Reducing medical errors: a practical guide

Coaching to enhance qualified surgeons' non-technical skills: a systematic review

INTRODUCTION

The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons.

METHODS

A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI).

RESULTS

Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study.

CONCLUSION

Surgical coaching of qualified surgeons' NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.

Patient safety issues and concerns in Bhutan's healthcare system: a qualitative exploratory descriptive study

OBJECTIVES

To investigate what healthcare professionals perceived and experienced as key patient safety concerns in Bhutan's healthcare system.

DESIGN

Qualitative exploratory descriptive inquiry.

SETTINGS

Three different levels of hospitals, a training institute and the Ministry of Health, Bhutan.

PARTICIPANTS

In total, 140 healthcare professionals and managers.

METHODS

Narrative data were collected via conversational in-depth interviews and Nominal Group Meetings. All data were subsequently analysed using thematic analysis strategies.

RESULTS

The data revealed that medication errors, healthcare-associated infections, diagnostic errors, surgical errors and postoperative complications, laboratory/blood testing errors, falls, patient identification and communication errors were perceived as common patient safety concerns. Human and system factors were identified as contributing to these concerns. Instituting clinical governance, developing and improving the physical infrastructure of hospitals, providing necessary human resources, ensuring staff receive patient safety education and promoting 'good' communication and information systems were, in turn, all identified as processes and strategies critical to improving patient safety in the Bhutanese healthcare system.

CONCLUSION

Patient safety concerns described by participants in this study were commensurate with those identified in other low and middle-income countries. In order to redress these concerns, the findings of this study suggest that in the Bhutanese context patient safety needs to be conceptualised and prioritised.

Crew resource management training in the intensive care unit. A multisite controlled before-after study

INTRODUCTION

There is a growing awareness today that adverse events in the intensive care unit (ICU) are more often caused by problems related to non-technical skills than by a lack of technical, or clinical, expertise. Team training, such as crew resource management (CRM), aims to improve these non-technical skills. The present study evaluated the effectiveness of CRM in the ICU.

METHODS

Six ICUs participated in a paired controlled trial, with one pretest and two post-test measurements (after 3 and 12 months). Three ICUs received CRM training and were compared with a matched control unit. The 2-day classroom-based training was delivered to multidisciplinary groups (ie, ICU physicians, nurses, managers). All levels of Kirkpatrick's evaluation framework were assessed using a mixed method design, including questionnaires, observations and routinely administered patient outcome data.

RESULTS

Level I-reaction: participants were very positive directly after the training. Level II-learning: attitudes towards behaviour aimed at optimising situational awareness were relatively high at baseline and remained stable. Level III-behaviour: self-reported behaviour aimed at optimising situational awareness improved in the intervention group. No changes were found in observed explicit professional oral communication. Level IV-organisation: patient outcomes were unaffected. Error management culture and job satisfaction improved in the intervention group. Patient safety culture improved in both control and intervention units.

CONCLUSIONS

We can conclude that CRM, as delivered in the present study, does not change behaviour or patient outcomes by itself, yet changes how participants think about errors and risks. This indicates that CRM requires a combination with other initiatives in order to improve clinical outcomes.

Integration of patient safety systems in a suburban hospital

Public awareness of hospital misadventure is now common. In response, we describe our integrated hospital safety system, which is dependent on the linkage of multiple individual safety committees, and the presence on each committee of senior and junior multidisciplinary healthcare professionals to provide feedback to their peer groups on required improvements.

Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial

BACKGROUND

Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail.

METHODS/DESIGN

Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data.

DISCUSSION

It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1976.

Improvement in documentation of compartment syndrome with a chart insert

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness

OBJECTIVE

To assess whether patients' perceptions of a hypothetical medical error are influenced by staff responsiveness, disclosure of error, and health consequences of the error.

DESIGN

Hypothetical scenario describing a medication error submitted by mail. Three factors were manipulated at random: rapid v slow staff responsiveness to error; disclosure v non-disclosure of the error; and occurrence of serious v minor health consequences.

PARTICIPANTS

Patients discharged from hospital.

MEASURES

Assessment of care described in the scenario as bad or very bad, rating of care as unsafe, and intent to not recommend the hospital.

RESULTS

Of 1274 participants who evaluated the scenario, 71.4% rated health care as bad or very bad, 60.2% rated healthcare conditions as unsafe, and 25.5% stated that they would not recommend the hospital. Rating health care as bad or very bad was associated with slow reaction to error (odds ratio (OR) 2.8, 95% CI 2.1 to 3.6), non-disclosure of error (OR 2.0, 95% CI 1.5 to 2.6), and serious health consequences (OR 3.4, 95% CI 2.6 to 4.5). Similar associations were observed for rating healthcare conditions as unsafe and the intent to not recommend the hospital. Younger patients were more sensitive to non-disclosure than older patients.

CONCLUSIONS

Former patients view medical errors less favorably when hospital staff react slowly, when the error is not disclosed to the patient, and when the patient suffers serious health consequences.

