I read with interest the article by Peerally et al (1) on 'The
problem with root cause analysis'. I reflected on the recent cases that
happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which
led me to consider which investigative tool is best applied to different
incidences and identified risks.
The use of appropriate tools and involvement of key stakeholders are
crucial elements to a successful investig...
I read with interest the article by Peerally et al (1) on 'The
problem with root cause analysis'. I reflected on the recent cases that
happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which
led me to consider which investigative tool is best applied to different
incidences and identified risks.
The use of appropriate tools and involvement of key stakeholders are
crucial elements to a successful investigative process and outcomes,
however, we cannot ignore the reality of the process cost versus event
severity and risk.
Use of tools by subject matter expert
Root cause analysis (RCA) is a tool used in many investigative incidences
(5,6). Often as a result recommendations are made yet similar errors still
happen. As correctly mentioned by Peerally et al, most investigations of
incidences are done by the local team involved with RCA tools but with a
lack of expert accident investigator involvement to ensure regular
feedback loops and ongoing corrective actions.
I do agree that hospitals should move toward proactively preventing
adverse incidences for high probability, high severity risks. Preventing
adverse incidences can eliminate harm to patients, reduce liability for
organisations and reduce both operating costs and the need for resources.
A proactive approach often uses Failure Mode Effect Analysis (FMEA) tools.
FMEA often requires a higher level of investigative expertise and as such
often costs more so it may be optimal to assess risks on a probability
severity matrix to identify which tools are optimal.
The proposal of engaging an independent professional body, while
preferable, can be time-consuming and expensive. I propose for most cases
(with exception for cases with significant legal liability) this level of
expertise and independence could be developed within the organisation. The
body i.e. quality or risk management department, should comprise of people
with qualifications such as system thinking, sound interviewing
techniques, able to involve staff, human factor analysis, current clinical
practice, health management and have the ability to analyse data (7). This
department could then act as a quasi-independent body to avoid situational
bias and provide a platform for disseminating the results to intra-
hospitals, inter-hospitals and governmental bodies as shared learning to
help prevent occurrence or recurrence. As a largely independent department
within the organisation, they can for most cases facilitate the
investigative processes objectively thus eliminating tendency to blame
(8,9,10).
Key stake holders' involvement
The involvement of key stakeholders is very crucial in any investigative
process; leaders, managers, clinicians.
The leaders provide governance, leadership and support to the managers.
They are involved in the investigative process to gain their input,
consensus and to commit resources for any recommendations that might be
made. It is critical leaders set departmental performance indicators with
due acknowledgment for the resources needed to achieve them as too often
the burden of performance and blame is levied on departments, middle
management and individuals where identified risk avoidance is under-
resourced.
The managers (department managers, quality and risk managers) are required
to provide a safe environment for practice. They are to ensure that the
protocols and standards of care are adhered to and patients are managed in
a consistent manner. The role of the manager also includes identifying
risks and establish processes to prevent the risks from reaching the
patient with the support from the leader.
The clinicians are required to conduct the procedures/practices in
compliance with their scope of practice, organisational and regulatory
boards.
Conclusion
The usage of an appropriate tool by a qualified person with the right
expertise makes a difference. It would be economically unrealistic to
apply full FMEA processes for every incident or identified risk profile,
so the establishment of an organisational risk severity/probability matrix
needs to be developed so the most appropriate tool is used.
The involvement of key people ensures that a holistic approach is applied
and outcomes of the investigations are implemented with feedback checks
and balances and shared across intra-departments, inter-hospitals and at
national level (11).
References:
1)Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root
cause analysis. BMJ Qual Saf. 2016 Aug;1:1-6
2)Bodies swapped: Dead baby mistakenly cremated and daughter finds
mother's body mislabelled at Royal North Shore Hospital [television
broadcast]. Sydney: The Sydney Morning Herald; 2016 Aug 31. Available
from: www.smh.com.au/nsw/daughter-finds-mothers-body-mislabelled-in-morgue
-mixup-at-royal-north-shore-hospital-20160830-gr4g3n.html
3)Joseph AP, Hunyor SN. The Royal North Shore Hospital inquiry: a analysis
of the recommendations and the implications for quality and safety in
Australian public hospitals. Med J Aust. 2008 April ;188(8):469-72
4)Family want justice for fatal gas mix up [television broadcast]. Sydney:
Skynews; 2016 Jul 26. Available from: http://www.skynews.com.au/news/top-
stories/2016/07/26/incorrect-gas-fitting-behind-nsw-baby-death.html
5)Clifford SP, Mick PB, Derhake, BM. A Case of Transfusion Error in a
Trauma Patient with Subsequent Root Cause Analysis Leading to
Instituitional Change. J Investig High Impact Case Rep. 2016 May; 4(2):1-4
6)Van-Galen LS, Struik PW, Driesen BEJM, Merten H, Ludikhuize J, Van der
Spoel JI, Kramer MHH, Nanayakkara PWB. Delayed Recognition of
Deterioration of Patients in General Wards Is Mostly Caused by Human
Related Monitoring Failures: A Root Cause Analysis of Unplanned ICU
Admissions. 2016 Aug; 11(8):1-14
7) Ibrahim JE. What is the quality of our quality managers? Is it time for
quality managers in Australia to be certified? J.Qual Clin Practice.
2000;20(1):32
8)Smetzer JL, Cohen MR. Lessons from the Denver medication error/criminal
negligence case: look beyond blaming individuals. Hosp Pharm. 1998;33:640-
57.
