Diagnostic errors in hospitalized patients are a leading cause of preventable morbidity and mortality.Significant challenges in defining and measuring diagnostic errors and underlying process failure points have led to considerable variability in reported rates of diagnostic errors and adverse outcomes.In this article, we explore the diagnostic process and its discrete components, emphasizing the centrality of the patient in decisionmaking as well as the continuous nature of the process.We review the incidence of diagnostic errors in hospitalized patients and different methodological approaches that have been used to arrive at these estimates.We discuss different but interdependent provider-and system-related process-failure points that lead to diagnostic errors.We examine specific challenges related to measurement of diagnostic errors and describe traditional and novel approaches that are being used to obtain the most precise estimates.Finally, we examine various patient-, provider-, and organizational-level interventions that have been proposed to improve diagnostic safety in hospitalized patients.
iagnostic errors are defined by the National Academies of Sciences, Engineering, and Medicine (NASEM) as the failure to either establish an accurate and timely explanation of the patient's health problem(s) or communicate that explanation to the patient. 1 According to a report by the Institute of Medicine, diagnostic errors account for a substantial number of adverse events in health care, affecting an estimated 12 million Americans each year. 1 Diagnostic errors are a common and serious issue in health care systems, with studies estimating that 5% to 15% of all diagnoses are incorrect. 1Such errors can result in unnecessary treatments, delays in necessary treatments, and harm to patients.The high prevalence of diagnostic errors in primary care has been identified as a global issue. 2 While many factors contribute to diagnostic errors, the complex nature of health care systems, the limited processing capacity of human cognition, and deficiencies in interpersonal patient-clinician communication are primary contributors. 3,4iscussions around the redesign of health care systems to reduce diagnostic errors have been at the forefront of medical research for years. 2,4To decrease diagnostic errors in health care, a comprehensive strategy is necessary.This strategy should focus on utilizing both human experience (HX) in health care and artificial intelligence (AI) technologies to transform health care systems into proactive, patient-centered, and safer systems, specifically concerning diagnostic errors. 1
ore than 55 million people worldwide are living with Alzheimer's disease and related dementias (ADRD). 1 With the aging of the Baby Boomer population, this number is expected to rise to more than 78 million worldwide by 2030. 1 Given the growing number of cognitively impaired older adults, there is an increased need for residences designed for the specialized care of this population.Although there are dozens of living options for the elderly, and although most specialized establishments have the resources to meet the immediate needs of their residents, many facilities lack universal design features that support a high quality of life for someone with ADRD or mild cognitive impairment.Previous research has shown relationships between behavioral and psy-chological symptoms of dementia (BPSD) and environmental characteristics such as acoustics, lighting, and indoor air temperature. 2,3Physical behaviors of BPSD, including aggression and wandering, and psychological symptoms, such as depression, anxiety, and delusions, put residents at risk of injury. 46][7][8] Patients with dementia may also experience a lower stress threshold, changes in perception of space, and decreased
Objective: Multidisciplinary teams (MDTs) improve outcomes for patients with infective endocarditis (IE), but methods of implementation vary.In our academic medical center, we developed an MDT approach guided by a clinical care pathway and assessed outcomes of patients with IE.Methods: We compared outcomes of patients with IE and indications for surgery between December 2018 and June 2020 with our prior published data for the period January to December 2016.MDT interventions involved recurring conferences with infectious diseases physicians in team meetings and promoting a clinical care pathway to guide providers on steps in management.Primary outcomes were surgery and inhospital death.Results: Prior to the intervention, 6 of 21 (28.6%)patients with indications for surgery underwent surgery or were transferred to higher centers for surgery, and 6 (28.6%) patients died.Post intervention, 17 of 31 (54.8%)patients underwent or were transferred for surgery, and 5 (16.1%) died.After adjusting for age and gender, the odds of surgery or transfer for surgery for patients in the postintervention period were 4.88 (95% CI, 1.20-19.79;P = .027)compared with the pre-intervention period.The odds ratio for death among patients in the postintervention period was 0.40 (95% CI, 0.09-1.69;P = .21). Conclusion:An MDT team approach using a clinical pathway was associated with an increased number of surgeries performed for IE and may lower rates of inhospital mortality.
