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Komagamine J. Prevalence of urgent hospitalizations caused by adverse drug reactions: a cross-sectional study. Sci Rep 2024; 14:6058. [PMID: 38480855 PMCID: PMC10937656 DOI: 10.1038/s41598-024-56855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024] Open
Abstract
Adverse drug reactions account for a substantial portion of emergency hospital admissions. However, in the last decade, few studies have been conducted to determine the prevalence of hospitalization due to adverse drug reactions. Therefore, this cross-sectional study was conducted to determine the proportion of adverse drug reactions leading to emergency hospital admission and to evaluate the risk factors for these reactions. A total of 5707 consecutive patients aged > 18 years who were emergently hospitalized due to acute medical illnesses between June 2018 and May 2021 were included. Causality assessment for adverse drug reactions was performed by using the World Health Organization-Uppsala Monitoring Centre criteria. The median patient age was 78 years (IQR 63-87), and the proportion of women was 47.9%. Among all the hospitalizations, 287 (5.0%; 95% confidence interval (CI) 4.5-5.6%) were caused by 368 adverse drug reactions. The risk factors independently associated with hospitalization due to adverse drug reactions were polypharmacy (OR 2.66), age ≥ 65 years (OR 2.00), and ambulance use (OR 1.41). Given that the population is rapidly aging worldwide, further efforts are needed to minimize hospitalizations caused by adverse drug reactions.
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Affiliation(s)
- Junpei Komagamine
- Department of Emergency and Critical Care Medicine, NHO Tokyo Medical Center, 2-5-1, Higashigaoka, Meguro, Tokyo, Japan.
- Department of Clinical Research, NHO Tochigi Medical Center, Utsunomiya, Japan.
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2
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Riblet NB, Soncrant C, Mills P, Yackel EE. Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care. Mil Med 2023; 188:e3173-e3181. [PMID: 37002596 PMCID: PMC10533708 DOI: 10.1093/milmed/usad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/22/2023] [Accepted: 03/10/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. MATERIALS AND METHODS A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. RESULTS Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. CONCLUSIONS It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.
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Affiliation(s)
- Natalie B Riblet
- Mental Health Service Line, Veterans Affairs Medical Center, White River Junction, VT 05009, USA
- Department of Psychiatry and Dartmouth Institute, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | | | - Peter Mills
- VA National Center for Patient Safety, Ann Arbor, MI 48106, USA
- Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Edward E Yackel
- VA National Center for Patient Safety, Ann Arbor, MI 48106, USA
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Abraham I, Lewandrowski KU, Elfar JC, Li ZM, Fiorelli RKA, Pereira MG, Lorio MP, Burkhardt BW, Oertel JM, Winkler PA, Yang H, León JFR, Telfeian AE, Dowling Á, Vargas RAA, Ramina R, Asefi M, de Carvalho PST, Defino H, Moyano J, Montemurro N, Yeung A, Novellino P, On Behalf Of Teams/Organizations/Institutions. Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models. J Pers Med 2023; 13:1044. [PMID: 37511657 PMCID: PMC10381640 DOI: 10.3390/jpm13071044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023] Open
Abstract
Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.
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Affiliation(s)
- Ivo Abraham
- Pharmacy Medicine, and Clinical Translational Sciences, University of Arizona, Roy P. Drachman Hall, Rm. B306H, Tucson, AZ 85721, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Department of Orthopedics, Hospital Universitário Gaffre e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20270-004, Brazil
| | - John C Elfar
- Department of Orthopaedic Surgery, College of Medicine-Tucson Campus, Health Sciences Innovation Building (HSIB), University of Arizona, 1501 N. Campbell Avenue, Tower 4, 8th Floor, Suite 8401, Tucson, AZ 85721, USA
| | - Zong-Ming Li
- Department of Orthopaedic Surgery, College of Medicine-Tucson Campus, Health Sciences Innovation Building (HSIB), University of Arizona, 1501 N. Campbell Avenue, Tower 4, 8th Floor, Suite 8401, Tucson, AZ 85721, USA
| | - Rossano Kepler Alvim Fiorelli
- Department of General and Specialized Surgery, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro 20270-004, Brazil
| | - Mauricio G Pereira
- Faculty of Medicine, University of Brasilia, Federal District, Brasilia 70919-900, Brazil
| | - Morgan P Lorio
- Advanced Orthopaedics, 499 E. Central Pkwy, Ste. 130, Altamonte Springs, FL 32701, USA
| | - Benedikt W Burkhardt
- Wirbelsäulenzentrum/Spine Center-WSC, Hirslanden Klinik Zurich, Witellikerstrasse 40, 8032 Zurich, Switzerland
| | - Joachim M Oertel
- Klinik für Neurochirurgie, Universität des Saarlandes, Kirrberger Straße 100, 66421 Homburg, Germany
| | - Peter A Winkler
- Department of Neurosurgery, Charite Universitaetsmedizin Berlin, 13353 Berlin, Germany
| | - Huilin Yang
- Orthopaedic Department, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou 215031, China
| | - Jorge Felipe Ramírez León
- Minimally Invasive Spine Center Bogotá D.C. Colombia, Reina Sofía Clinic Bogotá D.C. Colombia, Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 110141, Colombia
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Álvaro Dowling
- Department of Orthopaedic Surgery, University of São Paulo, Ribeirão Preto 14071-550, Brazil
| | - Roth A A Vargas
- Department of Neurosurgery, Foundation Hospital Centro Médico Campinas, Campinas 13083-210, Brazil
| | - Ricardo Ramina
- Neurological Institute of Curitiba, Curitiba 80230-030, Brazil
| | - Marjan Asefi
- Department of Biology, Nano-Biology, University of North Carolina, Greensboro, NC 27413, USA
| | | | - Helton Defino
- Department of Orthopaedic Surgery, University of São Paulo, Ribeirão Preto 14071-550, Brazil
| | - Jaime Moyano
- La Sociedad Iberolatinoamericana De Columna (SILACO), The Spine Committee of the Ecuadorian Society of Orthopaedics and Traumatology (Comité de Columna de la Sociedad Ecuatoriana de Ortopedia y Traumatología), Quito 170521, Ecuador
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Anthony Yeung
- Desert Institute for Spine Care, Phoenix, AZ 85020, USA
| | - Pietro Novellino
- Guinle and State Institute of Diabetes and Endocrinology, Rio de Janeiro 20270-004, Brazil
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Hallsworth M. A manifesto for applying behavioural science. Nat Hum Behav 2023; 7:310-322. [PMID: 36941468 DOI: 10.1038/s41562-023-01555-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/10/2023] [Indexed: 03/23/2023]
Abstract
Recent years have seen a rapid increase in the use of behavioural science to address the priorities of public and private sector actors. There is now a vibrant ecosystem of practitioners, teams and academics building on each other's findings across the globe. Their focus on robust evaluation means we know that this work has had an impact on important issues such as antimicrobial resistance, educational attainment and climate change. However, several critiques have also emerged; taken together, they suggest that applied behavioural science needs to evolve further over its next decade. This manifesto for the future of applied behavioural science looks at the challenges facing the field and sets out ten proposals to address them. Meeting these challenges will mean that behavioural science is better equipped to help to build policies, products and services on stronger empirical foundations-and thereby address the world's crucial challenges.
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Rosvig LH, Lou S, Hvidman L, Manser T, Uldbjerg N, Kierkegaard O, Brogaard L. Healthcare providers' perceptions and expectations of video-assisted debriefing of real-life obstetrical emergencies: a qualitative study from Denmark. BMJ Open 2023; 13:e062950. [PMID: 36918239 PMCID: PMC10016258 DOI: 10.1136/bmjopen-2022-062950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES Video-assisted debriefing (VAD) of real-life obstetrical emergencies provides an opportunity to improve quality of care, but is rarely used in clinical practice. A barrier for implementation is the expected mental reservations among healthcare providers. The aim of this study was to explore healthcare providers' perceptions and expectations of VAD of real-life events. SETTING Participants were recruited from two Labour and Delivery Units in Denmark. In both units, VAD of real-life obstetrical emergencies had never been conducted. PARTICIPANTS 22 healthcare providers (10 physicians, 9 midwives and 3 nursing assistants). During the study period (August-October 2021), semi-structured, individual interviews were conducted. Interviews were analysed using thematic analysis. PRIMARY AND SECONDARY OUTCOME MEASURES A qualitative description of healthcare providers' perceptions and expectations of VAD of real-life events. RESULTS Three major themes were identified: (1) Video-assisted debriefing (VAD) as an opportunity for learning: All participants expected VAD to provide an opportunity for learning and improving patient care. All participants expected the video to provide a 'bigger picture', by showing 'what was actually done' instead of 'what we believed was done'. (2) Video-assisted debriefing (VAD) as a cause for concern: The primary concern for all participants was the risk of being exposed as less competent. Participants were concerned that being confronted with every minor detail of their clinical practice would enhance their self-criticalness. (3) Preconditions for video-assisted debriefing (VAD): Participants emphasised the importance of organisational support from management. In addition, creating a safe environment for VAD, for example, by using only expert debriefers was considered an essential precondition for successful implementation. CONCLUSIONS The risk of being exposed as less competent was a barrier towards VAD of real-life events. However, the majority found the educational benefits to outweigh the risk of being exposed.
