Lauge Sokol-Hessner

Talking with Patients about Other Clinicians' Errors

The authors discuss the challenges facing a clinician who discovers that her patient has been harmed by another health care workers medical error. They provide guidance to help clinicians and institutions disclose such errors to patients.

Emotional harm from disrespect: the neglected preventable harm

Consider these actual patient experiences: Despite being simultaneously dreadful and familiar to healthcare professionals,1 cases like these are not systematically identified or addressed in hospital quality improvement programmes.2 As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. These cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system. The 1999 Institute of Medicine (IOM) Report To Err is Human found that existing definitions and systems for preventing harm were inadequate and recommended urgent, decisive steps to raise ‘standards and expectations for improvements in safety’.3 Since then our ability to define, measure and prevent patient harm has improved substantially. For instance, in 1999, central line-associated bloodstream infections were considered unfortunate, but expected complications. Today they are commonly prevented, saving many lives.4 To date, the patient safety movement has focused primarily on physical injury, but definitions of harm in healthcare are much broader:5 any ‘outcome that negatively affects the patients health and/or quality of life’.6 When asked about consequences of adverse events, patients emphasise emotional …

Interhospital transfer patients discharged by academic hospitalists and general internists: Characteristics and outcomes

BACKGROUND Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. OBJECTIVE Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. DESIGN Retrospective cohort study. SETTING/PATIENTS A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. METHODS Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. RESULTS Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). CONCLUSIONS In this large national sample, IHT status is independently associated with inpatient mortality.

Interhospital transfer patients discharged by academic hospitalists and general internists

BACKGROUND Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. OBJECTIVE Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. DESIGN Retrospective cohort study. SETTING/PATIENTS A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. METHODS Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. RESULTS Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). CONCLUSIONS In this large national sample, IHT status is independently associated with inpatient mortality.

The Practice of Respect in the ICU

Abstract Although “respect” and “dignity” are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating “failures of respect” as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Improve Advance Care Planning

BACKGROUND Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths. METHODS A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution. Survey responses were reviewed to identify cases that required further investigation. An iterative process of inductive coding was used to create a coding taxonomy to classify survey response free-text comments. RESULTS During the distribution period (September 25, 2015-December 28, 2015), 82 patients died, and 191 care team members were surveyed. Responses (138; 72.3% response rate) were collected through January 28, 2016. Based on the survey responses, 5 patients (6.1%) not identified by other review processes were investigated further, resulting in the identification of several important opportunities for improvement. The free-text comment analysis revealed themes around the importance of advance care planning in seriously ill patients, as well as evidence of the emotional and psychological strain on clinicians who care for patients who die. CONCLUSION Postdeath care team surveys can augment mortality review processes to improve the way hospitals learn from deaths. Free-text comments on such surveys provide information not otherwise identified during traditional mortality review processes, including the importance of advance care planning and the strain on clinicians whose patients die.

It's a matter of respect

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS). In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission. A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be “patients with serious illness.” Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study’s data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work. Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality. Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient’s experience, helping inform an understanding of the challenges and opportunities for improvement? One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?” “How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?” It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor. Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting. Another key finding was about communication by doctors, and the questions patients answered were: “During this hospital stay, how often did doctors treat you with courtesy and respect?” “During this hospital stay, how often did doctors listen carefully to you?” “During this hospital stay, how often did doctors explain things in a way you could understand?” There is a growing and important body of literature about communication with seriously ill patients. Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patientphysician relationship, sadness, or anxiety. Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant. Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying. Although certainly other aspects of communication by doctors with seriously ill patients contributed to this *Address for correspondence and reprint requests: Lauge SokolHessner, MD, 330 Brookline Avenue, W/PBS-2, Boston, MA 02215; Telephone: 617-754-4677; Fax: 617-632-0215; E-mail: lhessner@bidmc. harvard.edu

Creating and using a digital image library: reasons and methods.

Many doctors in developing countries have large collections of clinical and diagnostic images (photographic prints and slides, X-rays, CT scans, MRIs, etc.) of pathology not often seen in the developed world or textbooks. Over time, these valuable collections become more difficult to use when creating lectures or presentations because of their size and lack of common medium. In addition, there is usually only one copy of each image, and there is no easy or inexpensive way of making copies or backups to protect against theft, loss or damage of originals. Creating a digital image library from the hardcopy sources solves these problems by making the images easy to find, use and backup. Our method is simple and can be implemented at only moderate extra cost to purchasing a computer system (see Appendix).