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Quality Improvement & Patient Safety Section Newsletter - March 2010, Vol 11, #2

Quality Improvement & Patient Safety Section

circle_arrow The Chair's Letter
circle_arrow Editor’s Note
circle_arrow Working through ABEM’s Assessment of Practice Performance (APP) Process
circle_arrow Diagnostic Errors in Medicine Conference
circle_arrow QIPS TIPS "Mislabeled Labs Revisited"
circle_arrow A Safe Culture in the Emergency Department
circle_arrow Quality and Safety Articles


Newsletter Index


Quality Improvement & Patient Safety Section

 

 

The Chair's Letter

Elaine Thallner, MD, MS, FACEP
E-mail 

Elaine ThallnerI would like to update you on what’s happening in our section.  

It has been a busy few months with more activity on the horizon. ‘Quality improvement’ will actually improve quality as we share our successes and learn from our failures. I invite any section member to contact me if you wish to increase your involvement with the section, have an idea, a question, or a concern.

A group of section members continue to work on the curriculum project and that work is nearing completion.   Another section initiative, the handoff paper was published last month.  And we have submitted two letters of intent to ACEP for section grants.   We continue to develop relevant and timely articles for the QIPS section newsletter.   We will begin an initiative in the late spring to increase our membership.                                                                     

I have been thinking about the value of ‘QI’ lately:  in a simple sense, are we walking the walk?  I mean this not only on an individual level, but also at the level of our systems.  In our current environment where information is available so fast and expectations are so high, I am wondering where we (again individually and organizationally) prioritize the expenditure of our resources of time, money, and effort.  If ‘quality’ is a top priority, how is it resourced in our departments?   (And if our families are our top personal priority, how well are we attending to them?)   I wonder what support could be garnered for the support of quality initiatives if positioned with an inquiry of its relative value to the department.  In the next several years, the perceived value of ‘quality’ will increase and hopefully support should increase proportionally. 

I also think that ‘quality’ is everyone’s job and that one of our more significant challenges is learning how to engage others, not only physicians, but also nursing and other front line staff.  The emergency departments that pay attention to how they accomplish QI will enjoy the most long-term success because they will have discovered how to build internal capacity for change and innovation.   


 

 

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Editor’s Note

Heather Farley, MD, FACEP
E-mail 

Heather Farley 
We are considering adding a new feature to the quarterly QIPS newsletter highlighting various facilities' experiences with the Joint Commission.  If you have recently been visited by the JC and would be willing to share your experiences, please email me.  Your contribution can be brief and can include whatever you feel would be of interest to other members (i.e., unexpected criticisms, techniques used by surveyors, unique ways your institution has prepared for the visit or responded to citations, lessons learned, etc).  I look forward to your submissions! 


 

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Working through ABEM’s Assessment of Practice Performance (APP) Process

Drew C. Fuller, MD, FACEP

Drew FullerSince the release of ABEM’s December 2009 letter outlining the requirements for fulfilling the Assessment of Practice Performance (APP) component of the Emergency Medicine Continuous Certification (EMCC), there has been considerable interest in attaining a better understanding of how to fulfill the requirements.  The APP, otherwise known as the "4th Component", is part of a new model for certification that is based on the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program.   This program is intended to establish a more comprehensive approach for assessing physicians' core competencies for providing quality patient care as they advance through the board certification process. 

In order to provide greater perspective on how to fulfill the APP requirements, the QIPS section will be developing a series of pieces that will aim to offer insight on strategies and will include cases, firsthand accounts, and lessons learned.   

For this newsletter, we will provide a brief review of the EMCC/APP structure.  

There are 4 components of the EMCC process: 

 

Component Term

What it means

1.

Professional Standing

Need to be licensed

2.

LLSA

Read yearly articles & take test

3.

Assessment of Cognitive Expertise

Take the ConCert exam every 10 years

4.

Assessment of Practice Performance (APP)

Participation in Practice Improvement & Communication/Professionalism activities

1.  Assessment of Practice Performance (APP)

There are two distinct Activity categories required to fulfill the APP:

Patient Care Practice Improvement (PI)

The practice improvement (PI) activities are essentially quality improvement activities that the physician must complete in years 4 and 8 of their certification cycle.  These activities can be group or individual projects. However, a portion of the data must include the individual physician’s practice.  There is a broad range of acceptable topics but the focus must be on a clinical area within emergency medicine. 

