Reducing the Risk of Delayed Colorectal Cancer Diagnoses Through an Ambulatory Safety Net Collaborative.

BACKGROUND: An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings. METHODS: A working group was convened to co-design implementation guidance, measures, and the collaborative model. Collaborative sites were recruited through a medical professional liability insurance program and chose to begin with developing an ASN for positive at-home CRC screening or overdue surveillance colonoscopy. The 18-month Breakthrough Series Collaborative ran from January 2022 to July 2023, with sites continuing to collect data while sustaining their ASNs. Data were collected from sites monthly on patients in the ASN, including the proportion that was successfully contacted, scheduled, and completed a follow-up colonoscopy. RESULTS: Six sites participated; four had an operational ASN at the end of the Breakthrough Series, with the remaining sites launching three months later. From October 2022 through February 2024, the Collaborative ASNs collectively identified 5,165 patients from the registry as needing outreach. Among patients needing outreach, 3,555 (68.8%) were successfully contacted, 2,060 (39.9%) were scheduled for a colonoscopy, and 1,504 (29.1%) completed their colonoscopy. CONCLUSION: The Collaborative successfully identified patients with previously abnormal CRC screening and facilitated completion of follow-up testing. The CRC ASN Implementation Guide offers a comprehensive road map for health care leaders interested in implementing CRC ASNs.

Establishing a regional registry for neonatal encephalopathy: impact on identification of gaps in practice.

BACKGROUND: Neonatal encephalopathy (NE) continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of a malpractice insurance patient safety organization. A NE registry was also established to include 14 centers representing around 50% of deliveries in the state of Massachusetts. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects. METHODS: This manuscript reports on the establishment of the registry and the primary findings to date. RESULTS: From 2018 to 2020, 502 newborns with NE were evaluated for Therapeutic Hypothermia (TH), of which 246 (49%) received TH, representing a mean of 2.91 per 1000 live births. The study reports on prenatal characteristics, delivery room resuscitation, TH eligibility screening, and post-natal management of newborns with NE who did and did not receive TH. CONCLUSIONS: The registry has allowed for the identification of areas of variation in clinical practices, which have guided ongoing quality improvement projects. The authors advocate for the establishment of local and regional registries to standardize and improve NE patient care. They have made the registry data collection tools freely available for other centers to replicate this work. IMPACT: Malpractice insurance companies can take an active role in supporting clinicians in establishing clinical practice guidelines and regional registries. Establishing a collaborative regional neonatal encephalopathy (NE) registry is feasible. Data Collection tools for a NE registry have been made publicly available to be adopted and replicated by other groups. Establishing a regional NE registry allowed for the identification of gaps in knowledge, variations in practice, and the opportunity to advance care through quality improvement projects.

Assessing the impact of hospital mergers and acquisitions on safety culture with proactive risk assessments.

Hospitals seeking to understand patient safety strengths and vulnerabilities in the context of mergers/acquisitions benefit more from a third-party perspective than from a limited internal process. A well-structured and highly-inclusive risk assessment-involving a broad cross-section of interviews-can be key to a successful transition of optimal health care safety during organizational changes.

Experimental oral delivery of the systemic acaricide moxidectin to free-ranging white-tailed deer (Artiodactyla: Cervidae) parasitized by Amblyomma americanum (Ixodida: Ixodidae).

Orally delivered, host-targeted, systemic acaricide treatment has potential to be an effective areawide tick abatement strategy. Past efforts using ivermectin for livestock were reported effective at controlling both Amblyomma americanum (L.) and Ixodes scapularis Say on Odocoileus virginianus (Zimmermann). However, the labeled 48-day withdrawal period for human consumption largely prevented utilization of this strategy targeting I. scapularis in autumn, when peak adult host-seeking activity coincides with regulated white-tailed deer hunting seasons. The modern-day compound moxidectin is the active ingredient in the pour-on formulation Cydectin (5 mg moxidectin/ml; Bayer Healthcare LLC), with a labeled 0-day withdrawal period for human consumption of treated cattle. We sought to re-examine the systemic acaricide approach for tick management by determining if we could successfully deliver Cydectin to free-ranging white-tailed deer. Over 2 yr in late spring/early summer, coinciding with adult and nymphal A. americanum activity, we fed Cydectin-coated corn to free-ranging white-tailed deer in coastal Connecticut. Through serum analysis, we documented moxidectin levels at or above those previously reported effective for control of ectoparasites (5-8 ppb for moxidectin and ivermectin) in 24 of 29 white-tailed deer captured (83%) while exposed to treated corn. While we did not document differences in burdens of parasitizing A. americanum based on moxidectin sera levels, we did document fewer engorged specimens on deer with increased sera levels. The systemic use of moxidectin for tick management in critical reproductive hosts has the potential to be effective in an areawide capacity while also permitting human consumption of treated venison.

