Amy N. Ship

Confidential Clinician‐reported Surveillance of Adverse Events Among Medical Inpatients

BACKGROUND: Although iatrogenic injury poses a significant risk to hospitalized patients, detection of adverse events (AEs) is costly and difficult.METHODS: The authors developed a confidential reporting method for detecting AEs on a medicine unit of a teaching hospital. Adverse events were defined as patient injuries. Potential adverse events (PAEs) represented errors that could have, but did not result in harm. Investigators interviewed house officers during morning rounds and by e-mail, asking them to identify obstacles to high quality care and iatrogenic injuries. They compared house officer reports with hospital incident reports and patients’ medical records. A multivariate regression model identified correlates of reporting.RESULTS: One hundred ten events occurred, affecting 84 patients. Queries by e-mail (incidence rate ratio [IRR]=0.16; 95% confidence interval [95% CI], 0.05 to 0.49) and on days when house officers rotated to a new service (IRR=0.12; 95% CI, 0.02 to 0.91) resulted in fewer reports. The most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform at test (12.7%). Respondents identified 29 (26.4%) AEs, 52 (47.3%) PAEs, and 29 (26.4%) other house officer-identified quality problems. An AE occurred in 2.6% of admissions. The hospital incident reporting system detected only one house officer-reported event. Chart review corroborated 72.9% of events.CONCLUSIONS: House officers detect many AEs among inpatients. Confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality.

A Physician-based Voluntary Reporting System for Adverse Events and Medical Errors

AbstractOBJECTIVE: To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients. DESIGN: Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers’ reports with hospital incident reports and conducted a retrospective chart review. SETTING: The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital. INTERVENTION: Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds. MEASUREMENTS AND MAIN RESULTS: Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis. CONCLUSIONS: A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians.

The Most Primary of Care — Talking about Driving and Distraction

Current data suggest that each year, at least 1.6 million traffic accidents (28% of all crashes) in the United States are caused by drivers talking on cell phones or texting. Dr. Amy Ship urges physicians to ask patients about driving and distraction.

Accuracy of physician prognosis in heart failure and lung cancer: Comparison between physician estimates and model predicted survival.

Background: Anticipating adverse outcomes guides decisions but can be particularly challenging in heart failure. Aim: We sought to assess the accuracy and comfort of physicians in predicting prognosis in heart failure. Design: Cross-sectional survey Participants/setting: Faculty and trainees in internal medicine, cardiology, and oncology estimated survival for three standardized patients: (1) 59-year-old patient with stage IV lung cancer; (2) 79-year-old woman with New York Heart Association class 4 heart failure symptoms and preserved ejection fraction; and (3) 40-year-old man with New York Heart Association class 3 heart failure symptoms and reduced ejection fraction of 20%. Survival predictions were derived from surveillance, epidemiology, and end results-Medicare database and the Seattle Heart Failure Model. Accuracy was defined as <2-fold difference between the clinician and model estimate. Results: Totally, 79% (338/427) of participants responded. Physicians were more accurate in survival estimates for lung cancer than heart failure (74% vs 48%, respectively; p < 0.001). Cardiologists were more accurate in predicting survival in heart failure symptoms and reduced ejection fraction compared to generalists (67% vs 45%; p = 0.005) and oncologists (39%; p = 0.041) but no different at predicting heart failure symptoms and preserved ejection fraction. Cardiologists predicted longer survival in heart failure compared to others (p < 0.05). Physicians felt more uncomfortable discussing palliative care with heart failure patients compared to lung cancer. Conclusions: Less than half of physicians accurately estimate survival in heart failure. Cardiologists were more accurate than other specialties for heart failure symptoms and reduced ejection fraction but no different for heart failure symptoms and preserved ejection fraction.

Clinically relevant correlates of accurate perception of patients' thoughts and feelings.