The American Board of Medical Specialties (ABMS) has put together 2 programs on quality improvement and patient safety that can use used to fulfill these requirements.  These programs will be assessed and reviewed for ACEP members and this information will be disseminated through future newsletters and/or other media.  

2.  Communication/Professionalism activities (CP)

This activity involves collecting & submitting data from patient feedback tools/surveys and must be completed in year 8 of the certification process.  The physician must submit data based on at least 10 of their patients and cover EACH of the three categories: communication/listening, providing information, showing concern for the patient.  This activity provides an opportunity for the physician to gain insight into how his/her practice and communication style impacts the patient.  This data can be easily collected from patient survey tools (e.g. Press-Ganey) currently used in many hospitals.  

The data from both of these activities, in addition to the contact information for a designated individual that can attest to the data are entered directly into the EMCC online. Components one, two, and three were implemented in 2004. Component four was implemented in 2010.  EMCC Online will accept diplomats’ APP attestations in 2010, and the first attestations will be required in 2011.


 

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Diagnostic Errors in Medicine Conference

David L. Meyers, MD, FACEP

Dr. David Meyers 
The second Diagnostic Errors in Medicine Conference, sponsored by the Society for Medical Decision Making, was held in late 2009 in Los Angeles.   In this newsletter last year, I discussed the first Diagnostic Errors in Medicine Conference, at which there was an intense focus on the nature and types of diagnostic errors which physicians commit, theories of mind and decision making as well as establishing a research agenda for understanding and changing physicians’ behavior to reduce their frequency and severity.   

At this 2nd conference, there was significantly more emphasis on assessing our current understanding of clinical reasoning and where the field stands now after more than 20 years of effort.  Furthermore, emergency medicine figured prominently in the discussions of diagnostic errors because the emergency encounter is emblematic of the many features predisposing to diagnostic error, including 1) time constraints on decision-making, 2) resource limitations, 3) background information limitations (patients not well known to the clinician), 4) and context - distractions and other influences which can degrade human performance. 

Opening the conference was a panel of experts on clinical reasoning, including some pioneers in the field, names recognized by most practicing clinicians – Jerome Kassirer, MD, former Editor of the New England Journal of Medicine; Stephen Pauker, MD, an expert on clinical decision analysis, cost-effectiveness and cost-benefit analyses, and medical informatics; Arthur Elstein, PhD, co-author of Medical Problem Solving, published in 1978 and one of the seminal books in the field; and Valerie Reyna, PhD, highly regarded cognitive psychologist at Cornell. 

These speakers had some very interesting observations and historical vignettes on the subject.  For example, Dr Elstein discussed hypothesis generation and refinement, pointing out that experts rarely rely on formal probabilistic models; rather they use heuristics and pattern recognition to come to conclusions.  He suggested there may be a universal problem-solving model based on the role of memory, but raised the difficulty of avoiding errors in dealing with atypical presentations.  Elstein also spoke about the important early work of Nobel Economics Prize winner Daniel Kahnemann who, with Amos Tversky, established concepts about human reasoning and decision-making which became the foundation of the field now know as behavioral economics, a popular book about which (Freakonomics) was also discussed in a prior issue of this newsletter.  Their work also has ramifications for decision-making in nearly all areas, including clinical.. 

Dr Reyna reminded us of the seminal work by George Miller, whose paper "The Magical Number Seven, Plus or Minus Two: Some Limits on Our Capacity for Processing Information", published in Psychological Reviews in 1956, described limits of human mental capacity related to the volume of data we are capable of remembering and processing. This work is often mentioned in the context of how 7 digit phone numbers came to be because that was the maximum number of digits which humans could reliably remember. 

Apropos phone number length and human memory, she mentioned a 2005 Reuters report in a London newspaper based on the research of Ian Robertson, a prominent British neuroscientist who conducted a survey to assess young adults’ memory skills.  According to the news account, the survey found that "the boom in mobile phones and portable devices that store reams of personal information has created a generation incapable of memorizing simple things…a quarter of those polled said they couldn't remember their landline phone number, while two-thirds couldn't recall the birthdays of more than three friends or family members."  Tech-savvy young fared worse than older people. 

