Amy J. Markowitz

Learning from our mistakes: Quality grand rounds, a new case-based series on medical errors and patient safety

The case presentation has long been revered as an educational tool for physicians. Beginning early in medical school, many students eagerly devour the case presentations (often called clinical-pathologic conferences, or CPCs) in major medical journals, admiring both the marvelous complexity of the clinical details and the virtuoso performances of the invited discussants (1). Over the past 20 years, the case presentation and discussion method has become more varied and nuanced. In clinical problem-solving exercises, cases were presented to expert discussants in aliquots, giving learners a chance to observe the experts reasoning process (2). This format, as well as the incorporation of patients and providers perspectives into case protocols in two recent series (3, 4), has expanded the scope and utility of case presentations in medical education. These changes dovetailed nicely with a trend in many medical schools to replace lectures with case-based learning (5). Case-based learning can be tremendously instructive and stimulating but can also carry a subtle educational threat. By emphasizing the great case (usually the more unusual and complex the case, the better) and the remarkable reasoning abilities of the master clinician, learners may assimilate the seductive but unrealistic message that a physicians individual knowledge and skill play the dominant role in determining patient outcomes. The patient safety corollary to this message is that poor outcomes primarily reflect deficiencies in the physicians knowledge base or cognitive and technical abilities. This unrealistic expectation of perfection undoubtedly contributes to physicians traditional reluctance to discuss errors (6) and tends to distort these discussions when they do occur, such as in the morbidity and mortality (M&M) conferences held in many hospitals. Although designed to provide a setting in which mistakes can be discussed openly and honestly, most M&M conferences follow one of two paths, neither of which optimally promotes the goal of learning from errors. The conference either gradually but inexorably mutates into a CPC-like great case conference, or an error is presented followed by the excoriation of an individual physician for his or her failings (more common in the surgical specialties and popularized by many television and movie productions). As our understanding of patient safety and error reduction has matured, we now realize that, although the M&M-cum-CPC conference simply sidesteps the consideration of errors, the find-and-punish-the-bad-apple approach may be equally unproductive in efforts to decrease errors that harm patients (7, 8). Catalyzed by the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System, the medical system recently began to respond to the tremendous public outrage over medical errors (9). Many of the responses focused on reporting systems and other methods of gathering data about the problem (10, 11). Several important articles, monographs, and books highlighted some of the key issues in patient safety and the conceptual underpinnings of quality improvement, often drawn from industries unrelated to health care, such as aviation and nuclear power (12, 13). However, for reasons that include liability issues and a medical culture that has discouraged open discussion of mistakes, the power of the individual case presentation, so important in the physicians clinical medicine education, has not been harnessed to educate providers about medical errors. In this issue, Annals launches a new series, Quality Grand Rounds. In it, we present articles and companion conferences in a format similar to that of clinical problem-solving cases. Each article describes an actual case involving a medical error or quality issue but does not identify the patient, providers, or institution. Although much of the case material is clinical (that is, drawn from the medical record), in a few cases, the involved institutions allowed us (the series editors) to observe their internal fact-finding and problem-solving process, known as root-cause analysis. In addition, we often interviewed key participants (including the patient, doctor, nurse, or risk manager) to be sure we could convey a full understanding of the events. Parts of these interviews are included in several of the case presentations in Annals, and additional information can be found accompanying the on-line version of the articles. Each case was presented to the discussants in a conference format (Quality Grand Rounds), and the manuscripts were revised to reflect the issues raised at the conferencesincluding those discussed during the question-and-answer sessions. In contrast to traditional CPCs, in which the discussant focuses on diagnosing the disease based on the patients presenting symptoms, the focus in Quality Grand Rounds is on diagnosing the systems problems that led to a serious error or adverse outcome for the patient. Our discussants, who are national experts in the relevant patient safety and quality issues, help the reader understand the cause of the errors, frame them in the context of what we know about patient safety, and suggest ways of decreasing the risk to future patients of similar errors. Throughout the series, discussants emphasize not only individual errors but also system failings that allowed the inevitable human fallibility to reach the patient and cause harm (13-15). For example, in this issues The Wrong Patient, Drs. Chassin and Becher describe the 17 errors that came together to allow one patient to receive an invasive procedure intended for another (16). Although neither the authors nor the other discussants in the series deny or sugarcoat the individual errors, they identify the failure or absence of systems to catch patient misidentifications and a cultural milieu that provides rich soil for system problems and individual mishaps to blossom into errors. Throughout the series, readers will be introduced to patient safety concepts, such as systems thinking, the culture of safety, root-cause analysis, and human-factors engineering, as well as to controversies in the field, including the central question, What is an error?. This series, which will appear in every three to four issues of Annals, is supported by the California HealthCare Foundation as part of its Quality Initiative. We are also grateful to our consulting editor, Kathy Dracup, RN, DNSc; our discussants; and our conference audiences for their participation and interest. The Annals Editorsparticularly Drs. Harold Sox, Cynthia Mulrow, David Goldmann, and Frank Davidoffhave been unstinting supporters of this effort, demonstrating their commitment to educating physicians and trainees about quality and patient safety. Our largest debt, of course, is owed to the patients, family members, providers, and institutions that shared their stories with us. Almost to a person, participants told us that they did so in the hope that their tale would help prevent errors from harming other patients. Perhaps surprisingly, they reflected on their experiences with equanimity and even a sense of humor. For instance, the patient described in this issue, who underwent an unneeded invasive cardiac procedure because her name was similar to that of the intended patient, not only emphasized her desire to protect others but went on to say, I was glad that my heart checked out OK. We hope that Quality Grand Rounds does justice to this extraordinary spirit of generosity and makes a difference in promoting the systems and cultural changes needed to make health care safer.

