September 2009

Honesty and apology after medical errors result in 55 percent reduction in malpractice claims

Open communication and honesty with patients about medical errors, including an apology, were found to be the key to reducing malpractice claims by as much as 55 percent.

The evidence appears to support the position that patients file malpractice lawsuits because they get so angry when communication, honesty, accountability, and literally good customer service are lacking after a perceived error. A lawsuit is often the only way to find out what actually happened to a loved one. This position was addressed in a recent commentary in the British Medical Journal (BMJ) referencing decades of evidence published by "Sorry Works!," a coalition led by Doug Wojcieszak.

The University of Michigan Health System (UMHS) has adopted many of these strategies, including an apology after a medical error that resulted in a greater than 50 percent reduction in average litigation costs and reduced malpractice claims by 55 percent between 1999 and 2006. UMHS published its effective strategy for reducing litigation and malpractice claims. The article notes that a principled accounting of what occurred is best not only for patients and their families and the institution, but also for the healthcare providers involved in the event, future patients and even the lawyers. In addition to the policy of owning up to responsibility for adverse events, apologizing, and compensation to the patient and family as the core of the program, UMHS has a comprehensive patient safety initiative that includes other structural and cultural changes.

Other organization's disclosure programs UMHS isn't the only organization to implement a comprehensive disclosure program. The Department of Veterans Affairs, the University of Illinois at Chicago (UIC) Medical Center, and Kaiser Permanente also have well-developed programs of apology and disclosure. As originally developed by UMHC and enhanced by the UIC, principles of "full disclosure" include the following elements:

• Provide effective and honest communication to patients and families following adverse patient events;
• Apologize and compensate quickly and fairly when inappropriate medical care causes injury;
• Defend medically appropriate care vigorously; and
• Reduce patient injuries and claims by learning from past experience.

Downloads and links

• You can say sorry. Feinmann BMJ 2009;
• Sorry works! Editorial Wojcieszak
• Journal of Health & Life Sciences Law-Boothman, January 2009
• Premier healthcare alliance Web conference on "Disclosure, Apology and Early Resolution" https://premierinc.com/risk/education-newsletters/websessions/may27/
• Patient Safety Share - January 2009: "Recent rise in "apology" laws in 36 states protect physicians from malpractice."
• Joint Commission White Paper: "Healthcare at the crossroads: Strategies for improving the medical liability system and preventing patient injury."

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AHRQ post-op VTE patient safety indicator not ready for prime time as reliable reporting tool

The patient safety indicator (PSI) screen for postoperative venous thromboembolism (VTE) performs well as a screening tool but is not a reliable tool for reporting.

The Agency for Healthcare Research and Quality's (AHRQ) set of patient safety indicators (PSI) for potentially preventable complications in hospitalized patients was tested in a recent study to identify cases of postoperative deep venous thromboembolism (DVT). Results of chart review revealed identification of nearly all true DVT cases, but also identified a significant number of false positives. The researchers concluded that this PSI is a good screening tool but given the risk of false positive, is unreliable for reporting purposes.

VTE represents a significant source of morbidity and mortality. In addition, pulmonary embolism (PE) is one of the most common preventable causes of death in hospitals. DVT/PE following total knee or total hip replacement is one of the hospital-acquired conditions for which CMS will not make additional payment if there are no other co-morbidities. The AHRQ indicator for postoperative VTE relies on the current disease classification (ICD-9-CM) codes for DVT or PE in secondary diagnoses fields. The accuracy of ICD-9-CM codes for identifying specific outcomes has been the subject of much debate. This study responds to those questions by finding that while the PSI is a good screening tool, it could be improved with better coding methods. Importantly, use of performance data for such purposes imposes additional requirements for accuracy and reliability that the PSIs may not meet for public reporting criteria.

Downloads and links

• JC JQS Abstract 2009 Clinical validation of the AHRQ post-op VTE PSI
• Premier Safety Institute - Venous Thromboembolism (VTE)
• Premier Advisor Live presentation on VTE

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Public report of adverse events - the sensitivity of event detection will vary with tool and method used

The sensitivity of three commonly used methods for adverse event detection varied significantly - raising caution about their use in public reporting.

Researchers in a recent study compared three available methods for detecting adverse events in hospitals - the AHRQ patient safety indicators (PSIs), provider-reported events, and the IHI Global Trigger Tool. The objective of this study was to compare patients who had been identified as having adverse events (AE), using these methods of detection.

Findings Four percent of discharges in 2005 (60,500) from three Mayo Clinic hospitals had an AE identified by at least one of the two hospital-wide methods - AHRQ (2.6 percent) and provider database (1.5 percent). Only 6 percent of hospitalizations with a PSI also had a provider-reported event, and only 10.5 percent of provider-reported events had a PSI, with a very small overlap. Using the IHI Global Trigger tool as an additional method to review a sample of cases, the trigger tool detected only 6 percent of AE detected by the other two methods.

Based on their findings, the authors suggest that measuring safety requires a multifaceted approach, and they caution against using any one indicator for public reporting and performance comparisons.

