Anonymous group peer review in surgery morbidity and mortality conference.

BACKGROUND: Surgical peer review might be characterized by assessment heterogeneity. METHODS: We performed a prospective, anonymous, peer review of surgeon and system performance during a morbidity and mortality conference. RESULTS: Twenty-two cases were reviewed by a mean of 48.9 respondents each, including attendings, fellows, and residents. A mean of 50% (standard deviation, 23%) of respondents identified some quality issue in each case, reflecting high heterogeneity. The mean percentage in identifying a system issue was 27%, and in identifying a physician issue was 37%. When identifying a physician issue, physician care was judged as appropriate by 72%, as controversial by 26%, or as inappropriate by 2%. Residents were more likely than attendings to identify system issues (odds ratio, 2.23) and physician issues (odds ratio, 3.58), but attendings were more likely to rate care controversial or inappropriate (odds ratio, 2.53). CONCLUSIONS: Surgical peer reviews, even after group discussion, display substantial heterogeneity. Review methods should account for this heterogeneity.

Lost opportunities: how physicians communicate about medical errors.

Although physicians have been described as "reluctant partners" in reporting medical errors, this survey of 1,082 U.S. physicians found that most were willing to share their knowledge about harmful errors and near misses with their institutions and wanted to hear about innovations to prevent common errors. However, physicians found current systems to report and disseminate this information inadequate and relied on informal discussions with colleagues. Thus, much important information remains invisible to institutions and the health care system. Efforts to promote error reporting might not reach their potential unless physicians become more effectively engaged in reporting errors at their institutions.

The emotional impact of medical errors on practicing physicians in the United States and Canada.

BACKGROUND: Being involved in medical errors can compound the job-related stress many physicians experience. The impact of errors on physicians was examined. METHODS: A survey completed by 3,171 of the 4,990 eligible physicians in internal medicine, pediatrics, family medicine, and surgery (64% response rate) examined how errors affected five work and life domains. RESULTS: Physicians reported increased anxiety about future errors (61%), loss of confidence (44%), sleeping difficulties (42%), reduced job satisfaction (42%), and harm to their reputation (13%) following errors. Physicians' job-related stress increased when they had been involved with a serious error. However, one third of physicians only involved with near misses also reported increased stress. Physicians were more likely to be distressed after serious errors when they were dissatisfied with error disclosure to patients (odds ratio [OR] = 3.86, confidence interval [CI] = 1.66, 9.00), perceived a greater risk of being sued (OR = .28, CI = 1.50, 3.48), spent greater than 75% time in clinical practice (OR = 2.20, CI = 1.60, 3.01), or were female (OR = 1.91, CI = 1.21, 3.02). Only 10% agreed that health care organizations adequately supported them in coping with error-related stress. DISCUSSION: Many physicians experience significant emotional distress and job-related stress following serious errors and near misses. Organizational resources to support physicians after errors should be improved.

Patients' concerns about medical errors during hospitalization.

BACKGROUND: A clear understanding of patients' understanding and perceived risk of medical errors is needed. Multiwave telephone interviews were conducted in 2002 with 1,656 inpatients from 12 Midwestern hospitals regarding patients' conceptualization of medical errors and perceived risk of seven types of medical errors. RESULTS: Patients defined medical errors to include not only clinical mistakes but also falls, communication problems, and responsiveness. Ninety-four percent of respondents reported their medical safety as good, very good, or excellent, but 39% experienced at least one error-related concern, most commonly medication errors (17% of respondents), nursing mistakes (15%), and problems with medical equipment (10%). Frequency of concerns was associated with reduced willingness to recommend the hospital (p < .001). DISCUSSION: If patients' definition of medical errors is broader than the traditional medical definition, providers should clarify the term "error" to ensure effective communication. Most patients felt a high level of medical safety but a sizeable proportion experienced a concern about an error during hospitalization. The selective nature of concerns and the impact of patient and hospital characteristics provide insight into ways to engage patients in error prevention programs.

Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital.

