Edward Etchells

Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial

Background Timely and reliable communication of critical laboratory values is a Joint Commission National Patient Safety Goal. The objective was to evaluate the effect of an automated system for paging critical values directly to the responsible physician. Methods A randomised controlled trial on the general medicine clinical teaching units at an urban academic hospital was conducted from February to May 2006; the unit of randomisation was the critical laboratory value. The intervention was an automated paging system that sent the critical value directly to the responsible physicians pager. The control arm was usual care, which was a telephone call to the patients ward by the laboratory technician. The primary outcome was response time, defined as the interval between acceptance of the critical value into the laboratory information system to the writing of an order on the patients chart in response to the critical value. If the time of order was not documented, the time of administration of treatment was used to calculate response time. Results For primary analysis, 165 critical values were evaluated on 108 patients with full response time data. The median response time was 16 min (IQR 2–141) for the automated paging group and 39.5 min (IQR 7–104.5) for the usual care group (p=0.33). Conclusions The automated paging system reduced the length of time physicians took to respond to critical laboratory values, but this difference was not statistically significant. Future reseach should evaluate the effects of alerts for conditions that currently do not generate a phone call and the addition of real-time decision support to the critical value alerts.

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

BackgroundUnresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.MethodsSix U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.DiscussionAt baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.Trial registrationClinicaltrials.gov identifier NCT01337063

Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward

Background Retrospective record review using trigger tools remains the most widely used method for measuring adverse events (AEs) to identify targets for improvement and measure temporal trends. However, medical records often contain limited information about factors contributing to AEs. We implemented an augmented trigger tool that supplemented record review with debriefing front-line staff to obtain details not included in the medical record. We hypothesised that this would foster the identification of factors contributing to AEs that could inform improvement initiatives. Method A trained observer prospectively identified events in consecutive patients admitted to a general medical ward in a tertiary care academic medical centre (November 2010 to February 2011 inclusive), gathering information from record review and debriefing front-line staff in near real time. An interprofessional team reviewed events to identify preventable and potential AEs and characterised contributing factors using a previously published taxonomy. Results Among 141 patients, 14 (10%; 95% CI 5% to 15%) experienced at least one preventable AE; 32 patients (23%; 95% CI 16% to 30%) experienced at least one potential AE. The most common contributing factors included policy and procedural problems (eg, routine protocol violations, conflicting policies; 37%), communication and teamwork problems (34%), and medication process problems (23%). However, these broad categories each included distinct subcategories that seemed to require different interventions. For instance, the 32 identified communication and teamwork problems comprised 7 distinct subcategories (eg, ineffective intraprofessional handovers, poor interprofessional communication, lacking a shared patient care, paging problems). Thus, even the major categories of contributing factors consisted of subcategories that individually related to a much smaller subset of AEs. Conclusions Prospective application of an augmented trigger tool identified a wide range of factors contributing to AEs. However, the majority of contributing factors accounted for a small number of AEs, and more general categories were too heterogeneous to inform specific interventions. Successfully using trigger tools to stimulate quality improvement activities may require development of a framework that better classifies events that share contributing factors amenable to the same intervention.

Variable pre-transfusion patient identification practices exist in the perioperative setting

