Madelene J. Ottosen

Development and evaluation of a crowdsourcing methodology for knowledge base construction: identifying relationships between clinical problems and medications

OBJECTIVE We describe a novel, crowdsourcing method for generating a knowledge base of problem-medication pairs that takes advantage of manually asserted links between medications and problems. METHODS Through iterative review, we developed metrics to estimate the appropriateness of manually entered problem-medication links for inclusion in a knowledge base that can be used to infer previously unasserted links between problems and medications. RESULTS Clinicians manually linked 231,223 medications (55.30% of prescribed medications) to problems within the electronic health record, generating 41,203 distinct problem-medication pairs, although not all were accurate. We developed methods to evaluate the accuracy of the pairs, and after limiting the pairs to those meeting an estimated 95% appropriateness threshold, 11,166 pairs remained. The pairs in the knowledge base accounted for 183,127 total links asserted (76.47% of all links). Retrospective application of the knowledge base linked 68,316 medications not previously linked by a clinician to an indicated problem (36.53% of unlinked medications). Expert review of the combined knowledge base, including inferred and manually linked problem-medication pairs, found a sensitivity of 65.8% and a specificity of 97.9%. CONCLUSION Crowdsourcing is an effective, inexpensive method for generating a knowledge base of problem-medication pairs that is automatically mapped to local terminologies, up-to-date, and reflective of local prescribing practices and trends.

Patients as Partners in Learning from Unexpected Events.

IMPORTANCE Patient safety experts believe that patients/family members should be involved in adverse event review. However, it is unclear how aware patients/family members are about the causes of adverse events they experienced. OBJECTIVE To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. DESIGN We interviewed patients/family members using semistructured interviews to understand their perceptions about why these adverse events occurred. The adverse events occurred between 1991 and 2014. SETTING Participants described adverse events that occurred in various types of health care organizations (i.e., hospitals, ambulatory facilities/clinics, and dental clinics). PARTICIPANTS We interviewed 72 patients and family members who each described a unique adverse event. Eligibility requirements were that patients/family members spoke English or Spanish and were aware of an adverse event that happened to them or a loved one. INTERVENTION(S) FOR CLINICAL TRIALS OR EXPOSURE(S) FOR OBSERVATIONAL STUDIES: N/A. MAIN OUTCOME(S) AND MEASURE(S) The main outcome was determining whether patients/family members could identify at least one contributing factor they perceived as related to the adverse event they described. RESULTS Each participant identified at least one contributing factor and on average identified 3.67 contributing factors for their event. The most frequently mentioned contributing factors were Staff Qualifications/Knowledge (79 percent), Safety Policies/Procedures (74 percent), and Communication (64 percent). Participants knew about the contributing factors from personal observation only (32 percent), personal reasoning (11 percent), personal research (7 percent), record review (either their own medical records or reports they received in their own investigation; 6 percent), and being told by a physician (5 percent). Finally, patients/family members were able to provide recommendations that address each of the nine contributing factors we examined. CONCLUSIONS AND RELEVANCE Patients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed. Health care organizations should interview patients/family about the event that harmed them to help ensure a full understanding of the causes of the event.

Barriers to Speaking Up About Patient Safety Concerns

Objectives We sought to examine the association between willingness of health-care professionals to speak up about patient safety concerns and their perceptions of two types of organizational culture (ie, safety and teamwork) and understand whether nursing professionals and other health-care professionals reported the same barriers to speaking up about patient safety concerns. Methods As part of an annual safety culture survey in a large health-care system, we asked health-care professionals to tell us about the main barriers that prevent them from speaking up about patient safety concerns. Approximately 1341 respondents completed the anonymous, electronic survey. Results A little more than half (55%) of the participants mentioned leadership (fear of no change or retaliation) and personal (ie, fear of negative feedback or being wrong) barriers concerning why they would not speak up about patient safety concerns. The remaining participants (45%) indicated they would always speak up. These findings about barriers were consistent across nurses and other health-care professionals. Safety culture (SC) and teamwork culture (TC) scores were significantly more positive in those indicating they would always speak up (SC = 89%, TC = 89%) than in those who provided reasons for not speaking up (SC = 63%, TC = 64%) (t1205 = 13.99, P < 0.05, and t1217 = 13.61, P < 0.05, respectively). Conclusions Health-care professionals emphasized leadership and personal barriers as reasons for not speaking up. We also demonstrated an association between not speaking up and lower safety and teamwork culture scores.

Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise

OBJECTIVE The response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. STUDY SETTING Washington and Texas. STUDY DESIGN The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice. DATA COLLECTION AND ANALYSIS Lessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes. PRINCIPAL FINDINGS One hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration. CONCLUSIONS A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Surgical Safety Checklists in Children’s Surgery: Surgeons’ Attitudes and Review of the Literature

Introduction: Surgical safety checklists (SSCs) aim to create a safe operating room environment for surgical patients. Provider attitudes toward checklists affect their ability to prevent harm. Pediatric surgeons’ perceptions surrounding SSCs, and their role in improving patient safety, are unknown. Methods: American Pediatric Surgical Association members conducted an online survey to evaluate the use of and attitudes toward SSCs. The survey measured surgeons’ perceptions of checklists, including the components that make them effective and barriers to participation. To better evaluate the available data on SSCs, the authors performed a systematic literature review on the use of SSCs with a focus on pediatric studies. Results: Of the 353 survey respondents, 93.6% use SSCs and 62.6% would want one used in their own child’s operation, but only 54.7% felt that checklists improve patient safety. Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation. Conclusions: Almost all pediatric surgeons participate in SSCs at their institutions, but many question their benefit. Better pediatric surgeon engagement in checklist use is needed to change the safety culture, improve operating room communication, and prevent harm.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit

Background Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations. Conclusion These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

A Quiet Revolution: Communicating and Resolving Patient Harm

Good patient care includes not only avoiding error and injury but also acting honestly and constructively should it occur. Communication and Resolution Programs (CRPs) commit the sponsoring institution to vigilant detection of error, full disclosure to patients and families, and timely redress. CRPs also seek to incorporate the perspectives of patients and family members into safety improvement activities. This chapter explains the principles underlying CRPs, traces their history, and describes current best practices for physicians, provider organizations, and the legal and regulatory environment. Transparency about error and proactive response to injury lagged other professional commitments to patient self-determination because of the emotion and politics surrounding medical malpractice. However, recent generations of physicians, patients, and policymakers have engineered a “quiet” revolution. Silence and secrecy are no longer ethically acceptable responses to medical error. Although additional research is needed on how CRPs affect safety, patient and provider satisfaction, and cost, the American College of Surgeons in 2014 declared CRPs to be, on balance, the most promising approach to medical liability reform.

Steps in Developing a Patient-Centered Measure of Hospital Design Factors

Patients and families are at the center of care and have important perspectives about what they see occurring surrounding their healthcare, yet organizations do not routinely collect such perspectives from patients/families. Creating patient-centered measures is essential to understanding what they perceive about the environment as well as achieving the goal of patient-centered care. We focus this research methodology column on describing a four-step medical ethnography approach that can be used in developing patient-centered measures of interest to those studying built environments. In this column, we use this approach to illustrate how one might develop a measure that can be used to understand parent perceptions of the safety culture in neonatal intensive care units.