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Affiliation(s)
- Lena Have Rosvig
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Stina Lou
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- DEFACTUM - Public Health and Health Services Research, Aarhus, Denmark
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Hvidman
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja Manser
- School of Applied Psychology, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
| | - Niels Uldbjerg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Kierkegaard
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
| | - Lise Brogaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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Kane AD, Armstrong RA, Kursumovic E, Cook TM, Oglesby FC, Cortes L, Moppett IK, Moonesinghe SR, Agarwal S, Bouch DC, Cordingley J, Davies MT, Dorey J, Finney SJ, Kunst G, Lucas DN, Nickols G, Mouton R, Nolan JP, Patel B, Pappachan VJ, Plaat F, Samuel K, Scholefield BR, Smith JH, Varney L, Vindrola‐Padros C, Martin S, Wain EC, Kendall SW, Ward S, Drake S, Lourtie J, Taylor C, Soar J. Methods of the 7 th National Audit Project (NAP7) of the Royal College of Anaesthetists: peri-operative cardiac arrest. Anaesthesia 2022; 77:1376-1385. [PMID: 36111390 PMCID: PMC9826156 DOI: 10.1111/anae.15856] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 01/11/2023]
Abstract
Cardiac arrest in the peri-operative period is rare but associated with significant morbidity and mortality. Current reporting systems do not capture many such events, so there is an incomplete understanding of incidence and outcomes. As peri-operative cardiac arrest is rare, many hospitals may only see a small number of cases over long periods, and anaesthetists may not be involved in such cases for years. Therefore, a large-scale prospective cohort is needed to gain a deep understanding of events leading up to cardiac arrest, management of the arrest itself and patient outcomes. Consequently, the Royal College of Anaesthetists chose peri-operative cardiac arrest as the 7th National Audit Project topic. The study was open to all UK hospitals offering anaesthetic services and had a three-part design. First, baseline surveys of all anaesthetic departments and anaesthetists in the UK, examining respondents' prior peri-operative cardiac arrest experience, resuscitation training and local departmental preparedness. Second, an activity survey to record anonymised details of all anaesthetic activity in each site over 4 days, enabling national estimates of annual anaesthetic activity, complexity and complication rates. Third, a case registry of all instances of peri-operative cardiac arrest in the UK, reported confidentially and anonymously, over 1 year starting 16 June 2021, followed by expert review using a structured process to minimise bias. The definition of peri-operative cardiac arrest was the delivery of five or more chest compressions and/or defibrillation in a patient having a procedure under the care of an anaesthetist. The peri-operative period began with the World Health Organization 'sign-in' checklist or first hands-on contact with the patient and ended either 24 h after the patient handover (e.g. to the recovery room or intensive care unit) or at discharge if this occured earlier than 24 h. These components described the epidemiology of peri-operative cardiac arrest in the UK and provide a basis for developing guidelines and interventional studies.
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Tobin MJ. Fiftieth Anniversary of Uncovering the Tuskegee Syphilis Study: The Story and Timeless Lessons. Am J Respir Crit Care Med 2022; 205:1145-1158. [PMID: 35500908 PMCID: PMC9872801 DOI: 10.1164/rccm.202201-0136so] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This year marks the 50th anniversary of the uncovering of the Tuskegee syphilis study, when the public learned that the Public Health Service (precursor of the CDC) for 40 years intentionally withheld effective therapy against a life-threatening illness in 400 African American men. In 2010, we learned that the same research group had deliberately infected hundreds of Guatemalans with syphilis and gonorrhea in the 1940s, with the goal of developing better methods for preventing these infections. Despite 15 journal articles detailing the results, no physician published a letter criticizing the Tuskegee study. Informed consent was never sought; instead, Public Health Service researchers deceived the men into believing they were receiving expert medical care. The study is an especially powerful parable because readers can identify the key players in the narrative and recognize them as exemplars of people they encounter in daily life-these flesh-and-blood characters convey the principles of research ethics more vividly than a dry account in a textbook of bioethics. The study spurred reforms leading to fundamental changes in the infrastructure of research ethics. The reason people fail to take steps to halt behavior that in retrospect everyone judges reprehensible is complex. Lack of imagination, rationalization, and institutional constraints are formidable obstacles. The central lessons from the study are the need to pause and think, reflect, and examine one's conscience; the courage to speak; and above all the willpower to act. History, although about the past, is our best defense against future errors and transgressions.
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Affiliation(s)
- Martin J. Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois; and,Stritch School of Medicine, Loyola University of Chicago, Maywood, Illinois
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Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017. CMAJ Open 2022; 10:E35-E42. [PMID: 35042693 PMCID: PMC8920540 DOI: 10.9778/cmajo.20210026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA). METHODS We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians. RESULTS Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism. INTERPRETATION Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.
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Affiliation(s)
- Charlotte Crosbie
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Allan McDougall
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Harpreet Pangli
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Riyad B Abu-Laban
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont
| | - Lisa A Calder
- Department of Emergency Medicine (Crosbie, Abu-Laban), University of British Columbia, Vancouver, BC; Canadian Medical Protective Association (McDougall, Calder); Faculty of Education (McDougall), University of Ottawa, Ottawa, Ont.; Division of Plastic Surgery (Pangli), Faculty of Medicine, University of British Columbia, Vancouver, BC; Clinical Epidemiology Program (Calder), Ottawa Hospital Research Institute, Ottawa, Ont.
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Mullins CF, Free R, Kelly D, Porter JM. A desktop systems analysis of critical incidents within a university hospital department of anaesthesia. Ir J Med Sci 2021; 191:1831-1842. [PMID: 34472039 DOI: 10.1007/s11845-021-02766-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Medical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system. METHODS Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly. RESULTS Seventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department. CONCLUSION Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.
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Affiliation(s)
- Cormac F Mullins
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland.
| | - Ross Free
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
| | - Daire Kelly
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
| | - Jennifer M Porter
- Department of Anaesthesiology, St. James's Hospital, Dublin, Ireland
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Read GJM, Shorrock S, Walker GH, Salmon PM. State of science: evolving perspectives on 'human error'. ERGONOMICS 2021; 64:1091-1114. [PMID: 34243698 DOI: 10.1080/00140139.2021.1953615] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 07/02/2021] [Indexed: 06/13/2023]
Abstract
This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the 'human error approach' to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community. Practitioner statement This state-of-science review discusses the evolution of perspectives on human error as well as trends in the theories and methods applied to understand, prevent and mitigate error. It concludes that, although a useful contribution has been made, we must move beyond a focus on an individual error to systems failure to understand and optimise whole systems.
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Affiliation(s)
- Gemma J M Read
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Maroochydore, Australia
| | - Steven Shorrock
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Maroochydore, Australia
- EUROCONTROL, Brétigny-sur-Orge, France
| | - Guy H Walker
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Maroochydore, Australia
- Centre for Sustainable Road Freight, Heriot-Watt University, Edinburgh, UK
| | - Paul M Salmon
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Maroochydore, Australia
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Yang XJ, Schemanske C, Searle C. Toward Quantifying Trust Dynamics: How People Adjust Their Trust After Moment-to-Moment Interaction With Automation. HUMAN FACTORS 2021:187208211034716. [PMID: 34459266 PMCID: PMC10374998 DOI: 10.1177/00187208211034716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE We examine how human operators adjust their trust in automation as a result of their moment-to-moment interaction with automation. BACKGROUND Most existing studies measured trust by administering questionnaires at the end of an experiment. Only a limited number of studies viewed trust as a dynamic variable that can strengthen or decay over time. METHOD Seventy-five participants took part in an aided memory recognition task. In the task, participants viewed a series of images and later on performed 40 trials of the recognition task to identify a target image when it was presented with a distractor. In each trial, participants performed the initial recognition by themselves, received a recommendation from an automated decision aid, and performed the final recognition. After each trial, participants reported their trust on a visual analog scale. RESULTS Outcome bias and contrast effect significantly influence human operators' trust adjustments. An automation failure leads to a larger trust decrement if the final outcome is undesirable, and a marginally larger trust decrement if the human operator succeeds the task by him/herself. An automation success engenders a greater trust increment if the human operator fails the task. Additionally, automation failures have a larger effect on trust adjustment than automation successes. CONCLUSION Human operators adjust their trust in automation as a result of their moment-to-moment interaction with automation. Their trust adjustments are significantly influenced by decision-making heuristics/biases. APPLICATION Understanding the trust adjustment process enables accurate prediction of the operators' moment-to-moment trust in automation and informs the design of trust-aware adaptive automation.