Discrepancies One reason for the discrepancies is that these commonly used patient safety measures are derived from different data sources and codes, often with different purposes, methods, dimensions of the care processes, and levels of patient harm.

• PSIs are based on retrospective review of ICD-9 diagnosis codes from hospital discharge abstracts. They screen for patient safety events that appear to have occurred. In this study, the PSIs were modified to exclude "present on admission" diagnoses, reducing the likelihood of false positives.
• Provider reported events are events reported as part of routine hospital and clinical activities. Data are entered into a central database with a locally developed tool.
• Trigger tools are sentinel words or conditions found in a relatively quick review of the medical record to detect the possibility of the occurrence of an adverse event. The presence of one of these conditions ‘triggers' a more extensive record review by multiple reviewers, including a physician, to assess the cause of the condition. Several sets of trigger tools are now available for detecting errors in intensive care units and general care units, as well as in medication management.

Recommendations The findings in this study are consistent with those who argue for combining identification approaches to fully understand patient safety issues occurring within an organization. The authors caution the use of these indicators for public reporting. Differences in the frequencies of indentified events can arise from inconsistencies in the definitions used in practice and from the detection method employed. While standard definitions can improve the comparability of reported patient safety events, the possibility remains that the approaches used within organizations and by external agents may be measuring different constructs rather than common safety risks.

Downloads and links

• A comparison of hospital adverse events 2009 Abstract.
• AHRQ WebM&M commentary discusses the limitations of using PSIs for public reporting and hospital comparison purposes.

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Standardized OR briefings tool takes three minutes and improves communication and teamwork

Standardized tools for OR briefings/debriefing reported to take only three minutes were found to improve teamwork and communication.

Improving teamwork and communication is known to be a key strategy to prevent errors in the operative setting. Past studies have evaluated the role of checklists, briefings, and targeted educational programs as potential solutions. A recent study evaluated the feasibility and applicability of using standardized OR briefing and debriefing tools across multiple OR procedures and teams. The tools were developed by Johns Hopkins and Michigan Keystone Project and were found to increase the perception of communication and teamwork, as well as be feasible to implement given the existing staff workload.

The briefing/debriefing tool addressed a number of elements that are key to teamwork, including having the surgeon discussing the procedure with the staff (the critical steps and goals), any safety concerns and a review of necessary supplies. The debriefing tool, for example, asked for sharing among teams anything that could have been done differently or more safely.

The tools were evaluated in greater than 37,000 briefings and debriefings with an average compliance rate ranging from 76 to 95 percent. There was nearly 90 percent agreement among the team members that the tools were effective strategies to improve teamwork and communication.

Reasons for underlying communication issues among OR staff are examined in detail in a recent article free to the public titled "Silence, power and communication in the operating room."

Downloads and links

• Standardized operating room briefings Berenholtz 2009.
• Tool - A copy of the briefing and debriefing tool used by researchers, along with the interview tool, can be accessed via the online version of the subscription-based article.
• "Silence, power and communication in the operating room"
• Premier Safety Institute - Bundling Web site

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Lessons from high-reliability organizations provide guidance for successful handoffs in healthcare

Strategies for safe handoffs in a healthcare setting were identified by analyzing successful hand off strategies utilized in other high-risk industries.

New limits on resident hours increase the frequency of patient hand offs and opportunity for adverse outcomes. A recent study at the University of Iowa and the Henry Ford Health System compared the strategies used by high-reliability organizations (HROs) that may provide guidance for healthcare facilities wanting to improve their handoffs and understand transfer problems that contribute to adverse outcomes. This study conducted among resident physicians on inpatient rotations at these health systems found that some of the strategies used in high-reliability organizations were commonly used in healthcare settings.

Strategies used by HROS and healthcare that should be emphasized:

• Face-to-face verbal updates with interactive questions and answers.
• Topics initiated by incoming as well as outgoing residents.
• Limited initiation of actions during update (except for emergencies).
• Written summary before handoff by outgoing resident.
• Knowledge-sharing of previous shift activities by outgoing resident.
• Current status assessment always updated in a consistent order by incoming resident.

Ongoing problems and opportunities for improvement in handoffs:

• Truncated/omitted information due to work demands; constraints due to duty hour limits.
• Unfinished diagnostic/care activities at the end of the outgoing resident's shift.
• Perceived as challenging due to not knowing or trusting another resident.
• Problematic due to cross-coverage.
• Poorly coordinated due to not knowing who was responsible for patients.

Strategies identified that are essential for successful handoffs:

• Teaching residents how to hand off.
• Reducing or eliminating cross coverage.
• Use of alternative staffing models, e.g., larger teams with collective responsibility for patients across multiple units, or added faculty presence.

The study concluded that further research is needed to explore how to conduct effective handoffs under shortened duty periods. This research should assess how transfer strategies and data summaries could enhance efficiency and effectiveness, and how they could substitute when a verbal interactive handoff is not feasible.

Downloads and links

• WHO Patient Safety Solution: Safe HandOvers

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Physicians are more satisfied when engaged in quality improvement activities: survey

Involvement in quality improvement activities was found to improve job satisfaction, perception of work-life balance, and peer collaboration.