The Patient Safety Adoption Framework: A Practical Framework to Bridge the Know-Do Gap.

OBJECTIVES: Many patient safety initiatives fail to be adopted and implemented, even when proven effective. This creates the well-recognized know-do gap, referring to the discrepancy between what healthcare workers know should be done based on evidence and what takes place in practice. We aimed to develop a framework to improve the adoption and implementation of patient safety initiatives. METHODS: We conducted a background literature review followed by qualitative interviews with patient safety leaders to identify barriers and facilitators to adoption and implementation. Inductive thematic analysis was used to generate themes that informed the development of the framework. We used a consensus-building approach to co-create the framework and guidance tool with an Ad Hoc Committee made up of subject-matter experts and patient family advisors. The framework was tested for utility, feasibility, and acceptability through qualitative interviews. RESULTS: The Patient Safety Adoption Framework contains 5 domains and 6 subdomains. The domains are leadership (subdomains: prioritization, accountability, governance), culture and context, process (subdomains: co-creation, high reliability, engagement), meaningful measurement, and person-centeredness. A guidance tool was developed to provide practical guidance for improvement teams using the framework. Testing affirmed the framework and guidance tool with a high degree of acceptability, feasibility, and utility among implementers and subject-matter experts. CONCLUSIONS: The Patient Safety Adoption Framework provides the essential components necessary to facilitate the adoption and implementation of patient safety initiatives. The framework offers a roadmap for healthcare organizations striving to close the know-do gap.

SARS-CoV-2 Omicron (B.1.1.529) Infection of Wild White-Tailed Deer in New York City.

There is mounting evidence of SARS-CoV-2 spillover from humans into many domestic, companion, and wild animal species. Research indicates that humans have infected white-tailed deer, and that deer-to-deer transmission has occurred, indicating that deer could be a wildlife reservoir and a source of novel SARS-CoV-2 variants. We examined the hypothesis that the Omicron variant is actively and asymptomatically infecting the free-ranging deer of New York City. Between December 2021 and February 2022, 155 deer on Staten Island, New York, were anesthetized and examined for gross abnormalities and illnesses. Paired nasopharyngeal swabs and blood samples were collected and analyzed for the presence of SARS-CoV-2 RNA and antibodies. Of 135 serum samples, 19 (14.1%) indicated SARS-CoV-2 exposure, and 11 reacted most strongly to the wild-type B.1 lineage. Of the 71 swabs, 8 were positive for SARS-CoV-2 RNA (4 Omicron and 4 Delta). Two of the animals had active infections and robust neutralizing antibodies, revealing evidence of reinfection or early seroconversion in deer. Variants of concern continue to circulate among and may reinfect US deer populations, and establish enzootic transmission cycles in the wild: this warrants a coordinated One Health response, to proactively surveil, identify, and curtail variants of concern before they can spill back into humans.

Detection of SARS-CoV-2 Omicron variant (B.1.1.529) infection of white-tailed deer.

White-tailed deer ( Odocoileus virginianus ) are highly susceptible to infection by SARS-CoV-2, with multiple reports of widespread spillover of virus from humans to free-living deer. While the recently emerged SARS-CoV-2 B.1.1.529 Omicron variant of concern (VoC) has been shown to be notably more transmissible amongst humans, its ability to cause infection and spillover to non-human animals remains a challenge of concern. We found that 19 of the 131 (14.5%; 95% CI: 0.10-0.22) white-tailed deer opportunistically sampled on Staten Island, New York, between December 12, 2021, and January 31, 2022, were positive for SARS-CoV-2 specific serum antibodies using a surrogate virus neutralization assay, indicating prior exposure. The results also revealed strong evidence of age-dependence in antibody prevalence. A significantly (χ 2 , p < 0.001) greater proportion of yearling deer possessed neutralizing antibodies as compared with fawns (OR=12.7; 95% CI 4-37.5). Importantly, SARS-CoV-2 nucleic acid was detected in nasal swabs from seven of 68 (10.29%; 95% CI: 0.0-0.20) of the sampled deer, and whole-genome sequencing identified the SARS-CoV-2 Omicron VoC (B.1.1.529) is circulating amongst the white-tailed deer on Staten Island. Phylogenetic analyses revealed the deer Omicron sequences clustered closely with other, recently reported Omicron sequences recovered from infected humans in New York City and elsewhere, consistent with human to deer spillover. Interestingly, one individual deer was positive for viral RNA and had a high level of neutralizing antibodies, suggesting either rapid serological conversion during an ongoing infection or a "breakthrough" infection in a previously exposed animal. Together, our findings show that the SARS-CoV-2 B.1.1.529 Omicron VoC can infect white-tailed deer and highlights an urgent need for comprehensive surveillance of susceptible animal species to identify ecological transmission networks and better assess the potential risks of spillback to humans. KEY FINDINGS: These studies provide strong evidence of infection of free-living white-tailed deer with the SARS-CoV-2 B.1.1.529 Omicron variant of concern on Staten Island, New York, and highlight an urgent need for investigations on human-to-animal-to-human spillovers/spillbacks as well as on better defining the expanding host-range of SARS-CoV-2 in non-human animals and the environment.

