Patient safety incident analysis in healthcare: a novel curricular session for medical students.

Patient safety incident analysis is a tool which allows for the identification of and learning from patient safety incidents, which are common in healthcare settings. The University of Toronto introduced a patient safety incident analysis session for graduating medical students in the form of a lecture and subsequent student presentations of incident analyses. Student respondents to evaluation rated the session highly and felt that feedback on their presentations was helpful to reinforce material. Medical schools can incorporate this innovative session as an interactive addition to quality improvement and patient safety curricula to provide students with hands-on experience in incident analysis.

L'analyse des incidents liés à la sécurité des patients permet de repérer et d'apprendre de tels incidents qui sont fréquents dans les établissements de santé. L'Université de Toronto a introduit une séance d'analyse des incidents liés à la sécurité des patients pour les étudiants en médecine en fin de cursus, sous la forme d'un cours magistral suivi de présentations d'analyses d'incidents par les étudiants. Les étudiants qui ont évalué la formation ont rapporté un haut taux de satisfaction par rapport à la séance et ont trouvé que les commentaires reçus sur leurs présentations étaient utiles pour mieux assimiler le contenu du cours. Les facultés de médecine peuvent intégrer cette formation innovante et interactive comme complément aux programmes d'amélioration de la qualité et à ceux axés sur la sécurité des patients afin de fournir aux étudiants une expérience pratique en ce qui concerne l'analyse des incidents.

Adapting medical education during crisis: Student-Faculty partnerships as an enabler of success.

Restrictions imposed by the COVID-19 pandemic have required medical educators to reimagine almost every aspect of undergraduate medical training, including curriculum delivery and assessments in a short timeline. In this personal view article, executive members of the University of Toronto medical student government and Faculty leads of pre-clerkship and clerkship education highlight five practical ways in which a student-Faculty partnership enabled the rapid and smooth adaptation of curricula during the COVID-19 pandemic. These included involving students as partners in decision making to contribute learner perspectives early, agile and collaborative meeting structures, frequent and consistent communication with the student body, providing learners with Faculty perspectives from the frontlines, and striking a balance in the level of feedback collected from students. These strategies may be of utility to medical administrators, educators, and student leaders in future crises affecting medical learners.

How artificial intelligence can help us 'Choose Wisely'.

The overuse of low value medical tests and treatments drives costs and patient harm. Efforts to address overuse, such as Choosing Wisely campaigns, typically rely on passive implementation strategies- a form of low reliability system change. Embedding guidelines into clinical decision support (CDS) software is a higher leverage approach to provide ordering suggestions through an interface embedded within the clinical workflow. Growth in computing power is increasingly enabling artificial intelligence (AI) to augment such decision making tools. This article offers a roadmap of opportunities for AI-enabled CDS to reduce overuse, which are presented according to a patient's journey of care.

Medical education advances and innovations: A silver lining during the COVID-19 pandemic.

The COVID-19 pandemic has disrupted healthcare processes substantially including medical education, necessitating several changes along the spectrum of medical training. While this crisis presents major challenges to medical education, it is also an immense opportunity for innovation. In this commentary, Canadian medical students cast a spotlight on four domains of Canadian medical education which have seen substantial changes during the COVID-19 pandemic: medical school admissions, pre-clerkship content delivery, virtual care and telemedicine curricula, and the residency matching process. Using the 10 recommendations noted in the Association of Faculties of Medicine of Canada (AFMC) 2010 Future of Medical Education in Canada report as a guiding framework, we discuss why these changes represent key steps forward that should be preserved in medical education beyond the pandemic, and advocate for a continuous quality improvement approach to evaluate and implement these innovations.

La pandémie COVID-19 a considérablement perturbé les processus de soins de santé, y compris l'éducation médicale, ce qui a nécessité plusieurs changements dans le spectre de la formation médicale. Si cette crise pose des défis majeurs en éducation médicale, elle constitue également une immense opportunité d'innovation. Dans ce commentaire, les étudiants en médecine canadiens mettent en lumière quatre domaines de l'éducation médicale canadienne qui ont connu des changements substantiels durant la pandémie COVID-19 : les admissions dans les facultés de médecine, enseignement des cours au pré-externat, les cursus de soins virtuels et de télémédecine, et le processus de jumelage des résidents. En utilisant les 10 recommandations mentionnées dans le rapport 2010 sur l'avenir de l'enseignement médical au Canada de l'Association des facultés de médecine du Canada (AFMC) comme cadre d'orientation, nous expliquons pourquoi ces changements représentent des étapes clés qui devraient être préservées en éducation médicale au-delà de la pandémie, et nous préconisons une approche d'amélioration continue de la qualité pour évaluer et mettre en œuvre ces innovations.

Health Forums and Twitter for Dementia Research: Opportunities and Considerations.

BACKGROUND/OBJECTIVES: Social media platforms are promising sources for large quantities of participant-driven research data and circumvent some common challenges when conducting dementia research. This study provides a summary of key considerations and recommendations about using these platforms as research tools for dementia. DESIGN: Mixed methods. SETTING: Alzheimer's Society's online Dementia Talking Point forum from inception to April 17, 2018, and Twitter in February and March 2018. PARTICIPANTS: All users of Dementia Talking Point who posted in subforums labeled "I have dementia" and "I care for a person with dementia," and Twitter users whose posts contained the keywords "dementia," "Alzheimer," or "Alzheimer's." MEASUREMENTS: We quantified the average daily number of dementia-related posts on each platform and number of words per post. Guided by a codebook, we conducted thematic content analysis of 5% of the 15,513 posts collected from Dementia Talking Point, and 10% of the 25,948 comprehensible posts from Twitter containing "dementia," "Alzheimer," or "Alzheimer's." We also summarized research-relevant characteristics inherent to platforms and posts. RESULTS: On average, Dementia Talking Point provided less than two new daily dementia-related posts with 213.5 to 241.5 words, compared with 7,883 new daily Twitter posts with 14.5 words. Persons with dementia (PWDs) commonly shared dementia-related concerns (75.7%), experiences (68.6%), and requests for, as well as offers of, information and support (44.3% and 38.6%, respectively). Caregivers commonly shared caregiving experience (67.0%) and requests for information and support (52.5%). Most common dementia-related Twitter posts were derogatory use of the term dementia (14.5%), advocacy, fundraising, and awareness (11.6%), and research dissemination (8.0%). Recommendations about these platforms' unique technical and ethical considerations are outlined. CONCLUSIONS: Understanding the priorities of PWDs and their caregivers remains important to understand how clinicians can best support them. This study will help clinicians and researcher to better leverage online health forums and Twitter for such dementia-related information.

