Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Mays JA, Mathias PC. J Am Med Inform Assoc. 2019;26:269-272.
Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.
This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
Vaughan L, McAlister G, Bell D. Clin Med (Lond). 2011;11:322-326.
This survey of physicians about the UK equivalent of the "July effect"—a tradition of nearly 50,000 new doctors starting on the first Wednesday in August—found a high degree of concern for patient care, safety, and training. The authors conclude that there is a need for structural changes.
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-6.
Failure to follow up on test results has been linked to missed and delayed diagnoses in the ambulatory setting. Although electronic health records (EHR) hold great promise for addressing this issue, this systematic review found only modest published evidence linking EHR use to improved laboratory test monitoring. This finding corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests and radiologic studies despite use of an EHR. The authors conclude that further research will be required to develop optimal test management systems within electronic medical records.
Grossman E, Phillips RS, Weingart SN. J Patient Saf. 2010;6:172-179.
Tests pending after hospital discharge or following a clinic visit continue to challenge most health care systems. This study implemented a paper-based system to follow up abnormal mammograms and monitored provider responses to those reminders. Based on a report of abnormal mammograms generated by the radiology department, a practice administrator sent a letter to each provider with a copy of the report and a set of questions on behalf of their quality improvement committee. More than 90% of providers responded to the fail-safe reminders, 8% were unaware of the abnormal test, and there was no follow-up plan in place for 3% of cases. Less experienced providers were more likely to be unaware of abnormal mammograms and many lapses were noted in the context of care transitions. The authors conclude that their paper-based system is feasible and valuable but requires full engagement of providers in the process.
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory settings. Adoption of information technology approaches serves as a logical solution if designed to effectively notify providers of pending or necessary follow-up actions. This study used tracking software to determine if an electronic alert for abnormal imaging results was acknowledged and acted upon in a Veterans Affairs ambulatory setting. Investigators discovered that their seemingly fail-proof system, which included dual-alert communications, still led to persistent problems with missed test results. They also found that the dual-alert communication system was unexpectedly associated with a lack of timely follow-up. The authors advocate for greater multidisciplinary approaches to address these breakdowns.
Failure to adequately follow up on test results is a known problem after hospital discharge, in primary care settings, and within computerized systems. This study reviewed more than 5400 patient medical records from 19 community-based and 4 academic primary care practices and discovered a 7.1% rate of failure to inform (or document informing). Interestingly, investigators found that partial electronic health records (EHRs), with a mix of paper and electronic systems, were associated with higher failure rates than those practices without an EHR or with a complete EHR. Variations in failure rates among practices, ranging from 0% to 26%, suggest that best practices can make a significant difference. A past AHRQ WebM&M commentary discussed the impact of delayed notification for a test result following hospital discharge.
Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care.
El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-8.
Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.
Ferris TG, Johnson SA, Co JPT, et al. Pediatrics. 2009;123 Suppl 2:S85-91.
Implementation of information technology solutions for following up on test results improved reliability and provider satisfaction. However, clinics that only partially implemented such systems reported decreased efficiency and greater concern about patient safety issues.
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
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