Safety Culture in the Operating Room: Variability Among Perioperative Healthcare Workers.

INTRODUCTION: Safety culture is defined as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine an organization's health and safety management. There is a lack of studies assessing patient safety culture in the perioperative setting. OBJECTIVES: We examined safety culture at a single tertiary care hospital, across all types of surgery, using previously collected data from a validated survey tool. We aim to understand how safety culture varies among perioperative staff. METHODS: The Hospital Survey on Patient Safety Culture was administered at a single tertiary care hospital in 2014. We identified 431 respondents as perioperative healthcare workers: surgery attending physician, surgery trainee physician, anesthesia attending physician, anesthesia trainee physician, nurse, and technician. We calculated percent positive scores for each dimension of safety culture, as well as a composite score. Pairwise comparisons were calculated via analysis of variance. RESULTS: The average response rate was 67%. The dimensions with the highest average percent positive scores were teamwork within hospital units (69%) and organizational learning and continuous improvement (57%). The dimensions with the lowest scores were feedback and communication about error (34%) and hospital handoffs and transitions (30%). Surgery attending physicians perceived the strongest safety climate overall, whereas nurses and surgical technicians perceived significantly worse safety climate. CONCLUSIONS: We observed significant variability in perioperative safety culture, across dimensions of safety climate, professional roles, and levels of training. These variations in safety culture should be addressed when implementing culture change programs in the perioperative setting.

Development of a Web-Based Nonoperative Small Bowel Obstruction Treatment Pathway App.

OBJECTIVE: An electronic pathway for the management of adhesive small bowel obstruction (SBO) was built and implemented on top of the electronic health record. The aims of this study are to describe the development of the electronic pathway and to report early outcomes. METHODS: The electronic SBO pathway was designed and implemented at a single institution. All patients admitted to a surgical service with a diagnosis of adhesive SBO were enrolled. Outcomes were compared across three time periods: (1) patients not placed on either pathway from September 2013 through December 2014, (2) patients enrolled in the paper pathway from January 2017 through January 2018, and (3) patients enrolled in the electronic pathway from March through October 2018. The electronic SBO pathway pulls real-time data from the electronic health record to prepopulate the evidence-based algorithm. Outcomes measured included length of stay (LOS), time to surgery, readmission, surgery, and need for bowel resection. Comparative analyses were completed with Pearson's chi-squared, analysis of variance, and Kruskal-Wallis tests. RESULTS: There were 46 patients enrolled in the electronic pathway compared with 93 patients on the paper pathway, and 101 nonpathway patients. Median LOS was lower in both pathway cohorts compared with those not on either pathway (3 days [range 1-11] vs. 3 days [range 1-27] vs. 4 days [range 1-13], p = 0.04). Rates of readmission, surgery, time to surgery, and bowel resection were not significantly different across the three groups. CONCLUSION: It is feasible to implement and utilize an electronic, evidence-based clinical pathway for adhesive SBOs. Use of the electronic and paper pathways was associated with decreased hospital LOS for patients with adhesive SBOs.

Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework.

PURPOSE: The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors. METHODS: The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ2 analysis. RESULTS: Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79. CONCLUSIONS: Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.

Effects Of A Communication-And-Resolution Program On Hospitals' Malpractice Claims And Costs.

To promote communication with patients after medical injuries and improve patient safety, numerous hospitals have implemented communication-and-resolution programs (CRPs). Through these programs, hospitals communicate transparently with patients after adverse events; investigate what happened and offer an explanation; and, when warranted, apologize, take responsibility, and proactively offer compensation. Despite growing consensus that CRPs are the right thing to do, concerns over liability risks remain. We evaluated the liability effects of CRP implementation at four Massachusetts hospitals by examining before-and-after trends in claims volume, cost, and time to resolution and comparing them to trends among nonimplementing peer institutions. CRP implementation was associated with improved trends in the rate of new claims and legal defense costs at some hospitals, but it did not significantly alter trends in other outcomes. None of the hospitals experienced worsening liability trends after CRP implementation, which suggests that transparency, apology, and proactive compensation can be pursued without adverse financial consequences.

Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs.

Through communication-and-resolution programs, hospitals and liability insurers communicate with patients when adverse events occur; investigate and explain what happened; and, where appropriate, apologize and proactively offer compensation. Using data recorded by program staff members and from surveys of involved clinicians, we examined case outcomes of a program used by two academic medical centers and two of their community hospitals in Massachusetts in the period 2013-15. The hospitals demonstrated good adherence to the program protocol. Ninety-one percent of the program events did not meet compensation eligibility criteria, and those events that did were not costly to resolve (the median payment was $75,000). Only 5 percent of events led to malpractice claims or lawsuits. Clinicians were supportive of the program but desired better communication about it from staff members. Our findings suggest that communication-and-resolution programs will not lead to higher liability costs when hospitals adhere to their commitment to offer compensation proactively.