Proton Pump Inhibitors in the Elderly Hospitalized Patient: Evaluating Appropriate Use and Deprescribing.

Background: Proton pump inhibitors (PPIs) are often prescribed for elderly patients without appropriate indication, or for longer durations than recommended. Objective: To review appropriateness of PPI use prior to and in hospital, and deprescribing rates across different hospital units. Methods: Retrospective analysis of patients ≥65 years admitted to 5 acute care units: intensive care unit, acute care for elderly, orthopedics, surgery, and medicine. Patients who were "non-naive" (prehospital PPI use) or "naive" (new PPI initiated in hospital) users were included. For both groups, demographics, reason for admission, length of stay, comorbidities, name and number of home medications, PPI name, dose and indication, and PPI discharge instructions were collected. For naive patients, duration of in-hospital use and prescriber specialty was recorded. Results: Among non-naive patients (n = 377), for 37 patients (10%), the indication for a PPI was not appropriate, and for 92 patients (24%), the indication was unclear. Most patients had their home PPI continued while in hospital (87%) and at discharge (90%). Among naive (n = 93) patients, for 8 patients (9%), the indication for a PPI was not appropriate, and for 25 (27%) patients, the indication was unclear. PPI was prescribed to only 16 (18%) by the gastrointestinal consult service. Most patients had their new PPI continued at discharge (74%); only 7 (9%) were discharged with a plan to reassess PPI indication. Conclusion: PPIs are infrequently deprescribed during hospital admission, despite inappropriate or unclear indications for use. Thorough medication reconciliation, documentation of PPI indication and duration, and institutional focus on deprescribing are encouraged.

What Is Known About Preventing, Detecting, and Reversing Prescribing Cascades: A Scoping Review.

OBJECTIVES: To systematically describe the resources available on preventing, detecting, and reversing prescribing cascades using a scoping review methodology. MEASUREMENTS: We searched Medline, EMBASE, PsychINFO, CINAHL, Cochrane Library, and Sociological Abstracts from inception until July 2017. Other searches (Google Scholar, hand searches) and expert consultations were performed for resources examining how to prevent, detect, or reverse prescribing cascades. We used these three categories along the prescribing continuum as an organizing framework to categorize and synthesize resources. RESULTS: Of 369 resources identified, 58 met inclusion criteria; 29 of these were categorized as preventing, 20 as detecting, and 9 as reversing prescribing cascades. Resources originated from 14 countries and mostly focused on older adults. The goal of preventing resources was to educate and increase general awareness of the concept of prescribing cascades as a way to prevent inappropriate prescribing and to illustrate application of the concept to specific drugs (e.g., anticholinergics) and conditions (e.g., inflammatory bowel disease). Detecting resources included original investigations or case reports that identified prescribing cascades using health administrative data, patient cohorts, and novel sources such as social media. Reversing prescribing cascade resources focused on the medication review process and deprescribing initiatives. CONCLUSION: Prescribing cascades are a recognized problem internationally. By learning from the range of resources to prevent, detect, and reverse prescribing cascades, this review contributes to improving drug prescribing, especially in older adults. J Am Geriatr Soc 66:2079-2085, 2018.

Systematic Review of Sex-Specific Reporting of Data: Cholinesterase Inhibitor Example.

OBJECTIVES: To improve the value of research for older adults, we examine sex-specific reporting of data from drug trials for the management of dementia. These data are important because they may influence considerations ranging from the health of populations to shared decision-making by individual patient and caregiver about the risk and benefit of a drug therapy. METHODS: Randomized controlled trials of cholinesterase inhibitors (i.e., donepezil, rivastigmine, or galantamine) with clinical outcomes were identified from searches of MEDLINE, EMBASE, and the Cochrane Library. Sex-specific data were extracted from nine sections (title, abstract, introduction, methods, outcomes, results, discussion, limitations, and conclusion). Among the donepezil trials only, more detailed harms data were obtained. FINDINGS: Thirty-three randomized controlled trials were identified evaluating 15,971 participants (9,103 (57%) female). Trials were highly cited (median citations 158, interquartile range 62-441) and published in high impact journals (median impact factor 7.4, interquartile range 3.4-8.2). Sex was not mentioned in the title, introduction, limitations, or conclusion section of any trial. Only three trials (9%) mentioned sex in the abstract (all as a demographic characteristic), and 8 (24%) in the methods. Almost all (32 (97%)) trials mentioned sex in the results as a demographic variable. One trial reported a sex difference for a secondary outcome. Among the 16 trials studying donepezil, adverse events were frequently reported and often dose-related. No trial provided sex-specific reporting of adverse events. CONCLUSIONS: There is an almost complete lack of sex-specific reporting of data in clinical trials for dementia drug therapies, and no sex-specific reporting of adverse events. Sex-specific reporting of data should be required in drug trials to increase research value and ultimately inform more tailored prescribing for older adults.