What’s New in the Patient Safety World

April 2017



·         Joint Commission Sentinel Event Alert on Safety Culture

·         Relation of Complaints about Physicians to Outcomes

·         How Much Time Do We Actually Spend on the EMR?

·         ECRI Institute’s 2017 Top 10 Patient Safety Concerns




Joint Commission Sentinel Event Alert on Safety Culture



The Joint Commission has just published a Sentinel Event Alert on the role of leadership in establishing a culture of safety (TJC 2017). It emphasizes that leaders promote a culture of safety not by words but rather by their actions.


It stresses 3 of James Reason’s essential elements of a safety culture: (1) Just Culture (2) Reporting Culture (3) Learning Culture. It emphasizes the critical importance of a transparent, non-punitive approach to reporting and learning from adverse events, close calls, and unsafe conditions.


The alert identifies 11 tenets of a safety culture:

  1. Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions.
  3. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
  4. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop).
  6. Determine an organizational baseline measure on safety culture performance using a validated tool.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
  10. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.


The Alert provides examples of what some hospitals have done under each of the “tenets” described above. It also has excellent references and links to a variety of useful resources for leadership and safety culture.


We’ve never been fans of the variety of “culture” surveys that are widely used. When applied to assess the “culture” of an organization as a whole they can be terribly misleading. Culture at the unit level is much more important. All the surveys out there tend to show the same thing: physicians and administrators generally paint a more positive view of the “organizational culture” than do nurses and other frontline personnel. And the culture often varies dramatically from unit to unit. And people often respond to such surveys with the answers they think you want to hear rather than what they actually think, even when the surveys are “anonymous”.


We’ve always found that you get a much better feel for the “culture” of a unit on your Patient Safety Walk Rounds than you get from any formal survey. When you have direct interaction with frontline staff in an informal and non-punitive fashion, they are more likely to be forthcoming and point out potential vulnerabilities that they might not when responding to a formal survey or questionnaire. Our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds” discusses in detail how you can make such rounds valuable and help improve your culture of safety (and also warns how you can misuse such rounds to be detrimental in promoting a culture of safety!).


We are disappointed The Joint Commission barely mentioned the role of Patient Safety Walk Rounds. We would have given them a place as a formal “tenet” for the role of leadership in fostering a culture of safety.



Some of our prior columns related to the “culture of safety”:


April 2009                   New Patient Safety Culture Assessments

June 2, 2009                Why Hospitals Should Fly...John Nance Nails It!

January 2011               No Improvement in Patient Safety: Why Not?

March 2011                 Michigan ICU Collaborative Wins Big”).

March 29, 2011           The Silent Treatment: A Dose of Reality

May 24, 2011              Hand Hygiene Resources

March 2012                 Human Factors and Operating Room Safety

July 2012                     A Culture of Disrespect

July 2013                     "Bad Apples" Back In?

July 22, 2014               More on Operating Room Briefings and Debriefings

October 7, 2014          Our Take on Patient Safety Walk Rounds

July 7, 2015                 Medical Staff Risk Issues

September 22, 2015    The Cost of Being Rude

May 2016                    ECRI Institute’s Top Ten Patient Safety Concerns for 2016

June 28, 2016              Culture of Safety and Catheter-Associated Infections






TJC (The Joint Commission). Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. TJC 2017; March 1, 2017






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Relation of Complaints about Physicians to Outcomes



And speaking about the culture of safety…


While true learning organizations value non-punitive environments that promote transparency and the ability to report concerns without fear of retribution, there remains a role for recognizing that certain issues are red flags that merit review and often intervention. Complaints about physicians are a good example.


It’s long been known that a small number of physicians experience a disproportionate share of malpractice claims and expenses and that patient complaints are associated with a higher risk of malpractice actions. Hickson and colleagues (Hickson 2002) demonstrated that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity.


We’ve discussed patient complaints about physicians in a few columns (see below). But a new study demonstrates, apparently for the first time, that outcomes for surgeons are also clearly linked to such complaints (Cooper 2017). Prior unsolicited patient observations for surgeons were significantly associated with the risk of a patient having any complication, any surgical complication, any medical complication, and being readmitted. The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile.


The editorial (Kachalia 2017) accompanying the Cooper study points out that the relationship between a surgeon’s proneness to patient complaints and outcomes is likely complex. For example, they note that surgeons with poor interpersonal skills may end up with lower quality surgical teams, perhaps leading to poor overall performance even if the surgeon’s individual performance was adequate.