9)Leape L. Error in medicine. JAMA. 1994;272:1851-7
10)Runciman W, Merry A, Smith AM. Improving patients' safety by gathering
information. Anonymous reporting has an important role. BMJ. 2001;323:7308
11)Leape LL. Why should we report adverse incidents? J Eval Clin Pract.
1999;5:1-4
Editor - Professor Knight(1) highlights a serious problem with systems of organisational learning in maternity care that is endemic across a variety of acute care settings in the NHS. I write to share my experience with a trainee based structured case note review method so other organisations and patients may benefit from what I refer to as a black box medicine (BBM) approach to major maternal morbidity. Trainee based mixed expl...
Editor - Professor Knight(1) highlights a serious problem with systems of organisational learning in maternity care that is endemic across a variety of acute care settings in the NHS. I write to share my experience with a trainee based structured case note review method so other organisations and patients may benefit from what I refer to as a black box medicine (BBM) approach to major maternal morbidity. Trainee based mixed explicit and structured implicit (MESI) retrospective case record review (RCRR) methodology attempts to combine the rigour of external review with resource effectiveness of local review.
From personal experience, methodological, logistical and economic barriers often resulted in superficial, subjective and quite unstructured RCRR. Black box medicine evolved from the realisation that organisations needed to improve the RCRR process as learning opportunities were frequently missed. Furthermore, selection of cases for review often focuses on tip of the iceberg phenomenon as resources for a more inclusive review strategy are not available. Consequently patients would continue to be exposed to the same latent suboptimal care. Analysis of care with adverse clinical outcomes in other settings reveals the final common pathway to suboptimal care is failure to recognise and or rescue deteriorating patients. Recommendations for the use of modified obstetric early warning scores(2) reinforce the premise that opportunities to prevent major maternal morbidity lie in the analysis of this final common pathway, and that a BBM approach could enhance organisational learning.
Development of MESI RCRR is not a new concept. Recent work has been published on similar RCRR methods(3,4) and the Royal College of Physicians is developing a national RCRR programme to review adult acute care deaths in England and Scotland. However, logistical burden and cost are still significant, while a focus on general adult mortality is probably not applicable to major obstetric morbidity. Development of MESI RCRR that utilises junior members of a MDT to abstract and analyse most of the clinical information would reduce cost per case but threaten validity of the process. Repeated cycles of case note review at various organisations allowed this current method of trainee based RCRR to develop iteratively. Identification of new methodological issues during each cycle allowed refinement based on principles discussed below.
Acute care is essentially a series of clinical encounters that can be broadly classified as an assessment, intervention or monitoring event. Every care event has commission or omission characteristics that can be judged as part of a quality assessment process. Commission characteristics include timeliness, appropriateness, sufficiency and absence of adverse event. An event is considered as an omission if it did not occur but was indicated in the clinical context. Good maternal care in any clinical context can therefore be universally defined as an episode consisting of care encounters or events that are timely, appropriate, and adequate without adverse event or omission. Judging care events positively or negatively requires further explicit and structured implicit guidance. Explicit guidance allows decisions on events based on basic physiologic rationale and evidence based standards of care. Structured implicit guidance allows the reviewer to consider medico-legal vulnerability of documentation and the quality of clinical encounters by assessing documented content, evidence of cognitive bias or error, detail of contingency plans and documented communication.
By abstracting a predetermined time frame of care and transcribing into a simple database it is possible to generate a timeline of events with those that contribute to suboptimal care highlighted for discussion at a designated MDT meeting. With minimal training senior medical trainees and midwives or clinical coders can abstract the notes allowing most of the labour intensive work to be done with minimal resource before an MDT meeting. With evolution of electronic health care records (EHCR) it is foreseeable that the burden on data mining will reduce considerably. However, many organisations are a long way off implementing EHCR to this level. Participation in the RCRR process also generates a valuable learning for reviewers. Drawing conclusions on the overall quality of care or avoidability of an outcome is an additional step that requires more implicit reasoning and group consensus. This step can be taken during the MDT meeting if needed but should not distract from reflecting more broadly on lessons amenable to recommendations on ways to optimise care.
Hopefully consideration of the MESI RCRR principles outlined above will enable or stimulate obstetric units to undertake more inclusive, frequent and detailed review of major obstetric morbidity. Better organisational learning will most likely be achieved if discussion of RCRR findings has a more reflective focus on ways that care could have been optimised in contrast to debates about avoidable outcomes.
References
1.Shah, A et al. Towards optimising local reviews of severe incidents in maternity care: messages from a comparison of local and external reviews. BMJ Qual Saf 2016;0:1-8
2.Carle C, Alexander P, Columb M, Johal J. Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia. 2013;68(4):354-67
3.Hutchinson A, et al. A structured judgement method to enhance mortality case note review: development and evaluation. BMJ Qual Saf 2013;22:12 1032-1040.
4.Hogan H, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012;21:737-745.
It appears that these authors believe that variability in the
disciplinary rates between states is something that indicates a lack of
quality and/or a lack of uniformity of safety measures.
Nothing could be further from the truth.
There are many more reasons affecting a state's disciplinary rates
than those controlled for in the study. For just one glaringly obvious
example, in certain states and i...
It appears that these authors believe that variability in the
disciplinary rates between states is something that indicates a lack of
quality and/or a lack of uniformity of safety measures.
Nothing could be further from the truth.
There are many more reasons affecting a state's disciplinary rates
than those controlled for in the study. For just one glaringly obvious
example, in certain states and in DC many licensees do not ever set foot
in a state, do not touch patients or do anything that could possibly
endanger patient safety.
