Diagnostic errors in ambulatory care: dimensions and preventive strategies

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may arise: (1) the provider–patient encounter, (2) performance and interpretation of diagnostic tests, (3) follow-up of patients and diagnostic test results, (4) subspecialty consultation, and (5) patients seeking care and adhering to their instruction/appointments, i.e. patient behaviors. We presented these risk domains to conference participants to elicit their views about sources of and solutions to diagnostic errors in ambulatory care. In this paper, we present a summary of discussion in each of these risk domains. Many novel themes and hypotheses for future research and interventions emerged.     

A Home Care Program for Children with Chronic Illness

Pediatric Home Care (PHC) of Albert Einstem College of Medicine was designed as a special ambulatory care unit for children who are seriously or chronically ill and whose needs were not being met successfully through conventional programing Services include monitoring the patient's care, delivering direct services in the home, clinic, and hospital, teaching therapeutic programs to the family and patient, coordinating services, patient advocacy, health education, and supportive counseling Each patient has a core team consisting of a generalist pediatrician, a PNP, and the patient's family Visits are provided in the patient's home as needed, as well as in the traditional locations of the clinic, the inpatient units, and the PHC office The program accepts patients with serious medical problems and who face any of a series of other difficulties, including especially complex management problems that cannot be handled well in the customary outpatient settings, unstable family settings, or extended hospitalizations Because it is not restricted to any single type of disease, the PHC provides a model that is applicable in a wide range of medical and community settings Results of a program evaluation show that PHC is an effective intervention that has positive mental health outcomes and improves satisfaction with care.     

An empirical study for medication delivery improvement based on healthcare professionals’ perceptions of medication delivery system

Medication errors are major safety concerns in all hospital settings. The insufficient knowledge about managerial and process improvement strategies required to reduce medication errors can be considered as one of the most important factors holding back hospitals from achieving the desired goals for patient safety. However, strategies for medication error reduction cannot be successfully implemented without a clear understanding of factors affecting medication delivery errors. This paper presents a study in which healthcare professionals’ perceptions on three factors, namely (1) technical complexity of tasks/connections; (2) resources problems; and (3) qualification of human resources, are analyzed within the medication delivery system at one community hospital. The outcomes of this research are a theoretical model for reducing medication delivery errors and a set of workflow design rules for healthcare professionals to continuously reduce medication delivery errors.     

A two-dimensional equity proposal for self-sufficiency in municipal safety-net hospitals

This article advances a two-dimensional equity approach for self-sufficiency in municipal safety-net hospitals that will strengthen provider self-sufficiency and protect the safety-net mission of providing a dignified floor of health services to the most disadvantaged members of the society. The model responds to the failure of current delivery strategies to effectively cope with the changing market configurations in safety-net systems that have eliminated the possibility of cross-subsidization which has long been the mainstay of safety-net systems. The identified pathway to self sufficiency is made up of (1) a differential service delivery framework which includes a two-tier patient system, uniform standards of care and service levels, and the creation of a community health campus; (2) independent sector ownership; and (3) intergovernmental policy actions restricting ownership of safety-net hospitals to nonprofit entities. Although this model is explained by demonstrating potential application in safety-net hospitals, it is believed that the model is applicable in ambulatory care settings. Future work can focus on the construction of an ambulatory variation of the model and the empirical testing of the hospital and ambulatory models.     

Implementation of Health and Mental Health Evidence-Based Practices in Safety Net Settings

Implementation of evidence-based practices (EBP) in health and mental health settings has not been as successful as anticipated. Patients in safety net settings have even less opportunity to receive evidence-based care. Translation research has been dominated by efficacy trials, which often do not translate to the complexity of safety net settings. Implementation research to date seems to focus mostly on provider and organizational contextual factors more than macro and patient factors crucial to outcomes in safety net settings. Focus on translation and adaptation of interventions to safety net settings, and use of qualitative methods to flesh out complex processes and involve more stakeholders will help give safety net patients access to state of the art care. This issue is important for social workers to understand due to their ethical obligation to advocate for social justice and access to care for vulnerable and oppressed populations.     

Improving Quality and Safety of Care Using “Technovigilance”: An Ethnographic Case Study of Secondary Use of Data from an Electronic Prescribing and Decision Support System

Context

“Meaningful use” of electronic health records to improve quality of care has remained understudied. We evaluated an approach to improving patients’ safety and quality of care involving the secondary use of data from a hospital electronic prescribing and decision support system (ePDSS).