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Taylor E, Hignett S. DEEP SCOPE: A Framework for Safe Healthcare Design. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:7780. [PMID: 34360068 PMCID: PMC8345507 DOI: 10.3390/ijerph18157780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 11/16/2022]
Abstract
Thinking in patient safety has evolved over time from more simplistic accident causation models to more robust frameworks of work system design. Throughout this evolution, less consideration has been given to the role of the built environment in supporting safety. The aim of this paper is to theoretically explore how we think about harm as a systems problem by mitigating the risk of adverse events through proactive healthcare facility design. We review the evolution of thinking in safety as a safety science. Using falls as a case study topic, we use a previously published model (SCOPE: Safety as Complexity of the Organization, People, and Environment) to develop an expanded framework. The resulting theoretical model and matrix, DEEP SCOPE (DEsigning with Ergonomic Principles), provide a way to synthesize design interventions into a systems-based model for healthcare facility design using human factors/ergonomics (HF/E) design principles. The DEEP SCOPE matrix is proposed to highlight the design of safe healthcare facilities as an ergonomic problem of design that fits the environment to the user by understanding built environments that support the "human" factor.
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Affiliation(s)
- Ellen Taylor
- The Center for Health Design, Concord, CA 94520, USA
| | - Sue Hignett
- Design School, Loughborough University, Leicestershire LE11 3TU, UK;
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Alberto EC, Jagannath S, McCusker ME, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review. J Eval Clin Pract 2021; 27:464-471. [PMID: 33249690 PMCID: PMC7961264 DOI: 10.1111/jep.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies. METHODS We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature. RESULTS We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation." CONCLUSIONS NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
| | - Swathi Jagannath
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Maureen E. McCusker
- Office of Institutional Research and Decision Support, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC, USA
| | - Randall S. Burd
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
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Lewandrowski KU, Hellinger S, De Carvalho PST, Freitas Ramos MR, Soriano-SáNchez JA, Xifeng Z, Calderaro AL, Dos Santos TS, Ramírez León JF, de Lima E SilvA MS, Dowling Á, DataR G, Kim JS, Yeung A. Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management. Int J Spine Surg 2021; 15:280-294. [PMID: 33900986 DOI: 10.14444/8038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication. MATERIALS AND METHODS To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy. RESULTS There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively. CONCLUSIONS The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, Arizona.,Department of Neurosurgery, UNIRIO, Rio de Janeiro, Brazil
| | | | | | - Max Rogério Freitas Ramos
- Orthopedics and Traumatology, Federal University of the Rio de Janeiro State UNIRIO, Brazil.,Orthopedic Clinics, Gaffrée Guinle University Hospital, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Zhang Xifeng
- The Chinese PLA General Hospital, Beijing, China
| | - André Luiz Calderaro
- Centro Ortopedico Valqueire, Departamento de Full Endoscopia da Coluna Vertebral, Rio de Janeiro, Brazil
| | | | - Jorge Felipe Ramírez León
- Reina Sofía Clinic and Center of Minimally Invasive Spine Surgery, Bogotá, Colombia.,Spine Surgery Program, Universidad Sanitas, Bogotá, Colombia
| | | | - Álvaro Dowling
- Endoscopic Spine Clinic, Santiago, Chile.,Department of Orthopaedic Surgery, USP, Ribeirão Preto, Brazil
| | - Girish DataR
- Center for Endoscopic Spine Surgery, Sushruta Hospital for Orthopaedics and Traumatology, Miraj, Sangli, Maharashtra, India
| | - Jin-Sung Kim
- Seoul Saint Mary's Hospital, Seocho-gu, Seoul, Republic of Korea
| | - Anthony Yeung
- University of New Mexico School of Medicine, Albuquerque, New Mexico.,Desert Institute for Spine Care, Phoenix, AZ
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Lewandrowski KU, Muraleedharan N, Eddy SA, Sobti V, Reece BD, Ramírez León JF, Shah S. Reliability Analysis of Deep Learning Algorithms for Reporting of Routine Lumbar MRI Scans. Int J Spine Surg 2020; 14:S98-S107. [PMID: 33122182 DOI: 10.14444/7132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Artificial intelligence could provide more accurate magnetic resonance imaging (MRI) predictors of successful clinical outcomes in targeted spine care. OBJECTIVE To analyze the level of agreement between lumbar MRI reports created by a deep learning neural network (RadBot) and the radiologists' MRI reading. METHODS The compressive pathology definitions were extracted from the radiologist lumbar MRI reports from 65 patients with a total of 383 levels for the central canal: (0) no disc bulge/protrusion/canal stenosis, (1) disc bulge without canal stenosis, (2) disc bulge resulting in canal stenosis, and (3) disc herniation/protrusion/extrusion resulting in canal stenosis. For both, neural foramina were assessed with either (0) neural foraminal stenosis absent or (1) neural foramina stenosis present. Reporting criteria for the pathologies at each disc level and, when available, the grading of severity were extracted, and the Natural Language Processing model was used to generate a verbal and written report. The RadBot report was analyzed similarly as the MRI report by the radiologist. MRI reports were investigated by dichotomizing the data into 2 categories: normal and stenosis. The quality of the RadBot test was assessed by determining its sensitivity, specificity, and positive and negative predictive value as well as its reliability with the calculation of the Cronbach alpha and Cohen kappa using the radiologist MRI report as a gold standard. RESULTS The authors found a RadBot sensitivity of 73.3%, a specificity of 88.4%, a positive predictive value of 80.3%, and a negative predictive value of 83.7%. The reliability analysis revealed the Cronbach alpha as 0.772. The highest individual values of the Cronbach alpha were 0.629 and 0.681 when compared to the MRI report by the radiologist, rending values of 0.566 and 0.688, respectively. Analysis of interobserver reliability rendered an overall kappa for the RadBot of 0.627. Analysis of receiver operating characteristics (ROC) showed a value of 0.808 for the area under the ROC curve. CONCLUSIONS Deep learning algorithms, when used for routine reporting in lumbar spine MRI, showed excellent quality as a diagnostic test that can distinguish the presence of neural element compression (stenosis) at a statistically significant level (P < .0001) from a random event distribution. This research should be extended to validated and directly visualized pain generators to improve the accuracy and prognostic value of the routine lumbar MRI scan for favorable clinical outcomes with intervention and surgery. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE Validity, clinical teaching, and evaluation study.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Staff Orthopaedic Spine Surgeon Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, Arizona
| | | | | | - Vikram Sobti
- Innovative Radiology, PC, River Forest, Illinois
| | - Brian D Reece
- The Spine and Orthopedic Academic Research Institute, Lewisville, Texas
| | - Jorge Felipe Ramírez León
- Fundación Universitaria Sanitas, Bogotá, Colombia, Research Team, Centro de Columna. Bogotá, Colombia, Centro de Cirugía de Mínima Invasión, CECIMIN-Clínica Reina Sofía, Bogotá, Colombia
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Erkelens DC, Rutten FH, Wouters LT, de Groot E, Damoiseaux RA, Hoes AW, Zwart DL. Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort. J Clin Epidemiol 2020; 127:117-124. [PMID: 32730853 DOI: 10.1016/j.jclinepi.2020.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/02/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability. STUDY DESIGN AND SETTING This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation. RESULTS In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32). CONCLUSIONS Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.
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Affiliation(s)
- Daphne C Erkelens
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes T Wouters
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther de Groot
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger A Damoiseaux
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien L Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Turner K, Stapelberg NJ, Sveticic J, Dekker SW. Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework. Aust N Z J Psychiatry 2020; 54:571-581. [PMID: 32383403 DOI: 10.1177/0004867420918659] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. METHOD We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. RESULTS An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. CONCLUSIONS The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.
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Affiliation(s)
- Kathryn Turner
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia
| | - Nicolas Jc Stapelberg
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia.,Faculty of Health Sciences & Medicine, Bond University, Robina, QLD, Australia
| | - Jerneja Sveticic
- Mental Health and Specialist Services, Gold Coast Hospital and Health Services, Southport, QLD, Australia
| | - Sidney Wa Dekker
- School of Humanities, Languages and Social Science, Griffith University, Nathan, QLD, Australia
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Inherent Bias in Artificial Intelligence-Based Decision Support Systems for Healthcare. ACTA ACUST UNITED AC 2020; 56:medicina56030141. [PMID: 32244930 PMCID: PMC7142873 DOI: 10.3390/medicina56030141] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/08/2020] [Accepted: 03/12/2020] [Indexed: 11/17/2022]
Abstract
The objective of this article is to discuss the inherent bias involved with artificial intelligence-based decision support systems for healthcare. In this article, the authors describe some relevant work published in this area. A proposed overview of solutions is also presented. The authors believe that the information presented in this article will enhance the readers’ understanding of this inherent bias and add to the discussion on this topic. Finally, the authors discuss an overview of the need to implement transdisciplinary solutions that can be used to mitigate this bias.
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Farquhar CM, Armstrong S, Masson V, Thompson JMD, Sadler L. Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand. JAMA Netw Open 2020; 3:e1921363. [PMID: 32074288 DOI: 10.1001/jamanetworkopen.2019.21363] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided. OBJECTIVE To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event. DESIGN, SETTING, AND PARTICIPANTS This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017. EXPOSURES Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan. MAIN OUTCOMES AND MEASURES Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported. RESULTS A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]). CONCLUSIONS AND RELEVANCE Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.
