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What’s New in the
Patient Safety World
February 2022
· Communication
Failures and Malpractice
· TIA
Clinics Provide Safe Patient Care
· Does
Time of Day Matter?
· Managing
Incidental Findings
Communication
Failures and Malpractice
It should come as no
surprise that communication issues are a major contributor to malpractice
claims, since communication issues are contributing factors in the majority of our root cause analyses into serious adverse
events. But there has been little actual data published on the role of
miscommunication in malpractice claims.
In a new study researchers
reviewed a random sample of malpractice claims from 2001 to 2011, collected in
CRICO Strategies’ Comparative Benchmarking System, a national claims database (Humphrey
2021). They identified communication failures in 49% of claims. Moreover, claims
with communication failures were significantly less likely to be dropped,
denied, or dismissed than claims without (54% versus 67%, P = 0.015) and
total costs were higher for those claims with communication failures. Of those
claims with communication failures 53% involved provider-patient miscommunication
and 47% involved provider-provider miscommunication. Communication errors among
medical staff most often occurred between the attending physician and the
nursing staff (37%), attending physicians between specialties (30%) and within
a specialty (19%). Specific information types most frequently identified were
contingency plans, diagnosis, and illness severity. The researchers found that 40%
of communication failures involved a failed handoff and that 77% could
potentially have been averted by using a handoff tool.
The focus on handoffs is also not surprising, since the
senior author of the study was Chris Landrigan, M.D.,
M.P.H., Co-Founder of the I-PASS
Patient Safety Institute, whose work we have highlighted in our many
columns on handoff issues (listed below). Handoffs occur between multiple types
of healthcare providers and always represent potential opportunities for error.
Handoffs should be done using structured formats, such as I-PASS or one of the
other tools highlighted in the columns below. But equally important, handoffs
should be conducted in a venue in which interruptions and distractions are
minimized, ample time is allotted, and the receipient
of the handoff is an active participant, asking questions and acknowledging
important points.
Read about many other
handoff issues (in both healthcare and other industries) in some of our
previous columns:
May 15, 2007 “Communication,
Hearback and Other Lessons from Aviation”
May 22, 2007 “More
on TeamSTEPPS™”
August 28, 2007 “Lessons
Learned from Transportation Accidents”
December 11,
2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The
Hospital at Night”
September 30, 2008 “Hot
Topic: Handoffs”
November 18, 2008 “Ticket
to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another
Good Paper on Handoffs”.
June 30, 2009 “iSoBAR:
Australian Clinical Handoffs/Handovers”
April 25, 2009
“Interruptions,
Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff
Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012
“Handoffs
– More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving
Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to
OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative
Handoff”
March 2017 “Adding
Structure to Multidisciplinary Rounds”
August 22, 2017 “OR
to ICU Handoff Success”
October 2017 “Joint
Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital
Transfers”
April 9, 2019 “Handoffs for Every Occasion”
November 2019 “I-PASS Delivers Again”
August 2020 “New
Twist on Resident Work Hours and Patient Safety”
September 29, 2020 “ISHAPED for Nursing Handoffs”
May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
References:
Humphrey KE, Sundberg M, Milliren
CE, et al. Frequency and Nature of Communication and Handoff Failures in
Medical Malpractice Claims. Journal of Patient Safety 2021; December 15, 2021 -
Volume - Issue -
I-PASS Patient Safety Institute
https://www.ipassinstitute.com/
Print “February 2022 Communication Failures and
Malpractice”
TIA Clinics
Provide Safe Patient Care
Speed is of the utmost importance when dealing with patients
having a stroke. But it is also of importance in patients having a TIA
(transient ischemic attack). The risk of stroke is especially high within the
first 48 hours following a TIA. Hence, prompt evaluation and implementation of
measures to prevent stroke is essential when confronted with a patient having a
TIA.
Of patients presenting to an emergency department with TIA,
5.3% had a stroke during the first 2 days, and 10.5% within 90 days of TIA
presentation (Johnston
2000). Another study (Lovett
2003) found that, of patients with a first-ever TIA, the risk of stroke was
8.6% at 7 days and 12.0% at 30 days
A systematic review and meta-analysis showed the rate of
subsequent ischemic stroke after TIA was estimated to be 2.4% within 2 days,
3.8% within 7 days, 4.1% within 30 days, and 4.7% within 90 days (Shahjouei
2021).
The Framingham Heart Study showed that after TIA, 21.5% of
strokes occurred within 7 days, 30.8% within 30 days, 39.2% within 90 days, and
48.5% more than 1 year after the index TIA (Lioutas 2021).
