Alexander R. Carbo

Do Medical Inpatients Who Report Poor Service Quality Experience More Adverse Events and Medical Errors

Purpose:Service quality deficiencies are common in health care. However, little is known about the relationship between service quality and the occurrence of adverse events and medical errors. We hypothesized that patients who reported poor service quality were at increased risk of experiencing adverse events and medical errors. Subjects and Methods:Patients were interviewed during and after their admissions regarding problems experienced during the hospitalizations. We used this information to identify service quality deficiencies. We then performed a blinded, retrospective chart review to independently identify adverse events and errors. We used multivariable methods to analyze whether patients who reported service quality deficiencies (obtained by patient report) experienced any adverse event, close call, or low risk error (ascertained by chart review). Results:The 228 participants (mean age 63 years, 37% male) reported 183 service quality deficiencies. Of the 52 incidents identified on chart review, patients experienced 34 adverse events, 11 close calls, and 7 low risk errors. The presence of any service quality deficiency more than doubled the odds of any adverse event, close call, or low risk error (adjusted odds ratio = 2.5; 95% confidence interval = 1.2–5.4). Service quality deficiencies involving poor coordination of care (adjusted odds ratio = 4.4; 95% confidence interval = 1.4–14.0) were associated with the occurrence of adverse events and medical errors. Conclusions:Patient-reported service quality deficiencies were associated with adverse events and medical errors. Patients who report service quality incidents may help to identify patient safety hazards.

A Faculty Development Program to Train Tutors to Be Discussion Leaders Rather Than Facilitators

Purpose During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. Method During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students’ overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. Results In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. Conclusions The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam’s mean score.

Risk of Topical Anesthetic–Induced Methemoglobinemia: A 10-Year Retrospective Case-Control Study

IMPORTANCE Methemoglobinemia is a rare but serious disorder, defined as an increase in oxidized hemoglobin resulting in a reduction of oxygen-carrying capacity. Although methemoglobinemia is a known complication of topical anesthetic use, few data exist on the incidence of and risk factors for this potentially life-threatening disorder. OBJECTIVE To examine the incidence of and risk factors for procedure-related methemoglobinemia to identify patient populations at high risk for this complication. DESIGN AND SETTING Retrospective study in an academic research setting. PARTICIPANTS Medical records for all patients diagnosed as having methemoglobinemia during a 10-year period were reviewed. EXPOSURES All cases of methemoglobinemia that occurred after the following procedures were included in the analysis: bronchoscopy, nasogastric tube placement, esophagogastroduodenoscopy, transesophageal echocardiography, and endoscopic retrograde cholangiopancreatography. MAIN OUTCOMES AND MEASURES Comorbidities, demographics, concurrent laboratory values, and specific topical anesthetic used were recorded for all cases. Each case was compared with matched inpatient and outpatient cases. RESULTS In total, 33 cases of methemoglobinemia were identified during the 10-year period among 94,694 total procedures. The mean (SD) methemoglobin concentration was 32.0% (12.4%). The methemoglobinemia prevalence rates were 0.160% for bronchoscopy, 0.005% for esophagogastroduodenoscopy, 0.250% for transesophageal echocardiogram, and 0.030% for endoscopic retrograde cholangiopancreatography. Hospitalization at the time of the procedure was a major risk factor for the development of methemoglobinemia (0.14 cases per 10,000 outpatient procedures vs 13.7 cases per 10,000 inpatient procedures, P < .001). CONCLUSIONS AND RELEVANCE The overall prevalence of methemoglobinemia is low at 0.035%; however, an increased risk was seen in hospitalized patients and with benzocaine-based anesthetics. Given the potential severity of methemoglobinemia, the risks and benefits of the use of topical anesthetics should be carefully considered in inpatient populations.

