Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

INTRODUCTION: Prescribers have the medicolegal responsibility to ensure a sufficiently reliable system is in place to securely monitor the process of efficiently communicating laboratory results. With added complexity of technologies such as electronic medical record systems, few studies address the monitoring, verification and improvement of test results follow-up especially within a teaching facility including resident prescribers. METHOD: The main goal of this quality improvement project was to ensure safety of care through reliable test results follow-up and adapting processes to available technology by (1) implementing an improved, more reliable and efficient system for tracking test results in the setting; and (2) increasing perceived reliability of test results monitoring system of prescribers in the clinical setting. Through three Plan-Do-Study-Act cycles, changes were implemented: (1) family medicine residents recognised as prescribers; (2) connection of prescribers to regional techno-centre; and (3) computer protocol eliminating duplicates. Patients and clinical staff completed surveys (satisfaction, perceived safety and reliability). ANALYSIS: Quantitative and qualitative data were collected, reported incidents, requested prescriptions and received results and time spent communicating normal results. Immediate feedback from prescribers and staff members was considered to improve the process. Microsoft Excel software was used to calculate mean and SD of error rate. Shewhart chart rules were used to determine special cause of change and sustainability. RESULTS: Implemented changes led to decrease in mean error rate (from 6.1% to 1.9%), variation of range (from 2.7-12.1% to 0-4.8%) and SD (from 2.1% to 1.2%). The improvement is sustained over 24 months after the last cycle. 100% of the 30 patients surveyed were satisfied with the changes implemented. Prescribers (75% response rate) including residents (15.8% response rate) perceived the improved system to be safer, more reliable and efficient. CONCLUSION: Implemented changes improved reliability, efficiency and perceived safety of the test results monitoring system while ensuring patient satisfaction.

A step-by-step approach to patients leaving against medical advice (AMA) in the emergency department.

OBJECTIVES: Patients leaving against medical advice (AMA) can be distressing for emergency physicians trying to navigate the medical, social, psychological, and legal ramifications of the situation in a fast-paced and chaotic environment. To guide physicians in fulfilling their obligation of care, we aimed to synthesize the best approaches to patients leaving AMA. METHODS: We conducted a scoping review across various fields of work, research context and methodology to synthesize the most relevant strategies for emergency physicians attending patients leaving AMA. We searched Medline, CINAHL, PSYCHO Legal Source, PsycINFO, PsycEXTRA, Psychological and Behavioural Sciences collection, SocIndex and Scopus. Search strategies included controlled vocabulary (i.e., MESH) and keywords relevant to the subject chosen by a team of four people, including two specialized librarians. RESULTS: The literature review included 34 relevant papers about approaches to patients leaving AMA: 8 case presentations, 4 ethical case analyses, 10 legal letters, 4 reviews and 8 original studies. The main identified strategies were prioritizing a patient-centered approach, proposing alternative discharge and reducing harm while properly documenting the encounter. CONCLUSION: A systematic approach to patients leaving AMA could help improve patient care, support physicians and decrease stigmatization of this population. We advocate that emergency physicians should receive training on how to approach patients leaving AMA to limit the impact on this vulnerable population.

RéSUMé: OBJECTIFS: Les patients qui quittent contre avis médical peuvent être angoissants pour les médecins d'urgence tentant de naviguer les ramifications médicales, sociales, psychologiques et juridiques dans un environnement chaotique et au rythme effrené. Afin de guider ces médecins dans l'accomplissement de leur obligation de soins, nous avons cherché à synthétiser les meilleures approches dans la littérature face à cette situation. MéTHODES: Nous avons réalisé une revue de la littérature de type « scoping review¼ dans une grande variété de domaines de travail, de contextes de recherche et de méthodologies afin de synthétiser les stratégies les plus pertinentes visant à guider les médecins d'urgence faisant face à un départ contre avis médical. Cette recherche a été effectuée dans plusieurs banques de données: Medline, CINAHL, PSYCHO Legal, Source, PsycINFO, PsycEXTRA, psychological and Behavioral sciences collection, SocIndex et Scopus. Les stratégies de recherche comprenaient un vocabulaire contrôlé (soit les MESH) et des mots clés pertinents au sujet choisis par une équipe de quatre personnes, dont une bibliothécaire universitaire spécialisée. RéSULTATS: Cette revue de littérature a identifié 34 études pertinentes sur les stratégies pour les patients quittant contre avis médical: huit présentations de cas, quatre analyses éthiques, dix lettres d'opinion d'experts juridiques, huit recherches originales et quatre revues de littérature. Les principales stratégies identifiées proposent de préconiser une approche centrée sur le patient, de proposer un congé alternatif et de diminuer les impacts pour le patient tout en documentant chacune des étapes de la démarche. CONCLUSION: Une approche systématique des patients qui quittent contre avis médical pourrait aider la pratique, soutenir les médecins et réduire la stigmatisation de cette patientèle. Nous suggérons que les médecins d'urgence reçoivent une formation visant la prise en charge de ces patients afin de limiter les impacts sur cette population vulnérable.