Patient Engagement Activities and Patient Experience: Are Patients With a History of Depression the Canary in the Coal Mine?

Little is known about the effectiveness of primary care practices' efforts to engage patients in their health and health care. We examine the association between patient engagement efforts and patients' experiences of care. We found no association between an unweighted count of patient engagement activities and patient experience. Compared with the bottom quartile of practices, however, the top quartile had better performance on patient experience domains of communication, front-office staff, and organizational access (out of nine domains). Furthermore, patients reporting a diagnosis of depression have higher ratings across five domains of patient experience when in practices with higher levels of patient engagement activities measured using an unweighted scale. Future research is needed to understand how the benefits of patient engagement activities can accrue to more patient subgroups. These promising results suggest that payers and policy makers should continue to support implementation and benchmarking of patient engagement efforts across practices.

Red oak seedlings as indicators of deer browse pressure: Gauging the outcome of different white-tailed deer management approaches.

After decades of high deer populations, North American forests have lost much of their previous biodiversity. Any landscape-level recovery requires substantial reductions in deer herds, but modern societies and wildlife management agencies appear unable to devise appropriate solutions to this chronic ecological and human health crisis. We evaluated the effectiveness of fertility control and hunting in reducing deer impacts at Cornell University. We estimated spring deer populations and planted Quercus rubra seedlings to assess deer browse pressure, rodent attack, and other factors compromising seedling performance. Oak seedlings protected in cages grew well, but deer annually browsed ≥60% of unprotected seedlings. Despite female sterilization rates of >90%, the deer population remained stable. Neither sterilization nor recreational hunting reduced deer browse rates and neither appears able to achieve reductions in deer populations or their impacts. We eliminated deer sterilization and recreational hunting in a core management area in favor of allowing volunteer archers to shoot deer over bait, including at night. This resulted in a substantial reduction in the deer population and a linear decline in browse rates as a function of spring deer abundance. Public trust stewardship of North American landscapes will require a fundamental overhaul in deer management to provide for a brighter future, and oak seedlings may be a promising metric to assess success. These changes will require intense public debate and may require new approaches such as regulated commercial hunting, natural dispersal, or intentional release of important deer predators (e.g., wolves and mountain lions). Such drastic changes in deer management will be highly controversial, and at present, likely difficult to implement in North America. However, the future of our forest ecosystems and their associated biodiversity will depend on evidence to guide change in landscape management and stewardship.

Role of Patient Safety Organizations in Improving Patient Safety.

Research into the incidence of harm and death resulting from medical error has continued after the release of "To Err Is Human." Although debate of the incidence of harm from medical errors continues, patient safety experts agree that medical errors still occur at considerable and unacceptable rates. Continued attention and examination of medical errors are required. Patient Safety Organizations are a federal program that enables providers across the health care delivery system to analyze and learn from errors with the protection of privilege and confidentiality.

Seasonal home ranges and habitat selection of three elk (Cervus elaphus) herds in North Dakota.

