James Battles

The Role of Teamwork in the Professional Education of Physicians: Current Status and Assessment Recommendations

BACKGROUND The Institute of Medicine (IOM) has recommended that organizations establish interdisciplinary team training programs that incorporate proven methods for team management. Teamwork can be assessed during physician medical education, board certification, licensure, and continuing practice. Team members must possess specific knowledge, skills, and attitudes (KSAs), such as the ability to exchange information, which enable individual team members to coordinate. ASSESSING PHYSICIAN TEAMWORK KSAs might be elicited and assessed across a physicians career, starting in medical school and continuing through licensure and board certification. Professional bodies should be responsible for the development of specific team knowledge and skill competencies and for promoting specific team attitude competencies. Tools are available to assess medical student, resident, and physician competence in these critical team KSAs. CHALLENGES AND COMPLEXITIES IN TEAM PERFORMANCE MEASUREMENT For teamwork skills to be assessed and have credibility, team performance measures must be grounded in team theory, account for individual and team-level performance, capture team process and outcomes, adhere to standards for reliability and validity, and address real or perceived barriers to measurement.

National Trends in Patient Safety for Four Common Conditions, 2005–2011

BACKGROUND Changes in adverse-event rates among Medicare patients with common medical conditions and conditions requiring surgery remain largely unknown. METHODS We used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. We estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. RESULTS The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates. CONCLUSIONS From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery. (Funded by the Agency for Healthcare Research and Quality and others.).

Adverse-event-reporting practices by US hospitals: results of a national survey

Context: Little is known about hospitals’ adverse-event-reporting systems, or how they use reported data to improve practices. This information is needed to assess effects of national patient-safety initiatives, including implementation of the Patient Safety and Quality Improvement Act of 2005 (PSQIA). This survey generated baseline information on the characteristics of hospital adverse-event-reporting systems and processes, for use in assessing progress in improvements to reporting. Methods: The Adverse Event Reporting Survey, developed by Westat, was administered in September 2005 through January 2006, using a mixed-mode (mail/telephone) survey with a stratified random sample of 2050 non-federal US hospitals. Risk managers were the respondents. An 81% response rate was obtained, for a sample of 1652 completed surveys. Results: Virtually all hospitals reported they have centralised adverse-event-reporting systems, although characteristics varied. Scores on four performance indexes suggest that only 32% of hospitals have established environments that support reporting, only 13% have broad staff involvement in reporting adverse events, and 20–21% fully distribute and consider summary reports on identified events. Because survey responses are self-reported by risk managers, these may be optimistic assessments of hospital performance. Conclusions: Survey findings document the current status of hospital adverse-event-reporting systems and point to needed improvements in reporting processes. PSQIA liability protections for hospitals reporting data to patient-safety organisations should also help stimulate improvements in hospitals’ internal reporting processes. Other mechanisms that encourage hospitals to strengthen their reporting systems, for example, strong patient-safety programmes, also would be useful.

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care

BACKGROUND Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI. METHODS The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates. RESULTS Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001). CONCLUSIONS A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

The Validity of ICD-9-CM Codes in Identifying Postoperative Deep Vein Thrombosis and Pulmonary Embolism

BACKGROUND Deep vein thrombosis and pulmonary embolism (DVT/PE) are common complications after surgery and are associated with substantial excess mortality and length of stay. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes recorded in hospital claims have been used to identify and study DVT/PE, but the validity of this method is not well studied. METHODS Identification of postoperative DVT/PE events were compared using ICD-9-CM codes and medical record abstraction in random samples of hospital discharges of Medicare beneficiaries in 2002-2004. RESULTS Among 20,868 eligible surgical hospitalizations, 232 DVT cases and 95 PE cases were identified by ICD-9-CM codes; 108 DVT cases and 31 PE cases by medical record abstraction; 72 DVT cases and 23 PE cases by both methods. The resulting estimates of PPV of ICD9-CM coding were 31% (72/232 cases) for DVT, 24% (23/95) for PE, and 29% (90/308) for DVT/PE combined. The resulting sensitivity estimates were 67% (72/108 cases) for DVT, 74% (23/31) for PE, and 68% (90/133) for DVT/PE combined. DISCUSSION ICD-9-CM codes in Medicare claims are sensitive but have limited predictive validity in identifying postoperative DVT/PE. Improvements in the validity are needed before the indicator can be used for safety performance assessment.

Establishing a global learning community for incident-reporting systems

Background Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation. Discussion Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.

Adverse event reporting systems and safer healthcare

At the heart of improvement and safety in healthcare is the now-familiar tenet that was espoused decades ago by Demming and paraphrased by Berwick.1 Need we repeat it again? Every defect should lead to improvement processes that make care safer. It is time to deliver on the promise of reporting systems in patient safety. While it is clear that event-reporting systems are now central elements in effective patient safety systems, their growth and implementation have been slow, and their effective use for implementing strategies for safer care has been even slower. In the decade since the report of the Institute of Medicine (IOM) to Err is Human 2 released in 1999, and an Organization with a Memory 3 published in 2000, consensus has grown that learning from patient safety events is an essential part of creating safer healthcare systems—at both national and local levels. This journal has devoted …

Improving patient safety by instructional systems design

Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training. Instructional systems design (ISD) is a systematic method of development of education and training programs for improved learner performance. The ISD process involves five integrated steps: analysis, development, design, implementation, and evaluation (ADDIE). The application of ISD using the ADDIE approach can eliminate or prevent education and training from being a contributing factor of health associated injury or harm, and can also be effective in preventing injury or harm.