Studies have shown up to an 80% reduction in the risk of
stroke after a TIA with early implementation of secondary stroke prevention
strategies (Shahjouei
2022). Therefore, it is incumbent upon us to get the evaluation of
the TIA patient completed as soon as possible following the TIA. In the past,
most such evaluations were done in the emergency department or hospital. But in
recent years we have had a push to get that evaluation done promptly on an
outpatient basis in “TIA clinics”.
There has always been some concern about doing that
evaluation as an outpatient. So, recently, Shahjouei
and colleagues (Shahjouei
2022) did a systematic review and meta-analysis of studies on the
risk of subsequent stroke among patients receiving outpatient vs inpatient care
for TIA.
Among the patients who were treated at a TIA clinic, the
risk of subsequent stroke following a TIA or minor ischemic stroke was 0.3%
within 2 days, 1.0% within 7 days, 1.3% within 30 days, and 2.1% within 90
days. Among the patients who were treated as inpatients, the risk of subsequent
stroke was to 0.5% within 2 days, 1.2% within 7 days, 1.6% within 30 days, and
2.8% (95% CI, 2.1%-3.5%) within 90 days. For those seen in the ED’s, the risk
was 1.9% within 2 days, 3.4% within 7 days, 3.5% within 30 days, and 3.5%
within 90 days. The risk of stroke among patients treated at TIA clinics was
not significantly different from those hospitalized.
The authors conclude that the risk of subsequent stroke
among patients who were evaluated in a TIA clinic was not higher than those
hospitalized. Patients who received treatment in ED’s without further follow-up
had a higher risk of subsequent stroke. These findings suggest that TIA clinics
can be an effective component of the TIA care component pathway.
Note, however, that patients seen in TIA clinics tended to
be younger and had lower ABCD2 scores. Many guidelines suggest that higher risk
patients with TIA, such as those with higher ABCD2 scores, be evaluated as
inpatients.
The authors also note that many patients seen in the ED may
not have formal neurological consulations. They note
that the percentage of TIA misdiagnosis can be as high as 60% in ED’s and
primary care offices. They also note that “TIA mimics” (eg.
migraine aura) may be misdiagnosed as TIA’s in such patients.
Overall, the Shahjouei
meta-analysis is reassuring that the outcomes of TIA patients evaluated at TIA
clinics are at least as good as those of hospitalized TIA patients,
and may be even better than those of patients evaluated in the ED
without designated followup. But any TIA clinic must
be staffed by neurologists (or other provider with equivalent neurological
training) and have ready access to ultrasound, imaging, and cardiac tools. And followup is essesntial for
appropriate management of stroke risk factors, and compliance with more recent
recommendations for antiplatelet therapy.
References:
Johnston SC, Gress DR, Browner WS,
Sidney S. Short-term prognosis after emergency department diagnosis of TIA.
JAMA 2000; 284: 2901-2906
https://jamanetwork.com/journals/jama/fullarticle/193353
Lovett JK, Dennis MS, Sandercock
PAG, et al. Very Early Risk of Stroke After a First Transient Ischemic Attack. Stroke
2003; 34: e138-e140
https://www.ahajournals.org/doi/full/10.1161/01.str.0000080935.01264.91
Shahjouei S, Sadighi
A, Chaudhary D, et al. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke
After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA
Neurol 2021; 78(1): 77=87
https://jamanetwork.com/journals/jamaneurology/fullarticle/2771410
Lioutas V, Ivan CS, Himali JJ, et al. Incidence of Transient Ischemic Attack
and Association With Long-term Risk of Stroke. JAMA
2021; 325(4): 373-381
https://jamanetwork.com/journals/jama/fullarticle/2775447
Shahjouei S, Li J, Koza E, et al. Risk of Subsequent Stroke Among Patients
Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A
Systematic Review and Meta-analysis. JAMA Netw Open
2022; 5(1): e2136644
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787633
Print “February 2022 TIA Clinics Provide Safe
Patient Care”
Does Time of Day
Matter?
We’ve
done multiple columns on “the weekend effect” and “the after hours effect”, in which patient outcomes tend
to be worse than for those during “normal” daytime hours. But beyond time of
day or day of the week, there is variation in performance by time during a
working shift.
In
our May 3, 2011 Patient Safety Tip of the Week “It’s All in the Timing” we noted that detection rates for polyps or
adenomas during colonoscopy fell off during colonoscopies done later in a
shift. And in our June 2019 What's New in the Patient Safety World column “More on the Time of Day” we noted your chance of getting an
influenza vaccination or one of several preventive screening procedures also
falls off when you are seen late in the day.