Methods

We conducted a case study of a large English acute care hospital with a well-established ePDSS. Our study was based on ethnographic observations of clinical settings (162 hours) and meetings (28 hours), informal conversations with clinical staff, semistructured interviews with ten senior executives, and the collection of relevant documents. Our data analysis was based on the constant comparative method.

Findings

This hospital''s approach to quality and safety could be characterized as “technovigilance.” It involved treating the ePDSS as a warehouse of data on clinical activity and performance. The hospital converted the secondary data into intelligence about the performance of individuals, teams, and clinical services and used this as the basis of action for improvement. Through a combination of rapid audit, feedback to clinical teams, detailed and critical review of apparent omissions in executive-led meetings, a focus on personal professional responsibility for patients’ safety and quality care, and the correction of organizational or systems defects, technovigilance was—based on the hospital''s own evidence—highly effective in improving specific indicators. Measures such as the rate of omitted doses of medication showed marked improvement. As do most interventions, however, technovigilance also had unintended consequences. These included the risk of focusing attention on aspects of patient safety made visible by the system at the expense of other, less measurable but nonetheless important, concerns.

Conclusions

The secondary use of electronic data can be effective for improving specific indicators of care if accompanied by a range of interventions to ensure proper interpretation and appropriate action. But care is needed to avoid unintended consequences.     

To what extent are women free to choose where to give birth? How discourses of risk,blame and responsibility influence birth place decisions

Over the past 50 years, two things have changed for women giving birth in high-income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in ‘alternative’ settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for ‘alternative’ settings for birth, these discourses constrain women’s decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.     

Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative

BACKGROUND: We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports. METHODS: Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy. RESULTS: Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data. CONCLUSION: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.     

A Paradoxical and Persistent Pneumonitis

Abstract

Despite increased awareness of the risks to patients within the health care system, there has been little improvement in patient safety, with 1 in 7 patients experiencing an adverse event during hospitalization. Patients are exposed to harm not only through medical errors but also by physicians' failure to adhere to evidence-based best practices, as patients receive recommended therapies only half of the time. Although much research has been devoted to developing new therapies, little time has been spent investigating the science of health care delivery. We developed 2 models for improving health care delivery that have been successfully utilized in the Michigan Keystone Project to eliminate catheter-related bloodstream infections. The first is the Comprehensive Unit-Based Safety Program (CUSP), which is aimed at changing the culture of safety and provides a framework for addressing patient safety issues at a local level. CUSP takes advantage of local wisdom to identify potential patient harms and create individualized solutions. The second is the Translating Evidence Into Practice (TRIP) model, which evaluates best practices at a hospital or hospital system level, and then creates strategies for implementation at a local level. TRIP seeks to identify barriers to implementation of best-practice medicine and standardize care over multiple care units. Components of the 2 programs are not mutually exclusive and both can be used to mitigate potential patient harms.     

Studying patient safety in health care organizations: accentuate the qualitative

BACKGROUND: The study of patient safety can benefit from greater methodological diversity to improve scientific knowledge and to increase the effectiveness and tailoring of strategies aimed at improving it. METHODOLOGICAL DIVERSITY TO BETTER CAPTURE CAUSAL MECHANISMS AND PROCESSES: Additional methods for studying patient safety and errors to reflect the complexity of what goes on within health care organizations should be made routine. Interviews, focus groups, and observation--the predominant methods used in qualitative research--are infrequently used in health services research, generally and specifically in the study of errors and patient safety. However, they offer several advantages over quantitative designs. They often are less expensive and quicker to implement; they may not need a lot of advance work; and they can be used to study retrospectively a particular failure event, outcome, or situation. ACTION STEPS: Organizations can use an action agenda to better implement and promote the use of qualitative methods. Implementing these action steps can help achieve the attributes-trust, honesty, communication, participation, and efficiency-necessary to facilitate the qualitative approach in health care work settings. SUMMARY AND CONCLUSION: Qualitative approaches should be used in studying patient safety as a complement to (not a substitute for) quantitative approaches. They can be implemented more easily in organizations through structural and cultural adjustments that provide a more supportive foundation for this work.     

Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity

The development of patient safety culture in health care organizations is a necessary precursor to patient safety improvement. However, existing tools to measure patient safety culture are intended for implementation in hospitals. A new, abbreviated patient safety culture survey was developed for use in ambulatory health care settings. This survey was tested for content validity utilizing a panel of six experts. It had a clarity interrater agreement (IR) of 0.75, a clarity content validity index (CVI) of 0.95, a representativeness IR of 0.75 and a representativeness CVI of 0.95. The content validity analysis served as a useful tool for assessing the relevance and comprehensiveness of this survey of patient safety culture in ambulatory care organizations.     

