Jeffrey M. Riggio

Attitudes About Patient Safety: A Survey of Physicians-in-Training

Little is known about the attitudes of physicians-in-training on patient safety, although success in error reduction strategies requires their support. We surveyed house staff and fourth-year medical students from 1 academic institution about their perceptions of adverse patient events. Three hundred twenty-one trainees (41%) completed the survey. Most believe adverse events are preventable (61%) and think improved teamwork (88%), better procedural training (74%), and improved sign-out (70%) would reduce medical mishaps. Forty-seven percent of trainees agree computerized order entry and restricted work hours would prevent adverse events. Although 60% feel malpractice fears inhibit discussion, 80% of trainees agreed physicians must disclose adverse events to patients and grow more comfortable with disclosure as training progresses ( P for trend <.01). In conclusion, trainees believe adverse events are preventable and are poised to respond to many components of the patient safety movement.

Measuring Informed Decision Making about Prostate Cancer Screening in Primary Care

Purpose. To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure. Methods. Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0–9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated. Results. Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%). Conclusions. In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

Effectiveness of a clinical-decision-support system in improving compliance with cardiac-care quality measures and supporting resident training.

Many of the quality measures for patients with heart failure (HF) or acute myocardial infarction (AMI) require the completion of comprehensive discharge instructions, including instructions about medications to be taken after discharge. To improve compliance in a tertiary care teaching hospital with these evidence-based quality measures, a clinical-decision-support system (CDSS) that uses an electronic checklist was developed. The CDSS prompts clinicians at every training level to consistently create comprehensive discharge instructions addressing quality measures. The authors compared compliance during the 15-month preintervention and postintervention periods. Compliance with discharge measures for AMI (i.e., aspirin, beta-blocker, angiotensin-converting enzyme inhibitor [ACEI], or angiotensin receptor blocker [ARB] use) and for HF (i.e., discharge instructions, left ventricular systolic function [LVSF] evaluation, and ACEI/ARB use) was assessed. The delivery of discharge instructions showed significant improvement from the preintervention period to the postintervention period (37.2% to 93.0%; P < .001). Compliance with prescription of ACEI or ARB also improved significantly for HF (80.7% to 96.4%; P < .001) and AMI (88.1% to 100%; P = .014) patients. Compliance with the remaining measures was higher before intervention, and, thus, the modest improvement in the postintervention period was not statistically significant (AMI patients: aspirin, 97.5% to 98.8%; P = .43; and beta-blocker, 97.9% to 98.7%; P = .78; HF patients: LVSF, 99.3% to 99.1%; P = .78). Implementation of a CDSS with computerized electronic prompts improved compliance with selected cardiac-care quality measures. The design of quality-improvement decision-support tools should incorporate educational missions in their message and design.

The Hybrid Progress Note: Semiautomating Daily Progress Notes to Achieve High-Quality Documentation and Improve Provider Efficiency

Health care institutions are moving toward fully functional electronic medical records (EMRs) that promise improved documentation, safety, and quality of care. However, many hospitals do not yet use electronic documentation. Paper charting, including writing daily progress notes, is time-consuming and error prone. To improve the quality of documentation at their hospital, the authors introduced a highly formatted paper note template (hybrid note) that is prepopulated with data from the EMR. Inclusion of vital signs and active medications improved from 75.5% and 60% to 100% (P < .001), respectively. The use of unapproved abbreviations in the medication list decreased from 13.3% to 0% (P < .001). Prepopulating data enhances provider efficiency. Interviews of key clinician leaders also suggest that the initiative is well accepted and that documentation quality is enhanced. The hybrid progress note improves documentation and provider efficiency, promotes quality care, and initiates the development of the forthcoming electronic progress note.

Clinical decision support systems to improve utilization of thromboprophylaxis: a review of the literature and experience with implementation of a computerized physician order entry program.

Abstract Objective: A literature review was conducted of studies investigating the effectiveness of paper- and computer-based clinical decision support systems (CDSS) used with or without educational programs designed to increase the use of venous thromboembolism (VTE) prophylaxis. Methods: Medline was searched on August 9, 2010, without limits on publication year, but with restrictions to English-language articles only. The search terms used were “venous thromboembolism,” “deep vein thrombosis,” “pulmonary embolism,” “prophylaxis,” “thromboprophylaxis,” “computerized,” “computerised,” “decision support,” “alerts,” “reminder,” “paper system,” “risk assessment,” and “risk score.” All types of studies regarding the effects of CDSS on VTE prophylaxis rates were included. Studies were included if ≥ 1 post-implementation outcome was measured, such as rates of VTE, rates of prophylaxis prescribing, or guideline-adherence measures. Results: Studies evaluating paper-based CDSS used different strategies, including risk-assessment forms with prophylaxis recommendations, standard order sets, and preprinted sticker reminders on patient notes. Paper-based systems consistently improved prophylaxis rates; however, in most studies, there was still room for improvement. Furthermore, the effect of paper-based CDSS on VTE rates was not conclusively established. Studies evaluating computer-based systems used approaches including risk-assessment models integrated in the computerized physician order entry system, with or without alerts, and automatic reminders on operating schedules. Conclusion: Computerized systems are associated with substantial improvements in the prescribing of appropriate prophylaxis and reductions in VTE events, particularly in medical patients. More robust systems can be established with computer-based rather than paper-based CDSS. A drawback of computerized systems is that some hospitals may not have adequate information technology system resources.

