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Physicians
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Annual Perspective

Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research, through findings on clinician bias, technological tools, current initiatives directed at improving health equity, and in clinical areas such as obstetrics.

Delay in Malignancy Diagnosis Reflects Systemic Failures
Hang Mieu Ha, DO and Kristin Alexis Olson, MD,  

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation. However, this procedure was followed by a series of events that increased the likelihood for harm, including the inability to provide a definitive diagnosis at the time of frozen section examination, the subsequent delayed diagnosis, lack of cross coverage for leave among care team members, and poor communication and handoffs.

Walking Out of a Hospital After Attempted Suicide
Commentary by James A. Bourgeois, OD, MD and Glen Xiong, MD ,  

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring. He eloped, then further complications resulted when law enforcement personnel were involved in his psychiatric emergency and when correctional mental health services were not available in a timely manner. The commentary discusses the importance of assessing for hypoxia-associated delirium and/or hippocampal damage/amnesia after any strangulation and the need for inpatient psychiatric hospitalization after emergency stabilization and management of delirium

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.
Spotlight Case
CE/MOC
Theresa Duong, MD, Noelle Boctor, MD, and James Bourgeois, OD, MD,  

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion. The treating team had planned to wean the infusion; however, the following day, the patient was noted to be obtunded on a high dose of dexmedetomidine. He remained somnolent for two additional days and subsequently developed aspiration pneumonia and Clostridioides difficile colitis, which further prolonged his hospital stay and strained relationships among the patient's family, the nursing staff and medical team. The commentary reviews the medications commonly used to treat alcohol withdrawal and the risks associated with these medications, the use of standardized medication order sets for continuous weight-based infusions within the intensive care unit, and ways to minimize clinician bias in assessing and treating substance use disorders.

Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.
Sean Flynn, MD and David K. Barnes, MD, FACEP,  

A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED. She was discharged to home with a diagnosis of constipation, dehydration and failure to thrive and planned follow-up with her primary care provider. Three days later, she was admitted to a second hospital and the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon with disseminated fecal and purulent material. Despite aggressive surgical and postoperative care, she expired from sepsis ten days later. The commentary summarizes the diagnosis and management of stercoral colitis and the importance of prompt identification of bandemia, which should trigger further investigation for an underlying infection.

Summary

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis. Studies have found that the average duration of time from first symptom recognition to diagnosis, and finally to the initiation of lung cancer treatment is more than 4 ½ months.3 Research has found that even a four-week delay in cancer treatment is associated with increased mortality.4 Failure to recognize an abnormal test result creates missed treatment opportunities and is associated with higher healthcare costs.5

There are health disparities in cancer mortality rates and shorter survival times associated with race and socioeconomic status.6,7,8,9 In radiology, social determinants of health lead to the disparate use of imaging services, which can delay diagnosis and treatment.10 A study in Michigan found that patients at the greatest risk of late-stage cancer diagnosis and death were patients under 65 who were insured by Medicaid.11

To address these concerns, this Ambulatory Safety Net (ASN) innovation built on the work done by Kaiser Permanente Southern California, which developed the notion of a safety net in ambulatory settings.12 “Safety net” is defined many ways in healthcare settings, but a literature review on the topic developed a collective definition: “A consultation technique to communicate uncertainty, provide patient information on the red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient’s condition.”13 Furthermore, safety nets are developed in hospitals mainly through inpatient settings. The Brigham and Women’s Hospital’s (BWH) Patient Safety Collaborative, which included Ambulatory Patient Safety, Radiology Quality and Safety, and the Center for Evidence-Based Imaging (CEBI) teams, identified a gap and need for a safety net in their ambulatory care setting. This collaborative defined an ambulatory care setting as any outpatient setting or any place where a same-day procedure can be conducted, or any medical service that can be performed in a hospital that does not require hospital admission.14

Starting in 2017, the BWH Patient Safety Collaborative began to brainstorm ideas to prevent missed and delayed cancer diagnoses. Specifically, they investigated radiologist follow-up recommendations and colonoscopy test follow-up after abnormal test results to design a lung cancer safety net and a colon cancer safety net.1 The ASN was constructed for colon cancer by creating a quality metric to track the percentages of patients over time who were scheduled for or completed a colonoscopy following safety net outreach to the patient.1 After a test result was flagged, an outreach worker would contact the patient to ensure follow-up tests were scheduled.1 The quality metric for the lung cancer ASN was the proportion of patients with a scheduled or completed chest computed tomography (CT) scan after appropriate follow-up.1

Innovation Patient Safety Focus

The lack of necessary clinical follow-up after a key cancer screening or imaging test can delay diagnosis and treatment. In addition to the failure to follow up, the failure to recognize an abnormal test result creates missed treatment opportunities and is associated with higher healthcare costs.5 The impetus for the innovation stemmed from a patient experience of a preventable, serious adverse event at BWH. The event, which BWH researchers believe was in alignment with current national standards of care, was evaluated through a Collaborative Case Review.15 This review illuminated substantial opportunities within the existing systems of care. This patient case influenced much of the work. The hospital espouses an equity-informed high-reliability organizational framework; therefore, hospital leadership aspired to reduce the risk of similar events in the future. The chain of events leading to patient harm and the resulting commitment has built steady and staunch support for this project in all iterations moving forward.

Evidence Rating

Resources Used and Skills Needed

  • Leadership buy-in and support for ambulatory patient safety
  • Buy-in from a multidisciplinary stakeholder team
  • An equity-informed, highly reliable organizational framework
  • Subject matter expertise interpreting imaging exams, such as x-rays or CT scans, and performing colonoscopies
  • Workflow redesign
  • Information technology registries, tools, and analytic capabilities to track each clinically necessary recommendation to resolution and to evaluate progress, impact, and demonstrate value to sustain the innovation

Use By Other Organizations

Currently, this ASN innovation has been adapted and is being implemented across the Mass General Brigham system, which includes two academic medical centers, seven community hospitals, and three specialty care hospitals, as well as numerous ambulatory care and outpatient imaging centers.

Developing Organizations

Date First Implemented

2017
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