Objective: The COVID-19 pandemic posed unprecedented leadership challenges to health care organizations worldwide, especially those on the journey to high reliability.The objective of this pilot quality improvement initiative was to describe the experiences of medical center leaders continuing along the journey to high reliability during the pandemic.Methods: A convenience sample of Veterans Health Administration medical center directors at facilities that had initiated the journey to high reliability prior to or during the COVID-19 pandemic were asked to complete a confidential survey to explore the challenges experienced and lessons learned.Results: Of the 35 potential participants, 15 completed the confidential web-based survey.Five major themes emerged from participants' responses: (1) managing competing priorities, (2) staying committed, (3) adapting and overcoming, (4) prioritizing competing demands, and (5) maintaining momentum. Conclusion:This pilot quality improvement initiative provides some insight into the challenges experienced and lessons learned during the COVID-19 pandemic to help inform health care leaders' responses during crises they may encounter along the journey to becoming a high reliability organization.
Background: Emergency department (ED) crowding is associated with deleterious consequences for patient care and throughput.Admission delays worsen ED crowding.Time to admission (TTA)-the time between an ED admission request and internal medicine (IM) admission orders-can be shortened through implementation of a triage hospitalist role.Limited research is available highlighting the impact of triage hospitalists on throughput, care quality, interprofessional practice, and clinician experience of care.Methods: A triage hospitalist role was piloted and implemented.Run charts were interpreted using accepted rules for deriving statistically significant conclusions.Statistical analysis was applied to interprofessional practice and clinician experienceof-care survey results.Results: Following implementation, TTA decreased from 5 hours 19 minutes to 2 hours 8 minutes.Emergency department crowding increased from baseline.The reduction in TTA was associated with decreased time from ED arrival to IM admission request, no change in critical care transfers during the initial 24 hours, and increased admissions to inpatient status.Additionally, decreased TTA was associated with no change in referring hospital transfer rates and no change in hospital medicine length of stay.Interprofessional practice attitudes improved among ED clinicians but not IM clinicians.Clinician experience-of-care results were mixed. Conclusion:A triage hospitalist role is an effective approach for mitigating admission delays, with no evident adverse clinical consequences.A triage hospitalist alone was incapable of resolving ED crowding issues without a complementary focus on downstream bottlenecks.
Study 1 Overview (Park et al)Objective: To compare rates of adverse events and 30-day readmission among patients with dementia who undergo percutaneous coronary intervention (PCI) with those without dementia.Design: This cohort study used a national database of hospital readmissions developed by the Agency for Healthcare Research and Quality.Setting and participants: Data from State Inpatient Databases were used to derive this national readmissions database representing 80% of hospitals from 28 states that contribute data.The study included all individuals aged 18 years and older who were identified to have had a PCI procedure in the years 2017 and 2018.International Classification of Diseases, Tenth Revision (ICD-10) codes were used to identify PCI procedures, including drug-eluting stent placement, bare-metal stent placement, and balloon angioplasty, performed in patients who presented with myocardial infarction and unstable angina and those with stable ischemic heart disease.Patients were stratified into those with or without dementia, also defined using ICD-10 codes.A total of 755,406 index hospitalizations were included; 2.3% of the patients had dementia.Main outcome measures: The primary study outcome was 30-day all-cause readmission, with the cause classified as cardiovascular or noncardiovascular.Secondary outcome measures examined were delirium, in-hospital mortality, cardiac arrest, blood transfusion, acute kidney injury, fall in hospital, length of hospital stay, and other adverse outcomes.Location at discharge was also examined.Other covariates included in the analysis were age, sex, comorbidities, hospital characteristics, primary
s quality improvement (QI) has become an integral part of clinical practice, residency training programs have continued to evolve in how best to teach QI.The Accreditation Council for Graduate Medical Education (ACGME) Common Program requirements mandate that core competencies in residency programs include practice-based learning and improvement and systems-based practice. 1Residents should receive education in QI, receive data on quality metrics and benchmarks related to their patient population, and participate in QI activities.The Clinical Learning Environment Review (CLER) program was established to provide feedback to institutions on 6 focused areas, including patient safety and health care quality.In visits to institutions across the United States, the CLER committees found that many residents had limited knowledge of QI concepts and limited access to data on quality metrics and benchmarks. 2 There are many barriers to implementing a QI curriculum in residency programs, and creating and maintaining successful strategies has proven challenging.
