… more frequently up to one-year postintervention. … Schwartz A,  Peskin S, Spiro A, et al. Direct observation of …

Physician burnout has been associated with increased patient safety incidents. A recent national survey of pediatric residents found burnout rates exceeded 50%. The survey found that risk of burnout was associated with reported stress, sleepiness, dissatisfaction with work-life balance and recent medical error. Burnout rates were lowest among residents reporting empathy, self-compassion, quality of life, and confidence in providing compassionate care.

This observation and interview study examined instances of surgical trainees hesitating in the operating room. Both trainees and attending physicians interpreted hesitation as incompetence. The authors suggest that this interpretation of hesitation does not support progressive autonomy for trainees and must be addressed in order to promote surgical safety.

Contextual errors can occur when health care providers fail to consider a patient's individual context, such as limited literacy, when making a treatment plan. This qualitative study of clinicians identified 12 types of contextual errors that can impede patient self-management and lead to harm. The authors advocate a "contextual differential" to consider these potential errors.

This meta-analysis of three pooled studies revealed that patient-specific contextual factors, which may affect the care plan, were more often identified when providers specifically elicited such information rather than when it arose spontaneously. This finding demonstrates the benefits of recommended best practices for safe health communication, discussed in a past PSNet interview.

Physicians should consider contextual issues when developing care plans with patients. This commentary discusses how inattention to patient context, such as environmental or social factors, can contribute to medical errors. Contextual factors that physicians should consider include finances, religion, social support, and access to care.

Failure to appreciate the role of contextual factors—such as patients' access to care or social support—can result in diagnostic errors. In this analysis of data from a prior study, failure to appropriately individualize care based on contextual factors led to substantial excess costs, often due to prescribing unnecessary medications. The investigators also make the important point that most of these errors would not have been detected by standard quality measures for outpatient care.

Medical students who received specific training in probing for contextual factors (biomedical or psychosocial factors that could impact diagnosis or treatment) while interviewing patients were better able to develop individualized treatment plans.

The landmark Institute of Medicine report on patient safety categorized inappropriate plans of care as a medical error. This broad classification encompassed decision-making errors by clinicians that included diagnostic errors but also the notion of contextual errors. The latter are those that occur because of inattention to patient context such as environment, behavior, economic situation, or access to care and social support. This study used unannounced standardized patients who acted out four clinical scenarios presenting with biomedical and contextual complicating factors. Attending physicians probed fewer contextual red flags than biomedical ones and provided error-free plans of care in 73% of the uncomplicated encounters, 22% of the contextually complicated encounters, and only 9% of the combined biomedically and contextually complicated encounters. The authors advocate for greater attention and performance metrics to assess how well providers deliver individualized patient care plans based on probed contextual factors.

This study describes a methodology for measuring physician performance and focuses on the ability to expose forms of contextual error.

The authors address obstacles to effective communication with a conceptual framework that includes attention to information exchange among providers, use of information technology, and reduction of external disruptions that affect communication.