Dr Reyna also discussed her "fuzzy trace theory" which holds that there are 2 parallel memory representations of specific entities - "verbatim traces" which are exact memories of things and "gist traces" which are general memories of things.  She likened the former to poetry and the latter to logic-based formal decision models.  While both play a role in decision making, she opined that the gist trace approach is the one clinicians more typically use. 

Dr Pauker asked if we know how to teach clinical reasoning and about our obligation to be more aware of the biases we bring to the patient encounter.  Although there are numerous hypotheses for how doctors think, he is not sure we really KNOW how doctors think, Dr Jerome Groopman’s ideas and book notwithstanding. Not fully explored were the questions of whether these biases are fundamental to human biology and if or how they might be overcome.   

Dr Pat Croskerry, a Canadian emergency physician and expert in clinical decision making, summarized a recent study which looked at diagnostic errors in 100 patients and found that 19% of these errors were attributable to system related errors only, 28% to cognitive errors only and 46% to a combination of both and a 7% "no-fault".  He went on to discuss the misdiagnosis of common presentations using the concept of the "signal to noise ratio" which refers to the proportions of useful information compared to false or irrelevant data in a conversation or exchange.  Example clinical presentations with high signal to noise ratios were typical shingles, lacerations, anterior shoulder dislocations and similar conditions where the diagnosis is obvious. Conditions with low signal-to-noise rations were chest pain, abdominal pain, headache, "weak and dizzy", shortness of breath, etc.  His working model is based on the idea that "in every patient is a critical signal which I must find in my evaluation".  In summarizing, he presented a list of strategies which could reduce the number of diagnostic errors, including: 

  • presenting complaint should not be a diagnosis;
  • reframe any self-labeling or self-diagnosis;
  • watch out for "team diagnosing";
  • maintain vigilance against diagnosis momentum and premature diagnostic closure;
  • rule out worst case scenario (ROWS);
  • use checklists for common pitfalls;
  • increase vigilance with psychiatric patients;
  • consider all common diagnoses as diagnoses of exclusion; and
  • watch out for anything that doesn’t fit. 

All pretty much agreed that decision-making typically uses elements of both intuitive and formal approaches and the context in which the decisions are being made influences which is more prominent.  Interestingly, technologic approaches were noticeably absent from the strategies of these speakers, although several acknowledged that information technology is finally now at a point of sophistication such that those approaches might be reliably used. 

Elstein proposed a checklist approach to avoid some of the pitfalls of human decision-making.  Others suggested mindfulness as a countervailing force against error proposing that the provider stop and ask him/herself certain questions to guard against common errors.  My take on the types of questions:

  • "To avoid anchoring bias and early closure, did I reconsider my diagnosis after weighing other possibilities previously discarded?"
  • "Did I seek evidence to rule out other diagnoses than the one I settled on? Did I think only of horses when I heard hoofbeats?  Should I consider zebras in this case? Or giraffes?  What if I am in Africa?"
  • "What less likely diagnoses could this be?  Should/Did I perform sufficient diagnostic studies to rule these out?"
  • "Do I have feelings about this patient which might lead me to inappropriately work up or diagnose the problem?"
  • "Would I do anything different if this patient presented at another time of day or with/without the family member or if this was my family member?" 

As the conference continued, researchers presented the results of studies of interventions to improve decision making and reduce errors. They included studies of eye movement in visual diagnostic specialties, approaches to reducing errors in chromic care settings due to mishandling of diagnostic test results, efforts to improve identification of prevalent but missed conditions (dementia, fall risk, etc), and use of diagnostic "engines" such as Isabel, Visual Dx and clinical prediction rules. 

Other speakers addressed such topics as how to better teach clinical reasoning in medical schools, sensitizing students and trainees to the types of errors commonly made and how to avoid them, describing techniques to supplement and complement human limitations, use of information technology and the pitfalls of various approaches.  This year several medical malpractice insurance companies attended and one speaker reported on lessons learned from claims experience.   As the business case for this work becomes clearer, they may play a bigger role in future conferences via conference sponsorship and research support. 