Our July 7, 2015 Patient Safety Tip of the Week “Medical Staff Risk Issuesnoted a study which developed an algorithm to predict physician risk of formal patient complaints using routinely collected administrative data (Spittal 2015). The PRONE (Predicted Risk Of New Event) score is based upon 4 variables: (1) physician specialty (2) physician gender (3) number of previous complaints (4) time since last complaint. While most patient complaints (60%) were related to clinical issues, about a fifth were related to communication issues (13% related to physician attitude or manner). The algorithm led to a possible total score of 22. Those with scores of 0-2 had a 14% risk of a complaint in the next 2 years, whereas those with scores of 15-17 had an 88% risk of a complaint in the next 2 years. The authors suggest the PRONE score could be used to flag physicians needing deeper review. They also suggest one might “tier” interventions based upon the PRONE score. This is interesting and likely to be especially of interest to risk managers. But review of patient complaint patterns should be part of the credentialing process for all healthcare providers.


In our July 2013 What’s New in the Patient Safety World column “"Bad Apples" Back In?we noted a study by Bismark et al. (Bismark 2013) which found that 3% of Australia’s medical workforce accounted for 49% of all complaints by patients and 1% accounted for 25% of the complaints. Moreover, there was a striking dose-response relationship, i.e. the more complaints about a physician the higher the likelihood that there would be yet further complaints. A doctor with a third complaint had a 38% chance of a further complaint within a year and 57% chance of another complaint within 2 years. For one with a fifth complaint, the chance of another complaint within 1 and 2 years, respectively, was 59% and 79%. The authors point out that we are often too late to respond to physicians who have attracted multiple complaints and that we should really look at complaints as sentinel events. The hope is that early response may result in changes in physician behaviors. An accompanying editorial (Paterson 2013) noted that patient complaints are the “canaries in the coal mine” that should alert us to deeper problems and should not be ignored. Another accompanying editorial (Gallagher 2013) focuses on the need to end our silence and speak up and tell our colleagues about ways they can improve their care and communicate better. They argue we need to do a much better job acting locally (at the departmental, medical staff, academic unit, and clinical unit levels) to address these behaviors before they need to go to higher levels. They also note the need to develop better metrics for incorporating measures of patient satisfaction. And yet a third accompanying editorial (Shojania 2013) argues there is a systems problem and that we need to focus our resources on identifying such individuals and dealing with them. They also note that, in some cases, there may be multiple system problems that lead to a physician attracting multiple complaints (eg. understaffing in a clinical area).


We, of course, would remind you that staff complaints about physicians are just as important as patient complaints. Sometimes the patient complaints go elsewhere (eg. to state health departments, professional disciplinary bodies, medical societies, etc.) and you may not be aware of these for some time. Staff complaints are more often available to you immediately. It would be interesting to see how the PRONE score algorithm would work using staff complaints rather than patient complaints.




Some of our prior columns on the impact of “bad behavior” of healthcare workers:


January 2011               No Improvement in Patient Safety: Why Not?

March 29, 2011           The Silent Treatment: A Dose of Reality

July 2012                     A Culture of Disrespect

July 2013                     "Bad Apples" Back In?

July 7, 2015                 Medical Staff Risk Issues

September 22, 2015    The Cost of Being Rude







Hickson GB, Federspiel CF, Pichert JW, et al. Patient Complaints and Malpractice Risk. JAMA 2002; 287(22): 2951-2957




Cooper WO, Guillamondegui O, Hines OJ, et al. Use of Unsolicited Patient Observations to Identify Surgeons with Increased Risk for Postoperative Complications. JAMA Surg 2017; Published online February 15, 2017




Kachalia A, Mello MM, Studdert DM. Association of Unsolicited Patient Observations with the Quality of a Surgeon’s Care. JAMA Surg 2017; Published online February 15, 2017




Spittal MJ, Bismark MM, Studdert DM. The PRONE score: an algorithm for predicting doctors’ risks of formal patient complaints using routinely collected administrative data. BMJ Qual Saf 2015; Published Online First 8 April 2015




Bismark MM, Spittal MJ, Gurrin LC, et al. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. BMJ Qual Saf 2013; 22: 532-540 Published Online First: 10 April 2013 doi:10.1136/bmjqs-2012-001691




Paterson R. Not so random: patient complaints and ‘frequent flier’ doctors. BMJ Qual Saf 2013;22:525-527 Published Online First: 10 April 2013 doi:10.1136/bmjqs-2013-001902




Gallagher TH, Levinson W. Physicians with multiple patient complaints: ending our silence. BMJ Qual Saf 2013; 22: 521-524 Published Online First: 10 April 2013 doi:10.1136/bmjqs-2013-001880




Shojania KG, Dixon-Woods M. ‘Bad apples’: time to redefine as a type of systems problem? BMJ Qual Saf 2013; 22: 528-531 Published Online First: 6 June 2013 doi:10.1136/bmjqs-2013-002138







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How Much Time Do We Actually Spend on the EMR?