A state MLB is doing its job ONLY when it carefully considers each
potential disciplinary case on its own merits and the decisions reached
are totally separate and apart from all other cases and decisions in other
states. MLB members should never even be exposed to statistics from other
states, lest they fall prey to the perennial "Public Citizen" ploy of
daring them to play "let's us not be last in the disciplinary contest".
To imply that a narrower spread of disciplinary actions across all
states would reflect enhanced patient safety is ludicrous. What that
would in FACT suggest is that all state MLBs are "grading on a curve"
without regard to actual merit, not bothering to take either their jobs OR
their state patients' safety seriously, but simply attending to their
statistics and averages. A cynic would say "Oh, it's the 15th of the
month, better throw a few more docs under the bus!"
It would also appear that the authors are not aware of the Federation
of State Medical Boards, which does everything in its power to promulgate
standards and policies for disciplinary activities through its
conferences, webinars and publications.
Reynolds et al1 reported the impact of providing prescriber feedback
in reducing prescribing errors. The authors have concluded that reducing
prescribing errors needs a multifaceted approach and feedback alone is not
sufficient. Medication errors are often preventable and inappropriate
prescribing is identified as an important contributing factor to
medication errors.2 It is interesting to note that despite regular
feedb...
Reynolds et al1 reported the impact of providing prescriber feedback
in reducing prescribing errors. The authors have concluded that reducing
prescribing errors needs a multifaceted approach and feedback alone is not
sufficient. Medication errors are often preventable and inappropriate
prescribing is identified as an important contributing factor to
medication errors.2 It is interesting to note that despite regular
feedback, prescribing errors are not improved. It shows a failure in
improving underlying prescribing culture.
We need a shift in how we consider safety issues in an organisation.
It is important to assess underlying safety climate in an organisation.
Medication safety issues should be discussed as part of interdisciplinary
rounding or daily safety huddles. If medication errors were considered as
a safety concern during huddles or interdisciplinary rounding then
prescribers could see how errors can impact individual patients and it may
result in practice changes. Interventions that focus on improving safety
culture has proven to be effective in reducing adverse events in hospitals
such as catheter associated blood stream infections.3
It is also well recognised that a committed leadership and supportive
organisational culture is important in bringing practice changes.4 Senior
doctors play an important role in developing the prescribing culture of
junior doctors. Junior doctors have reported that early in their career,
their senior colleagues primarily influence prescribing practices.5 While
the authors decision to target junior doctors prescribing is based on
valid reasons, the lack of involvement of senior doctors in the feedback
process may have limited its effectiveness in bringing practice changes.
It may have been worthwhile considering the prescribing practices of a
team including the consultants and not just the prescribing of junior
doctors.
In conclusion, it is evident that feedback alone does not change
prescribing practices and we need a shift in our approach towards safety
and build an organisational culture that consider safety as a key
priority.
References:
1. Reynolds M, Jheeta S, Benn J, et al. Improving feedback on junior
doctors' prescribing errors: mixed-methods evaluation of a quality
improvement project. BMJ Qual Saf 2016:bmjqs-2015-004717.
2. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer
health system. Washington D.C: National Academies Press, 2000.
3. Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high
reliability in health care organizations. Health Serv Res
2006;41(4p2):1599-617.
4. Kaplan GS, Patterson SH, Ching JM, et al. Why Lean doesn't work for
everyone. BMJ Qual Saf 2014:bmjqs-2014-003248.
5. De Souza V, MacFarlane A, Murphy AW, et al. A qualitative study of
factors influencing antimicrobial prescribing by non-consultant hospital
doctors. J Antimicrob Chemother 2006;58(4):840-43.
In this article, the authors propose that little evidence exists in
healthcare to show that application of Highly Reliable Organization (HRO)
principles has resulted in significant or sustained improvement in
performance. Further, they attribute the problem partially to under-
recognizing the role of habit in the process. While we fully agree that
forming habitual behavior is essential to creating...
In this article, the authors propose that little evidence exists in
healthcare to show that application of Highly Reliable Organization (HRO)
principles has resulted in significant or sustained improvement in
performance. Further, they attribute the problem partially to under-
recognizing the role of habit in the process. While we fully agree that
forming habitual behavior is essential to creating an HRO, we are far less
pessimistic about the state of affairs in the healthcare industry,
particularly in pediatrics.
Vogus and Hillgoss primarily drew their many references to suboptimal
implementation of HRO principles from the adult patient care arena. In
pediatrics, multiple hospital systems have used HRO principles to achieve
significant and sustained improvement in safety performance related to
specific metrics such as reducing Adverse Drug Events(1), Hand Hygiene
compliance(2), Serious Safety Events(3), as well as reducing all forms of
preventable harm across entire systems(4). We are limited by the number
of references we are allowed to cite, however we could list at least
another dozen papers that show the use of high reliability principles,
effectively implemented and linked to sustained and robust improvement in
clinical outcomes. Further, beginning over a decade ago, pediatric
hospitals joined together to form collaboratives (currently over 100
participants), agreed NOT to compete on quality, to share data, and
discover best practices. The collaboratives implement high reliability
principles and measure compliance with clinical practice expectations in
order to improve outcomes on multiple patient safety related measures.
Compliance to various care practice bundles by participating hospitals is
at the core of these efforts, and the results are significant(5).