OBJECTIVES: Most research on hospital falls has focused on predictors of falling, whereas less is known about predictors of serious fall-related injury. Our objectives were to characterize inpatients who fall and to determine predictors of serious fall-related injury. METHODS: We performed a retrospective observational study of 1,082 patients who fell (1,235 falls) during January 2001 to June 2002 at an urban academic hospital. Multivariate analysis of potential risk factors for serious fall-related injury (vs no or minor injury) included in the hospital's adverse event reporting database was conducted with logistic regression to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CI95) RESULTS: The median age of patients who fell was 62 years (interquartile range, 49-77 years), 50% were women, and 20% were confused. The hospital fall rate was 3.1 falls per 1,000 patient-days, which varied by service from 0.86 (women and infants) to 6.36 (oncology). Some (6.1%) of the falls resulted in serious injury, ranging by service from 3.1% (women and infants) to 10.9% (psychiatry). The most common serious fall-related injuries were bleeding or laceration (53.6%), fracture or dislocation (15.9%), and hematoma or contusion (13%). Patients 75 years or older (aOR, 3.2; CI95, 1.3-8.1) and those on the geriatric psychiatry floor (aOR, 2.8; CI95, 1.3-6.0) were more likely to sustain serious fall-related injuries. CONCLUSIONS: There is considerable variation in fall rates and fall-related injury percentages by service. More detailed studies should be conducted by floor or service to identify predictors of serious fall-related injury so that targeted interventions can be developed to reduce them.

Randomized trial of a nurse-administered, telephone-based disease management program for patients with heart failure.

BACKGROUND: Heart failure is a common and important cause of morbidity and mortality. Disease management offers promise in reducing the need for hospitalization and improving quality of life for heart failure patients, but experimental data on the efficacy of such programs are limited. METHODS AND RESULTS: A total of 151 patients hospitalized with heart failure were randomized to usual care or scheduled telephone calls by specially trained nurses promoting self-management and guideline-based therapy as prescribed by primary physicians. Nurses also screened patients for heart failure exacerbations, which they managed with supplemental diuretics or by contacting the primary physician for instructions. Outcomes included time to hospital encounter, mortality, number and cost of hospitalizations, functional status, and satisfaction with care. Intervention patients had a longer time to encounter (hazard ratio [HR] = 0.67; 95% confidence interval [CI] 0.47-0.96; P = .029), hospital readmission (HR = 0.67; CI 0.46-0.99; P = .045), and heart failure-specific readmission (HR = 0.62; CI 0.38-1.03; P = .063). The number of admissions, hospital days, and hospital costs were significantly lower during the first 6 months after intervention but not at 1 year. The intervention had little effect on functional status, mortality, and satisfaction with care. CONCLUSION: A nurse-administered, telephone-based disease management program delayed subsequent health care encounters, but had minimal impact on other outcomes.

Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.

PURPOSE: To assess medical students' and housestaff's knowledge, attitudes, and behaviors regarding safe prescribing. METHOD: In 2003, 214 housestaff (interns and residents) and 77 medical students in medicine and surgery at Barnes-Jewish Hospital, St. Louis, Missouri, were asked to complete an anonymous, self-administered questionnaire about safe prescribing. Questions asked about training in and attitudes about safe-prescribing and current prescribing behaviors. Fisher exact test was used to compare attitudes and behaviors among subgroups. RESULTS: Of the 175 (60%) respondents, 73 (59%) of 123 housestaff and eight (15%) of 52 students agreed that their safe-prescribing training was adequate (p < .001), and 145 (83%) total respondents agreed that prescribing errors were unacceptable. Respondents reported always doing the following: 156 (89%) checked prescribing information before prescribing new drugs, 131 (75%) checked for drug allergies, 103 (59%) double-checked dosage calculations, 98 (56%) checked for renal impairment, and 53 (30%) checked for potential drug-drug interactions. CONCLUSION: Routine use of safe medication prescribing behaviors among housestaff and medical students was poor. Contributing factors may have included inadequate training and a culture that does not support safe prescribing. Effective strategies to increase safe medication prescribing need to be identified and implemented.

A case-control study of patient, medication, and care-related risk factors for inpatient falls.