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Affiliation(s)
- Cynthia M Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Sarah Armstrong
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Vicki Masson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - John M D Thompson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
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Abstract
Hindsight bias (HB) is the tendency to see known information as obvious. We studied metacognitive hindsight bias (MC-HB)-a shift away from one's original confidence regarding answers provided before learning the actual facts. In two experiments, participants answered general-knowledge questions in social scenarios and provided their confidence in each answer. Subsequently, they learned answers to half the questions and then recalled their initial answers and confidence. Finally, they reanswered, as a learning check. We measured confidence accuracy by calibration (over/underconfidence) and resolution (discrimination between incorrect and correct answers), expecting them to improve in hindsight. In both experiments, participants displayed robust HB and MC-HB for resolution despite attempts to recall the initial confidence in one's answer. In Experiment 2, promising anonymity to participants eliminated MC-HB, while social scenarios produced MC-HB for both resolution and calibration-indicative of overconfidence. Overall, our findings highlight that in social contexts, recall of confidence in hindsight is more consistent with answers' accuracy than confidence initially was. Social scenarios differently affect HB and MC-HB, thus dissociating these two biases.
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Yeung A, Lewandrowski KU. Five-year clinical outcomes with endoscopic transforaminal foraminoplasty for symptomatic degenerative conditions of the lumbar spine: a comparative study of inside-out versus outside-in techniques. JOURNAL OF SPINE SURGERY 2020; 6:S66-S83. [PMID: 32195417 DOI: 10.21037/jss.2019.06.08] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Foraminal stenosis is a condition that is underappreciated by traditionally trained surgeons because the entire foraminal zone is not adequately visualized with the translaminar approach unless extensive removal of the facet is performed to expose the extraforaminal zone. Its direct endoscopic visualization is feasible with the inside-out and outside-in endoscopic transforaminal technique. The authors analyzed the differences in long-term 5-year clinical outcomes of endoscopic transforaminal foraminoplasty for symptoms from lumbar foraminal stenosis to better establish clinical indications for each technique. Methods Long-term 5-year MacNab outcomes, VAS scores, complications, and unintended aftercare were analyzed in a series of 176 patients consisting of 86 inside-out (group 1) and 90 outside-in (group 2) patients treated for sciatica-type back and leg pain due to lumbar foraminal stenosis. Results At minimum 5-year follow-up, excellent results according to the MacNab criteria were obtained in 93 (52.8%) patients, good in 63 (35.8%), fair in 17 (9.7%), and poor in 3 (1.7%), respectively. The mean preoperative VAS was 6.87±1.96. The mean postoperative VAS was 3.15±1.59 and 2.98±1.75 at last follow-up, respectively. Both postoperative VAS and final follow-up VAS were statistically reduced at a significance level of P<0001. There were no major approach-, surgical- or anesthesia-related complications in this series. The vast majority of patients (112/176; 63.6% of the study population) did not require any additional interventional or surgical treatment following the index transforaminal endoscopic decompression. Postoperative dysesthesia due to irritation of the dorsal root ganglion (DRG) as a consequence of operation next to the DRG occurred in 17 patients (9.7%) and was the most common benign postoperative sequelae. There was a higher reoperation rate in the outside-in group (35.6%) than in the inside-out group (8.1%). The secondary fusion rate was also higher with the outside-in (8.9%) than with the inside-out technique (2.3%). Ultimately, the long-term clinical outcomes with the endoscopic transforaminal decompression procedure were favorable regardless of whether the inside-out or outside-in technique was used. These numbers were generated by two experienced endoscopic surgeons with thousands of case experience. Conclusions Patients with symptomatic foraminal stenosis may be treated successfully with either the inside-out or the outside-in selective endoscopic discectomy (SED™) method while maintaining favorable long-term outcomes with a 3.2× decreased need for secondary fusion at 5-year follow-up when compared to recently reported reoperation rates for traditional decompression/fusion. Long-term clinical outcomes with the inside-out technique were presumably better because of the ability to visualize and decompress underneath the dural sac, the ventral facet and the axilla known as the hidden zone of MacNab.
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Affiliation(s)
- Anthony Yeung
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.,Desert Institute for Spine Care, Phoenix, AZ, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ, USA.,Surgical Institute of Tucson, Tucson, AZ, USA.,Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
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Lewandrowski KU, Ransom NA. Five-year clinical outcomes with endoscopic transforaminal outside-in foraminoplasty techniques for symptomatic degenerative conditions of the lumbar spine. JOURNAL OF SPINE SURGERY 2020; 6:S54-S65. [PMID: 32195416 DOI: 10.21037/jss.2019.07.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Lumbar foraminal stenosis in the extraforaminal zone is best directly visualized with the outside-in transforaminal endoscopic technique. Stenosis in that area is often missed with traditional translaminar surgery. The authors analyzed the long-term 5-year clinical results, reoperation rates, and unintended after care with the outside-in endoscopic transforaminal foraminoplasty for symptoms from lumbar foraminal stenosis to better establish clinical indications and prognosticators of favorable outcomes. Methods Long-term 5-year Macnab outcomes, visual analog scale (VAS) scores, complications, and unintended aftercare were analyzed in a series of 90 patients treated with the transforaminal outside-in selective endoscopic discectomy (SED™) with foraminoplasty for foraminal and lateral recess stenosis. Results At minimum 5-year follow-up, excellent results according to the Macnab criteria were obtained in 61 (67.8%) patients, good in 23 (25.6%), fair in 6 (6.7%), respectively. The mean preoperative VAS 7.55. The mean postoperative VAS was 2.87 and at last follow-up 2.53. Both postoperative VAS and last follow-up VAS were statistically reduced at a significance level of P<0.0001. Postoperative dysesthesia occurred in 8 patients (8.9%). While most of the 32 follow-up surgeries following SED™ were additional endoscopic decompressions and rhizotomies (24/32; 75%) were non-fusion procedures, only 8 of the whole study series of 90 patients (8.9%) underwent fusion at the index SED™ level within the minimum 5-year follow-up period. One patient opted for an open laminectomy (1.1%). Conclusions Patients with symptomatic foraminal stenosis may be treated successfully in a staged manner with outside-in transforaminal endoscopic decompression while maintaining favorable long-term outcomes without the excessive need for fusion in the vast majority of patients. The reoperation fusion rate at 5-year follow-up was approximately 3 times lower when compared to recently reported reoperation rates following traditional translaminar decompression/fusion.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Surgical Institute of Tucson, Tucson, AZ, USA.,Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
| | - Nicholas A Ransom
- Department of Orthopaedics, Surgeon Surgical Institute of Tucson, Tucson, AZ, USA
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Brogaard L, Uldbjerg N. Filming for auditing of real-life emergency teams: a systematic review. BMJ Open Qual 2019; 8:e000588. [PMID: 31909207 PMCID: PMC6937091 DOI: 10.1136/bmjoq-2018-000588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 08/02/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Lise Brogaard
- Department of Obstetrics and Gynaecology, Regionshospitalet Horsens, Horsens, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
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25
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Harrison J, Klein J. ‘Remember that patient you saw…’: Advice for trainees on coping after making an error. Emerg Med Australas 2019; 31:667-668. [DOI: 10.1111/1742-6723.13347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Julia Harrison
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
| | - Jill Klein
- Melbourne Medical SchoolThe University of Melbourne Melbourne Victoria Australia
- Melbourne Business SchoolThe University of Melbourne Melbourne Victoria Australia
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26
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Hagley G, Mills PD, Watts BV, Wu AW. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual 2019; 8:e000646. [PMID: 31428706 PMCID: PMC6683108 DOI: 10.1136/bmjoq-2019-000646] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/24/2019] [Accepted: 06/28/2019] [Indexed: 01/09/2023] Open
Affiliation(s)
- Gregory Hagley
- National Center for Patient Safety, Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Rehabilitation Department, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Peter D Mills
- National Center for Patient Safety, White River Junction VA Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Bradley V Watts
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA.,National Center for Patient Safety, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Albert W Wu
- Center for Health Services and Outcomes Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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27
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O'Connor P, Lydon S, Mongan O, Connolly F, Mcloughlin A, McVicker L, Byrne D. A mixed-methods examination of the nature and frequency of medical error among junior doctors. Postgrad Med J 2019; 95:583-589. [PMID: 31341038 DOI: 10.1136/postgradmedj-2018-135897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 02/11/2019] [Accepted: 07/09/2019] [Indexed: 11/04/2022]
Abstract
PURPOSE OF THE STUDY To examine junior doctors' experience and perceptions of medical errors in which they had been involved. STUDY DESIGN A mixed-methods design, consisting of an error survey and critical incident technique (CIT) interviews, was used. The survey asked doctors in the first year of postgraduate training in Ireland whether they had made a medical error that had 'played on (their) mind', and if so, to identify factors that had contributed to the error. The participants in the CIT interviews were asked to describe a medical error in which they had been involved. RESULTS A total of 201 out of 332 (60.5%) respondents to the survey reported making an error that 'played on their mind'. 'Individual factors' were the most commonly identified group of factors (188/201; 93.5%), with 'high workload' (145/201; 72.1%) the most commonly identified contributory factor. Of the 28 CIT interviews which met the criteria for analysis, 'situational factors' (team, staff, task characteristics, and service user factors) were the most commonly identified group of contributory factors (24/28; 85.7%). A total of eight of the interviews were judged by subject matter experts (n=8) to be of medium risk to patients, and 20 to be of high-risk to patients. A significantly larger proportion of high-risk scenarios were attributed to 'local working conditions' than the medium-risk scenarios. CONCLUSIONS There is a need to prepare junior doctors to manage, and cope with, medical error and to ensure that healthcare professionals are adequately supported throughout their careers.
