Joseph Ming Wah Li

What Can Hospitalized Patients Tell Us About Adverse Events? Learning from Patient-Reported Incidents

PURPOSE: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near-miss errors.SUBJECTS: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital.METHODS: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about “problems,” “mistakes,” and “injuries” that occurred. Physician investigators classified patients’ reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient-reported events.RESULTS: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4).CONCLUSIONS: Inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.

An update on alcohol and atherosclerosis.

Purpose of review Epidemiological studies consistently link moderate alcohol use with a lower risk of cardiovascular disease, but a number of important issues remain controversial. These include the putative impact of non-alcoholic constituents of some alcoholic beverages, the role of genetic factors, potential mechanisms for this association, and confirmation of the relationship in experimental models. Recent findings Although high-density lipoprotein cholesterol (HDL-C) is considered the primary mediator of the cardiovascular effects of moderate drinking, recent evidence has shown the alcohol-HDL-C relation is not linear beyond the range of moderate drinking. Moderate alcohol use also has important inverse relations with inflammatory factors. Some, but not all, animal models confirm the anti-atherogenic effects of ethanol and highlight inflammatory factors as one possible mechanism. The non-alcoholic constituents of red wine also have anti-atherogenic and perhaps even life-extending properties in vitro, but their relevance to humans remains uncertain. Genetic variants of the apolipoprotein E and interleukin 6 genes in humans may modify how alcohol influences atherosclerosis, further emphasizing the importance of HDL-C and inflammatory factors as mediators. Summary The robust relationship between moderate drinking and lower risk of cardiovascular disease remains an intriguing area of investigation. Clarifying potential gene-environment interactions and translational research into uses for non-alcoholic components will be important areas for future investigation.

Pain management in the hospitalized patient

Effective management of acute pain should be a primary goal of each health care provider. Acute pain is a complex medical problem with multiple possible etiologies. This article describes the pathophysiology of pain, discusses the ways to assess pain, and reviews the principles of acute pain management, including the use of both pharmacologic and nonpharmacologic measures to treat pain.

Recommendations for management of community- and hospital-acquired pneumonia-the hospitalist perspective.

Clinical practice guidelines are evidence-based, diseasespecific, diagnostic treatment algorithms that are intended to improve clinical outcomes by minimizing practice variation. However, simple awareness of a guideline is insufficient to affect clinical behavior. Rather, guidelines must be implemented within a framework of welldesigned educational tools and ongoing feedback regarding compliance and outcomes to ensure that they are fully integrated into daily practice.

Advancement of geriatrics education.

Mazotti et al. describe a train-the-trainer (TTT) program for hospitalists that enables hospitalists to teach geriatric medicine to house staff. We agree that it is important to ensure geriatric medicine proficiency for all hospitalists. Despite caring for many older patients, most hospitalists are inadequately trained in geriatrics. In 2006, we started a TTT program called the Advancement of Geriatrics Education Scholars Program (AGESP). Funded by the Reynolds Foundation, AGESP is a year-long program to teach geriatric medicine to hospitalists. In 2010, 23 Harvard Medical School hospitalists participated. When asked if AGESP improved their knowledge of geriatrics, the average response was 4.5 (1 1⁄4 not at all, 5 1⁄4 extremely; n 1⁄4 19). When asked if they felt more confident to teach geriatrics, the score was 4.2 (n 1⁄4 19). This year, 30 hospitalists from Eastern Massachusetts are enrolled. By July, 70 hospitalists will have completed the program. Our program and others like Dr. Mazotti’s merit support from hospitals, foundations, and the government to provide training to hospitalists. This training is crucial because the medical school and residency training received by current hospitalists incorporated minimal, if any, geriatrics.

Evolution of Hospital Medicine as a Site-of-Care Specialty

Economic and patient safety concerns are driving forces in the hospitalist movement’s history. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Hospitalist Management of Community-Acquired Pneumonia: Consensus Statement

T he management of community-acquired pneumonia (CAP) is a topic of great interest for hospitalists, who individually care for an average of 20 to 40 cases of CAP in their hospitals each year. As specialists in the on-site medical care of hospital patients, hospitalists can be instrumental in improving the outcomes and efficiency of inpatient care for CAP patients. Although the percentage of CAP patients who require admission to the hospital is relatively small, the majority of the cost associated with CAP occurs in the hospital setting. In the mid-1990s, there were 5.6 million cases of CAP per year resulting in total costs of approximately US

Patient-reported service quality on a medicine unit

8.4 billion per year. Although only about 20% of these patients were admitted to the hospital, the hospitalized population accounted for more than 90% of the total cost. Hospitals are increasingly aware of the need to maintain high-quality care while reducing unnecessary expenditures. Because hospitalists are familiar with hospital systems and are comfortable managing illnesses such as complicated pneumonia, they are in a unique position to implement more efficient clinical pathways that optimize resource utilization and patient outcomes. This is borne out by the published outcomes literature, which to date has demonstrated that hospitalists are able to realize significant and consistent cost savings associated with no decrease in quality. The purpose of this report is to provide hospitalists with concise recommendations for the inpatient management of CAP, based on the suggestions of the Hospitalist Management of Community-Acquired Pneumonia (H-CAP) Consensus Panel, a panel of hospitalists, internists, and pulmonary disease specialists. The H-CAP Consensus Panel convened on September 27, 2003, to address the complex issues surrounding care of the hospitalized patient with CAP and to make recommendations that would help hospitalists evaluate and manage patients with respiratory infections. National guidelines issued by the American Thoracic Society (ATS), the Infectious Diseases Society of America, and the Centers for Disease Control and Prevention were reviewed and included in the process. The panel discussed specific issues relating to the hospitalist’s role in guideline use, admission strategies, choice of therapeutic agents, and duration of therapy. The resulting statement outlined below focuses only on the management of patients in regular hospital beds, not outpatients or intensive care unit (ICU) patients.