Cultural safety and the challenges of translating critically oriented knowledge in practice

Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge‐translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge‐translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of ‘culture’, ‘safety’, and ‘cultural safety’ need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge‐translation process is a ‘social justice curriculum for practice’ that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.     

中国基层卫生体系建设经验及其国际借鉴意义

在建设人类卫生健康共同体背景下,加强全球卫生安全和提高健康保障水平是世界各国共同关心的重大问题。发展基层卫生体系是世界各国实现全民健康覆盖和提高健康水平最重要的策略。我国在七十多年卫生体系建设中,特别是在加强基层卫生体系建设方面,通过不断努力和实践,以及互学互鉴,积累了许多宝贵经验,并为世界所称道。本文以历史文献为基础,以基层卫生体系建设为重点,选取农村基本医疗保障体系建设、基层卫生服务体系建设和基本公共卫生服务均等化制度建设为主题,对我国实践经验进行了总结,以期为国际有所借鉴。     

The challenges to transparency in reporting medical errors

In an ideal health care environment, physicians and health care organizations would acknowledge and factually report all medical errors and "near misses" in an effort to improve future patient safety by better identifying systemic safety lapses. Truth must permeate the health care system to achieve the goal of transparency. The Institute of Medicine has estimated that 44,000 to 98,000 patients die each year as a result of medical errors. Improving the reporting of medical errors and near misses is essential for better prevention of medical errors and thus increasing patient safety. Higher rates of reporting can permit identification of the root causes of errors and create improved processes that can significantly reduce errors in future patient care. Multiple barriers exist with respect to reporting medical errors, despite the ethical and various professional, regulatory, and legislative expectations and requirements generating this obligation. As long as physicians perceive that they are at risk for sanctions, malpractice claims, and unpredictable compensation of injured patients as determined by the United States' tort law system, legislative or regulative reform is unlikely to affect the underreporting of medical errors, and patient safety cannot benefit from the lessons derived from past medical errors and near misses. A new infrastructure for creating patient safety systems, as identified in the Patient Safety and Quality Improvement Act of 2005 is needed. A patient compensation system guided by an administrative health court that includes some form of no-fault insurance must be studied to identify benefits and risks. Most urgent is the development of a reporting system for medical errors and near misses that is transparent and effectively recognizes the legitimate concerns of physicians and health care providers and improves patient safety.     

An organizational approach to understanding patient safety and medical errors

Progress in patient safety, or lack thereof, is a cause for great concern. In this article, we argue that the patient safety movement has failed to reach its goals of eradicating or, at least, significantly reducing errors because of an inappropriate focus on provider and patient-level factors with no real attention to the organizational factors that affect patient safety. We describe an organizational approach to patient safety using different organizational theory perspectives and make several propositions to push patient safety research and practice in a direction that is more likely to improve care processes and outcomes. From a Contingency Theory perspective, we suggest that health care organizations, in general, operate under a misfit between contingencies and structures. This misfit is mainly due to lack of flexibility, cost containment, and lack of regulations, thus explaining the high level of errors committed in these organizations. From an organizational culture perspective, we argue that health care organizations must change their assumptions, beliefs, values, and artifacts to change their culture from a culture of blame to a culture of safety and thus reduce medical errors. From an organizational learning perspective, we discuss how reporting, analyzing, and acting on error information can result in reduced errors in health care organizations.     

Roadmap for safety: National Quality Forum officially releases 30 safe practices for better healthcare

After 2 years of reviewing current research and studies on patient safety, the National Quality Forum released its evidence-based consensus report listing 30 "safe practices for better healthcare" at a meeting in Los Angeles. The forum's president and CEO, Kenneth Kizer, calls the report "basically a road map for safety" that can be used in not only hospitals but also other healthcare facilities such as nursing homes and ambulatory care settings.     

Medication-related adverse events: perception of nursing aides

The process of administering medication is linked to an elevated rate of adverse events and has been the focus of institutional investments. This study aimed at uncovering the perception of nursing aides regarding medication-related adverse events. A qualitative research was carried out with ten nursing aides from a clinical and surgical inpatient unit in a university hospital in Porto Alegre,RS, Brazil. Results show that the factors most commonly involved in medication errors are work overload and incorrect patient/client identification, as well as other associated factors. It was concluded that there is a need for the development of actions that favor cultural change that guarantees patient safety in hospital institutions.