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Affiliation(s)
- Paul O'Connor
- Department of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Sinéad Lydon
- School of Medicine, National University of Ireland Galway, Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
| | - Orla Mongan
- School of Medicine, National University of Ireland Galway, Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
| | - Fergal Connolly
- Department of Health Systems, University College Dublin, Dublin, Ireland
| | | | - Lyle McVicker
- Medicine, Galway University Hospital, Galway, Ireland
| | - Dara Byrne
- School of Medicine, National University of Ireland Galway, Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, National University of Ireland Galway, Galway, Ireland
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Erkelens DC, Wouters LT, Zwart DL, Damoiseaux RA, De Groot E, Hoes AW, Rutten FH. Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study. BMJ Open 2019; 9:e027477. [PMID: 31266836 PMCID: PMC6609078 DOI: 10.1136/bmjopen-2018-027477] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In the Netherlands, the 'Netherlands Triage Standard' (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain. METHODS AND ANALYSIS An observational study in which 3000 telephone triage recordings (period 2014-2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers' own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses. ETHICS AND DISSEMINATION The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.
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Affiliation(s)
- Daphne Ca Erkelens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes Tcm Wouters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien Lm Zwart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger Amj Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther De Groot
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Smaggus A. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. BMJ Qual Saf 2019; 28:667-671. [DOI: 10.1136/bmjqs-2018-009147] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 05/17/2019] [Accepted: 05/29/2019] [Indexed: 11/03/2022]
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Hautz WE, Kämmer JE, Hautz SC, Sauter TC, Zwaan L, Exadaktylos AK, Birrenbach T, Maier V, Müller M, Schauber SK. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med 2019; 27:54. [PMID: 31068188 PMCID: PMC6505221 DOI: 10.1186/s13049-019-0629-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/12/2019] [Indexed: 12/18/2022] Open
Abstract
Background Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. Trial registration https://bmjopen.bmj.com/content/6/5/e011585 Electronic supplementary material The online version of this article (10.1186/s13049-019-0629-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland. .,Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373, Oslo, Norway.
| | - Juliane E Kämmer
- Max Planck Institute for Human Development, Center for Adaptive Rationality (ARC), Lentzeallee 94, 14195, Berlin, Germany.,AG Progress Test Medizin, Charité Medical School, Hannoversche Straße 19, 10115, Berlin, Germany
| | - Stefanie C Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland.,Skills Lab Lernzentrum, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Laura Zwaan
- Institute of Medical Education Research Rotterdam, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland
| | - Tanja Birrenbach
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland.,Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010, Berne, Switzerland
| | - Volker Maier
- Department of General Internal Medicine, Inselspital University Hospital, University of Berne, Freiburgstrasse, 3010, Berne, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Freiburgstrasse, 3010, Berne, Switzerland
| | - Stefan K Schauber
- Centre for Educational Measurement, University of Oslo, Gaustadallén 30, 0373, Oslo, Norway.,Centre for Health Sciences Education, Faculty of Medicine, University of Oslo, Oslo, Norway
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Yeung A, Roberts A, Zhu L, Qi L, Zhang J, Lewandrowski KU. Treatment of Soft Tissue and Bony Spinal Stenosis by a Visualized Endoscopic Transforaminal Technique Under Local Anesthesia. Neurospine 2019; 16:52-62. [PMID: 30943707 PMCID: PMC6449822 DOI: 10.14245/ns.1938038.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/07/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To analyze long-term clinical outcomes of endoscopic transforaminal foraminoplasty for foraminal stenosis. METHODS Long-term 5-year MacNab outcomes, visual analogue scale (VAS) scores, complications, and unintended aftercare were analyzed in a series of 86 patients who underwent endoscopic transforaminal foraminoplasty for foraminal stenosis. RESULTS At minimum 5-year follow-up, excellent results according to the MacNab criteria were obtained in 32 patients (37.2%), Good in 40 (46.5%), fair in 11 (12.8%), and poor in 3 (3.5%), respectively. The mean preoperative VAS was 6.15. The mean postoperative and last follow-up VAS was 3.44. Both postoperative VAS and last follow-up VAS were statistically reduced at a significance level of p<0.0001. Postoperative dysesthesia occurred in 9 patients. Another 9 patients had recurrent disc herniations (10.5%). Failure to cure with persistent pain occurred in 3 patients. Two patients developed pain postoperatively stemming from a different level. One patient experienced a postoperative hematoma which ultimately was inconsequential and did not require any additional surgery. Only 3 patients opted for revision endoscopic discectomy and another 2 for revision fusion surgery. CONCLUSION Patients with symptomatic foraminal stenosis may be treated successfully with early transforaminal endoscopic decompression while maintaining favorable long-term outcomes without the need for fusion in the vast majority of patients.
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Affiliation(s)
- Anthony Yeung
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA.,Desert Institute for Spine Care, Phoenix, AZ, USA
| | - Andrew Roberts
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA.,Desert Institute for Spine Care, Phoenix, AZ, USA
| | - Lifan Zhu
- Department of Orthopedics, First People's Hospital of Wujiang, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Lei Qi
- Department of Spine Surgery, Qilu Hospital, Shandong University, Shandong, China
| | - Jun Zhang
- Department of Orthopedics, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Surgical Institute of Tucson, Tucson, AZ, USA.,Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
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Holmes AL, Bugeja L, Young C, Ibrahim JE. Deaths due to thermal injury from cigarette smoking in a 13-year national cohort of nursing home residents. Int J Older People Nurs 2019; 14:e12233. [PMID: 30925015 DOI: 10.1111/opn.12233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/05/2019] [Accepted: 02/10/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the nature and frequency of deaths due to thermal injuries from cigarette smoking reported to Australian coroners and to examine the decisions which surround these deaths. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Residents dwelling in accredited nursing homes whose deaths were reported to coroners between 1 July 2000 and 30 June 2013 and attributed to thermal injuries from cigarette smoking. MEASURES A descriptive analysis was undertaken to report socio-demographic characteristics of the deceased, medical history, mobility, level of observation, safety equipment provided/used, nursing home location, decision to smoke, timing of incident, time from incident to death, incident findings, mechanism of death, formal reports attached and coroners' recommendations. RESULTS Ten deaths of nursing home residents due to thermal injury from cigarette smoking were reported in Australia over a 13-year period. The median age of residents was 78 years (IQR = 15.25); nine residents were female and one was male. Seven residents had impaired mobility with three residents being wheelchair bound and one resident bed bound. None of the residents were supervised by staff while they smoked, and none of the residents utilised any safety equipment to minimise harm. Burns/thermal injury was the mechanism of harm in most cases. CONCLUSIONS This national study confirms that thermal injuries caused by cigarette smoking in nursing homes result in fatalities, particularly in the absence of supervision. It also demonstrates the complex tension arising from balancing autonomy with safety. IMPLICATIONS FOR PRACTICE Nurses and aged care practitioners should endeavour to give effect to each resident's wishes while mitigating the risk of harm. The supervision requirements for cigarette smoking residents should be tailored to the needs of individual residents and staff should try to ensure that residents who require supervision receive it.
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Affiliation(s)
- Alice L Holmes
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Southbank, Victoria, Australia
| | - Lyndal Bugeja
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Southbank, Victoria, Australia
| | - Carmel Young
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Southbank, Victoria, Australia
| | - Joseph Elias Ibrahim
- Health Law and Ageing Research Unit, Department of Forensic Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Southbank, Victoria, Australia
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Lewis PJ, Seston E, Tully MP. Foundation year one and year two doctors' prescribing errors: a comparison of their causes. Postgrad Med J 2019; 94:634-640. [PMID: 30635431 DOI: 10.1136/postgradmedj-2018-135816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/10/2018] [Accepted: 11/10/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Junior doctors have the highest rates of prescribing errors, yet no study has set out to understand the differences between completely novice prescribers (Foundation year one (FY1) doctors) and those who have gained some experience (Foundation year two (FY2) doctors). The objective of this study was to uncover the causes of prescribing errors made by FY2 doctors and compare them with previously collected data of the causes of errors made by FY1 doctors. DESIGN Qualitative interviews, using the critical incident technique, conducted with 19 FY2 doctors on the causes of their prescribing errors and compared with interviews previously conducted with 30 FY1 doctors. Data were analysed using a constant comparison approach after categorisation of the data using Reason's model of accident causation and the London protocol. RESULTS Common contributory factors in both FY1 and FY2 doctors' prescribing errors included working on call, tiredness and complex patients. Yet, important differences were revealed in terms of application of prescribing knowledge, with FY1 doctors lacking knowledge and FY2 misplacing their knowledge. Due to the rotation of foundation doctors, both groups are faced with novel prescribing contexts, yet the previous experience that FY2 doctors gained led to misplaced confidence when caution would have been expedient. CONCLUSIONS Differences in the contributory factors of prescribing errors should be taken into account when designing interventions to improve the prescribing of foundation doctors. Furthermore, careful consideration should be taken when inferring expertise in FY2 doctors, who are likely to prescribe in contexts in which their experience is little different to an FY1 doctor.