Objective: Promoting a culture of safety is a critical component of improving health care quality.Recognizing staff who stop the line for safety can positively impact the growth of a culture of safety.The purpose of this initiative was to demonstrate to staff the importance of speaking up for safety and being acknowledged for doing so.Methods: Following a review of the literature on safety awards programs and their role in promoting a culture of safety in health care covering the period 2017 to 2020, a formal process was developed and implemented to disseminate safety awards to employees.Results: During the initial 18 months of the initiative, a total of 59 awards were presented.The awards were well received by the recipients and other staff members.Within this period, adjustments were made to enhance the scope and reach of the program. Conclusion:Recognizing staff behaviors that support a culture of safety is important for improving health care quality and employee engagement.Future research should focus on a formal evaluation of the impact of safety awards programs on patient safety outcomes.
Background: The COVID-19 pandemic has had broad effects on surgical care, including operating room (OR) staffing, personal protective equipment (PPE) utilization, and newly implemented anti-infective measures. Our aim was to assess neurosurgery OR efficiency before the COVID-19 pandemic, during peak COVID-19, and during current times. Methods: Institutional perioperative databases at a single, highvolume neurosurgical center were queried for operations performed from December 2019 until October 2021. March 12, 2020, the day that the state of Tennessee declared a state of emergency, was chosen as the onset of the COVID-19 pandemic. The 90-day periods before and after this day were used to define the pre-COVID-19, peak-COVID-19, and post-peak restrictions time periods for comparative analysis. Outcomes included delay in first-start and OR turnover time between neurosurgical cases. Preset threshold times were used in analyses to adjust for normal leniency in OR scheduling (15 minutes for first start and 90 minutes for turnover). Univariate analysis used Wilcoxon rank-sum test for continuous outcomes, while chi-square test and Fisher's exact test were used for categorical comparisons. Significance was defined as P<.05. Results: First-start time was analyzed in 426 pre-COVID-19, 357 peak-restrictions, and 2304 post-peak-restrictions cases. The unadjusted mean delay length was found to be significantly different between the time periods, but the magnitude of increase in minutes was immaterial (mean [SD] minutes, 6 [18] vs 10 [21] vs 8 [20], respectively;P=.004). The adjusted average delay length and proportion of cases delayed beyond the 15-minute threshold were not significantly different. The proportion of cases that started early, as well as significantly early past a 15-minute threshold, have not been impacted. There was no significant change in turnover time during peak restrictions relative to the pre-COVID-19 period (88 [100] minutes vs 85 [95] minutes), and turnover time has since remained unchanged (83 [87] minutes). Conclusion: Our center was able to maintain OR efficiency before, during, and after peak restrictions even while instituting advanced infection-control strategies. While there were significant changes, delays were relatively small in magnitude.
Study 1 Overview (Oberhaus et al)Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.