Over the past 6 months there have been multiple studies documenting how much time various healthcare professionals actually spend on the EMR (electronic medical record) or associated healthcare technologies. Self-reported estimates of time spent on such activities have not always been accurate so studies using methodologies such as direct observation or computer time logs provide us with a better picture.


The amount of time we spend with healthcare IT is important for several reasons. While many of the HIT activities clearly improve patient safety, they also take time away from our face-to-face interactions with patients. Moreover, time spent on the computer has been linked to higher levels of burnout. In a large national study, physicians' satisfaction with their EHRs and CPOE was generally low and those who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout (Shanafelt  2016).


A study using observation of nurses (Higgins 2016) found that nurses spent an average of 33% of a shift interacting with technology including time in the EMR. In the Higgins study nurses overestimated the amount of time they spent charting in the EMR. Whereas they estimated they spent 26% of each shift charting, the actual observed percentage was only 11% per shift. However, “Overall time in the EHR (documenting, reviewing, and medication preparation) of about 3 hours per 12-hour shift was corroborated by observations and the automatically generated computer time stamps.” Higgins and colleagues did note, however, that both nurses’ and patients’ perceptions of quality of care and satisfaction with technology use were high.


A time-motion study of physicians in ambulatory practices (Sinsky 2016) found that, during the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. In addition, outside of office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. Thus, for every hour physicians provide direct clinical face time to patients, they spent nearly 2 additional hours on EHR and desk work within the clinic day. Of the time spent on EHR and desk work, 38.5% was spent on documentation and review tasks, 6.3% on test results, 2.4% on medication orders, and 2.0% on other orders. They spent 1.1% of their time on administrative tasks (0.6% involved insurance-related tasks and 0.5% involved scheduling).


Two studies looked at time allocation for residents. Wenger and colleagues (Wenger 2017) found that resident activities indirectly related to patients accounted for 52.4% of the time and activities directly related to patients accounted for 28.0%. On an average shift (11.6 hours on average) residents spent an average of 1.7 hours with patients, 5.2 hours using computers, and 13 minutes doing both. Time spent using a computer was scattered throughout the day, with the heaviest use after 6:00 p.m. The other study (Chen 2016), on first year residents/interns, found each intern spent on average 112 hours per month on 206 electronic patient record encounters. However, the amount of time spent on the computer decreased from July to January as they became more proficient.


Certain healthcare venues may be associated with even higher levels of health information technology (HIT) use. A recent ethnographic study of three academic ICUs found that the average HIT use on the two “high-use” ICUs was 49 percent (Leslie 2017). But there was considerable variation. On the “low-use” ICU it was 10 percent but ranged as high as 90% on others. The authors also found that clinicians in high-use ICU’s experienced “silo” effects that had the potential to adversely impact communication, situational awareness, patient satisfaction, quality and patient safety.


So are there ways to reduce time spent interacting with technology and increase face-to-face time with patients? In the Sinsky study (Sinsky 2016) about half the physicians used some form of documentation support (dictation or a documentation assistant). Those physicians using documentation support spent more time on direct clinical face time with patients (31.4% for those using dictation and 43.9% for those with a documentation assistant) than those without documentation support (23.1%).


A recent article in Medical Economics (Shehata 2017) describes how use of scribes improved both office efficiency and patient satisfaction. The authors note that the average physician spends 30% to 50% of a patient encounter looking directly at the EHR. But with use of appropriately trained medical scribes, the physician is able to have more direct face-to-face interaction with the patient. After the encounter, the physician reviews the scribe’s note to ensure the documentation is complete, attaches orders, and signs the note. This results in more patients who believe the physician is more attentive, compassionate, and courteous during their interactions and physicians who feel more efficient. One physician found his use of scribes allowed him to spend 93.7% of each patient encounter directly interacting with the patient. The article further describes a study in which video recordings of the gaze of both physicians and patients was recorded in a setting where medical scribes were used. Direct gaze between patient and physician occurred during 81.8% of the total visit length. And the physician and patient spent an additional 11.88% of the patient encounter screen sharing. The physician only spent an average of 6.31% of the total visit length gazing elsewhere.