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Affiliation(s)
- Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
| | - Elizabeth Seston
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
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Sandal S, Charlebois K, Fiore JF, Wright DK, Fortin MC, Feldman LS, Alam A, Weber C. Health Professional-Identified Barriers to Living Donor Kidney Transplantation: A Qualitative Study. Can J Kidney Health Dis 2019; 6:2054358119828389. [PMID: 30792874 PMCID: PMC6376531 DOI: 10.1177/2054358119828389] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Living donor kidney transplantation (LDKT) has several advantages over deceased donor kidney transplantation. Yet rates of living donation are declining in Canada and there exists significant interprovincial variability. Efforts to improve living donation tend to focus on the patient and barriers identified at their level, such as not knowing how to ask for a kidney or lack of education. These efforts favor those who have the means and the support to find living donors. Thus, a Canadian Institutes of Health Research (CIHR)-organized workshop recommended that education efforts to understand and remove barriers should focus on health professionals (HPs). Despite this, little attention has been paid to what they identify as barriers to discussing LDKT with their patients. OBJECTIVE Our aim was to explore HP-identified barriers to discuss living donation with patients in 3 provinces of Canada with low (Quebec), moderate (Ontario), and high (British Columbia) rates of LDKT. DESIGN This study consists of an interpretive descriptive approach as it enables to move beyond description and inform clinical practice. SETTING Purposive criterion and quota sampling were used to recruit HPs from Quebec, Ontario, and British Columbia who are involved in the care of patients with kidney disease and/or with transplant coordination. PATIENTS Not applicable. MEASUREMENTS Semistructured interviews were conducted. The interview guide was developed based on a preliminary analytical framework and a review of the literature. METHODS Thematic analysis was used to analyze the data stemming from the interviews. The coding process comprised of a deductive and inductive approach, and the use of a qualitative analysis software (NVivo 11). Following this, themes were identified and developed. Interviews were conducted until thematic saturation was obtained. In total, we conducted 16 telephone interviews as thematic saturation was attained. RESULTS Six predominant themes emerged: (1) lack of communication between transplant and dialysis teams, (2) absence of referral guidelines, (3) role perception and lack of multidisciplinary involvement, (4) HP's lack of information and training, (5) negative attitudes of some HP toward LDKT, (6) patient-level barriers as defined by the HP. HPs did mention patients' attitudes and some characteristics as the main barriers to discussions about living donation; this was noted in all provinces. HPs from Ontario and British Columbia indicated multiple strategies being implemented to address some of these barriers. Those from Ontario mentioned strategies that center on the core principles of provincial-level standardization, while those from British Columbia center on engaging the entire multidisciplinary team and improved role perception. We noted a dearth of such efforts in Quebec; however, efforts around education and promotion, while tentative, have emerged. LIMITATIONS Social desirability and selection bias. Our analysis might not be applicable to other provinces. CONCLUSIONS HPs involved with the referral and coordination of transplantation play a major role in access to LDKT. We have identified challenges they face when discussing living donation with their patients that warrant further assessment and research to inform policy change.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Julio F. Fiore
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - David Kenneth Wright
- St. Mary’s Research Center, Montreal, QC, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Chantal Fortin
- Division of Nephrology, Department of Medicine, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Liane S. Feldman
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Ahsan Alam
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Weber
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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Waliany S, Caceres W, Merrell SB, Thadaney S, Johnstone N, Osterberg L. Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC MEDICAL EDUCATION 2019; 19:31. [PMID: 30674302 PMCID: PMC6343267 DOI: 10.1186/s12909-019-1453-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/04/2019] [Indexed: 05/19/2023]
Abstract
BACKGROUND Case-based teaching with real patient cases provides benefit of simulating real-world cognition. However, while clinical practice involves a prospective approach to cases, preclinical instruction typically involves full disclosure of case content to faculty, introducing hindsight bias into faculty teaching in medical curricula. METHODS During 2015-2018, we piloted an optional medical school curriculum involving 6-7 one-hour sessions over a 3-month period each year. New groups enrolled each year from first- and second-year classes. A facilitator provided a blinded physician discussant and blinded students with case information during and not in advance of each session, allowing prospective case-based discussions. Cases were based on real patients treated in the Department of Medicine. Clinical material was presented in the chronologic sequence encountered by treating physicians. Content covered a median of 5 patient visits/case (range: 2-10) spanning over months. A 14-item survey addressing components of the reporter-interpreter-manager-educator (RIME) scheme was developed and used to compare self-reported clinical skills between course participants and non-participant controls during the 2016 course iteration. RESULTS This elective curriculum at Stanford School of Medicine involved 170 preclinical students (22.7% of 750 eligible). During the 2016 course iteration, a quasi-experimental study compared self-reported clinical skills between 29 course participants (response rate: 29/49 [59.2%]) and 35 non-participant controls (response rate: 35/132 [26.5%]); students self-assessed clinical skills via the RIME-based survey developed for the course. Two-sample t-tests compared the change in pre- and post-course skills between course participants and non-participants. Of 15 Department of Medicine faculty members invited as discussants, 12 (80%) consented to participate. Compared with controls, first-year participants self-assessed significantly greater improvement in understanding how clinicians reason through cases step-by-step to arrive at diagnoses (P = 0.049), work through cases in longitudinal settings (P = 0.049), and share information with patients (P = 0.047). Compared with controls, second-year participants self-assessed significantly greater improvement (P = 0.040) in understanding how clinicians reason through cases step-by-step to arrive at diagnoses. CONCLUSIONS Prospective case-based discussions with blinding of faculty and students to clinical content circumvents hindsight bias and may impart real-world cognitive skills as determined by student self-report.
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Affiliation(s)
- Sarah Waliany
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, MSOB x152, Stanford, CA 94305 USA
| | - Wendy Caceres
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, MSOB x152, Stanford, CA 94305 USA
| | | | - Sonoo Thadaney
- Program for Bedside Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Noelle Johnstone
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA USA
| | - Lars Osterberg
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, MSOB x152, Stanford, CA 94305 USA
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Woo SA, Cragg A, Wickham ME, Peddie D, Balka E, Scheuermeyer F, Villanyi D, Hohl CM. Methods for evaluating adverse drug event preventability in emergency department patients. BMC Med Res Methodol 2018; 18:160. [PMID: 30514232 PMCID: PMC6280499 DOI: 10.1186/s12874-018-0617-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/14/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is a high degree of variability in assessing the preventability of adverse drug events, limiting the ability to compare rates of preventable adverse drug events across different studies. We compared three methods for determining preventability of adverse drug events in emergency department patients and explored their strengths and weaknesses. METHODS This mixed-methods study enrolled emergency department patients diagnosed with at least one adverse drug event from three prior prospective studies. A clinical pharmacist and physician reviewed the medical and research records of all patients, and independently rated each event's preventability using a "best practice-based" approach, an "error-based" approach, and an "algorithm-based" approach. Raters discussed discordant ratings until reaching consensus. We assessed the inter-rater agreement between clinicians using the same assessment method, and between different assessment methods using Cohen's kappa with 95% confidence intervals (95% CI). Qualitative researchers observed discussions, took field notes, and reviewed free text comments made by clinicians in a "comment" box in the data collection form. We developed a coding structure and iteratively analyzed qualitative data for emerging themes regarding the application of each preventability assessment method using NVivo. RESULTS Among 1356 adverse drug events, a best practice-based approach rated 64.1% (95% CI: 61.5-66.6%) of events as preventable, an error-based approach rated 64.3% (95% CI: 61.8-66.9%) of events as preventable, and an algorithm-based approach rated 68.8% (95% CI: 66.1-71.1%) of events as preventable. When applying the same method, the inter-rater agreement between clinicians was 0.53 (95% CI: 0.48-0.59), 0.55 (95%CI: 0.50-0.60) and 0.55 (95% CI: 0.49-0.55) for the best practice-, error-, and algorithm-based approaches, respectively. The inter-rater agreement between different assessment methods using consensus ratings for each ranged between 0.88 (95% CI 0.85-0.91) and 0.99 (95% CI 0.98-1.00). Compared to a best practice-based assessment, clinicians believed the algorithm-based assessment was too rigid. It did not account for the complexities of and variations in clinical practice, and frequently was too definitive when assigning preventability ratings. CONCLUSION There was good agreement between all three methods of determining the preventability of adverse drug events. However, clinicians found the algorithmic approach constraining, and preferred a best practice-based assessment method.