Beyond blame: cultural barriers to medical incident reporting

The paper explores the attitudes of medical physicians towards adverse incident reporting in health care, with particular focus on the inhibiting factors or barriers to participation. It is recognised that there are major barriers to medical reporting, such as the 'culture of blame'. There are, however, few detailed qualitative accounts of medical culture as it relates to incident reporting. Drawing on a 2-year qualitative case study in the UK, this paper presents data gathered from 28 semi-structured interviews with specialist physicians. The findings suggest that blame certainly inhibits medical reporting, but other cultural issues were also significant. It was commonly accepted by doctors that errors are an 'inevitable' and potentially unmanageable feature of medical work and incident reporting was therefore 'pointless'. It was also found that reporting was discouraged by an anti-bureaucratic sentiment and rejection of excessive administrative duties. Doctors were also apprehensive about the increased potential for managers and non-physicians to engage in the regulation of medical quality through the use of incident data. The paper argues that the promotion of incident reporting must engage with more than the ubiquitous 'culture of blame' and instead address the 'culture of medicine', especially as it relates to the collegial and professional control of quality.

Documentation of acute compartment syndrome at an academic health-care center

BACKGROUND

Documentation of the clinical course of a compartment syndrome is critical to effective treatment; however, such documentation often is found to be inadequate.

METHODS

Notes and consent forms for thirty consecutive patients with adequate follow-up who had undergone fasciotomy for the treatment of compartment syndrome were reviewed for legibility, notation of the time and date, and documentation of the presence of core physical examination and history findings, including pain, paresthesias, tenseness, pain on passive stretch, sensory deficit, motor deficit, pulses, compartment pressures, and diastolic blood pressure.

RESULTS

Documentation was inadequate for twenty-one patients (70%): the notes and consent forms were not timed or not dated (or both) for nine patients (30%), and the notes were at least partially illegible for sixteen patients (53%). The documentation was incomplete with regard to the presence of paresthesias in eleven patients, pain on passive stretch in ten, sensory deficit in nine, motor deficit in eight, pulses in seven, pain in five, and tenseness in three. The documentation was incomplete with regard to the blood and compartment pressures for sixteen and six patients, respectively.

CONCLUSIONS

The documentation of the core history and physical examination findings was inadequate in this series of patients with compartment syndrome. On the basis of the results of this study, and through an organizational systems approach, we have instituted for our residents, nursing staff, and faculty an educational program on the documentation of compartment syndrome in patients who are at risk for this condition.

Using checklists and reminders in clinical pathways to improve hospital inpatient care

OBJECTIVES

To determine whether the quality of hospital inpatient care can be improved by using checklists and reminders in clinical pathways.

DESIGN

Comparison of key indicators before and after the introduction of clinical pathways incorporating daily checklists and reminders of best practice integrated into patient medical records.

SETTING AND PARTICIPANTS

The study, at Wimmera Base Hospital in Horsham, Victoria, included patients admitted between 1 January 1999 and 31 December 2002 with ST-elevation acute myocardial infarction (AMI) and patients admitted between 31 July 1999 and 31 December 2002 with stroke.

MAIN OUTCOME MEASURES

Compliance with key process measures determined as best practice for each clinical pathway.

RESULTS

116 patients with AMI and 123 patients with stroke were included in the study. ST-elevation AMI. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 21.4% (95% CI, 7.3%-32.7%) for patients receiving aspirin in the emergency department; 42.7% (95% CI, 26.3%-59.0%) for eligible patients receiving beta-blockers within 24 h of admission; 48.1% (95% CI, 31.4%-64.8%) for eligible patients being prescribed beta-blockers on discharge; 43.7% (95% CI, 28.4%-59.1%) for patients having fasting lipid levels measured; and 41.2% (95% CI, 19.0%-63.5%) for eligible patients having lipid therapy. Stroke. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 40.7% (95% CI, 21.0%-60.2%) for dysphagia screening within 24 h of admission; 55.4% (95% CI, 32.9%-77.9%) for patients with ischaemic stroke receiving aspirin or clopidogrel within 24 h of admission; and 52.4% (95% CI, 33.8%-70.9%) for patients having regular neurological observations during the first 48 h after a stroke. There was a fall of 1.0 percentage point (ie, a difference of -1% [95% CI, -4.7% to 10.0%]) in the proportion of patients having a computed tomography brain scan within 24 h of admission.

CONCLUSION

Significant improvements in the quality of patient care can be achieved by incorporating checklists and reminders into clinical pathways.

How safe is the safety paradigm?

This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.

How safe is the safety paradigm?

This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

OBJECTIVES

To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events.

DESIGN

Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program.

PARTICIPANTS AND SETTING

49,834 inpatients (July 1991 to September 1999) and 20,050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria.

MAIN OUTCOME MEASURES

Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting.

RESULTS

The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P<0.001). Absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P< 0.001). Absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and relative risk reduction was 85.3% (95% CI, 62.7%-100%).

CONCLUSIONS

Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program.