We applaud the Virginia Mason Production System (VMPS) and the
Comprehensive Unit-based Safety Program (CUSP) and the results they have
achieved. The cultivation of mindfulness and shared habits through the
various mechanisms described are all variations of similar tactics and
strategies we have been using in pediatrics. However, we do not agree with
the statement that these programs "operate independently of any specific
leader". While specific leaders can and do change, we believe that
vigorous and steady leadership from the top is necessary to maintain the
gains. Therefore, we agree the process can be fragile in the face of
leadership change.
The authors did not discuss an element that we believe is essential
to achieve optimal quality and safety outcomes: transparency. Early in the
Ohio Children's Hospitals' collaborative, the declaration by hospital CEOs
to put inter-hospital rivalries and competition aside for the sake of
safety was made. Their stated goal was to develop the kind of trust which
allowed open data and best practice sharing, so that a culture of rapid
information sharing (all teach, all learn) could develop. Real and
sustained progress requires internal and external transparency and we
suggest the Ohio Solutions for Patient Safety Collaborative results
support this belief(5).
To be clear, in pediatrics we are not yet where we want to be
regarding quality and safety. Most systems have declared elimination of
preventable harm as the ultimate goal - recognizing that, in many ways, it
is an un-ending journey, but the only truly acceptable aspirational goal.
Yet pediatrics is making measurable and significant progress using HRO
principles, and we fully embrace the importance of developing mindful
habits as an important part of that process.
References
1. McClead RE, Catt C, Davis JT, Morvay S, Merandi J, Lewe D, Stewart B,
Brilli RJ. An Internal Quality Improvement Collaborative Significantly
Reduces Hospital-wide Medication Error Related Adverse Drug Events. J
Pediatr 2014;165(6):1222-9.
2. Toltziz P, O'Riordan M, Cunningham DJ, Ryckman FC, Bracke TM, Olivea
J, Lyren A. A Statewide Collaborative to Reduce Pediatric Surgical Site
Infections. Pediatrics 2014;134(4):e1174-e1180.
3. Muething SE, Goudie A, Schoettker PJ, Donnelly LF, Goodfriend MA,
Bracke TM, Brady PW, Wheeler DS, Anderson JM, Kotagal UR. Quality
Improvement Initiative to Reduce Serious Safety Events and Improve Patient
Safety Culture. Pediatrics 2012;130:e423-e431.
4. Brilli RJ, McClead RE Jr, Crandall WV, Stoverock L, Berry JC, Wheeler
TA, Davis JT. A comprehensive patient safety program can significantly
reduce preventable harm, associated costs, and hospital mortality. J
Pediatr. 2013 Dec;163(6):1638-45. Epub 2013 Jul 30.
5. Lyren A, Brilli R, Bird M, Lashutka N, Muething S. Ohio Children's
Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient
Safety Improvement. J Healthc Qual 2015;38(4):213-222.
Dhaliwal's comment [1] on Zwaan et al [2] nicely refutes what has been called "the hypothesis of special cause" [3] - the notion that when things turn out wrong, the cognitive processes leading to that outcome must have been fundamentally different (ie, error-prone) from when they turn out right. Dhaliwal's argument recapitulates thinking that is over 100 years old; one of the early contributors to psychology, Ernst Mach, wr...
Dhaliwal's comment [1] on Zwaan et al [2] nicely refutes what has been called "the hypothesis of special cause" [3] - the notion that when things turn out wrong, the cognitive processes leading to that outcome must have been fundamentally different (ie, error-prone) from when they turn out right. Dhaliwal's argument recapitulates thinking that is over 100 years old; one of the early contributors to psychology, Ernst Mach, wrote (in 1905): "Knowledge and error flow from the same mental source; only success can tell one from the other" [4].
What is interesting here is not that the hypothesis of special cause is wrong, but rather the question of why has it been so popular and persistent. What is it about the notion of humans as fundamentally irrational, poor decision-makers that gives this idea such wide appeal? After all, broad acceptance of this sort is not the norm for most psychological or medical research; controversy, argument, or outright disbelief are much more common [5]. Christensen-Szalanski and Beach surveyed decision-making studies in psychology and reported that, although the studies' conclusions were roughly evenly divided between finding good or poor decision-making performance (56% vs 44%), studies reporting human performance as flawed were cited almost 6 times more frequently than those reporting it good. Citations outside of psychology journals were overwhelmingly used to advance the claim that people are poor decision-makers [5].
One reason for this strange popularity is that the people-are-irrational claim provides benefits for those who have rationality to sell: guideline authors, health care managers, and other proponents of scientific-bureaucratic medicine [6,7]. Another is that it paradoxically provides individual benefits: once we understand the clever puzzles of heuristics and biases problems, even in retrospect, we tend to feel that we must be pretty clever also. And a final, and likely strongest influence, is that it protects organizations and elites: attributing adverse events to flawed mental processes at the front lines serves as a kind of lightning rod, conducting the harmful consequences of bad outcomes down an organizationally safe pathway [8].
Unfortunately, the history of patient safety to date does not suggest that cautions such as Dhaliwal's will have much effect; such cautions have been raised and ignored before [9-12]. Patient safety's fixation on 'medical error' as the fundament of medical harm serves many (perhaps extraneous) purposes, but is based on an ontological will-of-the-wisp [3,13,14]. Given general agreement on the meagre progress of the patient safety movement to date [15-18], a fundamental re-thinking of our basic premises and hidden assumptions is desperately needed if we are to move forward. And as with many fixations, a sea-change of this sort is not likely to come from within the present patient safety movement, but must come from the outside [19,20]. We can only hope 'these barbarians' challenge us sooner rather than later [21].
References
1. Dhaliwal G. Premature closure? Not so fast. BMJ Quality & Safety 2016 bmjqs-2016-005267:online ahead of print.
2. Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Quality & Safety 2016.
3. Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. Farnham, UK: Ashgate; 2014, 187 pages.
4. Mach E. Knowledge and Error. Translated by Foulkes P, McCormack TJ. Dordrecht, Netherlands: Reidel Publishing Co; 1905 (English translation 1976), 393 pages.
5. Lopes LL. The Rhetoric of Irrationality. Theory & Psychology 1991;1(1):65-82.
6. Harrison S, Moran M, Wood B. Policy emergence and policy convergence: the case of 'scientific-bureaucratic medicine' in the United States and United Kingdom. The British Journal of Politics & International Relations 2002;4(1):1-24.
7. Wears RL, Hunte GS. Seeing patient safety 'Like a State'. Safety Science 2014;67:50-57.
8. Cook RI, Nemeth C. "Those found responsible have been sacked": some observations on the usefulness of error. Cogn Technol Work 2010;12(1):87-93.
9. Henriksen K, Kaplan H. Hindsight bias, outcome knowledge and adaptive learning. Qual Saf Health Care 2003;12(Suppl 2):ii46-ii50.
10. Dekker SWA. Patient Safety: A Human Factors Approach. Boca Raton, FL: CRC Press; 2011, 250 pages.
11. Hollnagel E. Does human error exist? In: Senders JW, Moray NP, eds. Human Error: Cause, Prediction, and Reduction. Hillsdale, NJ: Lawrence Erlbaum Associates; 1991: pp 153.
12. Wears RL. The error of chasing 'error'. Northeast Florida Medicine 2007;58(3):30-31.
13. Dekker SWA. Is it 1947 yet? http://www.safetydifferently.com/is-it-1947-yet/, accessed 19 May 2015.
15. National Patient Safety Foundation. Free From Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Cambridge, MA: National Patient Safety Foundation; 2015, http://www.npsf.org/custom_form.asp?id=03806127-74DF-40FB-A5F2-238D8BE6C24C, accessed 8 December 2015, 59 pages.
16. Pronovost PJ, Ravitz AD, Stoll RA, Kennedy SB. Transforming Patient Safety: A Sector-Wide Systems Approach: Report of the WISH Patient Safety Forum 2015. Qatar: World Innovation Summit for Health; 2015, http://dpnfts5nbrdps.cloudfront.net/app/media/1430, accessed 18 February 2015, 52 pages.
17. Baker GR, Black G. Beyond the Quick Fix. Toronto, ON: University of Toronto; 2015, http://ihpme.utoronto.ca/wp-content/uploads/2015/11/Beyond-the-Quick-Fix-Baker-2015.pdf, accessed 12 November 2015, 32 pages.
18. Illingworth J. Continuous improvement of patient safety: the case for change in the NHS. London, UK: The Health Foundation; 2015, http://www.health.org.uk/sites/default/files/ContinuousImprovementPatientSafety.pdf, accessed 12 November 2015, 40 pages.
19. De Keyser V, Woods DD. Fixation Errors: Failures to Revise Situation Assessment in Dynamic and Risky Systems. In: Colombo AG, de Bustamante AS, eds. Systems Reliability Assessment: Springer Netherlands; 1990: pp 231-251.
20. Woods DD, Cook RI. Perspectives on human error: hindsight biases and local rationality. In: Durso FT, Nickerson RS, Schvaneveldt RW, et al., eds. Handbook of Applied Cognition. 1st ed. New York, NY: John Wiley & Sons; 1999: pp 141-171.
21. Cavafy C. Waiting for the Barbarians. http://www.cavafy.com/poems/content.asp?id=119&cat=1 . accessed 6 March 2014.
I read with interest the paper by Gillespie and Reader presenting the
Healthcare Complaints Analysis Tool (HCAT) (1). The authors suggest that
the HCAT could be used "as an alternative metric of success in meeting
standards" and as a way "to benchmark units or regions". However, this
makes the assumption that the volume and strength of complaints received
is an accurate reflection of the standard of care being delivered....
I read with interest the paper by Gillespie and Reader presenting the
Healthcare Complaints Analysis Tool (HCAT) (1). The authors suggest that
the HCAT could be used "as an alternative metric of success in meeting
standards" and as a way "to benchmark units or regions". However, this
makes the assumption that the volume and strength of complaints received
is an accurate reflection of the standard of care being delivered. In
fact, it may be more heavily influenced by the ability and willingness of
patients (or their relatives) to make a complaint. A hospital or unit
could have a poor standard of care but receive few complaints, especially
if it has a high proportion of patients from demographic groups that are
less likely to complain. For example, a recent report from the
Parliamentary and Health Service Ombudsman found far fewer complaints from
the elderly than would be expected based upon their service usage (2).
Patients from certain ethnic minorities and less affluent social grades
have also been identified as groups less likely to complain (3). Moreover,
many complaints may be verbalised but not formally articulated in a
written statement (4). The HCAT may have a valuable role in organising
complaints, but using it to benchmark quality as the authors suggest could
be misleading and give a false sense of reassurance. We must have a
mechanism to systematically assess poor quality care and whilst written
patient complaints can be part of this, it should not be regarded as an
independent metric of quality.
1. Gillespie A and Reader TW. The Healthcare Complaints Analysis
Tool: development and reliability testing of a method for service
monitoring and organisational learning. BMJ Qual. Saf. 2016 25:937-946
2. Breaking down the barriers: older people and complaints about
health care. Parliamentary and Health Service Ombudsman December 2015.