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Affiliation(s)
- Stephanie A. Woo
- Pharmaceutical Sciences, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
| | - Maeve E. Wickham
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z9 Canada
| | - David Peddie
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Diane Villanyi
- Division of Geriatrics, Department of Medicine, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- Emergency Department, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
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Cattanach DE, Wysocki AP, Ray-Conde T, Nankivell C, Allen J, North JB. Post-mortem general surgeon reflection on decision-making: a mixed-methods study of mortality audit data. ANZ J Surg 2018; 88:993-997. [DOI: 10.1111/ans.14796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Daniel E. Cattanach
- Department of Surgery; Hervey Bay Hospital; Hervey Bay Queensland Australia
- School of Medicine; Griffith University; Gold Coast Queensland Australia
| | - Arkadiusz P. Wysocki
- School of Medicine; Griffith University; Gold Coast Queensland Australia
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Therese Ray-Conde
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Charles Nankivell
- Department of Surgery; Redland Hospital; Cleveland Queensland Australia
| | - Jennifer Allen
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - John B. North
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
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Reiss JP, Jarmain S, Vasudev K. Quality Review in Psychiatry. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63. [PMID: 29513630 PMCID: PMC5846967 DOI: 10.1177/0706743717752916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This position paper has been substantially revised by the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on August 31, 2016. The original position paper1 was developed by the Professional Standards and Practice Council and approved by the Board of Directors on April 9, 1994.
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Affiliation(s)
- Jeffrey P Reiss
- 1 Professor and Interim Chair/Chief, Department of Psychiatry, Western University and London Hospitals, London, Ontario
| | - Sarah Jarmain
- 2 Chair, MAC and Director of Medical Quality, St Joseph's Health Care London; Associate Professor, Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | - Kamini Vasudev
- 3 Associate Professor, Departments of Psychiatry and Medicine, Western University; Scholarly Portfolio Lead, Residency Program Committee, Department of Psychiatry, Western University; Physician Lead, General Adult Ambulatory Mental Health Service, London Health Sciences Centre (Victoria Hospital), London, Ontario
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Parand A, Faiella G, Franklin BD, Johnston M, Clemente F, Stanton NA, Sevdalis N. A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. ERGONOMICS 2018; 61:104-121. [PMID: 28498024 DOI: 10.1080/00140139.2017.1330491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Increasingly, medication is being administered at home by family and friends of the care-recipient. This study aims to identify and analyse risks associated with potential drug administration errors made by informal carers at home. We mapped medication administration at home with a multidisciplinary team that included carers, health care professionals and patients. Evidence-based risk-analysis methodologies were applied: Healthcare Failure Modes and Effect Analysis (HFMEA), Systematic Human Error Reduction and Prediction Analysis (SHERPA) and Systems-Theoretic Accident Model and Processes (STAMP). The process of administration comprises seven sub-processes. Thirty-four possible failure modes were identified and six of these were rated as high risk. These highlighted that medications may be given with a wrong dose, stored incorrectly, not discontinued as instructed, not recorded, or not ordered on time, and often caused by communication and support problems. Combined risk analyses contributed unique information helpful to better understand the medication administration risks and causes within homecare. Practitioner Summary: Increasingly, medication is being administered at home by family and friends of the care-recipient. This study identifies risks associated with potential drug administration errors made by informal carers at home through consensus-based quantitative techniques. The different analyses contribute unique information helpful to better understand the administration risks and causes.
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Affiliation(s)
- Anam Parand
- a Department of Social Psychology , London School of Economics , London , UK
- b The National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre, Imperial College London , London , UK
| | - Giuliana Faiella
- c National Centre of Research, Institute of Bio-structure and Bio-imaging, University of Naples , Rome , Italy
| | - Bryony Dean Franklin
- d Centre for Medication Safety and Service Quality, Pharmacy Department , Imperial College Healthcare NHS Trust/UCL School of Pharmacy , London , UK
| | - Maximilian Johnston
- b The National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre, Imperial College London , London , UK
| | - Fabrizio Clemente
- c National Centre of Research, Institute of Bio-structure and Bio-imaging, University of Naples , Rome , Italy
| | - Neville A Stanton
- e Engineering and the Environment , University of Southampton , Southampton , UK
| | - Nick Sevdalis
- f Centre for Implementation Science , King's College London , London , UK
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Juriga LL, Murray DJ, Boulet JR, Fehr JJ. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error.Methods:We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis).Results:Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis.Conclusions:Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.
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Abstract
Abstract. How are judgments in moral dilemmas affected by uncertainty, as opposed to certainty? We tested the predictions of a consequentialist and deontological account using a hindsight paradigm. The key result is a hindsight effect in moral judgment. Participants in foresight, for whom the occurrence of negative side effects was uncertain, judged actions to be morally more permissible than participants in hindsight, who knew that negative side effects occurred. Conversely, when hindsight participants knew that no negative side effects occurred, they judged actions to be more permissible than participants in foresight. The second finding was a classical hindsight effect in probability estimates and a systematic relation between moral judgments and probability estimates. Importantly, while the hindsight effect in probability estimates was always present, a corresponding hindsight effect in moral judgments was only observed among “consequentialist” participants who indicated a cost-benefit trade-off as most important for their moral evaluation.
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Affiliation(s)
- Nadine Fleischhut
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Björn Meder
- Center for Adaptive Behavior and Cognition, Max Planck Institute for Human Development, Berlin, Germany
| | - Gerd Gigerenzer
- Center for Adaptive Behavior and Cognition, Max Planck Institute for Human Development, Berlin, Germany
- Center for Adaptive Behavior and Cognition, Harding Center for Risk Literacy, Max Planck Institute for Human Development, Berlin, Germany
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Ashley L, Armitage G, Taylor J. Recognising and referring children exposed to domestic abuse: a multi-professional, proactive systems-based evaluation using a modified Failure Mode and Effects Analysis (FMEA). HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:690-699. [PMID: 27192966 DOI: 10.1111/hsc.12359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/15/2016] [Indexed: 06/05/2023]
Abstract
Failure Modes and Effects Analysis (FMEA) is a prospective quality assurance methodology increasingly used in healthcare, which identifies potential vulnerabilities in complex, high-risk processes and generates remedial actions. We aimed, for the first time, to apply FMEA in a social care context to evaluate the process for recognising and referring children exposed to domestic abuse within one Midlands city safeguarding area in England. A multidisciplinary, multi-agency team of 10 front-line professionals undertook the FMEA, using a modified methodology, over seven group meetings. The FMEA included mapping out the process under evaluation to identify its component steps, identifying failure modes (potential errors) and possible causes for each step and generating corrective actions. In this article, we report the output from the FMEA, including illustrative examples of the failure modes and corrective actions generated. We also present an analysis of feedback from the FMEA team and provide future recommendations for the use of FMEA in appraising social care processes and practice. Although challenging, the FMEA was unequivocally valuable for team members and generated a significant number of corrective actions locally for the safeguarding board to consider in its response to children exposed to domestic abuse.
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Affiliation(s)
- Laura Ashley
- School of Social, Psychological and Communication Sciences, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds, UK
| | - Gerry Armitage
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Julie Taylor
- School of Nursing, Institute of Clinical Sciences, University of Birmingham, and Birmingham Children's Hospital, Birmingham, UK
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Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf 2016; 26:417-422. [PMID: 27340202 PMCID: PMC5530340 DOI: 10.1136/bmjqs-2016-005511] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 11/24/2022]
Affiliation(s)
| | - Susan Carr
- John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK
| | - Justin Waring
- CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK
| | - Mary Dixon-Woods
- SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK
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Manaseki-Holland S, Lilford RJ, Bishop JRB, Girling AJ, Chen YF, Chilton PJ, Hofer TP. Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. BMJ Qual Saf 2016; 26:408-416. [PMID: 27334868 PMCID: PMC5530333 DOI: 10.1136/bmjqs-2015-004849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 05/05/2016] [Accepted: 05/08/2016] [Indexed: 12/29/2022]
Abstract
Background Standardised mortality ratios do not provide accurate measures of preventable mortality. This has generated interest in using case notes to assess the preventable component of mortality. But, different methods of measurement have not been compared. We compared the reliability of two scales for assessing preventability and the correspondence between them. Methods Medical specialists reviewed case notes of patients who had died in hospital, using two instruments: a five-point Likert scale and a continuous (0–100) scale of preventability. To enhance generalisability, we used two different hospital datasets with different types of acute medical patients across different epochs, and in two jurisdictions (UK and USA). We investigated the reliability of measurement and correspondence of preventability estimates across the two scales. Ordinal mixed effects regression methods were used to analyse the Likert scale and to calibrate it against the continuous scale. We report the estimates of the probability a death could have been prevented, accounting for reviewer inconsistency. Results Correspondence between the two scales was strong; the Likert categories explained most of the variation (76% UK, 73% USA) in the continuous scale. Measurement reliability was low, but similar across the two instruments in each dataset (intraclass correlation: 0.27, UK; 0.23, USA). Adjusting for the inconsistency of reviewer judgements reduced the proportion of cases with high preventability, such that the proportion of all deaths judged probably or definitely preventable on the balance of probability was less than 1%. Conclusions The correspondence is high between a Likert and a continuous scale, although the low reliability of both would suggest careful measurement design would be needed to use either scale. Few to no cases are above the threshold when using a balance of probability approach to determining a preventable death, and in any case, there is little evidence supporting anything more than an ordinal correspondence between these reviewer estimates of probability and the true probability. Thus, it would be more defensible to use them as an ordinal measure of the quality of care received by patients who died in the hospital.
