Contributing factors identified by hospital incident report narratives.

CONTEXT: A major purpose of incident reporting is to understand contributing factors so that causes of errors can be uncovered and systems made safer. For established reporting systems in US hospitals, little is known about how well the reports identify contributing factors. OBJECTIVE: To characterise the information incident report narratives provide about contributing factors using a taxonomy we developed for this purpose. DESIGN: Descriptive study examining 2228 reports for 16 575 randomly selected patients discharged from an academic and a community hospital in the US between 1 January and 31 December 2001. MAIN OUTCOMES MEASURED: Reports in which patient, system and provider (errors, mistakes and violations) factors were identifiable. RESULTS: 80% of reports described at least one contributing factor. Patient factors were identifiable in 32%, most frequently illness (61% of these reports) and behaviour (24%). System factors were identifiable in 32%, most commonly equipment malfunction or difficulty of use (38%), problems coordinating care among providers (31%), provider unavailability (24%) and tasks that were difficult to execute correctly (20%). Provider factors were evident in 46%, but half of these reports contained insufficient detail to determine which specific factor. When detail sufficed, slips (52%), exceptional violations (22%), lapses (15%) and applying incorrect rules (13%) were common. CONCLUSIONS: Contributing factors could be identified in most incident-report narratives from these hospitals. However, each category of factors was present in a minority of reports, and provider factors were often insufficently elucidated. Greater detail about contributing factors would make incident reports more useful for improving patient safety.

Underuse of cardiac procedures: do women, ethnic minorities, and the uninsured fail to receive needed revascularization?

BACKGROUND: Women, ethnic minorities, and uninsured persons receive fewer cardiac procedures than affluent white male patients do, but rates of use are crude indicators of quality. The important question is, Do women, minorities, and the uninsured fail to receive cardiac procedures when they need them? OBJECTIVE: To measure receipt of necessary coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA) overall; by patient sex, ethnicity, and payer status; and by availability of on-site revascularization. DESIGN: Retrospective, randomized medical record review. SETTING: 13 of the 24 hospitals in New York City that provide coronary angiography. PATIENTS: 631 patients who had coronary angiography in 1992 and met the RAND expert panel criteria for necessary revascularization. MEASUREMENTS: The percentage of patients who had CABG surgery or PTCA was measured, as were variations in use rates by sex, ethnic group, insurance status, and availability of on-site revascularization. Clinical and laboratory data were retrieved from medical records to identify patients who met the panel criteria for necessary revascularization. Receipt of revascularization was determined from state reports, medical records, and information provided by cardiologists. RESULTS: Overall, 74% (95% CI, 71% to 77%) of patients who met the panel criteria for necessary revascularization had CABG surgery or PTCA (underuse rate, 26%). No differences were found in use rates by patient sex, ethnic group, or payer status, but hospitals that provided on-site revascularization had higher use rates (76% [CI, 74% to 79%]) than hospitals that did not provide it (59% [CI, 56% to 65%]) (P < 0.01). In hospitals that did not provide on-site revascularization, uninsured patients were less likely to have revascularization recommended to them (52% [CI, 32% to 78%]); rates of recommendation for patients with private insurance, Medicare, and Medicaid were 82%, 91%, and 75%, respectively (P = 0.026). CONCLUSIONS: Although revascularization procedures are substantially underused, no variations in rate of use by sex, ethnic group, or payer status were seen among patients treated in hospitals that provide CABG surgery and PTCA. However, underuse was significantly greater in hospitals that do not provide these procedures, particularly among uninsured persons.

Visual function impairments in relation to gender, age, and visual acuity in patients who undergo cataract surgery.

PURPOSE: This study aimed to determine the relationship between visual function impairment in 776 patients who had extracapsular cataract extraction with posterior chamber intraocular lens implantation and gender, age, preoperative visual acuity (VA) of both the operative and the contralateral eye, and presence of other ocular disease in the operative eye. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: 1139 patients whose medical records were abstracted and who had cataract surgery performed at 1 of 10 participating academic medical centers in 1990. MAIN OUTCOME MEASURE: In the 776 patients who had explicit statements about impairment of visual function documented in their medical records, univariate and multivariable logistic analyses were used to assess the above relationship. RESULTS: The most severe visual functional deficit that justified the cataract operation varied in relation to gender, age, and VA. On bivariate analysis, men were more likely to have impairment with employment, driving, and glare, whereas women were more likely to have impairment with activities of daily living and recreational activities. Significant findings between visual impairment and the independent variables from the logistic regression models included: (1) employment limitation and male gender (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.08-3.40); (2) employment limitation and younger age (OR, 0.12; 95% CI, 0.050-0.28 for ages 70-79); (3) recreational impairment and older age (OR, 2.77; 95% CI, 1.64-4.70 for ages 80+); (4) impairment in performing activities of daily living and female gender (OR, 0.72; 95% CI, 0.53-0.98 for male gender); (5) impairment in performing activities of daily living and worse VA in the operative eye (OR, 5.13; 95% CI, 2.93-9.00 for VA < 20/100); (6) glare-associated impairment and younger age (OR, 0.40; 95% CI, 0.24-0.69 for age 80+); and (7) glare-associated impairment and better VA (OR, 0.16; 95% CI, 0.067-0.38 for VA < 20/100). CONCLUSION: When deciding whether to perform cataract surgery, functional impairment must be considered in relation to the age and the gender of the patient, for the type of functional impairment varies in association with age and gender.