The
phenomenon is seen in radiologists, too. In our August 25, 2020 Patient Safety
Tip of the Week “The Off-Hours Effect in
Radiology” we noted a
study which looked at the performance of radiology fellows who have completed
full radiology residencies (all of whom successfully completed the American
Board of Radiology board certification following their fellowship year),
comparing CT scan reading error rates during daytime or night shifts (Patel 2020). Nighttime studies had error rates of 3%,
compared to 2% for daytime studies, and 69% of the radiology fellows had higher
error rates for night cases. But, while the focus of the study was on nighttime
vs. daytime error rates, there
were significantly more errors during the last half of night assignments (3.7%) compared with the first half (2.5%). Diagnostic
error rates were also lower in the first half of the day assignment from 7:00
AM to 11:59 AM compared with the second half from 12:00 PM to 5:59 PM (1.1% vs.
2.6%), but that difference was not statistically significant.
A new
study (Bernstein 2022) showed
that patients were more likely to be recalled when their screening digital
breast tomosynthesis images were interpreted later in the day by
less-experienced radiologists. Thr researchers looked
at recall and false-positive (FP) rates in radiologists’ interpretation of
digital breast tomosynthesis (DBT) images digital mammography (DM) images (the
authors note that digital breast tomosynthesis image interpretation might be
more cognitively demanding than interpretation of digital mammography images).
But they also looked at the impact of time of day on these rates.
Overall,
for every additional hour of reading time, the odds of recall increased by 6.6%
for DBT, a sharper increase than that for DM. Similarly, for every additional hour
in reading time, the odds of an falso positive finding
increased by 6.8%, whereas the increase for DM was 3.9%. For every additional
hour in reading time, the odds of a true positive finding increased by 3.4% for
DBT and by 2.2% for DM. But results were significantly impacted by experience
of the radiologist. For radiologists with 5 or fewer posttraining
years of experience, odds of recall increased 11.5% with every hour when using
DBT, but this was not found for DM. For radiologists with more than
5 posttraining years of experience, no evidence of
increase in recall was observed for DBT or DM.
Physicians, nurses, and really all healthcare
workers tend to have drop-offs in performance when fatigued. There are, of
course, multiple studies demonstrating the impact of fatigue on on radiologists. Krupinski
et al. (Krupinski 2010)
found that, after a day of clinical
reading, radiologists have reduced ability to focus, increased symptoms of
fatigue and oculomotor strain, and reduced ability to detect fractures. In our
April 2018 What's New in the Patient Safety World column “Radiologists
Get Fatigued, Too” we highlighted a study looking at the
effect of overnight shifts on performance of radiologists (Hanna
2018). The researchers used a tool for measuring
fatigue and advance eye tracking technology to assess the performance of
radiologists (both attendings and residents). Not surprisingly, participants
demonstrated worse diagnostic performance in the fatigued versus not-fatigued
state. Viewing time per case was significantly prolonged when the radiologists
were fatigued. Mean total fixations generated during the search increased by
60% during fatigued sessions. Mean time to first fixate on bone fractures
increased by 34% during fatigued sessions. Moreover, dwell times associated
with true- and false-positive decisions increased, whereas those with false
negatives decreased. Effects of fatigue were more pronounced in residents, in
keeping with the findings of Bernstein et al. regarding the impact of
experience.
Hanna et al. concluded that further research
is needed to address and reverse the impact of such fatigue-related changes.
They speculate that environmental changes (eg. lighting) and activity changes (eg. periodic
breaks, moving around, etc.) might help mitigate the adverse effects of fatigue
on performance.
Some of our other columns on the impact of time of day on
patient outcomes:
May 3, 2011 “It’s All in the Timing”
June 2019 “More on the Time of Day”
August 25, 2020 “The
Off-Hours Effect in Radiology”
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping Air Traffic Controllers: What About
Healthcare?”
