Diagnostic error in children presenting with acute medical illness to a community hospital.

OBJECTIVE: To determine incidence and aetiology of diagnostic errors in children presenting with acute medical illness to a community hospital. DESIGN: A three-stage study was conducted. Stage 1: retrospective case note review, comparing admission to discharge diagnoses of children admitted to hospital, to determine incidence of diagnostic error. Stage 2: cases of suspected misdiagnosis were examined in detail by two reviewers. Stage 3: structured interviews were conducted with clinicians involved in these cases to identify contributory factors. SETTING: UK community (District General) hospital. PARTICIPANTS: All medical patients admitted to the paediatric ward and patients transferred from the Emergency Department to a different facility over a 90-day period were included. MAIN OUTCOME MEASURES: Incidence of diagnostic error, type of diagnostic error and content analysis of the structured interviews to determine frequency of emerging themes. RESULTS: Incidence of misdiagnosis in children presenting with acute illness was 5.0% (19/378, 95% confidence interval (CI) 2.8-7.2%). Diagnostic errors were multi-factorial in origin, commonly involving cognitive factors. Reviewers 1 and 2 identified a median of three and four errors per case, respectively. In 14 cases, structured interviews were possible; clinicians believed system-related errors (organizational flaws, e.g. inadequate policies, staffing or equipment) contributed more commonly to misdiagnoses, whereas reviewers found cognitive factors contributed more commonly to diagnostic error. CONCLUSIONS: Misdiagnoses occurred in 5% of children presenting with acute illness and were multi-factorial in aetiology. Multi-site longitudinal studies further exploring aetiology of errors and effect of educational interventions are required to generalize these findings and determine strategies for mitigation.

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

OBJECTIVE: To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm. DESIGN: Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009. PARTICIPANTS: 52 preventable hospital deaths. SETTING: England. MAIN OUTCOME MEASURES: The nature of problems in care and contributory factors underlying avoidable deaths in hospital. RESULTS: The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. CONCLUSION: Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.

Relationship between preventable hospital deaths and other measures of safety: an exploratory study.

OBJECTIVE: To explore associations between the proportion of hospital deaths that are preventable and other measures of safety. DESIGN: Retrospective case record review to provide estimates of preventable death proportions. Simple monotonic correlations using Spearman's rank correlation coefficient to establish the relationship with eight other measures of patient safety. SETTING: Ten English acute hospital trusts. PARTICIPANTS: One thousand patients who died during 2009. RESULTS: The proportion of preventable deaths varied between hospitals (3-8%) but was not statistically significant (P = 0.94). Only one of the eight measures of safety (Methicillin-resistant Staphylococcus aureus bacteraemia rate) was clinically and statistically significantly associated with preventable death proportion (r = 0.73; P < 0.02). There were no significant associations with the other measures including hospital standardized mortality ratios (r = -0.01). There was a suggestion that preventable deaths may be more strongly associated with some other measures of outcome than with process or with structure measures. CONCLUSIONS: The exploratory nature of this study inevitably limited its power to provide definitive results. The observed relationships between safety measures suggest that a larger more powerful study is needed to establish the inter-relationship of different measures of safety (structure, process and outcome), in particular the widely used standardized mortality ratios.

Hospital patients' reports of medical errors and undesirable events in their health care.

OBJECTIVE: To investigate hospital patients' reports of undesirable events in their health care. DESIGN: Cross-sectional mixed methods design. PARTICIPANTS: A total of 80 medical and surgical patients (mean age 58, 56 male). INTERVENTION: Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed. MAIN OUTCOME MEASURES: Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care. RESULTS: In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system. CONCLUSION: Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.

Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.

INTRODUCTION: Monitoring hospital mortality rates is widely recommended. However, the number of preventable deaths remains uncertain with estimates in England ranging from 840 to 40 000 per year, these being derived from studies that identified adverse events but not whether events contributed to death or shortened life expectancy of those affected. METHODS: Retrospective case record reviews of 1000 adults who died in 2009 in 10 acute hospitals in England were undertaken. Trained physician reviewers estimated life expectancy on admission, to identified problems in care contributing to death and judged if deaths were preventable taking into account patients' overall condition at that time. RESULTS: Reviewers judged 5.2% (95% CI 3.8% to 6.6%) of deaths as having a 50% or greater chance of being preventable. The principal problems associated with preventable deaths were poor clinical monitoring (31.3%; 95% CI 23.9 to 39.7), diagnostic errors (29.7%; 95% CI 22.5% to 38.1%), and inadequate drug or fluid management (21.1%; 95% CI 14.9 to 29.0). Extrapolating from these figures suggests there would have been 11 859 (95% CI 8712 to 14 983) adult preventable deaths in hospitals in England. Most preventable deaths (60%) occurred in elderly, frail patients with multiple comorbidities judged to have had less than 1 year of life left to live. CONCLUSIONS: The incidence of preventable hospital deaths is much lower than previous estimates. The burden of harm from preventable problems in care is still substantial. A focus on deaths may not be the most efficient approach to identify opportunities for improvement given the low proportion of deaths due to problems with healthcare.

Junior doctors' reflections on patient safety.