By the end of the conference there was cautious optimism that progress is being made, but the pace of that progress has been maddeningly slow.  Meanwhile, errors continue to cause unnecessary patient death and disability, while a heavy toll in emotion and money is exacted from clinicians and the health care institutions which make up our system.  Understanding what changes to make and how to make them will be a challenge for some time to come.


 

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QIPS TIPS "Mislabeled Labs Revisited"

Shari Welch, MD, FACEP

Shari WelchThe problem of mislabeled lab specimens is a problem  plaguing emergency departments every day. 

An ED based lab tech is an innovation trialed with success around the country.  These are often career lab techs that are quite skilled at lab draws.  They are typically funded by both the ED and the Lab and often do wonders to smooth that interface.  Their presence increases the reliability of all lab specimen processes and has the added benefit of letting nurses get back to nursing tasks.  Typically when such a tech is in place in an ED the number of lost or mislabeled specimens decreases and the number of contaminated specimens (ie: blood cultures) goes down.  The ED based Lab Tech will need a work space and is more efficient if he is in close proximity to the tube system for transporting specimens. 

A couple of other innovations in this area include the "Bloodloc TM " system whereby multiple tubes of blood can be stored with one handwritten label.  An even better system again developed by Bloodloc involves a wristband with preprinted labels stuck to it and a unique ID number. 

As the blood is drawn the labels are peeled from the patient’s wristband and applied to the tubes.  These tubes may be sent to the lab as is for stat results or held until full registration allows the permanent ID number to be assigned.  Reconciliation of the data can occur at any time. 

Figure 1:  Bloodloc temporary blood tube labels
WristBandfinal  

A mislabeled lab specimen is a catastrophe for the individual patient.  Emergency Department workers have a long history of improvisation and "jury rigging" the world to facilitate the needs of their patients:  Using a foley catheter balloon as a posterior nasal packing, using the seldinger technique and a central line guide wire for retrograde intubation, using bed sheets as levers to relocate a shoulder or bed sheets to tie the feet together and "close the book" on widely splayed pelvic fractures, using lidocaine to get a cockroach out of someone’s ear.  These are but a few examples of this ingenuity that you are likely familiar with.   It is now time to use that ingenuity to make the work we do foolproof and to make our departments safer for our patients.  


 

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A Safe Culture in the Emergency Department

Mark T. Fleming and Pat Croskerry

Excerpted with permission from Croskerry, P., Cosby, K.S., Schenkel, S.M., and Wears, R.L, Patient Safety in Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins, 2009.

DrSchenkel0310INTRODUCTION

Three overarching influences determine the culture of a particular emergency department (ED): the general culture of medicine, the culture of the discipline of emergency medicine (EM), and the local factors that prevail for a particular ED.  The first embraces factors that are intrinsic to the very nature of medicine—what does the practice of medicine entail, and what is expected of its professional bodies and its practitioners?  The second focuses on the discipline of EM.  How does the culture of this discipline differ, for example, from that of surgery or psychiatry?  The third relates to prevailing local and systemic factors—the local culture of the hospital or health organization, its history, its administrators and clinical leaders, and its physical plant and resources. 

Departmental and institutional culture influence how health care is delivered and, consequently, the quality and safety of patient care.  It is critical, therefore, to ensure that the culture is consistent with patient safety objectives.  Creating a safe ED culture requires an understanding of the current culture and how this culture evolved.  Schein defined organizational culture as:…a pattern of basic assumptions—invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration—that has worked well enough to be considered valid and therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems (1, p.9).

Thus, culture influences how individuals and groups view the world (i.e., what is important to them and how they interpret new information) and is stable over time.  Culture transcends the individuals that share the culture, as it is the things that are passed on and endure.  Culture is independent of people who are currently part of the group; the culture will exist after all these people have left.  New members of the organization informally "learn" the culture through observation, social feedback, and trial and error.  Pidgeon (2) suggests that culture provides a useful heuristic for managing risk and safety in organizations and that it provides an overall characterization of the common features of high reliability organizations (HROs). 