February 2011 “Update
on 12-hour Nursing Shifts”
September 2011 “Shiftwork and Patient Safety
November 2011 “Restricted Housestaff
Work Hours and Patient Handoffs”
January 2012 “Joint Commission Sentinel Event Alert:
Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended Consequences of Restricted Housestaff Hours”
June 2012 “June 2012 Surgeon Fatigue”
November 2012 “The Mid-Day Nap”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
August 2015 “Surgical Resident Duty Reform and
Postoperative Outcomes”
September 2015 “Surgery Previous Night Does Not Impact
Attending Surgeon Next Day”
September 29, 2015 “More on the 12-Hour Nursing Shift”
September 6, 2016 “Napping
Debate Rekindled”
April 18, 2017 “Alarm
Response and Nurse Shift Duration”
July 11, 2017 “The
12-Hour Shift Takes More Hits”
February 13, 2018 “Interruptions
in the ED”
April 2018 “Radiologists
Get Fatigued, Too”
August 2018 “Burnout
and Medical Errors”
September 4, 2018 “The
12-Hour Nursing Shift: Another Nail in the Coffin”
August 2020 “New
Twist on Resident Work Hours and Patient Safety”
August 25, 2020 “The Off-Hours Effect in
Radiology”
September 2020 “Daylight
Savings Time Impacts Patient Safety?”
January 19, 2021 “Technology to Identify
Fatigue?”
October 12, 2021 “FDA Approval of Concussion
Tool – Why Not a Fatigue Detection Tool?”
References:
Patel AG, Pizzitola VJ, Johnson
CD, et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies
during Overnight Assignments as Compared with Daytime Assignments. Radiology 2020;
297(2): 374-379 Published Online: Aug 18 2020
https://pubs.rsna.org/doi/10.1148/radiol.2020201558
Bernstein MH, Baird GL, Lourenco AP. Digital Breast
Tomosynthesis and Digital Mammography Recall and False-Positive Rates by Time
of Day and Reader Experience
Radiology 2022; Publlished online
January 11, 2022
https://pubs.rsna.org/doi/10.1148/radiol.210318
Krupinski EA, Berbaum
KS, Caldwell RT, Schartz KM, Kim J. Long radiology
workdays reduce detection and accommodation accuracy. JAm
Coll Radiol 2010; 7(9): 698-704
https://www.jacr.org/article/S1546-1440(10)00134-1/fulltext
Hanna TN, Zygmont ME, Peterson R,
et al. The effects of fatigue from overnight
shifts on radiology search patterns and diagnostic
performance. J Am Coll Radiol 2018; 15(12): 1709-1716
https://www.jacr.org/article/S1546-1440(17)31661-7/fulltext
Print “February 2022 Does Time of Day Matter?”
Managing
Incidental Findings
Incidental findings
on imaging studies may be benign and have no impact on patients. But they may
also be important signs of serious conditions, such as cancer. Hence, it is
important that incidental findings be managed appropriately. “Closing
the loop” and communicating about incidental findings is critical to ensure
patients do not “fall through the cracks”. Keep in mind that almost everything
we say about incidental findings on imaging studies may also apply to
incidental findings on other diagnostic studies, like lab and pathology
studies.
Our April 13, 2021 Patient Safety Tip of the Week “Incidental
Findings – What’s Your Strategy?” outlined many strategies for managing incidental
findings. We stressed that the most appropriate followup
actions depend on the specific nature of the incidental finding. There are
numerous guidelines regarding what to do for specific incidental findings. But
there are 2 key issues:
- ensuring
that the presence of the incidental finding gets communicated to the
clinician who “needs to know” (and usually to the patient as well)
- having
a system in place to find out that appropriate follow up, indeed, occurred
Since that column we came across an excellent article on
managing incidental findings (Makeeva
2021). Makeeva et al. note that approximately
65% of all incidental findings are “actionable” and that, among these, a
diagnosis is confirmed in approximately 45% of patients. They also note the
incidence of cancer among all incidental findings completing follow-up is
2.3-4.5%.
As we have pointed out, many medical societies and the
American College of Radiology have published guidelines on how to approach
various incidental findings. Makeela et al. point out
that evidence-based documents guide radiologists in identifying findings that
do or do not require follow-up and can help radiologists issue follow-up
recommendations with regards to imaging modality and follow-up time intervals.
Importantly, they note that evidence-based guidance can prevent unnecessary
follow-up tests, thereby decreasing patient anxiety and financial burden on
patients and society. Bt, unfortunately, there is not
always a strong evidence base to provide guidance for some incidental findings.