The goal was to explore the clinical relevance of accurate understanding of patients’ thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients’ Affect, or TAPPA). Participants’ accuracy scores were then correlated with participants’ attitudes toward patient-centered care, clinical course background, recall of clinical conversation, evaluations of clinical performance made by preceptors, evaluations of interpersonal skill made by standardized patients in clinical encounters, and independent coding of behavior in a clinical encounter. Accuracy in understanding patients’ thoughts and feelings was significantly correlated with nursing students’ clinical course experience, clinicians’ favorable attitudes to psychosocial discussion, standardized patients’ evaluations of medical students’ interpersonal skill, independent coding of medical students’ patient-centered behavior while taking a social history, and undergraduates’ more accurate recall of what an actor-physician said on video. Accuracy in perceiving patients’ thoughts and feelings can be objectively measured and is a skill relevant to clinical performance.

Communicate, don't litigate: The Schwartz Center Connections Program

Little is known about effective educational approaches intended to reduce malpractice risk by improving communication with patients and among multidisciplinary teams in outpatient settings in order to prevent diagnostic delays and errors. This article discusses a prospective, controlled educational intervention that aimed to open lines of communication among teams in two disciplines: identifying how and why communication lapses occur between disciplines and with patients, and articulating strategies to avert them.

PHYSICIAN ESTIMATES OF PROGNOSIS IN HEART FAILURE

Anticipating adverse outcomes guides timely decisions, helping patients plan, but can be challenging in heart failure (HF). All faculty and trainees in internal medicine and cardiology at our institution were surveyed about palliative care and asked to estimate survival for standardized patients: 1

“Thinking Time”: Doctor Envies Curlers

U ntil I sat down to watch the Olympics this winter, I hadn’t heard of curling. When I surveyed the Internet, I was surprised to learn that each curling team is allocated a certain amount of official BThinking Time^—to confer, to look at the options, to consider their strategy. And all this is in order to aim a granite rock down an icy path where the stakes are low; the worst that can happen is losing the game. I’m jealous. As a seasoned primary care doctor, I’m acutely aware that my profession provides no such time, despite the fact that primary care is fundamentally an intellectual field. Our Bprocedure^ is purely cognitive; our skill set is exactly that—thinking. And in healthcare, the stakes are high. Much has been written about the impossibly over-burdened primary care visit—the unwieldy and unattainable expectations to assess quality metrics, HEDIS measures, preventative care, medication reconciliation, updates on health, vaccinations, family history, and allergies—and then to make sure that all of this is documented in the electronic health record (EHR). Each of these issues has its own important basis, to be sure, but their collective weight has done more than threaten the foundation of the primary care visit; it has broken it. Overwhelmed clinicians cannot provide consistently meaningful care. Both caregivers and patients suffer. Burnout among caregivers is endemic. And patients experience not just the effects of medical errors, but the equally significant, unseen consequence of losing care—of knowing that their doctor has put together the unique pieces of their illness, of having been heard, of feeling compassion, of time. Thinking is essential to our work. And BThinking Time^ is effectively a pause—a moment to take a breath, to step back, to ponder. If BThinking Time^ were to be mandated for primary care clinicians just as other metrics, what might that look like? Clinicians would have an incentive to do that which is most important—time to listen, consider the patient, the presentation, and to focus on diagnostic reasoning. That time would reduce the frequency of cognitive errors we make, and diminish the number of unnecessary tests we order, saving not only money but also the possible downstream complications of these procedures. In 2008, The World Health Organization made a Btime out^ a component of their Universal Protocol for surgery. During this compulsory interval, members of the surgical team pause to review a checklist and confirm accurate patient identity, surgical site, and planned procedure. Just a decade later, it is difficult to imagine any medical procedure without this, and to consider the complications and errors that its absence engendered. Required BThinking Time^ should become the primary care equivalent of a procedural Btime out.^ Such a pause would be a sustaining locus of care for both caregiver and recipient. A requirement that the components of this BThinking Time^ be documented in the medical record would strengthen the cognitive portion that was once its sole domain. As it once did, it would allow students and trainees to observe the now invisible course of diagnostic reasoning, to learn how doctors think. When was I first in practice, requiring time to think would have seemed absurd; it was a given. And as a physician who bristles at all the current compulsory components of a visit, I am sad to find myself advocating to mandate yet another element. But the primary care appointment has been so thoroughly co-opted that its essential work has been made peripheral. A requirement is unfortunately necessary; what caregivers and patients need most must be put on a par with all the other visit metrics. Curling provides BThinking Time.^ Healthcare should too. An expected, obligatory BThinking Time^ would provide a pause, a cognitive caesura. In poetry, this is the break between lines. In music, it’s taking a breath. In both of these settings, the caesura gives meaning to the words or sounds that surround it. Primary care needs this caesura desperately; we need a scheduled time to breathe. This breath will resuscitate caregiver and patient alike, and literally inspire and enable us to return that which is primary to primary care.