Quality Grand Rounds: The Case for Patient Safety

In this issue, we present the 13th and final article in the Quality Grand Rounds series, the case of an elderly woman admitted to a teaching hospital early in the academic year with a mild episode of acute pancreatitis (1). Despite initial improvement, her condition deteriorated over the course of several days; her ultimate death was attributable to delayed diagnosis and management of a small-bowel obstruction. The case highlights problems in resident supervision, fumbled handoffs, adverse consequences of housestaff duty-hour limitations, and deficient safety systems. As with many cases of medical errors, the explanation is messy and multifaceted, resisting a clean, simple fix. The case stands as a fitting bookend to the entire Quality Grand Rounds series. Our first case, The Wrong Patient, described a woman who received an invasive electrophysiology procedure intended for a patient with a similar last name (2). In their discussion of that case, Chassin and Becher identified 17 individual mistakes, none remarkable or difficult to understand in isolation. Together, they provided the necessary ingredients for a breathtaking error. In between, we have published 11 other cases that illustrate the breadth of the patient safety field (313). Some casesa patient dies after a nurse mistakenly flushes an intravenous line with insulin instead of heparin, another dies of an air embolism after incorrect removal of a central catheterbeg for such systems fixes as computerized physician order entry, bar coding, checklists, readbacks, and competency-based credentialing (3, 10). Other casesa patients hospitalization from hell, for example (6)demonstrate that safe systems need to be accompanied by an institutional culture that prizes safety and quality. In fact, 7 years after the Institute of Medicines report To Err Is Human catalyzed the modern patient safety movement (14), we have come to recognize that the solutions to medical errors must be as distinct as the problems themselves. It is no longer sufficient for researchers to simply demonstrate that a targeted intervention (for example, computerized physician order entry, teamwork training, higher nurse-to-patient ratios, or housestaff duty-hour limits) leads to improved safety. To be useful to decision makers in a specific institution, studies should help them to choose among the many potentially effective interventions in the face of limited resources, the quirks of a specific clinical environment, and a finite institutional capacity for change. Efforts to use evidence to help inform these prioritization decisions are in their infancy (15). In addition to the challenge of helping institutions to choose among several effective safety interventions, the safety field has begun to appreciate the frequency of unintended consequences of safety interventions. Both the case in this issue and our penultimate case (in which a bar-coded wristband identification system backfired when 2 patients wristbands got mixed up [13]) demonstrate that even easy fixes like housestaff duty-hour limitations and bar coding may cause unforeseen problems as they migrate from theory to widespread application. Several recent articles describing the negative consequences of computerized physician order entry amplify the same theme (1618). As the patient safety field matures, these unanticipated effects should no longer surprise us. Initial studies are often conducted by investigators who are passionate about a given practice, take place in relatively controlled settings, and have unusually robust funding and experienced support personnel (19). Although subsequent, more real-world studies with negative findings are often critiqued as simply illustrating problems with implementation (20), they may more accurately reflect the efficacy of the practices under natural conditions. Accordingly, we ignore them at our own, and our patients, peril. As Shojania and colleagues point out, the solution to