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Affiliation(s)
| | | | - Jonathan R B Bishop
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Alan J Girling
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter J Chilton
- Warwick Medical School, University of Warwick, Coventry, UK.,Warwick Business School, University of Warwick, Coventry, UK
| | - Timothy P Hofer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Baines RJ, Langelaan M, de Bruijne MC, Wagner C. Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. BMJ Open 2015; 5:e007380. [PMID: 26159451 PMCID: PMC4499703 DOI: 10.1136/bmjopen-2014-007380] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Adverse event studies often use patient record review as a way to assess patient safety. As this is a time-consuming method, hospitals often study inpatient deaths. In this article we will assess whether this offers a representative view of the occurrence of adverse events in comparison to patients who are discharged while still living. DESIGN Retrospective patient record review study. SETTING AND PARTICIPANTS A total of 11,949 hospital admissions; 50% of inpatient deaths; the other half of patients discharged while alive. The data originated from our two national adverse event studies in 2004 and 2008. MAIN OUTCOME MEASURES Overall adverse events and preventable adverse events in inpatient deaths, and in admissions of patients discharged alive. We looked at size, preventability, clinical process and type of adverse events. RESULTS Patients who died in hospital were on an average older, had a longer length of stay, were more often urgently admitted and were less often admitted to a surgical unit. We found twice as many adverse events and preventable adverse events in inpatient deaths than in patients discharged alive. Consistent with the differences in patient characteristics, preventable adverse events in inpatient deaths were proportionally less and were often related to the surgical process. Most types of adverse events and preventable adverse events occur in inpatient deaths as well as in patients discharged alive; however, these occur more often in inpatient deaths and are differently distributed. CONCLUSIONS Reviewing patient records of inpatient deaths is more efficient in identifying preventable AEs than reviewing records of those discharged alive. Although many of the same types of adverse events are found, it does not offer a representative view of the number or type of adverse events.
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Affiliation(s)
- Rebecca J Baines
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Maaike Langelaan
- Department of Public and Occupational Health, VU University Medical Center (VUmc), EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Martine C de Bruijne
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Cordula Wagner
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Department of Public and Occupational Health, VU University Medical Center (VUmc), EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
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Seta CE, Seta JJ, Petrocelli JV, McCormick M. Even better than the real thing: Alternative outcome bias affects decision judgements and decision regret. THINKING & REASONING 2015. [DOI: 10.1080/13546783.2015.1034779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Catherine E. Seta
- Department of Psychology, Wake Forest University, Winston-Salem, NC, USA
| | - John J. Seta
- Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - John V. Petrocelli
- Department of Psychology, Wake Forest University, Winston-Salem, NC, USA
| | - Michael McCormick
- Department of Psychology, University of North Carolina at Greensboro, Greensboro, NC, USA
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Lewis PJ, Ashcroft DM, Dornan T, Taylor D, Wass V, Tully MP. Exploring the causes of junior doctors' prescribing mistakes: a qualitative study. Br J Clin Pharmacol 2015; 78:310-9. [PMID: 24517271 DOI: 10.1111/bcp.12332] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 01/20/2014] [Indexed: 11/30/2022] Open
Abstract
AIMS Prescribing errors are common and can be detrimental to patient care and costly. Junior doctors are more likely than consultants to make a prescribing error, yet there is only limited research into the causes of errors. The aim of this study was to explore the causes of prescribing mistakes made by doctors in their first year post graduation. METHODS As part of the EQUIP study, interviews using the critical incident technique were carried out with 30 newly qualified doctors. Participants were asked to discuss in detail any prescribing errors they had made. Participants were purposely sampled across a range of medical schools (18) and hospitals (15). A constant comparison approach was taken to analysis and Reason's model of accident causation was used to present the data. RESULTS More than half the errors discussed were prescribing mistakes (errors due to the correct execution of an incorrect plan). Knowledge-based mistakes (KBMs) appeared to arise from poor knowledge of practical aspects of prescribing such as dosing, whereas rule-based mistakes (RBMs) resulted from inappropriate application of knowledge. Multiple error-producing and latent conditions were described by participants for RBMs and KBMs. Poor/absent senior support and a fear of appearing incompetent occurred with KBMs. Following erroneous routines or seniors' orders were major contributory factors in RBMs. CONCLUSIONS Although individual factors such as knowledge and expertise played a role in prescribing mistakes, there were many perceived interrelated factors contributing to error. We conclude that multiple interventions are necessary to address these and further research is essential.
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Affiliation(s)
- Penny J Lewis
- Manchester Pharmacy School, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Keers RN, Williams SD, Cooke J, Ashcroft DM. Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study. BMJ Open 2015; 5:e005948. [PMID: 25770226 PMCID: PMC4360808 DOI: 10.1136/bmjopen-2014-005948] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To investigate the underlying causes of intravenous medication administration errors (MAEs) in National Health Service (NHS) hospitals. SETTING Two NHS teaching hospitals in the North West of England. PARTICIPANTS Twenty nurses working in a range of inpatient clinical environments were identified and recruited using purposive sampling at each study site. PRIMARY OUTCOME MEASURES Semistructured interviews were conducted with nurse participants using the critical incident technique, where they were asked to discuss perceived causes of intravenous MAEs that they had been directly involved with. Transcribed interviews were analysed using the Framework approach and emerging themes were categorised according to Reason's model of accident causation. RESULTS In total, 21 intravenous MAEs were discussed containing 23 individual active failures which included slips and lapses (n=11), mistakes (n=8) and deliberate violations of policy (n=4). Each active failure was associated with a range of error and violation provoking conditions. The working environment was implicated when nurses lacked healthcare team support and/or were exposed to a perceived increased workload during ward rounds, shift changes or emergencies. Nurses frequently reported that the quality of intravenous dose-checking activities was compromised due to high perceived workload and working relationships. Nurses described using approaches such as subconscious functioning and prioritising to manage their duties, which at times contributed to errors. CONCLUSIONS Complex interactions between active and latent failures can lead to intravenous MAEs in hospitals. Future interventions may need to be multimodal in design in order to mitigate these risks and reduce the burden of intravenous MAEs.
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Affiliation(s)
- Richard N Keers
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, MAHSC, University of Manchester, Manchester, UK
| | - Steven D Williams
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- Pharmacy Department, University Hospital of South Manchester NHS Foundation Trust, MAHSC, Manchester, UK
- NHS England, Skipton House, London, UK
| | - Jonathan Cooke
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- Infectious Diseases and Immunity Section, Division of Infectious Diseases, Department of Medicine, Imperial College London, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, MAHSC, University of Manchester, Manchester, UK
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49
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Abstract
Diagnostic errors have emerged as a serious patient safety problem but they are hard to detect and complex to define. At the research summit of the 2013 Diagnostic Error in Medicine 6th International Conference, we convened a multidisciplinary expert panel to discuss challenges in defining and measuring diagnostic errors in real-world settings. In this paper, we synthesize these discussions and outline key research challenges in operationalizing the definition and measurement of diagnostic error. Some of these challenges include 1) difficulties in determining error when the disease or diagnosis is evolving over time and in different care settings, 2) accounting for a balance between underdiagnosis and overaggressive diagnostic pursuits, and 3) determining disease diagnosis likelihood and severity in hindsight. We also build on these discussions to describe how some of these challenges can be addressed while conducting research on measuring diagnostic error.
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Affiliation(s)
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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50
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Sousa P, Uva AS, Serranheira F, Nunes C, Leite ES. Estimating the incidence of adverse events in Portuguese hospitals: a contribution to improving quality and patient safety. BMC Health Serv Res 2014; 14:311. [PMID: 25034870 PMCID: PMC4114085 DOI: 10.1186/1472-6963-14-311] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 07/11/2014] [Indexed: 02/08/2023] Open
Abstract
Background Several review studies have shown that 3.4% to 16.6% of patients in acute care hospitals experience one or more adverse events. Adverse events (AEs) in hospitals constitute a significant problem with serious consequences and a challenge for public health. The occurrence of AEs in Portuguese hospitals has not yet been systematically studied. The main purpose of this study is to estimate the incidence, impact and preventability of adverse events in Portuguese hospitals. It is also our aim to examine the feasibility of applying to Portuguese acute hospitals the methodology of detecting AEs through record review, previously used in other countries. Methods This work is based on a retrospective cohort study and was carried out at three acute care hospitals in the Administrative Region of Lisbon. The identification of AEs and their impact was done using a two-stage structured retrospective medical records review based on the use of 18 screening criteria. A random sample of 1,669 medical records (representative of 47,783 hospital admissions) for the year 2009 was analyzed. Results The main results found in this study were an incidence rate of 11.1% AEs, of which around 53.2% were considered preventable. The majority of AEs were associated with surgical procedures (27%), drug errors (18.3%) and hospital acquired infections (12.2%). Most AEs (61%) resulted in minimal or no physical impairment or disability, and 10.8% were associated with death. In 58.6% of the AEs’ cases, the length of stay was prolonged on average 10.7 days. Additional direct costs amounted to €470,380.00. Conclusion The magnitude of these results was critical, reinforcing the need of more detailed studies in this area. The knowledge of the incidence and nature of AEs that occur in hospitals should be seen as a first step towards the improvement of quality and safety in health care.
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Affiliation(s)
- Paulo Sousa
- National School of Public Health, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-540 Lisboa, Portugal.
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