Objective: To examine the effect of a multifactorial intervention for fall prevention on fall injury in community-dwelling older adults.Design: This was a pragmatic, cluster randomized trial conducted in 86 primary care practices across 10 health care systems.Setting and participants: The primary care sites were selected based on the prespecified criteria of size, ability to implement the intervention, proximity to other practices, accessibility to electronic health records, and access to community-based exercise programs.The primary care practices were randomly assigned to intervention or control.Eligibility criteria for participants at those practices included age 70 years or older, dwelling in the community, and having an increased risk of falls, as determined by a history of fall-related injury in the past year, 2 or more falls in the past year, or being afraid of falling because
pistaxis, or nosebleed, is estimated to be the chief complaint in 1 in 200 emergency department visits in the United States. 1 Additionally, it represents up to one-third of otolaryngology-related emergency room admissions. 2 There is no existing literature, to our best knowledge, specifically investigating the incidence of epistaxis after a patient is admitted.Anecdotally, inpatients who develop epistaxis account for an appreciable number of consults to otolaryngology (ENT).Epistaxis is a cross-disciplinary issue, occurring in a range of clinical settings.For example, patients with epistaxis can present to the emergency department or to an outpatient primary care clinic before being referred to ENT.Additionally, inpatients on many different services can develop spontaneous epistaxis due to a variety of environmental and iatrogenic factors, such as dry air, use of nasal cannula, and initiation of anticoagulation.Based on the experience of our ENT providers and discussions with our nursing colleagues, we concluded that there was an interest in epistaxis management training among our nursing workforce.The presence of unmet demand for epistaxis education among our nursing colleagues was supported by our
As we transition out of the Omicron surge, the lessons we’ve learned from the prior surges carry forward and add to our knowledge foundation. Medical journals have published numerous research and perspectives manuscripts on all aspects of COVID-19 over the past 2 years, adding much-needed knowledge to our clinical practice during the pandemic. However, the story does not stop there, as the pandemic has impacted the usual, non-COVID-19 clinical care we provide. The value-based health care delivery model accounts for both COVID-19 clinical care and the usual care we provide our patients every day. Clinicians, administrators, and health care workers will need to know how to balance both worlds in the years to come. In this issue of JCOM, the work of balancing the demands of COVID-19 care with those of system improvement continues. Two original research articles address the former, with Liesching et al1 reporting data on improving clinical outcomes of patients with COVID-19 through acute care oxygen therapies, and Ali et al2 explaining the impact of COVID-19 on STEMI care delivery models. Liesching et al’s study showed that patients admitted for COVID-19 after the first surge were more likely to receive high-flow nasal cannula and had better outcomes, while Ali et al showed that patients with STEMI yet again experienced worse outcomes during the first wave. On the system improvement front, Cusick et al3 report on a quality improvement (QI) project that addressed acute disease management of heparin-induced thrombocytopenia (HIT) during hospitalization, Sosa et al4 discuss efforts to improve comorbidity capture at their institution, and Uche et al5 present the results of a nonpharmacologic initiative to improve management of chronic pain among veterans. Cusick et al’s QI project showed that a HIT testing strategy could be safely implemented through an evidence-based process to nudge resource utilization using specific management pathways. While capturing and measuring the complexity of diseases and comorbidities can be challenging, accurate capture is essential, as patient acuity has implications for reimbursement and quality comparisons for hospitals and physicians; Sosa et al describe a series of initiatives implemented at their institution that improved comorbidity capture. Furthermore, Uche et al report on a 10-week complementary and integrative health program for veterans with noncancer chronic pain that reduced pain intensity and improved quality of life for its participants. These QI reports show that, though the health care landscape has changed over the past 2 years, the aim remains the same: to provide the best care for patients regardless of the diagnosis, location, or time. Conducting QI projects during the COVID-19 pandemic has been difficult, especially in terms of implementing consistent processes and management pathways while contending with staff and supply shortages. The pandemic, however, has highlighted the importance of continuing QI efforts, specifically around infectious disease prevention and good clinical practices. Moreover, the recent continuous learning and implementation around COVID-19 patient care has been a significant achievement, as clinicians and administrators worked continuously to understand and improve processes, create a supporting culture, and redesign care delivery on the fly. The management of both COVID-19 care and our usual care QI efforts should incorporate the lessons learned from the pandemic and leverage system redesign for future steps. As we’ve seen, survival in COVID-19 improved dramatically since the beginning of the pandemic, as clinical trials became more adaptive and efficient and system upgrades like telemedicine and digital technologies in the public health response led to major advancements. The work to improve the care provided in the clinic and at the bedside will continue through one collective approach in the new normal.