MODELS OF CULTURE

Schein (3) proposes a model of culture that consists of three layers or levels: basic assumptions, espoused values, and artefacts.  Basic assumptions are implicit, taken for granted, unconscious, and difficult to measure.  Espoused values are the expressed attitudes of group members.  Artefacts are the outward or visible expressions of the culture, and include behaviors, language, and status symbols.  In EM, these three layers may appear as discussed in the following sections. 

Basic Assumptions

Emergency physicians and nurses have a unique view of the medical needs of a community and an implicit understanding of the roles they are expected to play.  Although adult-pediatric distinctions may be made by some departments, it is generally understood that the ED is a vital portal of access to care for any patient, with any illness, at any time (4); that full responsibility and accountability will be taken for them; that safe care will be provided; and that a safe disposition will occur.  In turn, ED personnel have expectations that other parts of the medical system will interact appropriately with and support them.  If a patient cannot be transferred to another level of care, he or she will be kept in the ED and cared for appropriately until the transfer can be made.  If a disaster happens, the department expects to have to handle it.  These various assumptions are implicitly understood.  Not everyone in the department will be able to fully articulate them, but they will be appreciated at some level.  Often, people may not recognize exactly what their basic assumptions are until they see them violated. 

Espoused Values

A particular ED may have a mission statement in which the overriding approach to care is clearly articulated, and paramedics, nurses, and physicians may conjointly or separately espouse its support.  Essentially, this is a statement of what is important and what is believed.  Patient safety may be stressed as the prevailing theme in patient care.  Morbidity and mortality rounds are a good place to articulate and remind the group of these fundamental espoused values.  Nevertheless, these espoused values may not necessarily be matched by behavior. 

Artefacts 

Artefacts are the visible expressions of the ED culture.  Protocols will be specified usually for any procedure that carries risk for the patient.  Other forcing functions may be in place to ensure accountability and safe practice.  There may be poster displays summarizing particular themes of care.  Certain dress codes may be in place, aspects of language may be emphasized, and particular behaviors endorsed that collectively convey reliability and professionalism in the delivery of care.  Department leaders may conduct walk-arounds specifically addressing safety. 

Culture can be likened to an iceberg (Fig 4.1).  Basic assumptions lie below the water line, where they are difficult to observe.  Espoused values and artifacts float above the water line, visible to all.  In common with icebergs, it is often tempting to focus on visible elements and underestimate the impact of the underlying basic cultural assumptions. 

 

Figure 4.1:  Three-level model of culture
 Threelevelmodel0310II 
           

CULTURE AND PATIENT SAFETY

The culture of an ED directly influences patient safety through the behavior of health care staff.  For example, a deviation from accepted best practices that increase the risk of an adverse event, can become normalized and so threaten patient safety.  The relationship between culture and patient safety is supported by a recent study by Zohar et al. (5), who demonstrated that nurse self-reported safety attitudes predicted independently observed medication and emergency safety practices.  If the culture of the ED is threatening to patient safety, then it is important to assess the current culture, identify negative aspects, and implement interventions to improve.  There are a number of instruments available to assess patient safety culture (6), and there is also guidance available on how to undertake the survey and improve the culture (7). 

Culture also influences the likelihood of successfully implementing patient safety interventions, such as medication reconciliation or adverse event reporting.  It is important to consider the cultural challenges before introducing a new patient safety precess and to identify the impact this change may have on the current culture.  Identifying those impacted by the change, the level of behavioral change required, and the impact on perceived power or status will help assess the level of challenge.  This information can be obtained by consulting with a wide range of stakeholders before implementation.  If the change threatens the current culture, then it is likely to be met with significant resistance.  In this situation the intervention should be adjusted to fit with the current culture.  Otherwise, additional resources and strong leadership will be required to push the change through. 

UNIQUENESS OF THE EMERGENCY DEPARTMENT CULTURE

The culture of the ED has developed in response to the variety of problems it has faced and reflects these challenges.  Clearly, the culture of EDs will vary both within and between countries, as they all have unique histories.  Yet, all EDs are likely to share common cultural elements related to the universality of the particular features of EM. 