Available at: http://www.ombudsman.org.uk/about-us/news-centre/press-
releases/2015/frail-older-people-too-afraid-to-complain-about-poor-care
[accessed 11/12/16]
3. Fear of raising concerns about care. A research report for the
Care Quality Commission. April 2013. Available at:
https://www.cqc.org.uk/sites/default/files/documents/201304_fear_of_raising_complaints_icm_care_research_report_final.pdf
[accessed 11/12/16]
4. Cornwell J, Levenson R, Sonola L, Poteliakhoff E. Continuity of
care for older hospital patients. A call for action. The King's Fund,
March 2012. Available at:
https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/continuity
-of-care-for-older-hospital-patients-mar-2012.pdf [accessed 11/12/16]
We have read with great interest the article by Schiff G D et al.,1
in which 6.1% of errors reported to the United States Pharmacopeia MEDMARX
reporting system were classified as being related to the computerized
prescription order entry (CPOE) system, representing the third most
frequently reported errors in this notification system.
Similarly, in a study conducted in our hospital, appro...
We have read with great interest the article by Schiff G D et al.,1
in which 6.1% of errors reported to the United States Pharmacopeia MEDMARX
reporting system were classified as being related to the computerized
prescription order entry (CPOE) system, representing the third most
frequently reported errors in this notification system.
Similarly, in a study conducted in our hospital, approximately 24% of
drug-related problems were due to the use of the CPOE.2 This type of error
was more frequently detected after a team of clinical pharmacists reviewed
the drug treatment of hospital inpatients.
One of the major limitations of current classifications of drug-
related problems is that they do not include the various types of CPOE-
related errors.3,4 Consequently, Schiff et al. developed a new taxonomy
for this type of error, which is essential for epidemiological
surveillance and for the continual improvement of the safety of CPOE
systems. These authors identified the 25 most frequent CPOE-related
errors. Similarly, the 8 most frequent types of CPOE-related error in our
study were the following: 1) Drugs included in the hospital formulary but
prescribed as "not available" in the CPOE (for example, spelling mistakes
or the use of the brand rather than the generic name lead to a failure to
find the drug in the application). 2) Duplicate orders (exact same drug
and dosage). 3) Incorrect entry of a prescribed dose resulting in a higher
or lower recommended dosage. 4) Inappropriate frequency of administration
(frequencies are often specified in a free text comment). For example,
digoxin, 1 tablet per day; the free text comments field may state "except
Saturday and Sunday". Since the free text comment bypasses the computer
circuit designed for discontinuous regimens, the medication chart will
state that this drug should be administered on Saturdays and Sundays. 5)
Inappropriate route of administration. 6) Inappropriate treatment duration
(due to failure to use of the end-date field or days of duration).7)
Unintended discrepancies in dosage (prescribed dosage different from
patients' existing dosage). 8) Designation of a clinical trial drug as
"not included in the hospital formulary" instead of the use of a specific
clinical trials application for the CPOE.
Unlike the study by Schiff et al., one of the most frequently
encountered CPOE-related errors in our experience was prescription of a
drug included in the hospital formulary using an option in the CPOE
designed for those drugs not available in the formulary, which can lead to
a delay in administering the drug to the patient, because the prescribed
drug requires pharmaceutical validation as if it were not included in the
formulary and nursing staff do not visualize it as included in the
medication chart to be administered. Unlike our study, one of the codes
identified by Schiff et al. was nursing administration issues. The lack of
this type of error in our study was due to the specific implantation,
parallel to that of the CPOE, of a computerized application that includes
information on the mode of drug administration for nursing staff with the
aim of unifying this process in the hospital.5 Together with this
information, the application allows the time of administration of each
drug to be specified, such that the time of administration will appear
automatically after its prescription, as well as the compatible diluent(s)
for those drugs requiring dilution.
Our study may have identified a lower number of types of CPOE-related
errors because the sample was drawn from a single hospital and because we
included only those errors due to the use of the CPOE.
In addition to analysing CPOE-related errors, Schiff et al. also
evaluated the causes of these errors and identified codes for their
prevention. Similarly, in our hospital, several strategies were
progressively adopted to reduce this type of error. Thus, administration
units were adapted to paediatric patients, numerous computerized protocols
were designed to standardise drugs associated with specific processes, and
the CPOE was modified to allow visualization, in the lower part of the
admission order, of the drug and dosage previously taken by the patient
before admission. However, several safety aspects related to the CPOE
remain to be resolved.
One of the limitations of our study is that it is difficult to extrapolate
the CPOE system to other hospital settings, given that the system was
designed and developed specifically for the characteristics of our
hospital and is not commercially available. One of the strengths of our
study is that the data are drawn from a prospective review of all the drug
treatments by a team of clinical pharmacists, while data from other
studies have been drawn from voluntary notification systems, which could
lead to underdetection of errors as well as a lack of data on their
registration.
In our opinion, the study by Schiff et al. is a highly valuable
contribution, because, in addition to providing a new classification of
CPOE-related errors, it also describes strategies for their prevention.
Given the strong impact of this type of errors, a common classification
system for CPOE-related errors is essential. Such a system would allow
benchmarking between different hospitals independently of the CPOE system
used, which in turn would allow the development of error prevention
systems and/or new CPOE systems to avoid them.
Olatz Urbina Bengoa1, Olivia Ferrandez Quirante1, Marta De Antonio
Cusco1, Nuria Carballo Martinez1
,Santiago Grau Cerrato1
1Pharmacy Department, Hospital del Mar
Pg Maritim, 25-29, CP 08003-Barcelona
Tel: 932483704
Fax: 932483256
References
1. Schiff GD, Amato MG, Eguale T, et al. Computerised physician order
entry-related medication errors: analysis of reported errors and
vulnerability testing of current systems. BMJ Qual Saf 2015;24(4):264-71.
