What’s New in the
Patient Safety World
September 2018
ECRI Institute
Partnership: Closing the Loop
One of our most frequent topics has been communication errors that cause diagnostic errors and delays that may lead to disastrous patient outcomes (see list of columns at the end of today’s column). Recently, there have been several initiatives or studies that have expounded upon this issue.
ECRI Institute partnered with multiple organizations and convened an expert advisory panel to address the issues of errors or delays in diagnosis related to failure to follow up and errors related to changes or discontinuation of medications (ECRI Institute 2018). That Partnership for Health IT Patient Safety identified three key safe practice recommendations:
- Develop and apply IT solutions to communicate the right information (including data needed for interpretation) to the right people, at the right time, in the right format
- Implement health IT solutions to track key areas
- Use health IT to link and acknowledge the review of information and the documentation of the action taken
We hope you’ll access the ECRI Partnership toolkit which also contains an excellent slide presentation. The report and toolkit are very valuable resources that every healthcare organization can benefit from.
Meanwhile, our neighbors to the north have launched a campaign Greg’s Wings, highlighted by the film Falling Through the Cracks: Greg's Story. This is a powerful story of how failures in communication (“no news is good news”) led to diagnostic and therapeutic delays and ultimately the death of a young man. You’ve heard us so many times use the phrase “stories, not statistics” to drive buy-in from healthcare workers in a variety of patient safety issues. This film provides such a story.
One of the salient features in Greg’s Story is faxed referrals to specialists being lost and ignored. We highlighted the surprising continued role faxes play in healthcare and the problems associated with them in our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am”. An editorial in the Canadian press (Picard 2018) notes that, just as in the US, Canadian physicians still rely primarily on fax for communication with other physicians, despite the fact most have electronic medical record systems.
And failures in communication about diagnoses also happen when patients are transferred from one hospital to another. A recent study from University of Minnesota researchers (Usher 2018) looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).
But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).
All these endeavors highlight the need for better communication on multiple levels in the healthcare continuum to reduce diagnostic errors and delays that may lead to adverse patient outcomes.
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”
Some of our prior columns on diagnostic error:
- September 28, 2010 “Diagnostic Error”
- November 29, 2011 “More
on Diagnostic Error”
- May 15, 2012 “Diagnostic
Error Chapter 3”
- May 29, 2008 “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”
- August 12, 2008 “Jerome Groopman’s “How Doctors Think”
- August 10, 2010 “It’s Not Always About The Evidence”
- January 24, 2012 “Patient
Safety in Ambulatory Care”
- October 9, 2012 “Call
for Focus on Diagnostic Errors”
- March 2013 “Diagnostic
Error in Primary Care”
- May 2013 “Scope
and Consequences of Diagnostic Errors”
- August 2013 “Clinical
Intuition”
- January 2014 “Trigger
Tools to Prevent Diagnostic Delays”
- January 14, 2014 “Diagnostic
Error: Salient Distracting Features”
- May 2014 “Frequency
of Diagnostic Errors in Outpatients”
- June 24, 2014 “Lessons
from the General Motors Recall Analysis”
- November 25, 2014 “Misdiagnosis
Due to Lab Error”
- April 21, 2015 “Slip
and Capture Errors”
- And our review of Malcolm
Gladwell’s “Blink” in our Patient Safety Library
References:
ECRI Institute. ECRI Institute's Partnership for Health IT Patient Safety Releases New Recommendations to Avoid Testing and Medication Mix-ups. Publicly available report offers important tools and guidance for all healthcare systems. ECRI Institute 2018; Press release July 26, 2018
Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT. ECRI Institute 2018
https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_Loop_Toolkit.pdf
Greg’s Wings
Film: Falling Through the Cracks: Greg’s Story
http://gregswings.ca/fttc-gregsstory/
Picard A. Why are fax machines still the norm in 21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11, 2018
Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. Journal of General Internal Medicine 2018; 33(9): 1447-1453
https://link.springer.com/article/10.1007/s11606-018-4491-x
http://www.patientsafetysolutions.com/