Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff.

BACKGROUND: The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse. OBJECTIVE: To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs. DESIGN: We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis. PARTICIPANTS: IM residents, IM program directors, and hospitalists at a large academic medical center. MAIN MEASURES: A nine-question open-ended interview guide. KEY RESULTS: We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education. CONCLUSIONS: The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

Using an online quiz-based reinforcement system to teach healthcare quality and patient safety and care transitions at the University of California.

QUALITY ISSUE: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. INITIAL ASSESSMENT: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. CHOICE OF SOLUTION: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. IMPLEMENTATION: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. EVALUATION: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. LESSONS LEARNED: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A "bridging" strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.

Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care.

Importance: Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. Objective: To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died. Design, Setting, and Participants: Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023. Main Outcomes and Measures: Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors. Results: Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors. Conclusions and Relevance: In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.

Physical examination education in graduate medical education--a systematic review of the literature.

OBJECTIVES: There is widespread recognition that physical examination (PE) should be taught in Graduate Medical Education (GME), but little is known regarding how to best teach PE to residents. Deliberate practice fosters expertise in other fields, but its utility in teaching PE is unknown. We systematically reviewed the literature to determine the effectiveness of methods to teach PE in GME, with attention to usage of deliberate practice. DATA SOURCES: We searched PubMed, ERIC, and EMBASE for English language studies regarding PE education in GME published between January 1951 and December 2012. STUDY ELIGIBILITY CRITERIA: Seven eligibility criteria were applied to studies of PE education: (1) English language; (2) subjects in GME; (3) description of study population; (4) description of intervention; (5) assessment of efficacy; (6) inclusion of control group; and (7) report of data analysis. STUDY APPRAISAL AND SYNTHESIS METHODS: We extracted data regarding study quality, type of PE, study population, curricular features, use of deliberate practice, outcomes and assessment methods. Tabulated summaries of studies were reviewed for narrative synthesis. RESULTS: Fourteen studies met inclusion criteria. The mean Medical Education Research Study Quality Instrument (MERSQI) score was 9.0 out of 18. Most studies (n = 8) included internal medicine residents. Half of the studies used resident interaction with a human examinee as the primary means of teaching PE. Three studies "definitely" and four studies "possibly" used deliberate practice; all but one of these studies demonstrated improved educational outcomes. LIMITATIONS: We used a non-validated deliberate practice assessment. Given the heterogeneity of assessment modalities, we did not perform a meta-analysis. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: No single strategy for teaching PE in GME is clearly superior to another. Following the principles of deliberate practice and interaction with human examinees may be beneficial in teaching PE; controlled studies including these educational features should be performed to investigate these exploratory findings.

Developing entrustable professional activities as the basis for assessment of competence in an internal medicine residency: a feasibility study.

BACKGROUND: Graduate medical education programs assess trainees' performance to determine readiness for unsupervised practice. Entrustable professional activities (EPAs) are a novel approach for assessing performance of core professional tasks. AIM: To describe a pilot and feasibility evaluation of two EPAs for competency-based assessment in internal medicine (IM) residency. SETTING/PARTICIPANTS: Post-graduate year-1 interns (PGY-1s) and attendings at a large internal medicine (IM) residency program. PROGRAM DESCRIPTION: Two Entrustable professional activities (EPA) assessments (Discharge, Family Meeting) were piloted. PROGRAM FEASIBILITY EVALUATION: Twenty-eight out of 43 (65.1 %) PGY-1 s and 32/43 (74.4 %) attendings completed surveys about the Discharge EPA experience. Most who completed the EPA assessment (10/12, 83.8 %, PGY-1s; 9/11, 83.3 %, attendings) agreed it facilitated useful feedback discussions. For the Family Meeting EPA, 16/26 (61.5 %) PGY-1s completed surveys, and most who participated (9/12 PGY1s, 75 %) reported it improved attention to family meeting education, although only half recommended continuing the EPA assessment. DISCUSSION: From piloting two EPA assessments in a large IM residency, we recognized our reminder systems and time dedicated for completing EPA requirements as inadequate. Collaboration around patient safety and palliative care with relevant clinical services has enhanced implementation and buy-in. We will evaluate how well EPA-based assessment serves the intended purpose of capturing trainees' trustworthiness to conduct activities unsupervised.

Characterizing patients hospitalized without an acute care indication: A retrospective cohort study.

BACKGROUND: Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays. OBJECTIVE: To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs. DESIGNS, SETTINGS, AND PARTICIPANTS: A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital. MAIN OUTCOME AND MEASURES: Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics. RESULTS: Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001). CONCLUSIONS: Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.

"July effect": impact of the academic year-end changeover on patient outcomes: a systematic review.