Implementation of a Comprehensive Post-Discharge Venous Thromboembolism Prophylaxis Program for Abdominal and Pelvic Surgery Patients.

BACKGROUND: Prophylactic anticoagulation is routinely used in the inpatient setting; however, the risk of venous thromboembolism (VTE) remains elevated after discharge. Extensive evidence and clinical guidelines suggest post-discharge VTE prophylaxis is critical in at-risk populations, but it remains severely underused in practice. STUDY DESIGN: We performed a single-institution retrospective, nonrandomized, pre- and post-intervention analysis of a systematic post-discharge pharmacologic prophylaxis program against the primary end point, which is post-discharge symptomatic VTE. An institutional American College of Surgeons NSQIP dataset was used to identify patients and outcomes. Patients undergoing major abdominal surgery for malignancy or inflammatory bowel disease were eligible for the post-discharge VTE prevention program. RESULTS: Among 1,043 patients who underwent abdominal surgery for malignancy or inflammatory bowel disease, 800 (77%) were in the pre-intervention cohort and 243 (23%) patients were in the post-intervention cohort. Rates of inpatient VTE did not significantly differ between cohorts (0.7%, n = 6 pre-intervention vs 1.7%, n = 4 post-intervention; p = 0.25). However, compared with the pre-intervention cohort, patients in the post-intervention cohort demonstrated a significantly lower post-discharge VTE rate (2.5%, n = 20 pre-intervention vs 0.0%, n = 0 post-intervention; p < 0.01). CONCLUSIONS: A systematic post-discharge VTE prophylaxis program including provider education, local guideline adaptation, bedside medication delivery, and education for at-risk patients, was associated with significantly fewer post-discharge VTE events.

Excessive diagnostic testing in acute kidney injury.

BACKGROUND: The patterns, performance characteristics, and yield of diagnostic tests ordered for the evaluation of acute kidney injury (AKI) have not been rigorously evaluated. METHODS: We characterized the frequency of AKI diagnostic testing for urine, blood, radiology, and pathology tests in all adult inpatients who were admitted with or developed AKI (N = 4903 patients with 5731 AKI episodes) during a single calendar year. We assessed the frequency of abnormal test results overall and by AKI stage. We manually reviewed electronic medical records to evaluate the diagnostic yield of selected urine, blood, and radiology tests. Diagnostic yield of urine and blood tests was determined based on whether an abnormal test affected AKI diagnosis or management, whereas diagnostic yield of radiology tests was based on whether an abnormal test resulted in a procedural intervention. In sensitivity analyses we also evaluated appropriateness of testing using prespecified criteria. RESULTS: Frequency of testing increased with higher AKI stage for nearly all diagnostic tests, whereas frequency of detecting an abnormal result increased for some, but not all, tests. Frequency of detecting an abnormal result was highly variable across tests, ranging from 0 % for anti-glomerular basement membrane testing to 71 % for urine protein testing. Many of the tests evaluated had low diagnostic yield. In particular, selected urine and blood tests were unlikely to impact AKI diagnosis or management, whereas radiology tests had greater clinical utility. CONCLUSIONS: In patients with AKI, many of the diagnostic tests performed, even when positive or abnormal, may have limited clinical utility.

Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists.

