Patient Harm Events Research Articles

Implementation of a standardized electronic tool improves compliance, accuracy, and efficiency of trainee-to-trainee patient care handoffs after complex general surgical oncology procedures

Duty-hour regulations have increased the frequency of trainee-trainee patient handoffs. Each handoff creates a potential source for communication errors that can lead to near-miss and patient-harm events. We investigated the utility, efficacy, and trainee experience associated with implementation of a novel, standardized, electronic handoff system. We conducted a prospective intervention study of trainee-trainee handoffs of inpatients undergoing complex general surgical oncology procedures at a large tertiary institution. Preimplementation data were measured using trainee surveys and direct observation and by tracking delinquencies in charting. A standardized electronic handoff tool was created in a research electronic data capture (REDCap) database using the previously validated I-PASS methodology (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis). Electronic handoff was augmented by direct communication via phone or face-to-face interaction for inpatients deemed "watcher" or "unstable." Postimplementation handoff compliance, communication errors, and trainee work flow were measured and compared to preimplementation values using standard statistical analysis. A total of 474 handoffs (203 preintervention and 271 postintervention) were observed over the study period; 86 handoffs involved patients admitted to the surgical intensive care unit, 344 patients admitted to the surgical stepdown unit, and 44 patients on the surgery ward. Implementation of the structured electronic tool resulted in an increase in trainee handoff compliance from 73% to 96% (P<.001) and decreased errors in communication by 50% (P=.044) while improving trainee efficiency and workflow. A standardized electronic tool augmented by direct communication for higher acuity patients can improve compliance, accuracy, and efficiency of handoff communication between surgery trainees.

Medical Harm: Patient Perceptions and Follow-up Actions.

Much research has been conducted to describe medical mistakes resulting in patient harm using databases that capture these events for medical organizations. The objective of this study was to describe patients' perceptions regarding disclosure and their actions after harm. We analyzed a patient harm survey database composed of responses from a voluntary online survey administered to patients by ProPublica, an independent nonprofit news organization, during a 1-year period (May 2012 to May 2013). We collected data on patient demographics and characteristics related to the acknowledgment of patient harms, the reporting of patient harm to an oversight agency, whether the patient or the family obtained the harm-associated medical records, as well as the presence of a malpractice claim. There were 236 respondents reporting a patient harm (mean age, 49.1 y). In 11.4% (27/236) of harms, an apology by the medical organization or the clinician was made. In 42.8% (101/236) of harms, a complaint was filed with an oversight agency. In 66.5% (157/236) of harms, the patient or the family member obtained a copy of the pertinent medical records. A malpractice claim was reported in 19.9% (47/236) of events. In this sample of self-reported patient harms, we found a perception of inadequate apology. Nearly half of patient harm events are reported to an oversight agency, and roughly one-fifth result in a malpractice claim.

A Multidisciplinary Care Pathway Significantly Increases the Number of Early Morning Discharges in a Large Academic Medical Center

In an environment where there is increased demand for hospital beds, it is important that inpatient flow from admission to treatment to discharge is optimized. Among the many drivers that impact efficient patient throughput is an effective and timely discharge process. Early morning discharge helps align inpatient capacity with clinical demand, thereby avoiding gridlock that adversely affects scheduled surgical procedures, diagnostic procedures, and therapies. At our large, academic medical center, we hypothesized that an interdisciplinary approach to scheduled discharge order entry would increase the percentage of discharges occurring before 11:00 AM and improve overall discharge time. The pilot study involved moving rate-limiting steps to earlier in the discharge process, specifically medication reconciliation to the night before discharge and "discharge to home" order entry before 9:00 AM the morning of discharge. The baseline rate of discharges before 11:00 AM was 8% and significantly increased to 11% after the intervention (P = .02). Moreover, in the subset of patients (21%) for whom early medication reconciliation and discharge to home order entry were both executed, the percentage of patient discharges occurring before 11:00 AM increased to 29.7%, with an associated average discharge time of more than 3 hours earlier. No patient harm events were associated with this pilot project. There was no significant change in length of stay, and 30-day readmission rate improved significantly from 13.8% to 10.3% (P = .002). Our study demonstrates that a multidisciplinary approach using prescribed order entry and medication reconciliation is a low cost, safe, and effective way to increase early morning discharges and improve patient flow for large hospitals with high volumes of scheduled patient admissions.

The association between patient-reported incidents in hospitals and estimated rates of patient harm.

