Benjamin H. Levi

Reporting Medical Errors to Improve Patient Safety: A Survey of Physicians in Teaching Hospitals

BACKGROUND Collecting data on medical errors is essential for improving patient safety, but factors affecting error reporting by physicians are poorly understood. METHODS Survey of faculty and resident physicians in the midwest, mid-Atlantic, and northeast regions of the United States to investigate reporting of actual errors, likelihood of reporting hypothetical errors, attitudes toward reporting errors, and demographic factors. RESULTS Responses were received from 338 participants (response rate, 74.0%). Most respondents agreed that reporting errors improves the quality of care for future patients (84.3%) and would likely report a hypothetical error resulting in minor (73%) or major (92%) harm to a patient. However, only 17.8% of respondents had reported an actual minor error (resulting in prolonged treatment or discomfort), and only 3.8% had reported an actual major error (resulting in disability or death). Moreover, 16.9% acknowledged not reporting an actual minor error, and 3.8% acknowledged not reporting an actual major error. Only 54.8% of respondents knew how to report errors, and only 39.5% knew what kind of errors to report. Multivariate analyses of answers to hypothetical vignettes showed that willingness to report was positively associated with believing that reporting improves the quality of care, knowing how to report errors, believing in forgiveness, and being a faculty physician (vs a resident). CONCLUSION Most faculty and resident physicians are inclined to report harm-causing hypothetical errors, but only a minority have actually reported an error.

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

BACKGROUNDDisclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood.OBJECTIVETo survey physicians and trainees about their practices and attitudes regarding error disclosure to patients.DESIGN AND PARTICIPANTSSurvey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States.MEASUREMENTSActual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors.RESULTSResponses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost.CONCLUSIONSThere appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.

Too Soon to Give Up: Re-examining the Value of Advance Directives

In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future, translates an individuals values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning.

Development of an interactive computer program for advance care planning

Objective  To describe the development of an innovative, multi‐media decision aid for advance care planning.

Do faculty and resident physicians discuss their medical errors

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues. Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables. Results: Responses were received from 338 participants (response rate  = 74%). In all, 73% of respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision (91%), wanting colleagues to learn from the mistake (80%) and wanting to receive support (79%). Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm (77%), minor harm (87%) or major harm (94%). Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion (OR 4.17, CI 2.34 to 7.42). Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners.

Child Abuse Experts Disagree About the Threshold for Mandated Reporting

Context: Though reasonable suspicion serves as the standard threshold for when to report suspected child abuse, there is little guidance how to interpret the term. Objective: To examine how experts on child abuse interpret reasonable suspicion using 2 probability frameworks. Participants: Anonymous survey of clinical and research experts on child abuse. Main outcome measures: Responses on ordinal and visual analog scales quantifying the probability needed for “suspicion of child abuse” to rise to reasonable suspicion. Results: A total of 81 of 117 experts completed the survey (69% response rate, mean age 47 years, 69% female). On both the ordinal probability scale (rank order on a differential diagnosis) and the estimated probability scale (1% to 99% likelihood), experts demonstrated wide variability in defining reasonable suspicion, with no statistically significant differences found for age, race, gender, professional training, seniority, or prior education on reasonable suspicion. Conclusions: This study found no consensus in how experts on child abuse interpret reasonable suspicion.

What Influences Individuals to Engage in Advance Care Planning

Background: Advance care planning (ACP) is an underutilized process that involves thinking about what kind of life-prolonging medical care one would want should the need arise, identifying a spokesperson, and then communicating these wishes. Objective: To better understand what influences individuals to engage in ACP. Design: Three focus groups using semistructured interactive interviews were conducted with 23 older individuals from 3 diverse populations in central Pennsylvania. Results: Four categories of influences for engaging in ACP were identified: (1) concern for self; (2) concern for others; (3) expectations about the impact of ACP; and (4) anecdotes, stories, and experiences. Conclusions: The motivations for undertaking ACP that we have identified offer health care providers insight into effective strategies for facilitating the process of ACP with their patients.

Trauma-induced heterotopic bone formation and the role of the immune system: A review.

ABSTRACT Extremity trauma, spinal cord injuries, head injuries, and burn injuries place patients at high risk of pathologic extraskeletal bone formation. This heterotopic bone causes severe pain, deformities, and joint contractures. The immune system has been increasingly implicated in this debilitating condition. This review summarizes the various roles immune cells and inflammation play in the formation of ectopic bone and highlights potential areas of future investigation and treatment. Cell types in both the innate and adaptive immune system such as neutrophils, macrophages, mast cells, B cells, and T cells have all been implicated as having a role in ectopic bone formation through various mechanisms. Many of these cell types are promising areas of therapeutic investigation for potential treatment. The immune system has also been known to also influence osteoclastogenesis, which is heavily involved in ectopic bone formation. Chronic inflammation is also known to have an inhibitory role in the formation of ectopic bone, whereas acute inflammation is necessary for ectopic bone formation.

Advance care planning for patients with ALS: Feasibility of an interactive computer program

Abstract This pilot study examined whether an interactive, computer based decision aid can help patients with amyotrophic lateral sclerosis (ALS) engage in effective advance care planning. Individuals being treated for ALS (>18 years old, English speaking, and without dementia) were recruited to use a decision aid and complete pre-/post-intervention measures. Seventeen individuals completed the pre-intervention questionnaires and decision aid; 16/17 (94%) completed the post-intervention measures, and none reported any burden from the intervention. ‘Overall satisfaction’ with the decision aid was very high (mean = 8.5 ± 0.27: 1 = not at all satisfied, 10 = extremely satisfied), as was ‘perceived accuracy’ of the computer generated advance directive in reflecting patients’ wishes (mean = 8.6 ± 0.27: 1 = not at all accurate, 10 = extremely accurate). Participants judged the ‘amount of information’ provided by the intervention appropriate (mean = 6.8 ± 0.38: 1 = too little, 5 = about right, 10 = too much), and on a detailed, 12-item assessment judged the decision aid very positively (mean = 4.16 ± 0.16: 1 = very dissatisfied, 5 = very satisfied). The intervention prompted many participants to discuss advance care planning with loved ones and to share their computer generated advance directive with their physician. This study demonstrates that individuals with ALS can successfully complete a computer based decision aid for advance care planning, and suggests that this intervention can help promote effective advance care planning.

The profit motive and spine surgery

Study Design. The profit motive and market medicine have had a significant impact on clinical practice and research in the field of spine surgery. An overview of current concerns is presented. Objective. The objective of this study was to provide those involved in the study and treatment of spinal disorders with a critical overview of the effects of the profit motive on our practices. Summary of Background Data. Historically, the profit motive has been viewed as eroding the standards of spine surgery, encouraging surgeons to operate aggressively and researchers to bias their results. Although there are legitimate concerns regarding the role played by such market forces, the profit motive exerts several quite positive effects on spine surgery as well. Methods. Negative and positive aspects of the profit motive in spine surgery are explored along with alternative approaches. Results. The profit motive in spine surgery can result in unnecessary surgery, as well as the push to market of unproven technologies. Yet, without a robust profit motive, it is unclear where sufficient funding could be found to support research and education, and to underwrite the advancement of new technologies. Conclusions. The profit motive significantly influences the way we practice and conduct research in spine surgery. To minimize the negative aspects of the profit motive, spine surgeons and researchers must refrain from being used by companies to rush products to market and/or compromising patient care out of self-interest.