Valerie L. Forman-Hoffman

Reporting Medical Errors to Improve Patient Safety: A Survey of Physicians in Teaching Hospitals

BACKGROUND Collecting data on medical errors is essential for improving patient safety, but factors affecting error reporting by physicians are poorly understood. METHODS Survey of faculty and resident physicians in the midwest, mid-Atlantic, and northeast regions of the United States to investigate reporting of actual errors, likelihood of reporting hypothetical errors, attitudes toward reporting errors, and demographic factors. RESULTS Responses were received from 338 participants (response rate, 74.0%). Most respondents agreed that reporting errors improves the quality of care for future patients (84.3%) and would likely report a hypothetical error resulting in minor (73%) or major (92%) harm to a patient. However, only 17.8% of respondents had reported an actual minor error (resulting in prolonged treatment or discomfort), and only 3.8% had reported an actual major error (resulting in disability or death). Moreover, 16.9% acknowledged not reporting an actual minor error, and 3.8% acknowledged not reporting an actual major error. Only 54.8% of respondents knew how to report errors, and only 39.5% knew what kind of errors to report. Multivariate analyses of answers to hypothetical vignettes showed that willingness to report was positively associated with believing that reporting improves the quality of care, knowing how to report errors, believing in forgiveness, and being a faculty physician (vs a resident). CONCLUSION Most faculty and resident physicians are inclined to report harm-causing hypothetical errors, but only a minority have actually reported an error.

Barriers to obesity management: a pilot study of primary care clinicians

BackgroundObesity is an increasing epidemic in both the US and veteran populations, yet it remains largely understudied in the Veterans Health Administration (VHA) setting. The purpose of our study was to identify barriers to the effective management of obesity in VHA primary care settings.MethodsThree focus groups of clinicians from a Veterans Affairs Medical Center (VAMC) and an affiliated Community Based Outpatient Center (CBOC) were conducted to identify potential barriers to obesity management. The focus groups and previously published studies then informed the creation of a 47-item survey that was then disseminated and completed by 55 primary care clinicians.ResultsThe focus groups identified provider, system, and patient barriers to obesity care. Lack of obesity training during medical school and residency was associated with lower rates of discussing diet and exercise with obese patients (p < 0.05). Clinicians who watched their own diets vigorously were more likely to calculate BMI for obese patients than other clinicians (42% vs. 13%, p < 0.05). Many barriers identified in previous studies (e.g., attitudes toward obese patients, lack of insurance payments for obesity care) were not prevalent barriers in the current study.ConclusionMany VHA clinicians do not routinely provide weight management services for obese patients. The most prevalent barriers to obesity care were poor education during medical school and residency and the lack of information provided by the VHA to both clinicians and patients about available weight management services.

Elevated prevalence of obesity, metabolic syndrome, and cardiovascular risk factors in bipolar disorder:

BACKGROUND Bipolar disorder is associated with excess cardiovascular mortality. We hypothesized outpatients with bipolar disorder would exhibit excess cardiovascular risk factors, particularly among prevalent users of the second-generation antipsychotics associated with weight gain and valproic acid derivatives. METHODS This chart review of 217 patients with bipolar disorder examined cardiovascular risk factors of the metabolic syndrome. We also evaluated if certain medications were cross-sectionally associated with metabolic syndrome. RESULTS Fifty-six patients were not weighed and many did not have available lipid profiles. Over three-quarters of those with available data (n = 161) were overweight or obese (body mass index >or= 25) and nearly half were obese (body mass index >or= 30). A prevalence exceeding general population estimates was also observed for hypertriglyceridemia, elevated blood pressure/hypertension, and elevated fasting glucose/diabetes. Among those with all requisite data (n = 60), over 50% met criteria for National Cholesterol Education Program-defined metabolic syndrome, nearly double the expected prevalence. A trend toward greater prevalence of metabolic syndrome among prevalent users of the second-generation antipsychotics associated with weight gain was observed. CONCLUSIONS Obesity and the metabolic syndrome were common in patients with bipolar disorder. These patients may be under-evaluated for cardiovascular risk and warrant screening and early intervention.

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

BACKGROUNDDisclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood.OBJECTIVETo survey physicians and trainees about their practices and attitudes regarding error disclosure to patients.DESIGN AND PARTICIPANTSSurvey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States.MEASUREMENTSActual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors.RESULTSResponses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost.CONCLUSIONSThere appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation.

Code status discussions and goals of care among hospitalised adults

Background and objective: Code status discussions may fail to address patients’ treatment-related goals and their knowledge of cardiopulmonary resuscitation (CPR). This study aimed to investigate patients’ resuscitation preferences, knowledge of CPR and goals of care. Design, setting, patients and measurements: 135 adults were interviewed within 48 h of admission to a general medical service in an academic medical centre, querying code status preferences, knowledge about CPR and its outcome probabilities and goals of care. Medical records were reviewed for clinical information and code status documentation. Results: 41 (30.4%) patients had discussed CPR with their doctor, 116 (85.9%) patients preferred full code status and 11 (8.1%) patients expressed code status preferences different from the code status documented in their medical record. When queried about seven possible goals of care, patients affirmed an average of 4.9 goals; their single most important goals were broadly distributed, ranging from being cured (n = 36; 26.7%) to being comfortable (n = 8; 5.9%). Patients’ mean estimate of survival to discharge after CPR was 60.4%. Most patients believed it was helpful to discuss goals of care (n = 95; 70.4%) and the chances of surviving inhospital CPR (n = 112; 83.0%). Some patients expressed a desire to change their code status after receiving information about survival following inhospital CPR (n = 11; 8.1%) or after discussing goals of care (n = 2; 1.5%). Conclusions: Doctors need to address patients’ knowledge about CPR and take steps to avoid discrepancies between treatment orders and patients’ preferences. Addressing CPR outcome probabilities and goals of care during code status discussions may improve patients’ knowledge and influence their preferences.

