Donna M. Woods

Adverse Events and Preventable Adverse Events in Children

Context. Patient safety has been recognized as an important problem in health care. However, knowledge about adverse events and preventable adverse events in children is relatively limited. Objective. To describe the incidence and types of adverse events and preventable adverse events in children. Design. Analysis of pediatric hospitalizations in the Colorado and Utah Medical Practice Study, which involved a retrospective, 2-level (nurse and physician) medical record review of a population-based, representative sample of all pediatric hospital discharges. Main Measures. Adverse events were defined as an injury caused by medical management rather than disease processes that resulted in either prolonged hospitalization or disability at discharge. A preventable adverse event was defined as an avoidable adverse event based on currently available knowledge and accepted practices. Patients. 3719 discharged hospital patients, 0–20 years old, and 7528 nonelderly (21–65 years old) discharged adult patients in Colorado and Utah. Setting. All hospitals in Colorado and Utah. Results. Adverse events occurred in 1% of pediatric hospitalizations in Colorado and Utah; 0.6% were preventable. Preventable adverse events rates were 0.53% in neonates and infants (0–0.99 years), 0.22% in children 1–12 years of age, and 0.95% in adolescents 13–20 years of age, compared with a rate of 1.50% in nonelderly adults. Of preventable adverse event types, birth related (32.2%) and diagnostic related (30.4%) events were the most common and were significantly more common than surgically related preventable adverse events (3.5%). Conclusions. These data suggest that ∼70 000 children hospitalized in the United States experience an adverse event each year; 60% of these events may be preventable. The epidemiology of adverse events and preventable adverse events in children is different than in adults. To reduce the adverse events that occur in hospitalized children, research should focus on adolescent hospitalized patients, birth-related medical care, and diagnostics in pediatric medicine.

Ambulatory care adverse events and preventable adverse events leading to a hospital admission

Background: Most healthcare in the US is delivered in the ambulatory care setting, but the epidemiology of errors and adverse events in ambulatory care is understudied. Methods: Using the population-based data from the Colorado and Utah Medical Practices Study, we identified adverse events that occurred in an ambulatory care setting and led to hospital admission. Proportions with 95% CIs are reported. Results: We reviewed 14 700-hospital discharge records and found 587 adverse events of which 70 were ambulatory care adverse events (AAEs) and 31 were ambulatory care preventable adverse events (APAEs). When weighted to the general population, there were 2608 AAEs and 1296 (44.3%) APAEs in Colorado and Utah, USA, in 1992. APAEs occurred most commonly in physicians’ offices (43.1%, range 46.8–27.8), the emergency department (32.3%, 46.1–18.5) and at home (13.1%, 23.1–3.1). APAEs in day surgery were less common (7.1%, 13.6–0.6) but caused the greatest harm to patients. The types of APAEs were broadly distributed among missed or delayed diagnoses (36%, 50.2–21.8), surgery (24.1%, 36.7–11.5), non-surgical procedures (14.6%, 25.0–4.2), medication (13.1%, 23.1–3.1) and therapeutic events (12.3%, 22.0–2.6). Overall, 10% of the APAEs resulted in serious permanent injury or death. The proportion of APAEs that resulted in death was 31.8% for general internal medicine, 22.5% for family practice and 16.7% for emergency medicine. Conclusion: An estimated 75 000 hospitalisations per year are due to preventable adverse events that occur in outpatient settings in the US, resulting in 4839 serious permanent injuries and 2587 deaths.

Length of stay as an outcome in an era of managed care: An Empirical Study☆

Longer length of stay (LOS) in substance abuse treatment, a standard measure of treatment success, conflicts with pressures from managed care. To maintain LOS as an outcome, we identified, for four modalities, LOS categories such that program completion rates were relatively constant within category and differed among categories. We validated the cutoffs by showing that future utilization over a 2-year period by clients differed by category. Clients in the long-LOS category used the system in a way consistent with more successful treatment. Thus, rather than using increase in LOS as an outcome, one can use increase in the percentage of clients reaching the long-LOS category. Categories were developed and utilization analyzed for discharges from publicly funded Boston treatment programs between 1/92 and 12/94 from the following modalities: short-term residential (5,462 discharges), long-term residential (5,086 discharges), outpatient (13,656 discharges), and detox (19,965 discharges).

Anatomy of a patient safety event: a pediatric patient safety taxonomy

Background: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety. Methods: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators. Results: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy. Conclusions: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.