Are physicians' office laboratory results of comparable quality to those produced in other laboratory settings?

CONTEXT: In 1995, California adopted a bill that brought laboratory laws in line with the 1988 Clinical Laboratory Improvement Amendments' standards for clinical laboratories and mandated a study comparing results in physicians' office laboratories (POLs) with other settings. OBJECTIVE: To determine whether persons conducting tests in POLs produce accurate and reliable test results comparable to those produced by non-POLs. DESIGN: Survey of clinical laboratories using proficiency testing data. SETTING: All California clinical laboratories participating in the American Association of Bioanalysts proficiency testing program in 1996 (n=1110). MAIN OUTCOME MEASURES: "Unsatisfactory" (single testing event failure) and "unsuccessful" (repeated testing event failure) on proficiency testing samples. RESULTS: The unsatisfactory failure rate for POLs was nearly 3 times (21.5% vs 8.1%) the rate for the non-POLs and about 1.5 times (21.5% vs 14.0%) for POLs that used laboratory professionals as testing or supervisory personnel (P<.001). The POL unsuccessful rate was more than 4 times (4.4% vs 0.9%) the rate for non-POLs and more than twice (4.4% vs 1.8%) the rate for the POLs using laboratory professionals (P<.001). CONCLUSIONS: Significant differences exist among POLs, POLs using licensed clinical laboratory scientists (medical technologists), and non-POLs. Testing personnel in many POLs might lack the necessary education, training, and oversight common to larger facilities. We must better understand the contributing factors that result in the poorer results of POLs relative to non-POLs. In the meantime, patients should be aware that preliminary findings suggest that differences in quality of laboratory tests based on testing site may exist. Laboratory directors at all testing sites must ensure that they understand laboratory practice sufficiently to minimize errors and maximize accuracy and reliability. Directors must understand their obligation when they elect to oversee those assigned testing responsibility. Legislators may wish to reconsider the wisdom of further easing restrictions on those to whom we entrust our laboratory specimens.

Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden.

OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved.

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium.

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.

Underuse of coronary revascularization procedures: application of a clinical method.

OBJECTIVES: Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients. BACKGROUND: Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before. METHODS: The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated. RESULTS: Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005). CONCLUSIONS: Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.

Documentation patterns before cataract surgery at ten academic centers.

PURPOSE: To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines. METHODS: In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines. RESULTS: Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria. CONCLUSION: Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

The appropriateness of coronary artery bypass graft surgery in academic medical centers. Working Group of the Appropriateness Project of the Academic Medical Center Consortium.

OBJECTIVE: To compare the appropriateness of use of coronary artery bypass graft (CABG) surgery in Academic Medical Center Consortium hospitals as judged 1) according to criteria developed by an expert panel, 2) according to revisions of those criteria made by cardiac surgeons from the Academic Medical Center Consortium, and 3) by review of cases by the surgeons responsible for those cases. DESIGN: Retrospective, randomized medical record review. SETTING: 12 Academic Medical Center Consortium hospitals. PATIENTS: Random sample of 1156 patients who had had isolated CABG surgery in 1990. MAIN OUTCOME MEASURES: 1) Percentage of patients with indications for which CABG surgery was classified as appropriate, Inappropriate, or of uncertain appropriateness and 2) percentage of cases in which CABG surgery was judged inappropriate or uncertain for which ratings changed after local case review. RESULTS: Data were retrieved from medical records by trained abstractors using an explicit data collection instrument. Cases in which CABG surgery was judged to be inappropriate or uncertain were individually reviewed by the responsible surgeons. According to the expert panel ratings, 83% of the CABG operations (95% CI, 81% to 85%) were necessary, 9% (CI, 8% to 10%) were appropriate, 7% (CI, 5% to 8%) were uncertain, and 1.6% (CI, 0.6% to 2.5%) were inappropriate. These rates are almost identical to those found in a previous study that was done in New York State and that used the same criteria (in that study, 91% of operations were classified as necessary or appropriate, 7% were classified as uncertain, and 2.4% were classified as inappropriate). Rates of inappropriate procedures varied from 0% to 5% among the 12 member hospitals (P = 0.02). The Academic Medical Center Consortium cardiac surgeons revised 568 (24%) of the indications used by the expert panel. However, because those revisions altered the appropriateness ratings in both directions and affected only 50 cases (4%), the net effect of the revisions was slight: The rate of inappropriate CABG surgery increased from 1.6% to 1.9%. Local review found that data collection errors had caused erroneous ratings in 12.5% of 64 cases in which surgery had been classified as inappropriate or uncertain. CONCLUSIONS: The Academic Medical Center Consortium hospitals had low rates of inappropriate and uncertain use of CABG surgery, regardless of the criteria used for assessment. Even though surgeons from the Consortium revised the appropriateness ratings extensively, their revisions had a negligible effect on the overall assessment of appropriateness. However, because of potential data collection errors, appropriateness criteria should be used for individual case audits only if supplemented by subsequent physician review.

Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures.

The authors compare the appropriateness ratings and mutual influence of panelists from different specialties rating a comprehensive set of indications for six surgical procedures. Nine-member panels rated each procedure: abdominal aortic aneurysm surgery, carotid endarterectomy, cataract surgery, coronary angiography, and coronary artery bypass graft surgery/percutaneous transluminal coronary angioplasty (common panel). Panelists individually rated the appropriateness of indications at home and then discussed and re-rated the indications during a 2-day meeting. Subsequently, they rated the necessity of those indications scored by the group as appropriate. There were 45 panelists, including specialists (either performers of the procedure or members of a related specialty) and primary care providers, all drawn from nominations by their respective specialty societies. Main outcome measures included: individual panelists' mean ratings over all indications, mean change and conformity scores between rounds of ratings, and the percentage of audited actual procedures rated appropriate or necessary. Performers had the highest mean ratings, followed by physicians in related specialties, trailed by primary care providers. One fifth of all actual procedures were for indications rated appropriate by performers and less than appropriate by primary care providers. At the panel meetings, primary care providers and related specialists showed no greater tendency to be influenced by other panelists than did performers. Multispecialty panels provide more divergent viewpoints than panels composed entirely of performers. This divergence means that fewer actual procedures are deemed performed for appropriate or necessary indications.

STAT testing? A guideline for meeting clinician turnaround time requirements. Practice parameter.

This practice parameter, developed by the Practice Parameters and Outcomes Measurement Committee of the American Society of Clinical Pathologists (ASCP), is a guideline for the development of reasonable stat lists. Stat testing lists vary according to practice setting. Furthermore, although stat lists exist, extenuating clinical circumstances may warrant performing a test stat that is otherwise considered routine. Successful development of a stat testing list requires organizations to take an interdisciplinary approach, focusing on clinical and operational considerations of both the care provider and the clinical laboratory.

Modified technique for fine needle aspiration biopsy that eliminates needle manipulation.

OBJECTIVE: To evaluate a modified technique of fine needle aspiration biopsy that eliminates needle manipulation after aspiration. STUDY DESIGN: Fine needle aspiration biopsy of 112 palpable lesions was performed using both the conventional and modified techniques. Cellularity, cell preservation and diagnostic yield of the new procedure were compared to those of the conventional technique. RESULTS: Cytologic smears prepared from each method were comparable in quality, quantity and diagnostic yield. CONCLUSION: The modified approach eliminates the hazard of needle manipulation without diminishing the diagnostic efficacy of fine needle aspiration biopsy.

Assessment of appropriateness of cataract surgery at ten academic medical centers in 1990.