Changes in land use have resulted in range shifts of many wildlife species, including those entering novel environments, resulting in the critical need to understand their spatial ecology to inform ecosystem effects and management decisions. Dispersing elk (Cervus elaphus) were colonizing areas of suitable habitat in the Northern Great Plains, USA, resulting in crop depredation complaints in these areas. Although state resource managers had little information on these elk herds, limited evidence suggested temporal movements into Canada. We collected and analyzed essential information on home range and habitat selection for 3 elk herds residing in North Dakota. We captured 5 adult female elk in each study area, affixed global positioning system collars, and monitored them for 1 year (2016-2017). We estimated diel period, seasonal, and hunting season home ranges using Brownian Bridge Movement Models for each individual. We analyzed habitat selection using multinomial logit models to test for differences in use of land classes, and for departures from proportionate use based on random sampling; our predictor variables included individual elk, diel period, and season. Home ranges differed between the 3 herds, seasons, and diel period; gun and winter season home ranges were both larger than in summer, as was night when compared with day. Female elk generally restricted themselves to cover during the day and entered open areas at night and during winter months. Our results also suggest that elk in our study areas tended to seek more cover, and in the case of our Turtle Mountain study area, some cross into Canada during gun season. Our study provides a better understanding of the spatial ecology of elk in the Northern Great Plains while highlighting the need for enhanced international cooperative management efforts.

Partnering With a Medical Malpractice Insurer to Improve Patient Safety and Decrease Risk.

Implementing evolving science into clinical practice remains challenging. Assimilating new scientific evidence into clinical protocols and best practice recommendations, in a timely manner, can be difficult. In this article, we examine the value of partnering with a captive medical malpractice insurance company and its Patient Safety Organization to use data and convening opportunities to build upon the principles of implementation science and foster efficient and widespread adoption of the most current evidence-based interventions. Analyses of medical malpractice and root-cause analysis data set the context for this partnership and acted as a catalyst for creating best practice guidelines for adopting therapeutic hypothermia in the treatment of neonatal encephalopathy. What follows is a powerful example of successfully leveraging the collective wisdom of healthcare providers across specialties and institutional lines to move patient safety forward while managing risk.

Biochemical variables in free-ranging white-tailed deer (Odocoileus virginianus) after chemical immobilization in clover traps or via ground-darting.

The objective of this prospective observational cohort study in free-ranging female white-tailed deer (Odocoileus virginianus) was to compare the physiologic effects of two methods of anesthetic drug administration: hand-injection in Clover traps and remote injection by dart after ground-stalking. Six trapped and 14 darted female deer were injected with a median (minimum, maximum) of 590 microg/kg butorphanol (401, 1070 microg/kg), plus 235 microg/kg medetomidine (160, 429 microg/kg) intramuscularly. In the trap, the deer struggled when approached and were restrained for injection. Darted deer sprinted away after injection. Once immobilized, deer were transported to a veterinary hospital where blood was collected and vital signs were measured on admission. Admission data from a subset of deer in which measurements were taken within 40 min of trapping (n = 6) or darting (n = 5) were analyzed. After salpingectomy under isoflurane and while still anesthetized, another blood sample was collected from all 20 deer. Body weight and immobilization drug doses were not different between groups. On admission, most deer from both groups were hypoxemic, although the darted deer were significantly more hypoxemic. The median rectal temperature in trapped deer was higher than in darted deer, and temperatures higher than 39 degrees C only occurred in trapped deer. The median heart rate in trapped deer was more than twice that in darted deer. Trapped deer had lower median pH and base excess; in trapped deer, the median plasma lactate concentration was more than fivefold higher than in darted deer. After surgery, the median serum creatine kinase concentration was nearly 10-fold higher in trapped deer, and the median cardiac troponin I concentration was higher in trapped deer but undetectable in 10 of 14 darted deer. The white-tailed deer immobilized by hand-injection in Clover traps experienced more severe physiologic perturbations than deer remotely injected by dart after ground-stalking. These perturbations might be sufficient to cause myocardial damage.

Comparison of suburban vaccine distribution strategies to control raccoon rabies.

Helicopters and hand baiting are commonly used to distribute vaccine-laden baits to help control raccoon (Procyon lotor) rabies in suburban landscapes, but these techniques may be labor intensive, costly, or unavailable in some areas. We tested conventional baiting strategies against polyvinyl-chloride (PVC) bait stations in Erie County (New York, USA) during July and August 2003-05. Hand, helicopter, and bait station treatments were randomly assigned to six 25-km(2) suburban study sites. To estimate the proportion of raccoons that ingested baits, tooth and blood samples from 954 raccoons were collected and examined for tetracycline biomarker and rabies-neutralizing antibodies, respectively. Overall, 38% (358/954) of the raccoons in Erie County tested positive for tetracycline; 16% (155/954) tested seropositive for rabies virus. Year of study significantly impacted biomarker prevalence; fewer raccoons tested positive for tetracycline in 2004. Probability of seropositivity increased with raccoon age. No statistically significant differences existed between baiting strategies and frequencies of biomarker and antibody-positive raccoons across all years combined. Thus, bait stations could be used as part of an integrated rabies control strategy.