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

Objectives Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and health-care utilization. Methods The researchers conducted a randomized, controlled clinical trial of MedCheck, an automated electronic message generated in a patient Internet portal. MedCheck asked intervention patients if they had filled a recent prescription and if they had experienced any problems with the medication. Patients’ responses were forwarded automatically to primary care physicians. The study enrolled 375 intervention patients and 363 controls. After 3 months, the investigators reviewed patients’ medical records and conducted telephone interviews to identify ADEs and to assess health-care utilization. Results Among the 375 intervention patients, 184 (49%) responded to at least 1 MedCheck message. Patients reported 52 unfilled prescriptions and 56 medication problems. Patients responded to 72% of messages within 1 day. There was no statistically significant difference between intervention and control groups in the rate of ADEs, preventable or ameliorable ADEs, serious ADEs, or in subjects’ health-care utilization. Conclusions Internet portals have the potential to enhance patient-physician communication. However, additional development is required to demonstrate that such interventions can improve medication safety or health-care utilization. ClinicalTrials.gov NCT00140504

Revitalizing pathology laboratories in a gastrointestinal pathophysiology course using multimedia and team-based learning techniques

In 2008, we changed the gastrointestinal pathology laboratories in a gastrointestinal pathophysiology course to a more interactive format using modified team-based learning techniques and multimedia presentations. The results were remarkably positive and can be used as a model for pathology laboratory improvement in any organ system. Over a two-year period, engaging and interactive pathology laboratories were designed. The initial restructuring of the laboratories included new case material, Digital Atlas of Video Education Project videos, animations and overlays. Subsequent changes included USMLE board-style quizzes at the beginning of each laboratory, with individual readiness assessment testing and group readiness assessment testing, incorporation of a clinician as a co-teacher and role playing for the student groups. Student responses for pathology laboratory contribution to learning improved significantly compared to baseline. Increased voluntary attendance at pathology laboratories was observed. Spontaneous student comments noted the positive impact of the laboratories on their learning. Pathology laboratory innovations, including modified team-based learning techniques with individual and group self-assessment quizzes, multimedia presentations, and paired teaching by a pathologist and clinical gastroenterologist led to improvement in student perceptions of pathology laboratory contributions to their learning and better pathology faculty evaluations. These changes can be universally applied to other pathology laboratories to improve student satisfaction.

The Ethics Liaison Program: building a moral community

Ethicists often struggle to maintain institution-wide awareness of and commitment to medical ethics. At Beth Israel Deaconess Medical Center (BIDMC), we created the Ethics Liaison Program to address that challenge by making ethics part of the moral culture of the institution. Liaisons represent clinical and non-clinical areas throughout the medical centre. The liaison has a four-part role: to spread awareness and understanding of Ethics Programs among their coworkers; share information regarding ethical dilemmas in their work area with the members of the Ethics Support Service; review ethics activities and needs within their area; and undertake ethics-related projects. This paper lists the notable attributes of the Ethics Liaison Program, and describes the purpose and structure of the programme, its advantages and the challenges to implementing it. The Ethics Liaison Program has helped to make ethics part of the everyday culture at BIDMC, and other medical centres might benefit from the establishment of similar programmes.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

https://www.journalofhospitalmedicine.com/jhospmed/article/175818/hospital-medicine/role-hospital-medicine-emergency-preparedness-framework

The “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Improve Advance Care Planning

BACKGROUND Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths. METHODS A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution. Survey responses were reviewed to identify cases that required further investigation. An iterative process of inductive coding was used to create a coding taxonomy to classify survey response free-text comments. RESULTS During the distribution period (September 25, 2015-December 28, 2015), 82 patients died, and 191 care team members were surveyed. Responses (138; 72.3% response rate) were collected through January 28, 2016. Based on the survey responses, 5 patients (6.1%) not identified by other review processes were investigated further, resulting in the identification of several important opportunities for improvement. The free-text comment analysis revealed themes around the importance of advance care planning in seriously ill patients, as well as evidence of the emotional and psychological strain on clinicians who care for patients who die. CONCLUSION Postdeath care team surveys can augment mortality review processes to improve the way hospitals learn from deaths. Free-text comments on such surveys provide information not otherwise identified during traditional mortality review processes, including the importance of advance care planning and the strain on clinicians whose patients die.