PurposeThe operating room (OR) has been identified by hemovigilance systems as a hospital area at high risk for transfusion errors. Where it was confirmed that transfusion products were being administered to the intended patient, we sought to determine the frequency that surgical patients’ identification (ID) bands were inaccessible, the procedures used to identify patients when ID bands were inaccessible, and the effect on pre-transfusion bedside checks when ID bands were inaccessible.MethodsWe tracked the accuracy, location, and accessibility of patient ID bands in the operative phase over three months at a single Canadian Academic Health Sciences Centre. We also evaluated the surgical team’s compliance with transfusion policy, focusing on bedside checks.ResultsForty-four percent of the 426 patients who were tracked had accessible ID bands intraoperatively. The ID bands were removed from 6.3% of surgical patients, primarily for the placement of additional vascular lines. Cardiovascular procedures, which have a high frequency of transfusions, had the highest rate of ID band removals (26.9%) and the third-to-lowest ID band accessibility rate (19.2%). General surgery procedures had the lowest percentage of accessible ID bands (14.8%). Sixty-four of the 77 patients observed receiving transfusions in the OR had inaccessible ID bands due to positioning of the patient’s arm, interference from equipment, or the surgeon. No patient ID bands were used at bedside checks, and addressograph cards and anesthetic records were used in place of the ID band in 97.4% and 2.6% of transfusions, respectively.ConclusionDue to intraoperative inacessibility, the system of patient ID banding has inherent limitations as a means for providing consistent pre-transfusion checks in surgical patients. A consistently accessible ID source that is continuously affixed to surgical patients should be introduced in the OR.RésuméObjectifLes systèmes d’hémovigilance ont permis d’identifier la salle d’opération comme une zone à haut risque d’erreurs de transfusion dans les hôpitaux. Dans les cas où il a été confirmé que les produits de transfusion étaient administrés au patient voulu, nous avons cherché à déterminer la fréquence à laquelle les bracelets d’identification des patients chirurgicaux étaient inaccessibles, les procédures utilisées pour identifier les patients lorsque les bracelets étaient inaccessibles, et l’effet sur les contrôles au chevet du patient avant la transfusion lorsque les bracelets d’identification étaient inaccessibles.MéthodeNous avons examiné l’exactitude, l’emplacement et l’accessibilité des bracelets d’identification des patients dans la phase opératoire sur une période de trois mois dans un seul centre universitaire des sciences de la santé canadien. Nous avons également évalué le respect des politiques de transfusion par l’équipe chirurgicale, avec une emphase sur les contrôles au chevet du patient.RésultatsLes bracelets d’identification de 44xa0% des 426 patients suivis étaient accessibles pendant la période peropératoire. Les bracelets d’identification ont été retirés chez 6,3xa0% des patients chirurgicaux, principalement dans le but de placer des voies d’accès supplémentaires. Les chirurgies cardiovasculaires, qui nécessitent fréquemment des transfusions, avaient le taux de retrait de bracelet d’identification le plus élevé (26,9xa0%) et l’antépénultième taux d’accessibilité du bracelet (19,2xa0%). Le taux d’accessibilité le plus bas des bracelets d’identification a été observé lors des interventions de chirurgie générale (14,8xa0%). Les bracelets d’identification de 64 des 77 patients évalués recevant des transfusions en salle d’opération étaient inaccessibles en raison du positionnement du bras du patient, ou d’interférence des équipements ou du chirurgien. Aucun bracelet d’identification du patient n’était utilisé lors des contrôles au chevet, et les cartes du patient et les dossiers d’anesthésie étaient utilisés à la place des bracelets dans 97,4xa0% et 2,6xa0% des transfusions, respectivement.ConclusionEn raison de l’inaccessibilité des bracelets pendant l’opération, le système d’identification des patients par bracelet a des limites inhérentes lorsqu’il est utilisé pour permettre des contrôles réguliers avant transfusion chez les patients chirurgicaux. Une source d’identification systématiquement accessible et fixée sans interruption aux patients chirurgicaux devrait être introduite en salle d’opération.

Admitting medication errors: five critical concepts

De Winter et al ( see page 371 ) studied 3594 patients admitted to hospital through an emergency department and found that 59% of patients had a discrepancy between the physicians medication history and a pharmacist technicians structured medication history.1 This result is consistent with over 20 small studies (median sample size 104 patients) showing 61–67% of patients have at least one discrepancy in the medication history at the time of hospital admission.2nnThere are at least three good reasons to obtain an accurate medication history at the time of hospital admission. First, more than 1 in 9 emergency department visits are due to drug-related adverse events.3 An accurate medication history will be the cornerstone for diagnosing this common problem. Second, medication history errors may result in incorrect medication orders and incorrect treatment during the admission, leading to patient harm. Third, an accurate medication history is the foundation for accurate medication instructions and prescriptions at the time of hospital discharge.nnMedication reconciliation (Med Rec) at admission is the process of obtaining the best-possible medication history (BPMH), and using this list to provide correct medications to patients at the time of hospital admission. Med Rec at admission is the cornerstone of Med Rec during subsequent transfers and at discharge. Med Rec is a major patient safety priority for safety improvement organisations such as the WHO,4 and hospital accreditors.5 Well-designed medication reconciliation programmes can reduce medication discrepancies6 and potential adverse drug events,7 although there are no studies to show a reduction in preventable adverse drug events.nnSuccessful medication reconciliation implementation is a challenge, as evidenced by the Joint Commissions recent decision …

eWasted time: Redundant work during hospital admission and discharge.

Potential unintended consequences of health information technology include fragmentation of workflow and redundant work. We could not identify any prior direct observation studies that quantified redundant work related to health information technology in the clinical setting. Our objective was to quantify redundant work during admission and discharge to our general internal medicine service at an academic medical center. We performed a time and motion study at Sunnybrook Health Sciences Centre in Toronto, Canada. We observed 13 clinicians performing an admission or a discharge, and the type and length of each task was recorded using an Apple iPad tablet. We identified redundant tasks related to health information technology and calculated the time spent completing these tasks. We found that 22 percent of clinician time was spent on redundant tasks. Our finding highlights the importance of workflow and software integration when implementing health information technology.