BACKGROUND: It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year. PURPOSE: To systematically review studies describing the effects of trainee changeover on patient outcomes. DATA SOURCES: Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010. STUDY SELECTION: Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator. DATA EXTRACTION: Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported. DATA SYNTHESIS: Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results. LIMITATIONS: The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data. CONCLUSION: Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

Time to ACT: launching an Addiction Care Team (ACT) in an urban safety-net health system.

Across the USA, morbidity and mortality from substance use are rising as reflected by increases in acute care hospitalisations for substance use complications and substance-related deaths. Patients with substance use disorders (SUD) have long and costly hospitalisations and higher readmission rates compared to those without SUD. Hospitalisation presents an opportunity to diagnose and treat individuals with SUD and connect them to ongoing care. However, SUD care often remains unaddressed by hospital providers due to lack of a systems approach and addiction medicine knowledge, and is compounded by stigma. We present a blueprint to launching an interprofessional inpatient addiction care team embedded in the hospital medicine division of an urban, safety-net integrated health system. We describe key factors for successful implementation including: (1) demonstrating the scope and impact of SUD in our health system via a needs assessment; (2) aligning improvement areas with health system leadership priorities; (3) involving executive leadership to create goal and initiative alignment; and (4) obtaining seed funding for a pilot programme from our Medicaid health plan partner. We also present challenges and lessons learnt.

Potential unintended consequences due to Medicare's "no pay for errors" rule? A randomized controlled trial of an educational intervention with internal medicine residents.

BACKGROUND: Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians. OBJECTIVE: To determine how physicians might change their behavior after learning about the Medicare rule. DESIGN: We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes. PARTICIPANTS: At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate. INTERVENTION: Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission. MAIN MEASURES: Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette. KEY RESULTS: Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study.

BACKGROUND: The prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge. METHODS: Retrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error. RESULTS: There were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission. CONCLUSION: The prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies.

Rapid response systems in adult academic medical centers.

A survey suggests that the academic medical centers with successful rapid response system programs defined each call as a chance to save a life, as well as an educational opportunity to increase the knowledge of nurses, interns, and residents throughout the institution.

Acute Care for Patients Who Are Incarcerated: A Review.

IMPORTANCE: The United States has the world's highest rate of incarceration. Clinicians practicing outside of correctional facilities receive little dedicated training in the care of patients who are incarcerated, are unaware of guidelines for the treatment of patients in custody, and practice in health care systems with varying policies toward these patients. This review considers legal precedents for care of individuals who are incarcerated, frequently encountered terminology, characteristics of hospitalized incarcerated patients, considerations for clinical management, and challenges during transitions of care. OBSERVATIONS: The Eighth Amendment of the US Constitution mandates basic health care for incarcerated individuals within or outside of dedicated correctional facilities. Incarcerated patients in the acute hospital setting are predominantly young men who have received trauma-related admitting diagnoses. Hospital practices pertaining to privacy, physical restraint, discharge counseling, and surrogate decision-making are affected by a patient's incarcerated status under state or federal law, institutional policy, and individual health care professional practice. Transitions of care necessitate consideration of the disparate medical resources of correctional facilities as well as awareness of transitions unique to incarcerated individuals, such as compassionate release. CONCLUSIONS AND RELEVANCE: Patients who are incarcerated have a protected right to health care but may experience exceptions to physical comfort, health privacy, and informed decision-making in the acute care setting. Research on the management of issues associated with hospitalized incarcerated patients is limited and primarily focuses on the care of pregnant women, a small portion of all hospitalized incarcerated individuals. Clinicians and health care facilities should work toward creating evidence-based and legally supported guidelines for the care of incarcerated individuals in the acute care setting that balance the rights of the patient, responsibilities of the clinician, and safety mandates of the institution and law enforcement.

Stigmatizing Language, Patient Demographics, and Errors in the Diagnostic Process.

This cohort study assesses the association between stigmatizing language, demographic characteristics, and errors in the diagnostic process among hospitalized adults.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis.

BACKGROUND: Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed. RESEARCH DESIGN AND METHODS: We searched the Cochrane Collaboration's Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics. RESULTS: Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair. CONCLUSIONS: QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

Implementing patient safety interventions in your hospital: what to try and what to avoid.

Hospitalists play an important role in improving patient safety through clinical expertise and leadership in hospital quality improvement activities. The evidence base in patient safety remains incomplete, despite an increasing body of published research in recent years. Thus, physicians must consider other factors in addition to the strength of evidence supporting a practice when deciding which patient safety interventions to implement. These factors include the prevalence of the safety problem targeted, the potential for unintended consequences of the intervention, the costs and complexity of implementing the intervention, and the potential of the intervention to generate momentum for further safety initiatives. In this article, the authors define a framework for evaluating patient safety interventions and discuss specific interventions hospitalists should consider.