PURPOSE: To develop criteria for the appropriateness of cataract surgery (extracapsular cataract extraction or phacoemulsification with planned implantation of a posterior chamber intraocular lens) and to apply these criteria to patients from ten academic medical centers. METHODS: The study is a retrospective case series from ten academic medical centers. One thousand one hundred thirty-nine patients who had had cataract surgery in 1990 at the medical centers were selected randomly. Patients, identified by specific ICD-9-CM or CPT-4 codes, had no other ocular surgery performed at the same time as cataract surgery. Rates of inappropriate, uncertain, appropriate, and appropriate and crucial surgeries were determined by application of the criteria established by a multidisciplinary expert panel. RESULTS: Approximately 2% of the procedures were classified as inappropriate, after adjusting for missing or nonspecific visual function by use of discriminant analysis. Ninety-one percent of the procedures were classified as appropriate (52%) or appropriate and crucial (39%). Seven percent were designated as uncertain, either due to a median rating in the uncertain range or to disagreement in ratings among the panelists. Significant variation occurred in the results among the different institutions: inappropriate surgeries ranged from 0% to 4%, uncertain from 1% to 14%, appropriate from 35% to 66%, and appropriate and crucial from 21% to 62% (P=0.02). CONCLUSION: A small percentage of cataract surgeries was performed at these ten academic medical centers for inappropriate indications using the study criteria. Given the large number of cataract surgeries performed annually, the small percentage of uncertain and inappropriate surgeries may translate into a large number of surgeries performed for less than appropriate or appropriate and crucial indications. Significant variation existed among the institutions in the distribution of appropriate and crucial and appropriate compared with uncertain and inappropriate surgeries.

Validity of criteria used for detecting underuse of coronary revascularization.

OBJECTIVE: To assess criteria used for detecting underuse of coronary artery revascularization procedures in terms of patient outcomes. DESIGN: Retrospective cohort study using medical records supplemented by a telephone survey and review of county death records. SETTING: Four public hospitals and two academically affiliated private hospitals in Los Angeles County, California. PARTICIPANTS: A total of 671 patients who had coronary angiography between June 1, 1990 and September 30, 1991, and who met explicit clinical criteria for the necessity of coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). MAIN OUTCOME MEASURES: For all patients (n = 671), we estimated the association between receipt of necessary revascularization and mortality (median follow-up after angiography, 797 days) after adjusting for potential confounders. For the patients completing the telephone interview (n = 374), we examined the relationship between receipt of necessary revascularization and frequency of chest pain. RESULTS: Patients who received necessary revascularization within 1 year of angiography had lower mortality than those who did not (8.7% vs 15.8%, P = .01), and this association persisted after adjustment for extent of coronary artery disease, clinical symptom complex, ejection fraction, and cardiac surgical risk index (adjusted odds ratio = 0.49; 95% confidence interval, 0.28 to 0.86). The same general results were obtained whether revascularization was received within 1 year or within 30 days of the catheterization, whether panelists' ratings or individual clinical variables were entered as covariates, and whether the statistical procedure used was logistic regression or Cox proportional hazards analysis. In addition, among patients responding to the telephone survey, those receiving necessary revascularization had less chest pain at follow-up (P = .03). CONCLUSIONS: Among patients meeting criteria for the necessity of revascularization, those receiving a revascularization procedure within 1 year had lower mortality than those treated medically. These results support the validity of the RAND/UCLA criteria for detecting underuse of these procedures, but more research is needed to confirm the findings and to determine the validity of guidelines for other procedures.

The link between the Department of Pathology and Laboratory Medicine and medical administration. Managing the quality continuum.

As hospital-based physicians, pathologists are positioned to play a key role in quality management at their institutions. As we enter into the era of increased competition for scarce health care resources, opportunities to increase efficiency, improve quality, and reduce expenses will expand. Laboratory medicine specialists possess much needed expertise in data management and quality improvement. Pathologists must now reach beyond their own departments, redefining their mission through a focus on clinical-managerial relationships.

The appropriateness of use of cardiovascular procedures in women and men.

OBJECTIVE: To determine whether there are differences between women and men in the appropriateness of use of cardiovascular procedures. DESIGN: Retrospective chart review. SETTING: Thirty hospitals located in New York State. PATIENTS: Random sample of 3979 patients undergoing coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery in 1990. MEASURES: We evaluated two measures: (1) the percent of women and men who underwent cardiovascular procedures for appropriate, uncertain, and inappropriate indications and (2) for coronary angiography patients, the prognostic exercise stress treadmill score that predicts before the coronary angiogram the 5-year probability of death from a cardiovascular event. RESULTS: The inappropriate rate of use of cardiovascular procedures was low and not significantly different for men and women (4% vs 5% for coronary angiography; 4% vs 3% for percutaneous transluminal coronary angioplasty; and 2% vs 3% for coronary artery bypass graft surgery, respectively), and the use of these procedures for uncertain reasons also did not vary significantly by gender. There was also no significant gender difference in the predicted risk of death from a cardiovascular event for coronary angiography patients: 24% of men and 22% of women were at high risk (ie, < 75% 5-year survival rate) and 20% and 16%, respectively, were at low risk (ie, > or = 95% 5-year survival rate). CONCLUSION: Based on two indicators, the RAND appropriateness score and the Duke prognostic exercise treadmill score, we were unable to find any evidence of a difference in the clinical appropriateness of use of these three cardiovascular procedures between women and men.