Survey The importance of physician well-being has been well-documented. However, little is known about how physicians' self-reported quality improvement (QI) activities and quality of care are related to their practice dissatisfaction, professional isolation and work-life stress. A random sample of 1,884 physicians in Massachusetts were surveyed to assess their practices' participation in QI activities and quality of care, as well as their feelings of professional isolation, work-life stress and practice dissatisfaction.

Findings Most respondents reported QI activities in their practices (85 percent) and subsequent evaluation of these activities (62 percent). Approximately one-third reported quality problems in their practice. In linear regression analyses, the presence of quality problems was independently associated with increased professional isolation, work-life stress and practice dissatisfaction.

In contrast, physicians from practices that were involved in the evaluation of QI activities had significantly less isolation, stress and dissatisfaction. Participation in QI activities was also independently associated with less job dissatisfaction. A substantial portion of physicians reported moderate to severe problems with isolation (17 percent), work-life stress (31 percent) and dissatisfaction (27 percent).

The authors advocate for greater efforts to engage physicians in quality improvement work, as this may impact the quality of care delivered to their patients.

Downloads and links

• The relationship between perceived practice quality and quality improvement activities Med Care. 2009

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H1N1 preparation in schools - CDC emphasizes screening of students, long-distancing learning, surface cleaning and vaccination

Updated Centers for Disease Control and Prevention (CDC) communications have noted continued H1N1 flu activity as schools open across the country. CDC also has highlighted the fact that children and young adults are still being hit the hardest as they were last spring, continuing through late summer and early fall.

Long distance learning CDC recommends that schools have plans to deal with possible infection when identified on-site. For instance, people with flu-like illness should be sent to a room away from other people until they can be sent home. Schools should have plans for continuing the education of students who are at home, through phone calls, homework packets, Internet lessons and other approaches. And schools should have contingency plans to fill important positions such as school nurses.

Routine cleaning School staff should also routinely clean areas that students and staff touch often with the cleaners they typically use. CDC does not believe any additional disinfection of environmental surfaces beyond the recommended routine cleaning is required. H1N1 does provde an opportunity to emphasize the need for cleaning any frequently touched surface during any flu season, including H1N1. The virus is easily killed by any standard cleaner since it is an Influenza A type virus. Read the full set of recommendations.

School guidance is a part of a broader national framework to respond to novel H1N1 influenza, which includes encouraging people to be vaccinated against the virus and to take other actions to avoid infection. The CDC anticipates more illness after the school year starts, because flu typically is transmitted more easily in the fall and winter.

For an outbreak similar in severity to the spring 2009 H1N1 infection, the guidelines recommend basic good hygiene, such as hand washing and staying home when ill. In addition, students or staff members with flu-like illness (showing symptoms of flu) should stay home at least 24 hours after fever symptoms have ended.

Vigilance needed for the seasonal flu According to the CDC, all healthcare personnel (HCP) should be vaccinated to help decrease the spread of seasonal flu to patients, which can lead to serious health risks and even death. The Joint Commission requires accredited hospitals, critical access hospitals and long-term care organizations to offer the flu vaccine annually on-site to staff and licensed independent practitioners and has launched the "FluVaccination Challenge" to help promote and increase HCP vaccination rates.

Downloads and links

• Safety Institute Novel A (H1N1) Influenza Flu resources: http://www.cdc.gov/h1n1flu/schools/schoolguidance.htm
• Flu Vaccination Challenge
  or go to: http://www.FluVaccinationChallenge.com
• Premier Safety Institute's Seasonal flu Web site
   

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Joint Commission's sentinel event alert emphasizes the role of leadership, including maintaining a culture of safety

The latest alert emphasizes the Joint Commission's Leadership standard requiring leaders to "create and maintain a culture of safety and quality throughout the organization."

The new alert specifically addresses the leadership of healthcare organizations, defined as the governing body, the chief executive and senior managers, and the leaders of the clinical staff, emphasizing that leadership is a critical function in promoting high quality, safe healthcare in a culture of safety. The following are among the suggested actions directed to senior leaders:

• Define and establish an organization-wide safety culture.
• Institute an organization-wide policy of transparency.
• Make the overall safety performance a key, measurable part of leadership evaluation.
• Ensure that caregivers involved in adverse events (AE) receive respectful attention.
• Create and communicate a policy that defines behaviors referred for disciplinary action.
• Regularly monitor and analyze AE and communicate findings to leadership.
• Conduct root cause analyses of AEs.
• Prioritize and address safety risks and barriers to safety.
• Establish partnerships with physicians and align incentives to improving safety.
• Add a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to the board and all leadership groups.
• Use the expertise of front-line staff who understand the risks to patients and processes.
• Regularly measure leadership's commitment to safety using climate surveys.
• When leaders assess managers during the annual performance review, ask about safety.
• Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.

Downloads and links

• Sentinel Event Alert #43 Leadership committed to safety
  or go to: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_43.htm
• Leadership Guide to Patient Safety - Free from IHI
• Premier Safety Institute's Culture of Safety Web site.
   

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