Eating Disorders, Post-Traumatic Stress, and Sexual Trauma in Women Veterans

We examine lifetime eating disorders (EDOs) and associations with post-traumatic stress disorder (PTSD) and sexual trauma during various stages of the life course (childhood, during military service, and lifetime) among women veterans. The sample included 1,004 women aged 20 to 52 years who had enrolled at 2 Midwestern Veterans Affairs Medical Centers or outlying clinics completed a retrospective telephone interview. Over 16% reported a lifetime EDO (4.7% had received a diagnosis, and an additional 11.5% self-reported suffering from an EDO). Associations were found between lifetime EDO, PTSD, and sexual trauma. Relationships maintained significance for both diagnosed and self-reported EDOs as well as lifetime completed rape and attempted sexual assaults. Sexual trauma during military service was more strongly associated with lifetime EDOs than childhood sexual trauma. The significant associations found between EDOs, PTSD, and sexual trauma indicate that EDO screening among women veterans with PTSD or histories of sexual trauma may be warranted.ABSTRACTWe examine lifetime eating disorders (EDOs) and associations with post-traumatic stress disorder (PTSD) and sexual trauma during various stages of the life course (childhood, during military service, and lifetime) among women veterans. The sample included 1,004 women aged 20 to 52 years who had enrolled at 2 Midwestern Veterans Affairs Medical Centers or outlying clinics completed a retrospective telephone interview. Over 16% reported a lifetime EDO (4.7% had received a diagnosis, and an additional 11.5% self-reported suffering from an EDO). Associations were found between lifetime EDO, PTSD, and sexual trauma. Relationships maintained significance for both diagnosed and self-reported EDOs as well as lifetime completed rape and attempted sexual assaults. Sexual trauma during military service was more strongly associated with lifetime EDOs than childhood sexual trauma. The significant associations found between EDOs, PTSD, and sexual trauma indicate that EDO screening among women veterans with PTSD...

Do faculty and resident physicians discuss their medical errors

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues. Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables. Results: Responses were received from 338 participants (response rate  = 74%). In all, 73% of respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision (91%), wanting colleagues to learn from the mistake (80%) and wanting to receive support (79%). Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm (77%), minor harm (87%) or major harm (94%). Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion (OR 4.17, CI 2.34 to 7.42). Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners.

Direct Reporting of Laboratory Test Results to Patients by Mail to Enhance Patient Safety

BACKGROUND: Missed test results are common in clinical practice and compromise patient safety. Direct reporting, whereby testing centers systematically notify both patients and providers of important test results, constitutes a potential solution, but provider acceptance is unknown. OBJECTIVE: To assess provider interest in direct reporting of selected test results and how interest varied across different tests. DESIGN, SETTING, AND PARTICIPANTS: Survey of primary care physicians at a tertiary care academic medical center. MEASUREMENT: Five-point Likert scores were used to gauge each physician’s interest (1=not at all interested to 5=very interested) in scenarios pertaining to the direct reporting of 3 diagnostic tests of low (DXA scan), intermediate (genital herpes testing), and high (breast biopsy) “emotional impact” and whether interest varied with each test’s result (normal vs abnormal). Physicians were also asked to cite specific advantages and disadvantages of direct reporting. RESULTS: The response rate was 73% (148/202). Physician interest in direct reporting decreased progressively as scenarios shifted from low (DXA scan) to high (breast biopsy) emotional impact (P<.001); interest in direct reporting was also higher when results were normal rather than abnormal (P<.001). Common advantages of direct reporting cited by respondents were reductions in workload (selected by 75% of respondents) and reductions in missed diagnoses (38%). The most common concerns were that patients would become unnecessarily frightened (70%) and would seek unreliable information (65%). CONCLUSION: Direct reporting of selected test results to patients is one system for insuring that important results are not missed, but implementation should consider the specific test in question, the test result, and provider preferences.

Borderline personality disorder and traits in veterans: psychiatric comorbidity, healthcare utilization, and quality of life along a continuum of severity.

OBJECTIVE To examine the presence of borderline personality disorder (BPD) traits in Gulf War veterans, and to assess psychiatric comorbidity, health status, healthcare utilization, and quality of life (QOL) along a continuum of BPD trait severity. METHOD BPD and traits were evaluated using the Schedule for Non-Adaptive and Adaptive Personality in 576 veterans who were either deployed to the Persian Gulf (1990-1991) or were on active duty though not deployed to the Gulf. Demographic and military characteristics, personal and family history, psychiatric comorbidity, and QOL were also assessed. RESULTS One or more BPD traits were present in 247 subjects (43%), and BPD (>5 traits) was identified in 15 subjects (3%). The number of traits was significantly associated with age and level of education. Lifetime psychiatric comorbidity was significantly associated with the number of BPD traits present, and level of functioning, health status, healthcare utilization, social functioning, self-injurious tendencies, and military/behavioral problems. CONCLUSION BPD and traits identified in Gulf War veterans were associated with significant psychiatric morbidity, poorer QOL, and increased utilization of healthcare resources. Early recognition and treatment of veterans with BPD symptoms may be warranted to minimize the burden on the healthcare system.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships

Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.