A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings.

In spite of increased attention to quality and efforts to provide safe medical care, adverse events (AEs) are still frequent in clinical practice. Reports from various sources indicate that a substantial number of hospitalized patients suffer treatment-caused injuries while in the hospital. While risk cannot be entirely eliminated from health-care activities, an important goal is to develop effective and durable mitigation strategies to render the system "safer." In order to do this, though, we must develop models that comprehensively and realistically characterize the risk. In the health-care domain, this can be extremely challenging due to the wide variability in the way that health-care processes and interventions are executed and also due to the dynamic nature of risk in this particular domain. In this study, we have developed a generic methodology for evaluating dynamic changes in AE risk in acute care hospitals as a function of organizational and nonorganizational factors, using a combination of modeling formalisms. First, a system dynamics (SD) framework is used to demonstrate how organizational-level and policy-level contributions to risk evolve over time, and how policies and decisions may affect the general system-level contribution to AE risk. It also captures the feedback of organizational factors and decisions over time and the nonlinearities in these feedback effects. SD is a popular approach to understanding the behavior of complex social and economic systems. It is a simulation-based, differential equation modeling tool that is widely used in situations where the formal model is complex and an analytical solution is very difficult to obtain. Second, a Bayesian belief network (BBN) framework is used to represent patient-level factors and also physician-level decisions and factors in the management of an individual patient, which contribute to the risk of hospital-acquired AE. BBNs are networks of probabilities that can capture probabilistic relations between variables and contain historical information about their relationship, and are powerful tools for modeling causes and effects in many domains. The model is intended to support hospital decisions with regard to staffing, length of stay, and investments in safety, which evolve dynamically over time. The methodology has been applied in modeling the two types of common AEs: pressure ulcers and vascular-catheter-associated infection, and the models have been validated with eight years of clinical data and use of expert opinion.

Early cost estimating model for new bioabsorbable orthopedic implant candidates: A theoretical study.

An early health technology assessment (HTA) study was performed to assess the need for developing a new bioabsorbable implant for the treatment of specific orthopedic injuries. The Anterior Cruciate Ligament Reconstruction (ACLR) procedure was selected based on the need and potential impact of bioabsorbable implants in the treatment of ACL injuries. The economic model considers the possible health events after an ACLR (failures and other complications such as stiffness and pain). A decision tree approach was used, and several sensitivity analyses were performed using a Monte Carlo simulation. A cost estimating model was applied comparatively for currently available metal and bioabsorbable implants against a potential new bioabsorbable implant with improved performance. A reduction in stiffness and pain symptoms were considered as targets for these new implants performance, with reduced inflammation resulting from the use of materials with appropriate biological and mechanical properties. The current study estimates that, under the assumptions made, the introduction of a new bioabsorbable implant in ACLR surgeries may generate yearly cost savings. The model estimates positive cost-benefits of the new implant when it reduces the probability of failure by more than 30%, or reduces at least 14% the probability of complications of an inflammatory nature. The development of a new bioabsorbable orthopedic implant for ACLR is encouraged by this study identifying the need for new bioabsorbable implants with improved biological and mechanical performance. The results of this early HTA have made it possible to anticipate design needs and objectives for the research and development of new orthopedic bioabsorbable implants.

Addressing the Challenges of Aging: How Elders and Their Care Partners Seek Information.

Purpose: Elders in retirement communities face many challenges concerning information and communication. We know little about whether or how online technologies help meet their medical and social needs. The objective of this study was to gain insights into how these elders and their families manage health information and communication. Design and Methods: Qualitative analysis of 10 focus groups with elders and family members. Participants were 30 elders at least 75 years of age residing in 5 senior living communities in and near Boston, MA, and 23 family members. Results: Elders and families turned first to their personal networks when they needed information or help. They stayed informed about elders' health primarily by talking directly with providers. They used online resources infrequently, including portal access to medical records. They wanted online access to medication lists and visit notes, up-to-date information about local services and social activities, and a way to avoid the overwhelming nature of Internet searches. Implications: Elders in senior living communities and their families piece together information primarily from word of mouth communication. In the future, electronic social and collaborative technologies may make information gathering easier.

A prospective study of patient safety in the operating room.

BACKGROUND: To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique. METHODS: A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors. RESULTS: Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome. CONCLUSIONS: This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to patient safety in the operating room.

Making the operating room of the future safer.

There is an increasing demand for interventions to improve patient safety, but there is limited data to guide such reform. In particular, because much of the existing research is outcome-driven, we have a limited understanding of the factors and process variations that influence safety in the operating room. In this article, we start with an overview of safety terminology, suggesting a model that emphasizes "safety" rather than "error" and that can encompass the spectrum of events occurring in the operating room. Next, we provide an introduction to techniques that can be used to understand safety at the point of care and we review the data that exists relating such studies to improved outcomes. Future work in this area will need to prospectively study the processes and factors that impact patient safety and vulnerability in the operating room.

Developing a simulation-based training program for medical first responders.

A major stumbling block for widespread incorporation of simulators into EMT training includes the limited availability of curricula infrastructure linking the key components of skills, scenarios, and measures as well as the expertise required to run such programs. To meet these needs we are developing a training program for first responders that uses mannequin-based simulator technology effectively to fill the identified training need for valid meaningful scenarios that can be integrated into the curriculum and are applicable for a variety of EMT skill levels. The program will provide detailed scenarios, instructions for administering the program, and measures for performance feedback. Each scenario will exercise a combination of task work and cognitive skills and the set of scenarios will span all of the higher-level skills that have been identified as benefiting from targeted training.