The aim of this study was to test the association between the rates of patient-reported incidents and patient harm documented in the patient record. The study was a secondary analysis of two national hospital assessments conducted in 2011. Hospital services in Norway. The patient survey was a standard national patient-experience survey conducted at the hospital level for all 63 hospitals in Norway. The medical record review was performed by 47 Global Trigger Tools (GTTs) in all 19 hospital trusts and 4 private hospitals. The two data sets were matched at the unit level, yielding comparable patient experiences and GTT data for 7 departments, 16 hospitals and 11 hospital trusts. No intervention. The correlation at the unit level between the patient-reported incident in hospital instrument (PRIH-I) and estimated rates of patient harm from the GTT. The PRIH-I index was significantly correlated with all patient-reported experience indicators at the individual level, with estimates for all patient harm events (Categories E-I) at the unit level (r = 0.62, P < 0.01), and with estimates of more serious harm events in Categories F-I (r = 0.42, P < 0.05). Patient-reported incidents in hospitals, as measured by the PRIH-I, are strongly correlated with patient harm rates based on the GTT. This indicates that patient-reported incidents are related to patient safety, but more research is needed to confirm the usefulness of patient reporting in the evaluation of patient safety.

The Science of Medical Decision Making: Neurosurgery, Errors, and Personal Cognitive Strategies for Improving Quality of Care

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making.

Error reporting: Just the fi rst step in safety and quality improvement

The Affordable Care Act requires all hospitals to run a Quality Assessment and Performance Improvement (QAPI) program in order to participate in Medicare. But although hospitals are required to maintain a system for reporting patient harm events, far from every event is reported. Hospital incident reporting systems capture less than 15% of patient harm events, according to a 2012 report from the U.S. Department of Health & Human Services. The same is true for medication-specific events, noted Lynn Lee, PharmD, Medication Safety Pharmacist for United Health Services.

The journey toward quality and patient safety in laboratory medicine continues.

Errors in laboratory medicine have a completely different meaning today than they had a century ago. At that time, the term referred to defects in the analytical performance of the test itself, the so-called analytical phase.[1] A dramatic change in addressing the issue of errors in laboratory medicine started at the end of the 1990s, when a body of evidence has been accumulated demonstrating vulnerability in the pre- and postanalytical phases.[2,3] The study by Abdollahi and co-workers confirms that more than 50% of errors are related to preanalytical steps, with 23.2% of errors in the intraanalytical and 11.7% in the postanalytical phase, respectively.[4] In addition, this study provides further evidence that the frequency of errors in inpatients is significantly higher than in outpatients due to several problems: Not always standard operating procedures (SOP) for test request, sample collection, handling, and transportation are followed by healthcare personnel who are not under the direct control of the laboratory; The complexity of some preanalytical steps (namely blood drawing) is higher for inpatients, due to age and disease issues; The trend toward consolidation and commoditization of laboratory services is decreasing the quality of communication between clinicians and laboratory professionals. The “take-home” message is the need to consensually develop and adopt SOP for safely performing patient identification and preparation, test requesting, sample collection and handling and that harmonization initiatives should be performed to improve procedures and processes at the laboratory–clinical interface. It seems likely that only a small proportion of laboratory errors results in actual patient harm and adverse events thanks to the several barriers and defensive layers present between the release of laboratory information, the decision-making process and, ultimately, the action on the patient. However, from a risk management viewpoint, even the great majority of laboratory errors with little direct impact on patient care provide important learning opportunities. In fact, any error, regardless of its apparent triviality, might indicate weaknesses in policies and procedures that may not lead to adverse events in their particular context, but might cause the patient harm in slightly different circumstances. An important step in the journey toward the reduction of the error rates in laboratory medicine is the implementation of a valuable quality system according to the International Standard ISO 15189:2012 and of reliable quality indicators (QIs) covering all steps of the intra- and extra-analytical phases of the total testing process (TTP).5 It has been demonstrated that performance and outcome measures improve the quality of patient care and, in particular, QIs represent valuable tools for quantifying the quality of selected aspects of care by comparing it against a defined criterion. The measurement and monitoring of QIs in laboratory medicine serve many purposes as they make possible to: Document the quality of the service provided; Improve performance and patient safety; Make comparison (benchmarking) over time between laboratories; Make judgments and set priorities (corrective actions to be performed); and Support accountability, quality improvement and accreditation. Recently a set of QIs has been consensually defined to allow clinical laboratories to measure and improve the quality of all steps of the TTP. The journey toward quality and patient safety continues.

What causes adverse events in prehospital care? A human-factors approach

BackgroundThe last decade has seen a vast amount of work directed at the investigation of patient harm events. Unfortunately, little of it has pertained to prehospital care and as such,...

Effect of an Anonymous Reporting System on Near-miss and Harmful Medical Error Reporting in a Pediatric Intensive Care Unit

Adverse event reporting is a key element for improving patient safety. This study describes a new voluntary, anonymous reporting system that facilitates reporting of near-miss and patient harm events and an assessment of patient harm by the bedside care provider in a pediatric intensive care unit. The results demonstrated the effectiveness of the Patient Safety Report as a method to capture near-miss and patient harm events.