National Quality Measures for Child Mental Health Care: Background, Progress, and Next Steps

OBJECTIVE: To review recent health policies related to measuring child health care quality, the selection processes of national child health quality measures, the nationally recommended quality measures for child mental health care and their evidence strength, the progress made toward developing new measures, and early lessons learned from these national efforts. METHODS: Methods used included description of the selection process of child health care quality measures from 2 independent national initiatives, the recommended quality measures for child mental health care, and the strength of scientific evidence supporting them. RESULTS: Of the child health quality measures recommended or endorsed during these national initiatives, only 9 unique measures were related to child mental health. CONCLUSIONS: The development of new child mental health quality measures poses methodologic challenges that will require a paradigm shift to align research with its accelerated pace.

High-alert medications in the pediatric intensive care unit

Objective: To identify pediatric intensive care unit (PICU) clinicians’ perceptions of high-alert medications and to develop a PICU-specific, high-alert medications list. We hypothesize that a PICU-specific list will include medications not identified on the Institute for Safe Medications Practices list and that the high-alert medications identified will differ by PICU clinician type (physicians, nurses, pharmacists). Design: PICU-specific multisite, institution-based survey of clinicians’ perceptions of high-alert medications. Setting: The PICU in each of five institutions participating in the Chicago Pediatric Patient Safety Consortium. Subjects: Nurses, physicians, and pharmacists working in the PICU. Interventions: None. Measurements and Main Results: PICU clinicians identified their top ten high-alert medications and their perceptions of each medication’s risks and frequency of misuse. Weighted responses were calculated and compared to the Institute for Safe Medications Practices list and by clinician type. Results are based on 112 surveys collected from 56 nurses (response rate: 29%), 26 physicians (79%), and 30 pharmacists (71%), with 90 different medications or medication classes named. The top high-alert medications identified included intravenous potassium (weighted response: 72%), heparin (63%), and insulin (48%). PICU-specific high-alert medications (e.g., calcium [27%], phenytoin [21%], aminoglycosides [15%]) were not reported on the Institute for Safe Medications Practices list. Nurses more often cited medications with administration error risk (e.g., adenosine, calcium, p < 0.01), while physicians reported those with narrow therapeutic windows (e.g., aminoglycosides, diuretics, p < 0.01), and pharmacists identified medications with both administration and narrow therapeutic window risks (e.g., insulin, digoxin, p < 0.01). Clinicians perceived the frequency of risk of misuse of the most common high-alert medications to be at least once a year. Conclusions: PICU clinicians identified high-alert medications not identified on the Institute for Safe Medications Practices list. Risks of the identified high-alert medications were attributed to a wide range of different stages in the medication process as well as clinicians’ varying experiences in the medication process.

The Patient Centered Medical Home as Curricular Model: Perceived Impact of the “Education-Centered Medical Home”

BackgroundThe patient-centered medical home (PCMH) model aims to provide patient-centered care, lower costs, and improve health outcomes. Medical students have not been meaningfully integrated in this model.AimTo test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives.SettingTwo community-based family medicine clinics, one academic internal medicine clinic, and one pediatric clinic affiliated with an urban medical school.Participants56 medical student volunteers.Program DescriptionWe embedded student teams in existing faculty practices and recruited a high-risk patient panel for each team. Clinical education occurred through a traditional clinic preceptor model and was augmented by 3rd and 4th year students directly observing 1st and 2nd year students. Didactic content included monthly Grand Rounds conferences.Program EvaluationStudents attended 699 clinics, recruited 273 continuity patients, and participated in 9 Grand Rounds conferences. Student confidence with PCMH principles increased and attitudes regarding continuity were highly positive. “Continuity,” “early clinical exposure,” and “peer teaching” were the most powerful themes expressed by students. Faculty response to the pilot was highly positive.DiscussionAn Education-Centered Medical Home (ECMH) is feasible and is highly rated by students and faculty. Expansion of this model is underway.

Joy and Challenges in Improving Chronic Illness Care: Capturing Daily Experiences of Academic Primary Care Teams

BACKGROUNDTwo chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.OBJECTIVEWe developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.DESIGNThe ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.PARTICIPANTSForty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.APPROACHEach team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).KEY RESULTSAt the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.CONCLUSIONSThe ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.

Developing Measures of Educational Change for Academic Health Care Teams Implementing the Chronic Care Model in Teaching Practices

BACKGROUNDThe Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents’ competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations.SUBJECTSTwenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives.METHODUsing successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs’ abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs.ANALYSISField notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance.RESULTSWork groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change.CONCLUSIONUsing an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.

Observation for assessment of clinician performance: a narrative review

Background Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery. Methods A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines. Results The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors. Conclusions Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.