these unforeseen consequences is not to eschew innovation for fear of the problems it may bring (1). Rather, it is to take promising technologies and practices, often drawn from other industries, and adapt them to the health care setting, maintaining vigilance to identify these problems if they exist (21). Even as the cases in the Quality Grand Rounds series illustrated the range and complexity of medical errors, we aimed for them to be a play within a play, demonstrating the unique power and drama of the case presentation as a patient safety teaching tool. Although one can readily comprehend the value of quality measurement for simple processes with demonstrated beneficial outcomes (such as the use of aspirin or -blockers in patients with acute myocardial infarction), no measurement system can capture the richness and nuance of a complex case of medical error. For example, even a relatively detailed chart review of the case discussed by Shojania and colleagues might have revealed an elderly patient who died after being admitted to the hospital for pancreatitis. Furthermore, because the patient did not want heroic measures, her death was peaceful and, for all but a clinically sophisticated reviewer, not entirely unexpected. Yet the analysis of the case demonstrates myriad errors and opportunities for improvement, with a drama and narrative drive that a blackboard full of failure mode and effects analyses (FMEAs) could not possibly match. Such casesand their powerful messageswill come to light only if clinicians feel comfortable bringing them forward. We hope that the series has illustrated the importance of providing safe venues for open, honest discussions of medical errors. (Parenthetically, in several years of publishing anonymous cases of medical errors in Annals, in a popular book [22], and in a federally sponsored Web-based journal [AHRQ WebM&M], we have not had a single uncomfortable inquiry from a journalist or an attorney. We believe that concerns about legal discovery of case discussions in public venues are often overblown.) The recently passed patient safety legislation (which calls for federally sanctioned Patient Safety Organizations that will protect storytelling and data sharing from legal discovery [23]) represents a positive step in the effort to facilitate unencumbered discussions of medical errors. We end the series with profound thanks to the many physicians, nurses, pharmacists, administrators, and patients who shared their stories with us in the hope that doing so might prevent another error. We are grateful to Annals for hosting the Quality Grand Rounds series and to the California HealthCare Foundation for its generous support. Although the series has concluded, we plan to publish a book containing the cases and additional commentary, which may serve as an ongoing resource for the field. We hope that the cases have not only been useful for their specific content but also that they have encouraged institutions and providers to share their own cases in a new way, using them to sow the seeds of systems and culture changes to ensure that patients receive safe, high-quality care.

Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study

Key Points Question Do patients with mild traumatic brain injury (mTBI) receive adequate levels of follow-up care? Findings In a cohort study using data on 831 patients with mTBI presenting to the emergency department at 1 of 11 level I trauma centers across the United States, 42% of patients reported receiving educational material at discharge and 44% reported seeing a physician or other medical practitioner within 3 months after injury. Among patients with 3 or more moderate to severe postconcussive symptoms, only 52% reported having seen a practitioner within 3 months following the injury. Meaning A large proportion of patients with mTBI do not receive follow-up care after injury even when they experience ongoing postconcussive symptoms.

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.