The ED is unlike any other setting in medicine.  To understand the ED culture we have to understand the development of EM over the past 30 years and the challenges commonly faced by EDs today.  The ED has evolved from "emergency rooms", which were typically staffed by casual, itinerant workers with limited skills, to "emergency departments", where residency-trained, full-time specialists practice with a wide repertoire of skills and a knowledge base specific to emergent, urgent, and general medical conditions.  A unique ED culture has evolved (8,9).  Several attributes of the ED have been described that may intrinsically compromise patient safety (Table 4.1). 
 

Table 4.1

Selected Operating Characteristics of the ED
That May Compromise Patient Safety

  • Unbounded demand
  • Multiplicity of patients and inherent variability
  • Uncertainty of diagnosis
  • Narrow time windows
  • Decision density and cognitive load
  • Low signal-to-noise ratio
  • Time constraints
  • Poor feedback
  • Interruptions and distractions
  • Limited opportunity for practice
  • Fatigue and shift work
 
The demand placed on EDs is unbounded because it is difficult to limit workload.  No patient is ever turned away, although ambulances may be diverted under certain conditions.  Unlike an intensive care unit, in which the number of patients is never allowed to exceed the number of beds, EDs are typically seen as infinitely expansible.  This means EDs are frequently in a state of overcrowding, often because beds cannot be found for patients admitted to the hospital.  Triage criteria and standards are then routinely violated.  The multiplicity of patients that emergency caregivers have to assess and treat at one time increases cognitive load.  There is a high level of uncertainty for emergency caregivers, as patients are generally unknown to their caregivers.  Furthermore, patients’ illnesses are explored within very narrow windows of time.  There is often a low signal-to-noise ratio—relatively benign complaints can masquerade as serious illness, and vice versa (10).  Error-producing conditions (EPCs) abound (8,11), and the situation in which a trade-off starts to occur between the availability of resources and the ability to provide safe care (described as RACQUITO: resource availability continuous quality improvement trade-off) is not uncommon (12), especially during surge conditions. 

Decision density in the ED is probably the highest of any area in medicine (13).  The time constraints on emergency caregivers are due to both the volume of patients and the time-critical nature of the care provided.  This places significant pressure to adopt shortcuts or heuristics, which increases the likelihood of error (14).  The lack of feedback on patient outcomes limits the extent to which emergency caregivers can learn from experience (15).  The variable nature of the presenting patient means that emergency caregivers will perform some complex procedures infrequently, limiting opportunity for practice.  Dedication to 24-hour staffing produces high leves of fatigue, sleep deprivation, and sleep debt. 

A study of process mapping of sources of error in the ED identified 25 discrete individual and systemic nodes (16, 17).  These varied constraints on ED function are described further in Chapter 13 (Chisholm and Croskerry).  The combination of these multiple factors creates a unique culture for EDs that inevitably impacts patient safety.  How safe, then, is the ED culture?  To answer this, we need to examine the elements of what others see as a "safe" culture. 

  • The remainder of this chapter will be published in the next QIPS newsletter. 

ReferencesI 
 References II 

 


 

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Quality and Safety Articles

Helmut Meisl, MD, FACEP

meisl 
Here again is a list of recent articles for your interest. These are compiled by AHRQ PSNet at (http://psnet.ahrq.gov/).

Origins of and solutions for neonatal medication-dispensing errors.
Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.
Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. Crit Care Nurse. 2010 Jan 12.

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.

Adverse Health Events in Minnesota: Sixth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2010.

Using Six Sigma methodologies: creating a revised discharge medication reconciliation process.
Dalton D, Humphrey M, Neptune C, Novario M, Scoates G, Wakefield R. Jt Comm Perspect Patient Saf. January 2010;10:1-6.

Patient participation: current knowledge and applicability to patient safety.

Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Mayo Clin Proc. 2010;85:53-62.

Clinical review: Checklists—translating evidence into practice.
Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. Crit Care. 2009;13:210.

Hospitalized patients' understanding of their plan of care.
O'Leary KJ, Kulkarni N, Landler MP, et al. Mayo Clin Proc. 2010;85:47-52.

ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

Dealing honestly with an honest mistake.
Liang NL, Herring ME, Bush RL. J Vasc Surg. 2009 Dec 16.