Amylase testing for abdominal pain and suspected acute pancreatitis

The “Things We Do for No Reason” (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. A 37-year-old man presents to the emergency department complaining of acute onset abdominal pain associated with nausea and vomiting. The pain is constant and achy in nature. It is located in the upper abdomen and radiates to the back. The patient reports binge alcohol consumption the day prior to the onset of his pain. His physical examination is remarkable for fever, with a temperature of 100.68F and epigastric tenderness to palpation without rebound or guarding. He is not hypotensive, and there is no evidence of the Cullen sign or Grey-Turner sign. In this patient presenting with acute abdominal pain, is ordering amylase alone, lipase alone, or amylase and lipase together the most high-value method to evaluate him for acute pancreatitis?

Reducing Co-Ordering of Amylase and Lipase Testing at an Academic Medical Center: A Quality Improvement Project.

To the Editor: Lipase is both more sensitive and specific than amylase, and it is recommended that providers order lipase alone for the diagnosis of acute pancreatitis. Despite this recommendation, amylase and lipase co-ordering remains a common practice at many health care institutions, and annual charges to Medicare for amylase testing exceed

Improved Supervision and Safety of Discharges Through Formal Discharge Education

19 million. Prior work has suggested that systemsbased interventions can be effective for reducing unnecessary testing. This study describes the implementation and impact of a hospital-wide, multispecialty intervention that included a systems-based component aimed at reducing amylase and lipase co-ordering at an academic medical center. In December 2014, we introduced a series of interventions in a medical resident–driven initiative aimed at reducing amylase and lipase co-ordering at Thomas Jefferson University Hospital, a 957-bed academic medical center. Partnering with key stakeholders including gastroenterology and surgery leadership, we distributed an educational newsletter to all physicians and house staff outlining the appropriate use of amylase and lipase. We then removed amylase from many common order sets in the electronic medical record while still allowing ad hoc ordering. An interrupted time series analysis was used to assess the impact of the intervention. Data analysis was performed in Stata 13 (StataCorp, College Station, Texas). The study was approved by the institutional review board at Thomas Jefferson University. In the 6 months preceding the intervention, there were a median of 618 (interquartile range 562-646) co-ordered amylase and lipase tests per month. In the 6 months following the intervention, there were a median of 294 (interquartile range 270-312) co-ordered tests per month. This change represents an elimination of approximately 3900 amylase tests per year at our academic medical center. At an average Medicare charge of

Utilization of the office, hospital and emergency department for adult sickle cell patients: a five-year study.

35 per test, the intervention would reduce patient charges by more than

Mediated decision support in prostate cancer screening: A randomized controlled trial of decision counseling

135 000 per year. Prior to the intervention, amylase and lipase were coordered with a frequency of 27.1% (95% confidence interval 25.3% to 28.9%). Immediately following the intervention, the absolute frequency of co-ordering decreased by 15.2% (95% confidence interval 12.7% to 17.8%). This change represents a 56.1% relative decrease in co-ordering (P < .001), which has been durable, with no statistically significant change in the frequency of co-ordering observed in the months following the intervention. Finally, we observed that 4.6% of co-ordered amylase and lipase tests had conflicting results, defining a positive test as greater than 3 times the upper limit of normal. We have demonstrated that a simple multispecialty intervention, including a systems-based approach, led to a significant and durable reduction in amylase and lipase co-ordering with associated savings. Additionally, we observed that amylase and lipase, when co-ordered, commonly had conflicting results, consistent with smaller studies. As this conflicting information could lead to misdiagnosis or additional unnecessary testing when compared to ordering lipase alone, reducing co-ordering also may improve quality of care. This study is limited by its quasi-experimental design and single site of study. Future studies will need to evaluate the impact of reduced co-ordering on quality of care and evaluate whether a similar approach can reduce other instances of low-value diagnostic testing.