Information Sharing Preferences of Older Patients and Their Families.

IMPORTANCE: Elderly patients often share control of their personal health information and decision making with family and friends when needed. Patient portals can help with information sharing, but concerns about privacy and autonomy of elderly patients remain. Health systems that implement patient portals would benefit from guidance about how best to implement access to portals for caregivers of elderly patients. OBJECTIVE: To identify how patients older than 75 years (hereinafter, elders) and family caregivers of such patients approach sharing of health information, with the hope of applying the results to collaborative patient portals. DESIGN, SETTING, AND PARTICIPANTS: A qualitative study was conducted from October 20, 2013, to February 16, 2014, inviting participants older than 75 years (n = 30) and participants who assist a family member older than 75 years (n = 23) to 1 of 10 discussion groups. Participants were drawn from the Information Sharing Across Generations (InfoSAGE) Living Laboratory, an ongoing study of information needs of elders and families based within an academically affiliated network of senior housing in metropolitan Boston, Massachusetts. Groups were separated into elders and caregivers to allow for more detailed discussion. A professional moderator led groups using a discussion guide. Group discussions were audiotaped, transcribed, and analyzed inductively using immersion/crystallization methods for central themes. MAIN OUTCOMES AND MEASURES: Central themes regarding sharing of health information between elderly patients and family caregivers. RESULTS: Seven lessons emerged from 2 main themes. First, sharing information has consequences: (1) elders and caregivers have different perspectives on what is seen as the "burden" of information, (2) access to medical information by families can have unintended consequences, and (3) elders do not want to feel "spied on" by family. Second, control of information sharing is dynamic: (4) elders wish to retain control of decision making as long as possible, (5) transfer of control occurs gradually depending on elders' health and functional status, (6) control of information sharing and decision making should be fluid to maximize elders' autonomy, and (7) no "one-size-fits-all" approach can satisfy individuals' different preferences. CONCLUSIONS AND RELEVANCE: Information sharing and control are complex issues even under the most well-meaning circumstances. While elders may delegate control and share information with family, they want to retain granular control of their information. When using patient portals, simple proxy access may not adequately address the needs and concerns of aging patients.

Organization and representation of patient safety data: current status and issues around generalizability and scalability.

Recent reports have identified medical errors as a significant cause of morbidity and mortality among patients. A variety of approaches have been implemented to identify errors and their causes. These approaches include retrospective reporting and investigation of errors and adverse events and prospective analyses for identifying hazardous situations. The above approaches, along with other sources, contribute to data that are used to analyze patient safety risks. A variety of data structures and terminologies have been created to represent the information contained in these sources of patient safety data. Whereas many representations may be well suited to the particular safety application for which they were developed, such application-specific and often organization-specific representations limit the sharability of patient safety data. The result is that aggregation and comparison of safety data across organizations, practice domains, and applications is difficult at best. A common reference data model and a broadly applicable terminology for patient safety data are needed to aggregate safety data at the regional and national level and conduct large-scale studies of patient safety risks and interventions.

Acceptance and use of health information technology by community-dwelling elders.

OBJECTIVES: With the worldwide population growing in age, information technology may help meet important needs to prepare and support patients and families for aging. We sought to explore the use and acceptance of information technology for health among the elderly by reviewing the existing literature. METHODS: Review of literature using PubMed and Google Scholar, references from relevant papers, and consultation with experts. RESULTS: Elderly people approach the Internet and health information technology differently than younger people, but have growing rates of adoption. Assistive technology, such as sensors or home monitors, may help 'aging in place', but these have not been thoroughly evaluated. Elders face many barriers in using technology for healthcare decision-making, including issues with familiarity, willingness to ask for help, trust of the technology, privacy, and design challenges. CONCLUSIONS: Barriers must be addressed for these tools to be available to this growing population. Design, education, research, and policy all play roles in addressing these barriers to acceptance and use.

Diagnostic, surgical judgment, and systems issues leading to reoperation: mining administrative databases.

BACKGROUND: Underreporting of surgical adverse events limits the ability to identify quality and safety issues. Automated screening of the clinical information system (CIS) can improve case capture and reduce dependency on self-reporting. We compared screening of a CIS to self-reporting for identifying unplanned reoperation and also examined the relationship between causality and probability of reporting. METHODS: Between 2005 and 2009, all unplanned reoperations identified by automated screening of databases were reviewed and classified according to causality. Comparison was made to cases self-reported to departmental morbidity and mortality; conditional probability analysis assessed the likelihood of reporting as a function of causality. RESULTS: Of 104,938 operations performed, automated CIS screening identified 1,010 cases requiring unplanned reoperation; 23.6% were self-reported to morbidity and mortality; the probability of reporting varied widely depending on causality. CONCLUSIONS: Screening of a CIS for adverse events requiring reoperation revealed significant underreporting, with additional bias in reporting based on underlying causality.

Coverage of patient safety terms in the UMLS metathesaurus.

The integration and large-scale analyses of medical error databases would be greatly facilitated by the use of a standard terminology. We investigated the availability in the UMLS metathesaurus of concepts that are required for coding patient safety data. Terms from three proprietary patient safety terminologies were mapped to the concepts in UMLS by an automated mapping program developed by us. From these candidate mappings, the concept that matched its corresponding term was selected manually. The reliability of the mapping procedure was verified by manually searching for terms in the UMLS Knowledge Source Server. Matching concepts in UMLS were identified for less than 27% of the terms in the study dataset. The matching rates of terms that describe the type of error and the causes of errors were even lower. The lack of such terms in the existing standard terminologies underscores the need for development of a standard patient safety terminology.