Do emergency physicians attribute drug-related emergency department visits to medication-related problems?
Hohl CM, Zed PJ, Brubacher JR, Abu-Laban RB, Loewen PS, Purssell RA. Ann Emerg Med. 2009 Dec 11.

Improving prescription drug warnings to promote patient comprehension.
Wolf MS, Davis TC, Bass PF, et al. Arch Intern Med. 2010;170:50-56.

Rapid response teams: a systematic review and meta-analysis.
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Arch Intern Med. 2010;170:18-26.

Distractions and surgical proficiency: an educational perspective.
Szafranski C, Kahol K, Ghaemmaghami V, Smith M, Ferrara JJ. Am J Surg. 2009;198:804-810.

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.
Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.

Briefings, checklists, geese, and surgical safety.
Karl R. Ann Surg Oncol. 2009 Nov 10.

Surgical site signing and "time out": issues of compliance or complacence.
Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.

The effects of stress and coping on surgical performance during simulations.
Wetzel CM, Black SA, Hanna GB, et al. Ann Surg. 2010;251:171-176.

Medical trainees' formal and informal incident reporting across a five-hospital academic medical center.
Logio LS, Ramanujam R. Jt Comm J Qual Patient Saf. 2010;36:36-42.

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

Lack of patient knowledge regarding hospital medications.
Cumbler E, Wald H, Kutner J. J Hosp Med. 2009 Dec 10.

Resident fatigue: is there a patient safety issue?
Mitchell CD, Mooty CR, Dunn EL, Ramberger KC, Mangram AJ. Am J Surg. 2009;198:811-816.

Understanding communication during hospitalist service changes: a mixed methods study.
Hinami K, Farnan JM, Meltzer DO, Arora VM. J Hosp Med. 2009;4:535-540.

Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety.
Porat N, Bitan Y, Shefi D, Donchin Y, Rozenbaum H. Qual Saf Health Care. 2009;18:505-509.

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

Neuromuscular blocking agents: reducing associated wrong-drug errors.

PA-PSRS Patient Saf Advis. December 2009;6:109-114.

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.
Hanson CC, Randolph GD, Erickson JA, et al. Qual Saf Health Care. 2009;18:500-504.

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.
Frey B, Ersch J, Bernet V, Baenziger O, Enderli L, Doell C. Qual Saf Health Care. 2009;18:446-449 

Year 1 medical undergraduates' knowledge of and attitudes to medical error.
Flin R, Patey R, Jackson J, Mearns K, Dissanayaka U. Med Educ. 2009;43:1147-1155.

How do physicians conduct medication reviews?
Tarn DM, Paterniti DA, Kravitz RL, Fein S, Wenger NS. J Gen Intern Med. 2009;24:1296-1302.

ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.
Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.
Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

Transforming healthcare: a safety imperative.
Leape L, Berwick D, Clancy C, et al; for the Lucian Leape Institute at the National Patient Safety Foundation. Qual Saf Health Care. 2009;18:424-428.

Burnout and medical errors among American surgeons.
Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2009 Nov 19.

Predictors of misunderstanding pediatric liquid medication instructions.
Bailey SC, Pandit AU, Yin S, et al. Fam Med. 2009;41:715-721.

Predictive value of alert triggers for identification of developing adverse drug events.
Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009 Sep 9.

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

Weighing in on medication safety.
Paparella S. J Emerg Nurs. 2009;35:553-555.

Following the patient journey to improve medicines management and reduce errors.
Crocker C. Nurs Times. November 19, 2009.

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.
Sarani B, Sonnad S, Bergey MR, et al. Crit Care Med. 2009;37:3091-3096.

Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency.
Thomas AN, Panchagnula U, Taylor RJ. Anaesthesia. 2009;64:1178-1185.

The challenges to transparency in reporting medical errors.
Paterick ZR, Paterick BB, Waterhouse BE, Paterick TE. J Patient Saf. 25 Sep 2009.

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.
Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2009 Nov 6.

Sleep deprivation, physician performance, and patient safety.
Olson EJ, Drage LA, Auger RR. Chest. 2009;136:1389-1396. 

 


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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