The weekend effect refers to the fact that mortality for several common conditions is higher in patients admitted on weekends compared to weekdays. While the mechanism for this effect is unclear, it likely varies for different disease processes. For example, prior studies have postulated that a weekend effect exists for patients with acute stroke. However, this study analyzed a large British database and found that many patients with a history of stroke who were later hospitalized for other reasons had their admission diagnosis inaccurately documented as acute stroke. This inaccuracy occurred more frequently in patients admitted on weekdays. Because the weekday admissions included many patients who were hospitalized for less morbid conditions, mortality appeared lower for patients admitted on weekdays than on weekends. When data was reanalyzed to include only those patients with a true acute stroke, no weekend effect was found. This study demonstrates the limitations of administrative data in analyzing patient safety issues.
Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.
Preventing readmissions after hospital discharge is a national policy priority. The Partnership for Patients has established a goal of reducing preventable readmissions by 20% by 2013, and hospitals now face financial penalties for excess readmission rates. However, the proportion of readmissions that is truly preventable remains unclear, as prior studies have found that only 1 in 5 readmissions may be preventable. This case series from the integrated Kaiser Permanente system found that nearly half of their 30-day readmissions were at least possibly preventable (with 11% being completely preventable). Most readmissions had multiple contributing causes, and interestingly, use of strategies to prevent readmissions such as postdischarge telephone calls and early primary care follow-up appointments varied widely across the 18 hospitals in the study. A potentially preventable readmission due to a medication error is discussed in an AHRQ WebM&M commentary.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Singh H, Thomas EJ, Petersen LA, et al. Arch Intern Med. 2007;167:2030-6.
This AHRQ-funded study uncovered distinctive features of errors involving trainees, including teamwork and communication breakdowns, failures of supervision and handoffs, and excessive workload. Building on a past study of closed malpractice claims, investigators conducted a subanalysis of those claims in which housestaff or fellows were thought to play an important role. As the claims predate the introduction of trainee work hour restrictions, the authors call for continued research into trainee errors and targeted training interventions to address current areas of concern. An accompanying editorial discusses a dramatically new model for inpatient care that would begin to address the problem areas identified in this study.
Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Medical errors in the outpatient setting have remained a relatively understudied aspect of patient safety. This study analyzed data from malpractice claims at four liability insurers, similar to companion studies of errors in surgical and emergency department patients, to determine the frequency and causes of missed and delayed diagnoses. Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed diagnoses of cancer. Failure to reach a timely diagnosis was generally due to multiple process breakdowns, including failure to order an appropriate diagnostic test and inadequate follow-up planning, many of which could be ascribed to physician cognitive errors. As with prior studies using chart review, reviewer's agreement on whether an error occurred was only moderate. The authors note that due to the complexity of contributing factors to outpatient errors, simple solutions are unlikely. An accompanying editorial, available via the link below, considers the differences in the nature of errors and approaches to solving them between the inpatient and outpatient settings and calls for greater attention to tackling outpatient safety issues.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
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