Council on Graduate Medical Education mandates. Ideally, feedback would come from patients who have experienced communication after medical harm, but medical researchers and leaders have found it difficult to reach this community, which has made this approach impractical at scale. The Video-Based Communication Assessment app is designed to engage crowdsourced laypeople to rate physician communication skills but has not been evaluated for use with medical harm scenarios. OBJECTIVE We aimed to compare the reliability of 2 assessment groups (crowdsourced laypeople and patient advocates) in rating physician error disclosure communication skills using the Video-Based Communication Assessment app. METHODS Internal medicine residents used the Video-Based Communication Assessment app; the case, which consisted of 3 sequential vignettes, depicted a delayed diagnosis of breast cancer. Panels of patient advocates who have experienced harmful medical error, either personally or through a family member, and crowdsourced laypeople used a 5-point scale to rate the residents' error disclosure communication skills (6 items) based on audiorecorded responses. Ratings were aggregated across items and vignettes to create a numerical communication score for each physician. We used analysis of variance, to compare stringency, and Pearson correlation between patient advocates and laypeople, to identify whether rank order would be preserved between groups. We used generalizability theory to examine the difference in assessment reliability between patient advocates and laypeople. RESULTS Internal medicine residents (n=20) used the Video-Based Communication Assessment app. All patient advocates (n=8) and 42 of 59 crowdsourced laypeople who had been recruited provided complete, high-quality ratings. Patient advocates rated communication more stringently than crowdsourced laypeople (patient advocates: mean 3.19, SD 0.55; laypeople: mean 3.55, SD 0.40; P<.001), but patient advocates' and crowdsourced laypeople's ratings of physicians were highly correlated (r=0.82, P<.001). Reliability for 8 raters and 6 vignettes was acceptable (patient advocates: G coefficient 0.82; crowdsourced laypeople: G coefficient 0.65). Decision studies estimated that 12 crowdsourced layperson raters and 9 vignettes would yield an acceptable G coefficient of 0.75. CONCLUSIONS Crowdsourced laypeople may represent a sustainable source of reliable assessments of physician error disclosure skills. For a simulated case involving delayed diagnosis of breast cancer, laypeople correctly identified high and low performers. However, at least 12 raters and 9 vignettes are required to ensure adequate reliability and future studies are warranted. Crowdsourced laypeople rate less stringently than raters who have experienced harm. Future research should examine the value of the Video-Based Communication Assessment app for formative assessment, summative assessment, and just-in-time coaching of error disclosure communication skills.
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Affiliation(s)
- Andrew A White
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Ann M King
- National Board of Medical Examiners, Philadelphia, PA, United States
| | | | - Karen Berg Brigham
- Collaborative for Accountability and Improvement, University of Washington, Seattle, WA, United States
| | - Suzanne Dintzis
- Department of Pathology, University of Washington School of Medicine, Seattle, WA, United States
| | - Emily E Fay
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States
| | - Thomas H Gallagher
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, United States
| | - Kathleen M Mazor
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, United States
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48
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Atallah F, Hamm RF, Davidson CM, Combs CA. Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities. Am J Obstet Gynecol 2022; 227:B2-B10. [PMID: 35487325 DOI: 10.1016/j.ajog.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.
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Affiliation(s)
- Fouad Atallah
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Rebecca F Hamm
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | | | - C Andrew Combs
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Trifunovic-Koenig M, Strametz R, Gerber B, Mantri S, Bushuven S. Validation of the German Version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP) and Its Correlation to the Second Victim Phenomenon. Int J Environ Res Public Health 2022; 19:4857. [PMID: 35457724 DOI: 10.3390/ijerph19084857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Comparable to second victim phenomenon (SVP), moral injury (MI) affects health professionals (HP) working in stressful environments. Information on how MI and SVP intercorrelate and their part in a psychological trauma complex is limited. We tested and validated a German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP) instrument, screening for MI and correlated it with the recently developed German version of the Second Victim Experience and Support Tool (G-SVESTR) instrument, testing for SVP. METHODS After translating Moral Injury Symptom and Support Scale for Health Professionals (MISS-HP), we conducted a cross-sectional online survey providing G-MISS-HP and G-SVEST-R to HP. Statistics included Pearson's interitem correlation, reliability analysis, principal axis factoring and principal components analysis with Promax rotation, confirmatory factor and ROC analyses. RESULTS A total of 244 persons responded, of whom 156 completed the survey (33% nurses, 16% physicians, 9% geriatric nurses, 7.1% speech and language therapists). Interitem and corrected item-scale correlations did not measure for one item sufficiently. It was, therefore, excluded from further analyses. The nine-item score revealed good reliability (Guttman's lambda 2 = 0.80; Cronbach's alpha = 0.79). Factor validity was demonstrated, indicating that a three-factor model from the original study might better represent the data compared with our two-factor model. Positive correlations between G-MISS-HP and G-SVESTR subscales demonstrated convergent validity. ROC revealed sensitivity of 89% and specificity of 63% for G-MISS-HP using a nine-item scale with cutoff value of 28.5 points. Positive and negative predictive values were 62% and 69%, respectively. Subgroup analyses did not reveal any differences. CONCLUSION G-MISS-HP with nine items is a valid and reliable testing instrument for moral injury. However, strong intercorrelations of MI and SVP indicate the need for further research on the distinction of these phenomena.
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Villalba C, Burke RC, Gurley K, Dhaliwal G, Grossman S. Electronic health record-based patient tracking by emergency medicine physicians. AEM Educ Train 2022; 6:e10732. [PMID: 35368507 PMCID: PMC8923647 DOI: 10.1002/aet2.10732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/06/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Emergency medicine (EM) physicians commonly track the progress of former patients to learn about their clinical outcome. While some studies have described the behavior, little is known about the specific information sought during tracking. The objective of this study was to determine how often EM physicians track patients and the motivations, strategies, and barriers to tracking. METHODS In June 2019 we surveyed EM physicians practicing at six hospitals. We defined patient tracking as viewing the chart of a patient who was no longer under the physician's care or contacting the patient or the patient's subsequent providers to learn about the patient's progress. The survey asked respondents how often they track patients, by what mechanisms, and for what reasons. The survey also asked what information physicians sought when tracking and what barriers to tracking exist. RESULTS Of the 156 EM physicians invited to respond, 111 completed the survey (72% response rate). Of those, 109 (98%) reported tracking their patients, and residents reported tracking a higher percentage of patients than attendings. Reasons for tracking included an unusual or complex case (98%), uncertain diagnosis (89%), and concern about a potential error (48%). Most respondents (86%) said that knowledge gained from patient tracking changed their subsequent practice patterns, and almost all respondents (98%) strongly agreed or agreed that tracking helps physicians avoid future mistakes. The most commonly sought information types during tracking were the hospital discharge summary or emergency department note from the index visit, test results since the index visit, and new diagnoses added since the index visit. Physicians cited time limitations and difficulty accessing information as the leading barriers to tracking. CONCLUSIONS Patient tracking is nearly ubiquitous among surveyed EM physicians, who find it valuable for learning and patient safety.
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Affiliation(s)
| | - Ryan C. Burke
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Kiersten Gurley
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Anna Jaques HospitalNewburyportMassachusettsUSA
| | - Gurpreet Dhaliwal
- Department of MedicineUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Medical ServiceSan Francisco VA Medical CenterSan FranciscoCaliforniaUSA
| | - Shamai Grossman
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
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