2. Urbina O, Ferrandez O, Grau S, et al. Design of a score to
identify hospitalized patients at risk of drug-related problems.
Pharmacoepidemiol Drug Saf 2014;23(9):923-32.
3. Pharmaceutical Care Network Europe. The PCNE classification for
drug-related problems V 6.2 [Internet]. 2010; http://www.pcne.org.
(Accesed 22 Nov 2016)
4. van Mil JW, Westerlund LO, Hersberger KE, Schaefer MA. Drug-
related problem classification systems. Ann Pharmacother 2004;38(5):859-
67.
5. Salas E, Bastida M, Grau S, et al. Quality project to improve drug
administration in the hospital trust of thecitycouncil of Barcelona.
International Forum on Quality and Safety in Health Care. British Medical
Journal Group. Barcelona, April 2007. (Oral communication). (Data not
published).
Overdyk et al. used remote video auditing with real-time feedback in
a surgical suite [1]. As part of their randomized trial clustered by
theatre, they report less turnover times among "fast rooms," those
generally including 3 or greater cases per day.
Successive turnover times between scheduled cases within theatres on
the same date tend to be correlated (e.g., caused by same surgeon, nurses,
and anaesthetist)....
Overdyk et al. used remote video auditing with real-time feedback in
a surgical suite [1]. As part of their randomized trial clustered by
theatre, they report less turnover times among "fast rooms," those
generally including 3 or greater cases per day.
Successive turnover times between scheduled cases within theatres on
the same date tend to be correlated (e.g., caused by same surgeon, nurses,
and anaesthetist). This was shown in Dexter et al. 2005 and Austin et al.
2014 [2,3]. Overdyk et al.'s description of their statistical model seems
not to describe consideration of correlations of turnover times within the
same theatre on the same day. This can be rectified by including the
theatre-day combination as a fixed or random effect. Alternatively, and
typically, analyses take the simpler approach of batching (binning) by
each day, week, 2 week, or 4-week period, and then comparing the periods
(e.g., week) pairwise between control (i.e., no feedback) and intervention
(i.e., feedback) theatres (e.g., Reference [3]). When the authors sort the
turnover times in sequence of date, then theatre, and then start time, do
the authors have statistically significant lag 1 correlation? If yes,
then, when analyses are repeated by either including that correlation in
the statistical model or by making comparison pairwise by week (or other
suitable interval), what are the revised results of the authors' Table 2?
Turnovers that are occurring simultaneously among theatres on the
same day can be correlated if personnel are shared (e.g., housekeepers and
anaesthesia technicians) [4,5]. For example, Wang et al. found most
turnovers greater than 1 hour occurred at their studied surgical suite
when there were >2 simultaneous turnovers [5]. Overdyk et al.'s
description of their statistical model does not seem to describe
consideration of correlations of turnover times on the same day and time
among theatres. Although this can be rectified by including a fixed effect
of the time varying number of simultaneous turnovers, usually analyses
compensate by batching (binning) by each day, week, etc. [2-5]. Do the
authors have significant correlation between numbers of simultaneous
turnovers at each time and turnover times? If yes, then when analyses are
repeated, what are the revised results of the authors' Table 2?
References
1 Overdyk FJ, Dowling O, Newman S, et al. Remote video auditing with real-
time feedback in an academic surgical suite improves safety and efficiency
metrics: a cluster randomised study. BMJ Qual Saf 2015; PMID: 26658775
2 Dexter F, Epstein RH, Marcon E, et al. Estimating the incidence of
prolonged turnover times and delays by time of day. Anesthesiology
2005;102:1242-8
3 Austin TM, Lam HV, Shin NS, et al. Elective change of surgeon during the
OR day has an operationally negligible impact on turnover time. J Clin
Anesth 2014;26:343-9
4 Dexter F, Marcon E, Aker J, et al. Numbers of simultaneous turnovers
calculated from anesthesia or operating room information management system
data. Anesth Analg 2009;109:900-5
5 Wang J, Dexter F, Yang K. A behavioral study of daily mean turnover
times and first case of the day start tardiness. Anesth Analg
2013;116:1333-41
Conflict of Interest:
Financial disclosure: Arrowsight paid the University of Iowa's Department of Anesthesia for consulting by Dr. Dexter in 2012 (see http://www.FranklinDexter.net/FAQ.htm).
It was with great interest that we read the study of O'Leary et al
published in the December issue of the journal and were quite surprised by
their findings that patient centered- rounds had no impact on patients'
perceptions of shared decision making, activation, and satisfaction with
care.1
Previous studies have shown that patients prefer their rounding team
conduct rounds at the bedside...
It was with great interest that we read the study of O'Leary et al
published in the December issue of the journal and were quite surprised by
their findings that patient centered- rounds had no impact on patients'
perceptions of shared decision making, activation, and satisfaction with
care.1
Previous studies have shown that patients prefer their rounding team
conduct rounds at the bedside 2-5and based on these studies, one would
expect that if bedside rounds were conducted, patients would feel more
satisfied with their care and be more engaged in medical decision making
compared to other forms of rounding.
The findings of this study do make us pause and reconsider some of
our perceived beliefs regarding patient benefits from bedside rounds. The
authors propose several explanations to support their findings. However,
before abandoning patient-centered bedside rounding (PCBR), one must
consider several potential issues that may make this study less
generalizable. One explanation not explored might be the possibility of
patients being asleep at that time of the day (7.30 am) and they may not
have wanted or have been in a position to participate in PCBR.