A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents

Importance Catheter-associated urinary tract infection (UTI) in nursing home residents is a common cause of sepsis, hospital admission, and antimicrobial use leading to colonization with multidrug-resistant organisms. Objective To develop, implement, and evaluate an intervention to reduce catheter-associated UTI. Design, Setting, and Participants A large-scale prospective implementation project was conducted in community-based nursing homes participating in the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. Nursing homes across 48 states, Washington DC, and Puerto Rico participated. Implementation of the project was conducted between March 1, 2014, and August 31, 2016. Interventions The project was implemented over 12-month cohorts and included a technical bundle: catheter removal, aseptic insertion, using regular assessments, training for catheter care, and incontinence care planning, as well as a socioadaptive bundle emphasizing leadership, resident and family engagement, and effective communication. Main Outcomes and Measures Urinary catheter use and catheter-associated UTI rates using National Healthcare Safety Network definitions were collected. Facility-level urine culture order rates were also obtained. Random-effects negative binomial regression models were used to examine changes in catheter-associated UTI, catheter utilization, and urine cultures and adjusted for covariates including ownership, bed size, provision of subacute care, 5-star rating, presence of an infection control committee, and an infection preventionist. Results In 4 cohorts over 30 months, 568 community-based nursing homes were recruited; 404 met inclusion criteria for analysis. The unadjusted catheter-associated UTI rates decreased from 6.78 to 2.63 infections per 1000 catheter-days. With use of the regression model and adjustment for facility characteristics, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001). Catheter utilization was 4.5% at baseline and 4.9% at the end of the project. Catheter utilization remained unchanged (4.50 at baseline, 4.45 at conclusion of project; IRR, 0.95; 95% CI, 0.88-1.03; P = .26) in adjusted analyses. The number of urine cultures ordered for all residents decreased from 3.49 per 1000 resident-days to 3.08 per 1000 resident-days. Similarly, after adjustment, the rates were shown to decrease from 3.52 to 3.09 (IRR, 0.85; 95% CI, 0.77-0.94; P = .001). Conclusions and Relevance In a large-scale, national implementation project involving community-based nursing homes, combined technical and socioadaptive catheter-associated UTI prevention interventions successfully reduced the incidence of catheter-associated UTIs.

Special Section Commentary: Opportunities and Challenges for Human Factors and Ergonomics in Enhancing Patient Safety

reserved. Can our science help? Yes! Of course, it can. It should. It must. It’s beginning to. But more is needed. Patient safety has become a national obsession among health care providers, and with much reason. In 1999 the Institute of Medicine (IOM) published a landmark report, To Err Is Human, which created a much-needed awareness of medical errors and launched several sociotechnical interventions designed to create a “safety culture” in all health care settings (Kohn, Corrigan, & Donaldson, 1999). In one way much has happened since the IOM report. Some hospitals across the country (and Europe) have launched diverse initiatives to prevent errors and improve organizational safety, mainly developing programs similar to those used in aviation The Joint Commission on Accreditation of Healthcare Organizations now look for “safer practices” in its inspections. A growing number of heath care delivery systems are trying to achieve high reliability status in patient safety (e.g., Sentara Healthcare System, Kaiser Permanente). These are aggressively applying human factors research and principles to make significant improvements in quality and safety. There is some (limited) funding available for research and demonstrations as well. And so some progress has been made. But in another way, not much has happened, progress is slow moving, or some key features for achieving safety and safe behaviors are still overlooked. Not all the relevant sciences (e.g., industrial/organizational psychology, modeling and simulation) are being leveraged or their findings used, applied, tried, or implemented. There is overreliance on one model – the aviation one. There is still some resistance to change – to behave, manage, reinforce, and function differently – on the part of physicians, chief executive officers, chief financial officers, and health care providers. The research seems uncoordinated, fragmented, and insufficient to tackle the different complex issues in some depth. However, there is hope: hope that more, better, and useful science will evolve and mature enough to have an impact. There is hope because some institutions, agencies, nurses, and physicians have embraced the need for change. There is hope that research will guide change and implementation of new ways of functioning. There is hope for the science of human factors and ergonomics. And so, we hope that this special section encourages research, debate, new ideas, better theories, practical interventions, and useful findings to ameliorate errors in health care. We next briefly outline some insights from diverse perspectives regarding the opportunities and challenges that our science will be faced with or is now facing. We draw from those who fund the work (Agency for Health Research and Quality, or AHRQ), those who are attempting to create a movement for culture change (Department of Defense), and those who are designing, developing, and evaluating interventions. Again, the insights are offered in the hope of promoting, motivating, and launching thinking, action, and passion for applications to reduce medical errors.