OBJECTIVE: To comprehensively analyze potential risk factors for falling in the hospital and describe the circumstances surrounding falls. DESIGN: Case-control study. Data on potential risk factors and circumstances of the falls were collected via interviews with patients and/or nurses and review of adverse event reports, medical records, and nurse staffing records. SETTING: Large urban academic hospital. PATIENTS: Ninety-eight inpatients who fell and 318 controls matched on approximate length of stay until the index fall. MEASUREMENTS AND MAIN RESULTS: In a multivariate model of patient-related, medication, and care-related variables, factors that were significantly associated with an increased risk of falling included: gait/balance deficit or lower extremity problem (adjusted odds ratio [aOR], 9.0; 95% confidence interval [CI], 2.0 to 41.0), confusion (aOR, 3.6; 95% CI, 1.6 to 8.4), use of sedatives/hypnotics (aOR, 4.3; 95% CI, 1.6 to 11.5), use of diabetes medications (aOR, 3.2; 95% CI, 1.3 to 7.9), increasing patient-to-nurse ratio (aOR, 1.6; 95% CI, 1.2 to 2.0), and activity level of "up with assistance" compared with "bathroom privileges" (aOR, 8.7; 95% CI, 2.3 to 32.7). Urinary or stool frequency or incontinence was of borderline significance (aOR, 2.3; 95% CI, 0.99 to 5.6). Having one or more side rails raised was associated with a decreased risk of falling (aOR, 0.006; 95% CI, 0.001 to 0.024). CONCLUSIONS: Patient health status, especially abnormal gait or lower extremity problems, medications, as well as care-related factors, increase the risk of falling. Fall prevention programs should target patients with these risk factors and consider using frequently scheduled mobilization and toileting, and minimizing use of medications related to falling.

Patient concerns about medical errors in emergency departments.

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.

Using focus groups to understand physicians' and nurses' perspectives on error reporting in hospitals.

BACKGROUND: To increase error reporting, a better understanding of physicians' and nurses' perspectives regarding medical error reporting in hospitals, barriers to reporting, and possible ways to increase reporting is necessary. METHODS: Nine focus groups--four with 49 staff nurses, two with 10 nurse managers, and three with 30 physicians--from 20 academic and community hospitals were conducted in May-June 2002 in the St. Louis metropolitan area. Qualitative analysis of focus group transcripts characterized participants' perspectives. RESULTS: Although participants knew they should report errors associated with serious adverse events, there was much uncertainty about reporting less serious errors or near misses. Nurses were more knowledgeable than physicians about how to report errors. All groups mentioned barriers to reporting, such as fear of reprisals and lack of confidentiality, time, and feedback after an error is reported. Some physicians doubted the benefit of reporting errors, but, generally, both physicians and nurses agreed that reporting was intended to change practice and policy to promote patient safety. CONCLUSIONS: A culture characterized by anonymous reporting, freedom from repercussions, and feedback about error reports should promote error reporting.

Early mobilization of patients hospitalized with community-acquired pneumonia.

STUDY OBJECTIVE: To determine if early mobilization (EM) of hospitalized adults with community-acquired pneumonia (CAP) reduces hospital length of stay. DESIGN: Group randomized trial. SETTING: Three Midwestern hospitals. PARTICIPANTS: Four hundred fifty-eight patients with CAP admitted to 17 general medical units between November 1997 and April 1998. INTERVENTION: EM was defined as sitting out of bed or ambulating for at least 20 min during the first 24 h of hospitalization. Progressive mobilization occurred each subsequent day during hospitalization. MEASUREMENTS AND RESULTS: Intervention (n = 227) and usual-care patients (n = 231) were similar in age, gender, disease severity, door-to-drug delivery time, and IV-to-po switchover time. Hospital length of stay for EM vs usual care was significantly less (mean, 5.8 vs 6.9 days; adjusted absolute difference, 1.1 days; 95% confidence interval, 0.0 to 2.2 days). There were no differences in adverse events or other secondary outcomes between treatment groups. CONCLUSIONS: Like patients hospitalized with acute myocardial infarction and total knee replacements, EM of hospitalized patients with CAP reduces overall hospital length of stay and institutional resources without increasing the risk of adverse outcomes.

Implementation of an automated guideline monitor for secondary prevention of acute myocardial infarction.

Clinical practice guidelines can be used to help improve health care quality, but they are often not optimally implemented. Practice enabling and reinforcing techniques, such as clinical reminders and academic detailing are effective methods for translating guidelines into practice. Following a study showing that we could improve adherence to secondary prevention guidelines for acute myocardial infarction (AMI) using computerized alerts and academic detailing, we implemented an automated monitor to accomplish the same goal in a less labor-intensive manner. This paper describes the implementation of this production application.