Additionally, the control group was cared for by a small team: one of the
units was a cardiac type unit where patients were being admitted to
initiate and monitor medications. It is possible that the small care team,
type of patients on that unit, and the general structure of the control
team was designed so patients may have had positive perceptions about
their care, which might explain their findings. It is also possible that
the language used by the team during PCBR after the initial few weeks of
mentoring may have contained medical jargon or the script used to invite
patient participation may not have been r conducive to patient engagement.
These potential factors could have affected the perception by patients.
An important critique of the study is that patients were not given a
choice of whether they in fact wanted PCBR. In our experience of querying
Veterans at our institution, while the majority state they would prefer
PCBR "If they have something to say, I want to hear it", a sizable
minority prefer NOT to have PCBR, as they are uncomfortable with medical
uncertainty and hearing worst case scenarios "You're the doctor. You tell
me". Perhaps a better approach would be to ask every patient upon
admission if they prefer team rounds at the bedside or outside the room.
The teams should ask the patient how much they would like to participate
in their care, and whether they'd be comfortable if there were other
patients in the hospital room, and then proceed accordingly. It is
essential to explain what these rounds entail and possible roles the
patient can assume. Once patients are provided this information they may
be in better position to think through their choice of actively
participating or not in becoming informed customers; they may be able to
make the choice that best suits their preferences. Given the challenges of
executing PCBR and O'Leary's findings perhaps PCBR should only be done on
those that actually want them. As simplistic as it sounds, patients should
actually be asked in a patient-centered manner whether they actually want
patient centered bedside rounding.
REFERENCES:
1. O'Leary, KJ, et al, Effect of patient-centered bedside rounds on
hospitalized patients' decision control, activation and satisfaction with
care, BMJ Qual Saf 2015;0:1-8. doi:10.1136/bmjqs-2015-004561
2. Wang-Cheng, R.M., et al., Bedside case presentations: why patients
like them but learners don't. J Gen Intern Med, 1989. 4(4): p. 284-7
3 Rogers, H.D., J.D. Carline, and D.S. Paauw, Examination room
presentations in general internal medicine clinic: patients' and students'
perceptions. Acad Med, 2003. 78(9): p. 945-9.
4. Gonzalo, J.D., et al., The return of bedside rounds: an educational
intervention. J Gen Intern Med, 2010. 25(8): p. 792-8.
5. Lehmann, L.S., et al., The effect of bedside case presentations on
patients' perceptions of their medical care. N Engl J Med, 1997. 336(16):
p. 1150-5.
I read with interest the article by Peerally et al (1) on 'The problem with root cause analysis'. I reflected on the recent cases that happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which led me to consider which investigative tool is best applied to different incidences and identified risks. The use of appropriate tools and involvement of key stakeholders are crucial elements to a successful investig...
It appears that these authors believe that variability in the disciplinary rates between states is something that indicates a lack of quality and/or a lack of uniformity of safety measures.
Nothing could be further from the truth.
There are many more reasons affecting a state's disciplinary rates than those controlled for in the study. For just one glaringly obvious example, in certain states and i...
Reynolds et al1 reported the impact of providing prescriber feedback in reducing prescribing errors. The authors have concluded that reducing prescribing errors needs a multifaceted approach and feedback alone is not sufficient. Medication errors are often preventable and inappropriate prescribing is identified as an important contributing factor to medication errors.2 It is interesting to note that despite regular feedb...
To the Editor:
In this article, the authors propose that little evidence exists in healthcare to show that application of Highly Reliable Organization (HRO) principles has resulted in significant or sustained improvement in performance. Further, they attribute the problem partially to under- recognizing the role of habit in the process. While we fully agree that forming habitual behavior is essential to creating...
Dhaliwal's comment [1] on Zwaan et al [2] nicely refutes what has been called "the hypothesis of special cause" [3] - the notion that when things turn out wrong, the cognitive processes leading to that outcome must have been fundamentally different (ie, error-prone) from when they turn out right. Dhaliwal's argument recapitulates thinking that is over 100 years old; one of the early contributors to psychology, Ernst Mach, wr...
I read with interest the paper by Gillespie and Reader presenting the Healthcare Complaints Analysis Tool (HCAT) (1). The authors suggest that the HCAT could be used "as an alternative metric of success in meeting standards" and as a way "to benchmark units or regions". However, this makes the assumption that the volume and strength of complaints received is an accurate reflection of the standard of care being delivered....
To the Editor,
We have read with great interest the article by Schiff G D et al.,1 in which 6.1% of errors reported to the United States Pharmacopeia MEDMARX reporting system were classified as being related to the computerized prescription order entry (CPOE) system, representing the third most frequently reported errors in this notification system.
Similarly, in a study conducted in our hospital, appro...
Overdyk et al. used remote video auditing with real-time feedback in a surgical suite [1]. As part of their randomized trial clustered by theatre, they report less turnover times among "fast rooms," those generally including 3 or greater cases per day.
Successive turnover times between scheduled cases within theatres on the same date tend to be correlated (e.g., caused by same surgeon, nurses, and anaesthetist)....
Dear Editor,
It was with great interest that we read the study of O'Leary et al published in the December issue of the journal and were quite surprised by their findings that patient centered- rounds had no impact on patients' perceptions of shared decision making, activation, and satisfaction with care.1
Previous studies have shown that patients prefer their rounding team conduct rounds at the bedside...
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