Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Walker S, Mason A, Quan P, et al. Lancet. 2017;390:62-72.
The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.
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.
Murphy DR, Wu L, Thomas EJ, et al. J Clin Oncol. 2015;33:3560-7.
Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.
Young JQ, Ranji SR, Wachter RM, et al. Ann Intern Med. 2011;155:309-15.
The beginning of residency training for new interns has long been rumored to result in preventable harm for patients, a phenomenon known as the "July Effect" in the US and by the more macabre term "August killing season" in the UK. However, prior studies have reached conflicting conclusions about whether the "July Effect" truly exists. This systematic review of 39 studies provides the first comprehensive evidence that being hospitalized in July may actually be harmful, as a subset of larger and higher quality studies did find that mortality increased and efficiency of care decreased in association with new residents assuming their duties. Unfortunately, most studies included in the review had methodological flaws, meaning that the exact degree of harm could not be quantified.
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.
Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Jha AK, Chan DC, Ridgway AB, et al. Health Aff (Millwood). 2009;28:1475-1484.
The seminal Institute of Medicine report To Err Is Human estimated that preventable errors cost the US health care system more than $17 billion annually. Although hospitals themselves currently bear only a small proportion of these costs, payers are increasingly seeking to realign incentives to both improve safety and control costs. This study examined the costs associated with both preventable adverse events and redundant tests (duplicate tests ordered for the same patient by different physicians). The authors estimate that eliminating preventable adverse events (principally health care–associated infections) alone could save the US health system more than $16 billion annually, with an additional $8 billion in savings potentially achievable by eliminating redundant tests. The Centers for Medicare and Medicaid Services' policy eliminating reimbursement for certain preventable conditions is an attempt to address this issue. A companion article explains that the savings realized by this policy are likely to be minimal.
Attempts to reduce medication discrepancies in hospitalized patients have been hampered by a lack of proven medication reconciliation strategies. In this cluster-randomized trial, a previously described electronic medication list that required input from nurses, physicians, and pharmacists was implemented at two academic hospitals. The tool resulted in a significant reduction in potential adverse drug events at discharge. However, potential drug errors still occurred at a rate of one per patient even after implementation. The intervention was more successful at preventing medication discrepancies among high-risk patients. This study is one of the first randomized trials of a medication reconciliation intervention, and points the way toward identifying medication reconciliation tools that are widely applicable.
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.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-85.
Direct observation of teamwork during surgical procedures revealed that poor teamwork was associated with higher rates of postoperative complications and overall mortality, even after adjusting for preoperative risk. Though suboptimal teamwork is a recognized problem in the operating room, this study is one of the first to directly link team behavior to patient outcomes. One method of improving teamwork, crew resource management training, has been extensively evaluated in a variety of clinical settings. A near miss resulting from poor teamwork is illustrated in a recent AHRQ WebM&M commentary.
Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-53.
The 2003 regulations that mandated 80-hour work week restrictions have generated significant debate over their impact on patient safety, fatigue, and discontinuity in care. This prospective study examined the role of intern workload and discovered that increased responsibilities were associated with greater sleep loss, longer shift durations, and less participation in educational activities. Investigators also determined that overnight duties during the week and early in the academic year were most problematic, a situation that is likely to worsen in the face of further work hour reductions being proposed. The authors advocate for greater research into workload, concerted efforts to minimize the administrative tasks of trainees, and thoughtful policies that balance patient safety and resident education.
Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33:19-29.
Efforts to comply with resident work-hour restrictions have placed a significant burden on hospitals and training programs, particularly in addressing the impact of these restrictions on patient safety. This AHRQ-supported study provides a framework to address the scheduling practices that aim to minimize sleep deprivation, optimize teamwork, and promote patient safety. The authors share a number of case examples and discuss policy implications around developing evidence-based scheduling and systematic culture change. This study’s lead author, Dr. Christopher Landrigan, was featured in a past AHRQ WebM&M conversation that discussed the role of sleep deprivation in residency training and its effect on medical errors.
Horwitz LI, Kosiborod M, Lin Z, et al. Ann Intern Med. 2007;147:97-103.
The 2003 regulations reducing housestaff duty hours have been controversial. Although some research has shown fewer errors when housestaff worked shorter shifts, many commentators have raised concern about the potential for errors associated with more transfers of care between physicians. This study sought to directly examine the effect of duty hours limitations on clinical outcomes by comparing medical patients hospitalized on a resident service to patients on a non-teaching service before and after duty hour reduction. There was no detectable increase in adverse events among patients cared for by residents, and some outcomes improved (eg, potential medication errors). Another study in the same issue also found reduced inpatient mortality among medical (but not surgical) patients after implementation of duty hour limitations. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours likely improved residents' quality of life, but the effect on patients has been controversial. A prior review did not find evidence linking reduced work hours to improved patient safety. This study analyzed administrative data from 591 community hospitals before and after implementation of duty hours limitations to determine their effect on inpatient mortality. Mortality was reduced among medical patients in teaching hospitals (compared with non-teaching hospitals) after duty hour limitations came into effect, but no such changes were seen in surgical patients. Another study published in the same issue found improvements in some clinical outcomes among medical patients at a single teaching hospital. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-8.
This case study presents the events surrounding the death of a woman admitted to an academic medical center with pancreatitis. The discussion analyzes the sequence of errors that transpired from initial delays in diagnosis and treatment to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal). The authors also explore the common yet unresolved tension in teaching hospitals for attending physicians who must provide appropriate supervision of trainees while also allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. An accompanying editorial (available via the link below) by the series editors reflects on the experiences of producing the 13 articles in this collection, the patient safety movement in general, and the importance of sharing these stories as educational tools to drive improvement.
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.
Robins NS. New York NY: Delacorte Press; 1995. ISBN: 9780385308090.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
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