BACKGROUND: Health care reform efforts and initiatives seek to improve quality and reduce costs by eliminating unnecessary care. However, little is known about overuse and its drivers, especially in hospitals. OBJECTIVE: To assess the extent of and factors associated with overuse of testing in U.S. hospitals. DESIGN: National survey of practice patterns for 2 common clinical vignettes: preoperative evaluation and syncope. Respondents were randomly selected and randomly provided 1 of 4 versions of each vignette. Each version contained identical clinical information but varied in factors that could change physician behavior. Respondents were asked to identify what they believed most hospitalists at their institution would recommend in each vignette. SETTING: Mailed survey conducted from June through October 2011. PARTICIPANTS: Physicians practicing adult hospital medicine in the United States. MEASUREMENTS: Responses indicating overuse (more testing than recommended by American College of Cardiology/American Heart Association guidelines). RESULTS: 68% (1020 of 1500) of hospitalists responded. They reported overuse in 52% to 65% of the preoperative evaluation vignettes and 82% to 85% of the syncope vignettes. Overuse more frequently resulted from a physician's desire to reassure patients or themselves than an incorrect belief that it was clinically indicated (preoperative evaluation, 63% vs. 37%; syncope, 69% vs. 31%; P < 0.001 for each). LIMITATION: Survey responses may not represent actual clinical choices. CONCLUSION: Physicians reported substantial overuse in 2 common clinical situations in the hospital. Improving provider knowledge of guidelines may help reduce overuse, but despite awareness of the guidelines, physicians often deviate from them to reassure patients or themselves. PRIMARY FUNDING SOURCE: Blue Cross Blue Shield of Michigan Foundation, Department of Veterans Affairs Center for Clinical Management Research, University of Michigan Specialist-Hospitalist Allied Research Program, and Ann Arbor Veterans Affairs/University of Michigan Patient Safety Enhancement Program.

Disclosing medical errors: the view from the USA.

BACKGROUND: Disclosure is increasingly seen as a key component of efforts to improve safety, but does not yet reliably occur in all organizations in the U.S. APPROACH: We describe the experience to date with disclosure in the U.S. and illustrate the issues with specific clinical examples. Both reputational and legal concerns represent substantial barriers. The evidence to date-mostly from single sites - shows that not only is disclosure the right thing to do, it also appears to decrease malpractice risk. We also discuss the related issue of compensation-practices around this vary greatly. Underlying the push for greater disclosure is also the belief that better disclosure results in an improved culture of safety, which in turn may improve the quality and safety of care. CONCLUSIONS: Providers have an ethical imperative to disclosure error to patients, and the limited available evidence shows that doing so actually decreases malpractice risk. While disclosure is not yet routine practice in the U.S., the approach is clearly gaining momentum. Telling patients what happened is not enough. They also deserve an apology, and if harmed, to be made whole emotionally and financially. Greater disclosure may not only help individual patients, but may also help with improving safety overall.

Greatest impact of safe harbor rule may be to improve patient safety, not reduce liability claims paid by physicians.

"Safe harbor" legislation that provides liability protection to physicians when they follow designated guidelines is often proposed as a way to reform the malpractice system while improving patient safety. However, published evidence provides little policy guidance on implementing safe harbors. With the support of an Agency for Healthcare Research and Quality planning grant, we conducted an empirical analysis of closed liability claims in Oregon to determine the potential effects of hypothetical safe harbor legislation. We found that such legislation would have changed the liability outcome in favor of the physician defendant in only 1 percent of 266 claims from the period 2002-09 that we reviewed. Nevertheless, if safe harbors can induce greater physician adherence to care guidelines, they have the potential to improve patient safety. Implementing safe harbor legislation, however, requires overcoming a number of hurdles, including selecting and updating approved guidelines, obtaining broad stakeholder support, and withstanding challenges to the legal validity of the legislation. More experimentation with safe harbors is needed to determine their effects on the performance of the liability system and on health care quality and costs.

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

PURPOSE: To erform a process analysis of missed and delayed diagnoses of breast and colorectal cancers to identify: (1) the cognitive and logistical factors that lead to these diagnostic errors, and (2) prevention strategies. METHODS: Using 56 cases (43 breast, 13 colon) of missed and delayed diagnosis, we performed structured analyses to identify specific points in the diagnostic process in which errors occurred. Each error was classified as either a cognitive error or logistical breakdown. Finally, two physician-investigators identified strategies to prevent the errors in each case. RESULTS: Virtually all cases involved one or more cognitive errors (53/56, 95 %) and approximately half (31/56, 55 %) involved logistical breakdowns. The clinical activity most prone to cognitive error was the selection of the diagnostic strategy, both during the office visit (25/56, 45 %) and during interpretation of test results (22/50, 44 %). Arrangement of follow-up visits with a primary care physician (8/29, 28 %) or specialist physician (7/29, 26 %) were especially prone to logistical breakdowns. Adherence to current clinical guidelines could have prevented at least one error in 66 % of cases and assistance from a patient advocate could have prevented at least one error in 48 % of cases. CONCLUSIONS: Cognitive errors and logistical breakdowns are common among missed and delayed diagnoses of breast and colorectal cancers. Prevention strategies should focus on ensuring improving the effectiveness and use of clinical guidelines in the selection of diagnostic strategy, both during office visits and when interpreting test results. Tools to facilitate communication and to ensure that follow-up visits occur should also be considered.