Update: A 52-Year-Old Woman With Disabling Peripheral Neuropathy

Update: A 52-Year-Old Woman With Disabling Peripheral Neuropathy IN A CLINICAL CROSSROADS ARTICLE PUBLISHED IN OCTOber 2009, Seward B. Rutkove, MD, discussed peripheral neuropathy, reviewing its epidemiology, the issue of screening, and the treatment options available. The patient, Ms Q, was a 52-year-old registered nurse with diabetes who had experienced neuropathic symptoms including cramping, burning, and numbness in both lower extremities for 8 years. Ms Q had tried multiple medications without improvement. She found that topiramate and gabapentin were ineffective. At the time of the conference, Ms Q used lidocaine patches; duloxetine, 60 mg/d; oxycodone/ acetaminophen, 5 mg/325 mg as needed; and arnica cream. Dr Rutkove observed that much of Ms Q’s discomfort was due to cramping and recommended the addition of carbamazepine. He also recommended supplementing her regimen with 600 mg of -lipoic acid orally per day. He stressed that weight loss, lowered cholesterol levels, and improved control of her blood glucose and blood pressure would be beneficial to her long-term prognosis.

A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health

Kenneth Mukamal, MD, MPH, discussed the epidemiology of drinking in the United States, the effect of moderate alcohol intake, and the potential risks and benefits of alcohol consumption. The patient, Mr Q, was a 42-yearold man contemplating his use of alcohol after his primary care physician queried him about his alcohol intake. Mr Q was a social drinker and had read about the positive effects that limited alcohol intake could have on his health. Since that time, Mr Q made a decision to drink a glass of wine daily. After talking to his physician, Mr Q became concerned about the long-term effects of alcohol consumption and was at the crossroads of whether to continue drinking alcohol for health purposes. Dr Mukamal addressed several issues relevant to alcohol consumption in general. He stated that drinkers are disproportionately more likely to smoke and both exposures must be addressed simultaneously. Clinicians should always assess for binge drinking. He stated that there is no clear advantage to drinking red wine. Finally, Dr Mukamal recommended that discussions between patients and clinicians be individualized to help patients make complex and personal decisions regarding drinking. Dr Mukamal indicated that because Mr Q has a healthy lifestyle, the absolute benefit of his drinking alcohol is modest at best and unlikely to significantly alter his cardiovascular risk. In conclusion, if Mr Q believes alcohol intake is a desirable part of his lifestyle, he will have made a reasoned decision. MR Q Since our initial interview, I have been keeping healthy. I do not have any underlying issues with my health except for a fall I had in 2010, which caused a fracture in my leg. It has healed, and I have been well ever since. I am currently taking finasteride daily for my prostate. I am still drinking about 4 ounces of alcohol about 5 times a week. However, I have moved on to hard liquor, not just wine, and I do not consider this for health reasons anymore. I had a follow-up visit with my primary care physician and we considered the risks and benefits of drinking alcohol. After this discussion I came to the conclusion that I am at relatively low risk for negative side effects based on my current behavior, but I am not consuming alcohol for health reasons. I have not specifically changed my diet in any way since our interview but am actually a little more lenient with my food intake. After the conference and my follow-up with my primary care physician I feel good about my health.