Neurologists for patient safety: where we stand, time to deliver.

Neurologists have a professional opportunity, an ethical responsibility, and sound clinical and economic reasons for engaging in efforts to improve patient safety. Better communication with patients and other providers, closer follow-up of consultation cases, and more focused supervision of trainees will help to reduce current patterns of error and misunderstanding. Patient education with attention to health literacy should improve adherence to management plans and help to bridge transitions of care across providers and sites. Through teaching and by example, neurologists can profoundly influence successive generations of clinicians to adopt safer practices, a culture of openness, and enhanced professionalism. The federal Safety and Quality Improvement Act of 2005, once implemented, should increase the evidence basis for safer care through voluntary, legally protected reporting of errors and adverse events within the framework of patient safety organizations.

Neurologic patient safety: an in-depth study of malpractice claims.

This in-depth study of neurologic malpractice claims indicated authentic, preventable patient harm in 24 of 42 cases, enabling comparison with larger but administratively abstracted summary reports. Principal findings included the common occurrence of outpatient events, lapses in communication with patients and other providers, the need for follow-through by the consultant neurologist even when not primarily responsible, the frequency of diagnostic errors, and pitfalls associated with imaging.

The neurologist and patient safety.

BACKGROUND: The objective of this article is to acquaint neurologists with the current status of evidence and opinion on patient safety in neurology. Research data on errors and preventable adverse events (harm from medical management) in neurology are sparse, with little light being cast thus far on the vulnerabilities of individual neurologists and neurologic office practices. However, areas of particular concern and lines of appropriate action are now becoming apparent. REVIEW SUMMARY: This review draws on the few studies of neurologic malpractice claims, inpatient incident reports and chart reviews, and articles and abstracts in the journal literature. These are placed in the context of the general epidemiology of medical errors, adverse events, and approaches to remediation. CONCLUSION: Accurate and timely diagnosis in all its aspects represents the single largest category of error. Most neurologists have their first interaction with a patient and family at the time of a critical illness, underlining the importance of improved communication, not only with them but with other caregivers. Systems of information transfer, such as those enabling timely imaging reports, are critical. Better consultative follow-up may be pivotal. Education in patient safety competencies and closer supervision of trainees can be expected to improve protection. Venues, such as emergency departments, in which relevant knowledge and skills may be insufficient to maximize patient safety, deserve particular attention.

Evidence-guided education: patients' outcome data should influence our teaching priorities.

How should medical educators choose learning objectives and teaching content in clinical education? Given the information chain reaction, coverage of all significant topics in sufficient depth is not possible. Choosing subjects of high priority is essential if education is to have maximum impact on quality of care. These priorities should not derive from tradition and opinion, but should be informed by patient outcomes, the ultimate standard for assessing educational effectiveness. Building upon prior initiatives linking education to practice, the author uses the term "evidence-guided education" to express the process of influencing curricular choices with evidence from health outcomes. Sources of outcome evidence include incident reports, morbidity and mortality conferences, surveillance of quality of care in particular venues, case series, surveys of adverse events and "near-misses," and malpractice claims. Starting with anecdotal occurrences, additional case-finding may establish patterns of poor outcomes, some of which may be preventable. Credible research data on outcomes can inform prioritization for objectives and content at successive institutional levels, which should improve practices and outcomes, completing the loop of feedback, implementation, and improved health. The closer the educational intervention is to practice, the more accountable it becomes. Thus, EGE is more amenable to evaluation at residents' and practitioners' levels and more difficult at the undergraduate level. However, outcome evidence should still inform undergraduate teaching, since this constitutes the platform for future learning. Severe constraints on learning time mandate prioritization of content and suggest the need for the judicious application of outcome evidence in place of mere opinion.

The sleep-deprived electroencephalogram: evidence and practice.

BACKGROUND: Sleep deprivation for the initial electroencephalogram for suspected seizures is a widespread but inconsistent practice not informed by balanced evidence. Daily practice suggests that nonneurologists are confused by the meaning and value of, and indications for, "sleep" (tracing) vs "sleep deprivation" (and other alternatives). They need specific, informed guidance from general neurologists on best practices. OBJECTIVES: To document illustratively the variability of neurologists' practices, the level of relevant information among nonneurologists, and the current state of published evidence; and to stimulate formulation of consensus advisories. DESIGN AND SETTING: I surveyed knowledge and practices of (1) nonneurologists in a community teaching hospital; (2) local and national neurologists and epileptologists; (3) electroencephalogram laboratory protocols; and (4) textbook accounts and recommendations and the relevant journal literature. National professional organizations were contacted for advisories or guidelines. RESULTS: Most nonneurologists surveyed misunderstood "sleep" vs "sleep-deprived" electroencephalograms and their actual protocols. They are unaware of evidence on benefits vs burdens. Neurologists' practices are inconsistent. Experts generally agree that sleep deprivation produces substantial activation of interictal epileptiform discharges beyond the activation of sleep per se. However, most published recommendations and interviewed epileptologists do not suggest sleep deprivation for the initial electroencephalogram because of "inconvenience" (burdens) for the patient. Evidence-based or reasoned guidance is minimal, and professional societies have not issued advisories. CONCLUSION: Confusion over sleep deprivation, disparities between evidence and recommendations, and inconsistent practices create a need for expert consensus for guidance, as well as comparative research on alternative methods of increasing diagnostic yield.

How best to evaluate clinician-educators and teachers for promotion?

The challenge of how best to evaluate educational scholars (and specifically, clinician-educators) and teachers for promotion continues to confront academia. While the work of educational scholars and teachers often overlaps, the terms for justifying their promotion differ substantially. In each case, the author maintains that evaluation should be oriented to evidence of the impact of their work. Educational scholars can be assessed mainly by objective impact, whereas the evidence for the impact of teachers should include profound, subjective effects on individual learners. For example, for clinician-educators engaged in scholarly work, the impact of that work can be identified in terms of changes in educational methods, career commitments, and practices (all intermediate outcomes), and even health outcomes. For teachers, in addition to customary criteria such as critical thinking, depth of knowledge, communication ability, and personal engagement, learners can be asked about the deep influence of these teachers. The author states his case for these principles, and also presents an innovative tool, the "impact map," as a way of graphically portraying the track record of an individual clinician-educator. Such maps are more vivid than narrative testimonials in organizing and displaying evidence of impact over time. This tool, combined with the author's other suggestions to assist the promotion process for educators and teachers, is aimed at fostering a greater emphasis on outcomes in assessing both clinician-educators and teachers to achieve greater rigor and fairness.