February 12, 2020 Weekly Issue

The Joint Commission has stated that “intimidating and disruptive behaviors” can result in medical errors that affect patient care and safety. In this study a 35-item, web-based survey was administered to physicians—and peers, colleagues, administrators, and staff— before and after they completed a professional development program on unprofessional physician behaviors. Results indicate that physician behavior can be positively modified by a relatively brief education program.

Prescription opioids play a significant role in the ongoing opioid crisis. This study examined whether reducing the default settings in the electronic health record (EHR) for number of opioid tablets for prescriptions could lower the number of pills actually prescribed by 104 health care professionals at two large, urban emergency departments. Results suggest that this easy to implement, low-cost intervention could be helpful in combatting the opioid epidemic.

This article describes results of a cross-sectional recontact survey of Massachusetts residents on the persisting impacts of medical errors. Of respondents who reported a medical error occurred 3-6 years ago, 51% reported at least one emotional impact, 57% reported avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents reported a loss of trust after the medical error. Logistical regression analyses, controlling for error severity, suggests that open communication can reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error.

This retrospective study used text mining to analyze the free text descriptions in 72,390 medication administration incident reports in the National Reporting and Learning System in England and Wales to identify terms most frequently associated with risk that might otherwise remain buried within other non-relevant text. The authors identified the most common medications described in free text (insulin, antibiotics, paracetamol and morphine) and presented the most common free text terms associated with these medications. Results indicate that checking patient allergies and medication doses, especially for intravenous and transdermal medications, should be a focus of efforts to increase medication administration safety.

The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.

This study examined whether increased team turnover raises the likelihood of sharp count errors by surgical teams and negatively affects patient outcomes. Analyses of all cardiac operations performed at Massachusetts General Hospital over a 5-year period revealed that sharp count errors were associated with higher rates of in-hospital mortality and were more prevalent with increased team turnover and on weekends. A prior Web M&M commentary discusses adverse outcomes arising due a retained foreign object during cardiac surgery.

Effectively engaging patients and family members is a necessary prerequisite to providing effective patient- and family-centered care. This article describes lessons learned during the six years after a large regional health care system in the U.S. established a systemwide infrastructure of patient and family advisory councils (PFACs) to help improve the quality, safety, and experience of care it provides. Successful elements are described, and the authors conclude that an openness to continuous improvement and adaptation was particularly important.