And does all this time spent on EMR activities have a good “return on investment”? In our March 22, 2011 Patient Safety Tip of the Week “An EMR Feature Detrimental to Teamwork and Patient Safety” we noted a study that had very bothersome results. Hripcsak and colleagues (Hripcsak 2011) analyzed time spent authoring notes and time spent reading notes in the EMR. They found most users spent 90 minutes a day authoring notes, 30 minutes a day reading notes. But the bothersome feature was a striking disparity in the rates of notes read that were authored by various healthcare workers. They found 97% of attending notes were read by someone and 99% of resident notes were read by someone. But fewer than 20% of nurses’ notes were read by attendings or residents! And only 38% of nurse’s notes were read by other nurses. 16% of all notes were never read by anyone!


In that column we noted how this seems like a journey into the past! For the longest time, hospitals were divided in how they partitioned the paper medical chart. Some hospitals kept notes by physicians, consultants, nurses, therapists, dietitians, etc. segregated from each other whereas other hospitals intermingled all the notes in the “progress note” section. We can recall medical staff meetings where some disgruntled physicians indignantly ranted “I’m not interested in seeing the *#!&ing social work note”. Generally, as the value of teamwork became increasingly appreciated and a culture of safety adopted, most organizations migrated toward the “intermingled” model. But with the advent of the EMR we have seen a trend back to the “partitioned” model. The statistics above mean that most physicians seldom read notes by anyone other than physicians. No wonder we have so many adverse events where communication breakdowns are identified as root causes or contributory factors.


Some of the problem may still be related to the “newness” of the EMR. Most EMR’s do allow some degree of customization of what is displayed and how and where it is displayed. So a user might choose to keep all clinical notes together or to sort them by provider type. In some cases, the “default” setting is the partitioned one and the physician may not even realize he/she can choose the intermingled model.




See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:







Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between Clerical Burden and Characteristics of the Electronic Environment with Physician Burnout and Professional Satisfaction. Mayo Clin Proc 2016; 91(7): 836-848




Higgins LW, Shovel JA, Bilderback AL, et al. Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment. Journal of Nursing Care Quality 2016; Published Ahead-of-Print November 10, 2016




Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med 2016; September 6, 2016




Wenger N, Méan M, Castion J, et al. Allocation of Internal Medicine Resident Time in a Swiss Hospital: A Time and Motion Study of Day and Evening Shifts. Ann Intern Med 2017; published online 31 January 2017




Chen L, Guo U, Illipparambil LC, et al. Racing Against the Clock: Internal Medicine Residents' Time Spent On Electronic Health Records. Journal of Graduate Medical Education 2016; 8(1): 39-44




Leslie M, Paradis E, Gropper MA, et al. An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units. Health Services Research 2017; 25 January 2017




Shehata H, Amparan A, Hizon G. How to use scribes to get off the computer and in front of patients. Medical Economics 2017; March 13, 2017




Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. JAMIA 2011; 18: 112-117






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ECRI Institute’s 2017 Top 10 Patient Safety Concerns


Every year ECRI Institute publishes its list of the “Top 10 Patient Safety Concerns for Healthcare Organizations”.


The list for 2017 (ECRI 2017):

  1. Information Management in EHRs
  2. Unrecognized Patient Deterioration
  3. Implementation and Use of Clinical Decision Support
  4. Test Result Reporting and Follow-Up
  5. Antimicrobial Stewardship
  6. Patient Identification
  7. Opioid Administration and Monitoring in Acute Care
  8. Behavioral Health Issues in Non-Behavioral-Health Settings
  9. Management of New Oral Anticoagulants
  10. Inadequate Organization Systems or Processes to Improve Safety and Quality



Once again, there is a heavy focus on healthcare IT. And the issue of inadequate management of behavioral health problems in non-behavioral health settings has been a frequent topic for us (many columns on suicide on general hospital units, wandering and elopement, and violence in healthcare), as have been opioid management/monitoring, antimicrobial stewardship, test result follow up, and patient identification issues.


New to this year’s list are #2, 9, and 10.


We’ll let you go to the full ECRI list for details. Click here to go to the ECRI Institute site where you can download the list.







ECRI Institute. Top 10 Patient Safety Concerns for Healthcare Organizations for 2017. ECRI Institute 2017






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Print “April 2017 Joint Commission Sentinel Event Alert on Safety Culture

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