AIM: To determine whether foundation year 1 (FY1) doctors reflect upon patient safety incidents (PSIs) within their portfolios and the potential value of such reflections for quality of care. METHODS: A cross-sectional retrospective review of every 'reflective practice' portfolio entry made by all FY1 doctors within an Acute Teaching Hospital Trust was conducted in February 2010. Entries were reviewed by two independent blinded researchers to determine whether they related to a PSI that is, any unintended or unexpected incident that could have or did lead to patient harm. For all entries rated positive by both reviewers, a content analysis approach was used to code PSI into incident type, contributing factors and patient outcome according to validated frameworks developed by the National Patient Safety Agency. RESULTS: 139 reflective practice entries were completed by 30 trainees (15 men, 15 women, mean age 24 years). Of the 139 entries, 49% reflected on a PSI. Of these, 22% were due to errors in clinical assessment; 22% were due to delayed access to care; 18% were due to infrastructure/staffing deficiencies; and 16% were due to medication errors. The most common contributing factors were team/social factors (23%), patient factors (22%), communication and task factors (both 17%). The majority of PSIs led to no harm. Six entries described PSIs resulting in patient death, the majority of which were attributable to diagnostic errors. CONCLUSIONS: FY1 doctors commonly reflect on PSIs within their professional portfolios. Such critical reflection can encourage learning but may also promote patient safety and the quality of healthcare across all medical specialties.

Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.

Diagnostic error underlies about 10% of adverse events occurring in hospital practice. However, there have been very few studies considering means of improving the mechanisms of diagnosis. As a result, misdiagnosis has been described as 'the next frontier for patient safety'. In this study of case records of patients admitted to hospital as emergencies, some key factors that may underlie diagnostic errors were assessed. From these observations, possibilities for improving the quality of diagnosis and the planning of subsequent care are explored. This paper shows that cognitive biases, believed to distort diagnostic conclusions, can be applied quite specifically to stages in clinical care. These observations led to the proposal of a clinical assessment with a method designed to encourage analytical reasoning. In addition, minor defects in standard practice are shown to adversely influence diagnosis. The findings of this study offer possible means of improving the quality of diagnosis and subsequent patient care, and perhaps pave the way for prospective studies.

Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study.

OBJECTIVE: To identify patient safety factors in pre-hospital and hospital management of critically ill children dying in a paediatric intensive care unit (PICU). DESIGN: Retrospective case notes review. SETTING: Single tertiary regional PICU in London. PARTICIPANTS: 47 patients (7%) who died from a total of 679 children admitted during 2007 and 2008. Median age was 1.1 years and median predicted mortality from the Paediatric Index of Mortality 2 score was 39%. MAIN OUTCOME MEASURES: Adverse events contributing to death (AEds) and critical incidents (CIs). AEd was defined as an unintended injury or complication caused by health care management, contributing to death. CI was defined as an undesirable event in healthcare management, which could have led to harm or did lead to harm of the patient but did not contribute to the patient's death. RESULTS: 22 AEds occurred in 17 of 47 (36%) cases. Two AEds occurred in primary care, 20 in pre-PICU hospital care, and none in PICU. AEds were mainly problems in diagnosis and management of critical illness. 37 CIs occurred in 28 of 47 (60%) cases. Two CIs occurred prior to hospital admission, 17 occurred in pre-PICU hospital care, 1 during inter-hospital transport and 17 in PICU. CIs were predominantly medical management and procedure related. Individual, team and organisational factors caused the majority of AEds and CIs. CONCLUSION: Adverse events in pre-PICU hospital care were common in children who subsequently died in PICU. CIs occurred throughout the patient journey. Interventional studies of healthcare organisation and delivery are necessary to identify appropriate strategies to improve patient safety.

The problem of engaging hospital doctors in promoting safety and quality in clinical care.

There is widespread agreement that the medical profession has much to learn about addressing adverse events in clinical practice and participating in clinical governance. In England and Wales centrally driven initiatives such as medical audit, clinical governance and the National Reporting and Learning System have failed to transform the management of iatrogenic adverse events. In this article we explore the historical and cultural background of these issues with respect to hospital medicine and suggest means of tackling the challenges ahead.

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.

BACKGROUND: Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi-hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real-time record review for the recognition of clinical risks associated with hospital inpatient care. METHODOLOGY: Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge. RESULTS: Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods. CONCLUSION: The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme.

Learning from litigation. The role of claims analysis in patient safety.

Claims for malpractice and medical negligence are a potentially important source of information on the causes of harm to patients and have provided valuable lessons in the past. However today, with many additional sources of information and methods of analysis, the role of claims analysis needs to be reappraised. We consider the role of claims analysis in relation to other methods of studying adverse outcomes, review previous studies of claims and summarize the findings of four recent British specialty claims reviews. Claims analysis has a number of inherent limitations. We suggest that there is now no case for ad hoc claims reviews which rely on data that have been assembled for legal purposes only. Claims review is still potentially useful for rare events or in cases where other sources of data are not available. However, future claims reviews need to meet basic criteria before being undertaken; these include prospective identification of the relevant questions and variables, adequacy and completeness of the data set, availability of expert reviewers and clear protocols for review.

Recognising adverse events and critical incidents in medical practice in a district general hospital.

A pilot audit of case records of consecutively discharged patients from a district general hospital was undertaken by specialist registrars, SHOs and senior nurses in order to identify adverse events (AEs) and critical incidents (CIs) related to hospital care. Experienced external assessors taught the clinical staff to use a previously validated structured method of case record review that facilitates analysis. The external assessors audited the same case records in parallel. Aggregated data from 154 case records of patients admitted to the general medical wards were collected for analysis. Fifteen AEs and 41 CIs were identified in the case records covering the hospital admission. In addition, 16 AEs and nine CIs were discovered to have occurred before admission or, for three AEs, shortly after discharge. One-half of the episodes related to problems arising during ward care and for one-half of these issues remained unresolved at the time of discharge. One-third of episodes related to medications or the administration of intravenous fluids--and in these cases there were defects in monitoring the patients' clinical progress. This study led to initiatives to improve care at the host hospital and we believe that further programmes along similar lines are indicated.