Proficiency in identifying, managing and communicating medical errors: feasibility and validity study assessing two core competencies.

BACKGROUND: Communication skills and professionalism are two competencies in graduate medical education that are challenging to evaluate. We aimed to develop, test and validate a de novo instrument to evaluate these two competencies. METHODS: Using an Objective Standardized Clinical Examination (OSCE) based on a medication error scenario, we developed an assessment instrument that focuses on distinctive domains [context of discussion, communication and detection of error, management of error, empathy, use of electronic medical record (EMR) and electronic medical information resources (EMIR), and global rating]. The aim was to test feasibility, acceptability, and reliability of the method. RESULTS: Faculty and standardized patients (SPs) evaluated 56 trainees using the instrument. The inter-rater reliability of agreement between faculty was substantial (Fleiss k = 0.71) and intraclass correlation efficient was excellent (ICC = 0.80). The measured agreement between faculty and SPs evaluation of resident was lower (Fleiss k = 0.36). The instrument showed good conformity (ICC = 0.74). The majority of the trainees (75 %) had satisfactory or higher performance in all six assessed domains and 86 % found the OSCE to be realistic. Sixty percent reported not receiving feedback on EMR use and asked for subsequent training. CONCLUSION: An OSCE-based instrument using a medical error scenario can be used to assess competency in professionalism, communication, using EMRs and managing medical errors.

Applying quality improvement methods in a hyperbaric oxygen program: reducing unnecessary glucose testing.

OBJECTIVE: To describe the implementation of a quality improvement (QI) project that aimed at improving and standardizing glucose checks on patients with diabetes undergoing hyperbaric oxygen (HBO2) therapy. METHODS: This is a prospective cohort study. Following the Model for Improvement, nurses and physicians ran several Plan-Do-Study-Act (PDSA) cycles over a four-month period, with multiple iteration and testing changes. They developed and implemented a nurse-led protocol that was tested prospectively. RESULTS: Compared to the pre-protocol baseline (N = 332), glucose checks per session guided by the protocol decreased by 37.7% (2.84 vs. 1.77 per session, P⟨0.001). Compliance with the new protocol was higher than compliance with the existing protocol (97.3% to 84.2%, P⟨0.001). There were no cases of a symptomatic hypoglycemic event after the implementation of the protocol. CONCLUSIONS: A quality improvement project implemented by a multidisciplinary team in a hyperbaric practice was feasible and has improved the management of diabetic patients undergoing HBO2 therapy. Considering how the hyperbaric community values the culture of safety and considering the feasibility of this project, more QI training and projects in hyperbaric programs should be performed.

The incidence of hypoglycemia during HBO2 therapy: A retrospective review.

BACKGROUND: Hypoglycemia is concerning in patients with diabetes undergoing hyperbaric oxygen (HBO2) therapy. We aimed to estimate the incidence, risk factors and a pretreatment glucose threshold of HBO2-associated hypoglycemia. METHODS: We retrospectively evaluated a patient cohort undergoing HBO2 therapy. We calculated the area under the curve (AUC) and odds ratio (OR) with 95% confidence interval (CI) adjusting for patients' age, gender, diabetes type, insulin use, body mass index, hemoglobin A1c and HBO2 treatment time. RESULTS: During 77 months, 3,136 HBO2 sessions were performed on patients with diabetes. In-chamber glucose was higher than pre-HBO2 glucose in 1,708/3,136 sessions (54%). The incidence of hypoglycemia (defined as ≤ 70 mg/dL) during or immediately after HBO2 treatment was 1.5% (0.8-2.1%). Hypoglycemia that was symptomatic or severe was rare. A glucose value pre-HBO2 of 150 mg/dL best predicted the risk of subsequent hypoglycemia (AUC 0.80; 95% CI, 0.75-0.86). Type 1 diabetes was independently associated with increased risk of hypoglycemia (OR 3.69; 95% CI, 1.67, 8.19) whereas insulin use was not. CONCLUSIONS: In patients with diabetes undergoing HBO2, severe hypoglycemia is rare and occurs more frequently in Type 1 diabetes. Pre-HBO2 glucose values may be used to predict subsequent hypoglycemia and reduce the need for routine glucose monitoring during and after HBO2.

Is an occupational examination superior to an occupational health history alone for preplacement screening in health care settings?

OBJECTIVES: To determine whether preplacement recommendations following an occupationally focused medical history is different from those following an occupational consultation. METHODS: This was a retrospective cohort study of 172 applicants to our institution. RESULTS: Following provider review of occupational history survey alone, none of the applicants had restrictions recommended. In comparison, only 163 applicants (94.7%) were recommended to be hired without restrictions following provider review of the same patient's occupational history and examination (P = 0.0078). CONCLUSION: A well-designed questionnaire is useful for screening applicants for preplacement examinations and assures sufficient detail to allow for a large proportion of individuals to proceed to employment without an occupational examination. However, in this study, a small but statistically significant portion (5%) of applicants required occupational examinations for appropriate work recommendations.

Preemployment screening for tuberculosis in a large health care setting: comparison of the tuberculin skin test and a whole-blood interferon-γ release assay.

OBJECTIVE: Determine the performance of an interferon-γ release assay in a health care occupational surveillance program. METHODS: From January 11, 2005, through January 31, 2006, all new employees (n = 652) undergoing standard, preemployment evaluation at Mayo Clinic, Rochester, Minnesota were evaluated for tuberculosis using a standard process of symptom screening combined with tuberculin skin test (TST) and QuantiFERON-TB Gold test (QFT-G). RESULTS: Comparing the results of QFT-G directly to TST, QFT-G showed an overall agreement of 92.5%. CONCLUSIONS: False-positive TST were the most significant issue affecting agreement, and in a low-tuberculosis prevalence population, the need for an effective strategy offering low false-positive results may be best met by combining the TST with QFT-G.

Hyperbaric oxygen therapy for chronic refractory osteomyelitis of the sternum.

This report describes a 32-year-old woman with chronic refractory osteomyelitis of the sternum after multiple surgical procedures including a sternotomy with underlying colonic interposition that was successfully managed with hyperbaric oxygen therapy. The clinical course is reviewed, and the complexities of this diagnosis are then discussed, including a brief review of the mechanisms of management with hyperbaric oxygen therapy.

The prevention and treatment of pertussis.

Since 2004, more than 25,000 cases of pertussis have been reported in the United States each year. Symptoms in adults range from mild cough to severe persistent cough with posttussive emesis. The characteristic paroxysmal cough (whoop) may be absent, and the diagnosis is often missed, especially when the cough is mild. The most useful diagnostic test to confirm pertussis is a polymerase chain reaction assay of a nasopharyngeal swab sample. Patients are infectious for three weeks from the cough onset. Antibiotic treatment, preferably with macrolide antibiotics, is indicated during this time for pertussis treatment and prophylaxis. In 2005, two new acellular pertussis vaccines were licensed: one (Boostrix) for patients aged 10 to 18 years and another (Adacel) for patients aged 11 to 64 years.