How you communicate the findings and recommendations is
important. Makeela et al. note that follow-up
recommendation language should be clear and concise. They should not be so
vague as to prevent the ordering clinician from understanding the necessity of
follow-up. For example, they note that statements
like, “If clinically indicated, follow-up CT could be performed in 4–6 weeks
to document resolution,” limit clinicians’ ability to judge the necessity of
follow-up and lead to low follow-up rates. Instead, they note that recommendations
which precisely
identify the lesion in question, the recommended modality, and time interval
can result in higher completion rates. They recommend those detailed recommendations
should be placed in the “Impression” section of the radiology report, where
they can be easily seen and noted by clinicians. Links to the references for
specific evidence-based guidelines can be included in the reports. Many
radiologists have access to templates that can be used for specific incidental
findings.
They also stress the importance of patient engagement in
ensuring adequate follow-up.They
note that in some venues, such as emergency departments and some radiology
sites, the radiologist can speak directly to the patient. Ensuring patients
fully understand the findings and their next steps. They also note that
patients now have potential access to all their medical records, including reports
of imaging studies. But the language in those reports may be too technical for
patients to fully understand. But they note that “placing Info-RADS messages
in radiology reports is an effective way to convey the nature of imaging
results and whether any further steps are necessary. These messages indicate
to patients either that the results are normal and no
additional steps need to be taken, or that there was a non-emergent finding for
which the patient should contact their provider to discuss next steps.”
They then discuss in detail our second key issue - having a
system in place to find out that appropriate follow up, indeed, occurred. They
note that tracking systems can considerably improve the chances that
appropriate follow-up took place.
Hybrid tracking systems, using both staff and IT resources,
may be effective. Including key words for phrases in imaging reports can flag
those cases in which the tracking system should be activated. One example they provide is including the text
“#follow” in the report. Newer tracking systems are also using natural language
processing (NLP) capabilities to identify cases needing tracking.
They go on to describe what a fully automated tracking
system would be able to do:
- mine
reports for actionable incidental findings based on descriptors used by
the radiologist
- insert
appropriate follow-up recommendations into the report
- transfer
cases into a tracking data base
- search
electronic medical records for follow-up completion
- send
reminders for any pending follow-up
- assist
with scheduling
- issue
a final alert should a completed follow-up not be identified
Of course, inadequate interoperability still presents challenges
to any tracking system. We often see patients who get all their subsequent care
in offices or health systems that do not communicate with the IT systems of the
imaging department or practice. Sometimes, the patient is not even in the same
geographic region after the initial imaging study. In our mind, that really
increases the importance of that direct communication with the patient at the
time of the study.
Overall, the Makeela paper has
good recommendations. It is also well-referenced and has a couple nice workflow
diagrams. We also refer you back to our many prior columns on communicating
significant results and especially our April 13, 2021 Patient Safety Tip of the
Week “Incidental
Findings – What’s Your Strategy?”.
See also our other
columns on communicating significant results:
- May 1,
2007 “The
Missed Cancer”
- February
12, 2008 “More
on Tracking Test Results”
- October
13, 2009 “Slipping
Through the Cracks”
- July
2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- March
9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- March 1, 2011 “Tests Pending at Discharge”
- August 21, 2012 “More on Missed Followup
of Tests in Hospital”
- October
2, 2012 “Test
Results: Everyone’s Worst Nightmare”
- March
12, 2013 “More
on Communicating Test Results”
- October 2013 “New AHRQ Toolkit: Improving Your Office
Testing Process”
- January 2014 “Email Alerts for Pending Test Results”
- July 2015 “Technology to Avoid Delays in Follow-up
of Significant Results”
- November 17, 2015 “Patient
Perspectives on Communication of Test Results”
- December 20, 2016 “End-of-Rotation
Transitions and Mortality”
- September 2018 “ECRI
Institute Partnership: Closing the Loop”
- September 24, 2019 “EHR-related Malpractice
Claims”
- November 26, 2019 “Pennsylvania Law on
Notifying Patients of Test Results”
- January 2020 “The Joint Commission on
Closing the Loop”
- September 8, 2020 “Follow Up on Tests
Pending at Discharge”
- April 13, 2021 “Incidental Findings –
What’s Your Strategy?”
- May 25, 2021 “Yes, Radiologists Have
Handoffs, Too”
References:
Makeeva V, Schofield K, Davis M, Kadom N. Managing Incidental Findings. Appl Radiol. 2021; 50(6): 22-26
https://www.appliedradiology.com/articles/managing-incidental-findings
Print “February 2022 Managing Incidental Findings”
Print “February
2022 What's New in the Patient Safety World (full column)”
Print “February 2022 Communication Failures and
Malpractice”
Print “February 2022 TIA Clinics Provide Safe
Patient Care”
Print “February 2022 Does Time of Day Matter?”
Print “February 2022 Managing Incidental Findings”
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