James B. Battles

A system of analyzing medical errors to improve GME curricula and programs.

The report of the Institute of Medicine (IOM) To Err is Human recommended that both mandatory and voluntary event-reporting systems be established to identify and learn from errors. Because of the tight coupling of graduate medical education (GME) programs and the delivery of care, any event-reporting system used in a teaching hospital should be able to document the types of errors that are being made by graduate medical trainees (GTs). The authors performed an analysis of the root causes of events involving GTs that were recorded in hospital-based near-miss reporting systems. The root causes were classified using the Eindhoven Classification Model, medical version. Case histories of three separate events, one from an accident and emergency department in the United Kingdom, and two from a large teaching hospital in the United States, are used to illustrate the method. In all three cases, lack of knowledge on the part of the trainee contributed to the incident. Inadequate educational preparation had the potential for causing significant harm to the patient. Organizational causes were also present in each case, which illustrates the need to examine not only educational issues but also procedural and management issues related to GME. In each case, the analysis revealed in striking clarity deficiencies of educational content and problems of program structure. The authors conclude that doing a root-cause analysis in conjunction with a near-miss event-reporting system in a teaching hospital can be a valuable source of documented information to guide needed educational and system changes to GME programs.

Using standardised patients in an objective structured clinical examination as a patient safety tool

Standardised patients (SPs) are a powerful form of simulation that has now become commonplace in training and assessment in medical education throughout the world. Standardised patients are individuals, with or without actual disease, who have been trained to portray a medical case in a consistent manner. They are now the gold standard for measuring the competence of physicians and other health professionals, and the quality of their practice. A common way in which SPs are used in performance assessment has been as part of an objective structured clinical examination (OSCE). The use of an SP based OSCE can be a powerful tool in measuring continued competence in human reliability and skill performance where such skills are a critical attribute to maintaining patient safety. This article will describe how an OSCE could be used as a patient safety tool based on cases derived from actual events related to postdonation information in the blood collection process. The OSCE was developed as a competency examination for health history takers. Postdonation information events in the blood collection process account for the majority of errors reported to the US Food and Drug Administration. SP based assessment is an important patient safety tool that could be applied to a variety of patient safety settings and situations, and should be considered an important weapon in the war on medical error and patient harm.

Enhancing self-efficacy and patient care with cardiovascular nutrition eduction

BACKGROUND Provision of medical education that develops nutrition knowledge and self-efficacy is critical if physicians are to incorporate nutrition in preventive care. We studied the impact of a cardiovascular nutrition module on the knowledge, attitudes, and self-efficacy of fourth-year medical students and the relationship of these attributes to patient care practices. METHODS Based on national practice guidelines and learner needs, an educational intervention consisting of two web-based cases, pocket reference cards, and classroom discussion was developed and implemented. Knowledge, attitudes, and self-efficacy were measured at the beginning and end of the 4-week ambulatory care rotation for 40 control and 156 experimental students. Performance in patient care was approximated using a self-report; chart audits were performed for a subset of students. CONCLUSIONS Knowledge scores of experimental students increased significantly from a mean of 10.3 to 14.4 (p<0.001), while the change for control students from 9.2 to 9.8 was not significant (p=0.20). The increase in self-efficacy scores from 26.2 to 35.7 in the experimental group (p<0.001) was twice that of the increase from 25.8 to 29.9 in the control group (p=0.001). Small but significant increases in attitude scores were similar for both groups. Limited data on student performance revealed that students with greater cardiovascular nutrition self-efficacy were more likely to address nutrition with cardiovascular patients. CONCLUSIONS Incorporation of cardiovascular nutrition concepts in an ambulatory care rotation including use of computer-based cases improved student knowledge and self-efficacy, which may translate to increased frequency of future physicians addressing nutrition with patients.

An objective structured clinical examination to evaluate health historian competencies

BACKGROUND : Post‐donation information events in the blood‐collection process account for the majority of errors reported to the FDA. An eight‐station objective structured clinical examination (OSCE) based on information reported after donation was developed as a competency examination for health historians.

Administration of a Parallel, Simultaneous Objective Structured Clinical Examination to Accommodate a Large Class of Students.

The use of an objective structured clinical examination (OSCE) to evaluate the clinical abilities of second‐year medical students at the end of an introduction to clinical medicine course in 2 successive years is reported. Due to the large number of students in our classes, two identical, simultaneous, parallel OSCEs were administered each year. Skills to be evaluated and cases used to measure these skills were determined by a modification of existing methods. The logistic feasibility of administering a large OSCE in this manner was confirmed. A thorough psychometric evaluation of the OSCE was performed, and findings were evaluated. When used in a pass‐fail context and calculated as a dependability index with cutoffs, the generalizability of the total OSCE and most individual skills measured was greater than .8 when the cutoff was 2 SD below the mean score. The number of cases required to achieve a generalizability of .8 for the total OSCE and each individual skill was fewer than 11. The potential for use...

Assessing the usefulness of using standardized patients in a clinical medicine course

No abstract available.

Using an Algebraic Inversion of the Dependability Index to Determine Pass/Fail Criteria for Clinical Performance Examinations

There has been considerable debate as to how to establish a pass/fail point for clinical performance examinations. Most standard setting techniques require considerable effort and may well be beyond the resources of most local institutions. At the University of Texas Southwestern Medical Center at Dallas we explored different pass/fail standards or criteria used in an OSCE given at the end of a second year Introduction to Clinical Medicine course. We compared the number of students who passed or failed for years 1990-1995 based upon using three different standards or cut scoring procedures: 1) a group or norm referenced cut point of two standard deviations below the mean, 2) an a priori estimated cut score based on 1991 group data applied to all OSCE scores, and 3) a cut point based upon an algebraic inversion dependability index of both 0.8 and 0.9. We found that the use of an estimated cut score as a reference in combination with algebraic inversion dependability index to be a most appropriate and simplest way to apply a standard setting process for pass/fail decisions. A well reasoned estimated score based upon faculty judgement and previous years test experience can serve as a useful benchmark.

Recording Patient Encounters to Verify the Clinical Curriculum of a Family Medicine Clerkship

The learning experience during a medical school clinical rotation is to a large extent shaped by students’ patient encounters. This paper reports on how a log system for recording these encounters can be used for both course planning and evaluation. Over the past five years, 960 third year students participating in a four-week family medicine clerkship at the University of Texas Southwestern Medical School completed log forms based on their clinical encounters. These forms were then optically scanned and directly entered into a computerized data base. The data revealed that the most common medical problems encountered by our students in ambulatory settings were similar to those reported in the general family practice literature. The data also indicated differences among clerkship sites in terms of patient demographics and the most frequently reported diagnoses, with a great deal of consistency in the types of encounters from year to year. Information from the log forms has been used by clerkship faculty to develop end-of-rotation examinations, determine required readings, prioritize didactic topics, adjust curriculum content, and prepare support materials. Given the utility of the information obtained and the ease of use of optical mark encounters sheets, we recommended this system for other clerkships.