Creating Patient Safety Team Members Through a Simulation-Based Interprofessional Root Cause Analysis Course.

Background: The Accreditation Council for Graduate Medical Education Common Program Requirements require residents to participate in real or simulated interprofessional patient safety activities. Root cause analysis (RCA) is widely used to respond to patient safety events; however, residents may lack knowledge about the process. Objective: To improve clinicians' knowledge of the tools used to conduct an RCA and the science behind them, and to describe this course and discuss outcomes and feasibility. Methods: A flipped classroom approach was used. Participants completed 5 hours of pre-course work then attended an 8.5-hour program including didactic sessions and small group, facilitator-led RCA simulations. Pre- and post-surveys, as well as a 10-month follow-up on knowledge of and comfort with the RCA process were compared. Statistical significance was evaluated for matched pairs using a repeated measures analysis of variance. Results: Of 162 participants trained, 59 were residents/fellows from 23 graduate medical education programs. Response rates were 96.9% (157 of 162) for pre-course, 92.6% (150 of 162) for post-course, and 81.5% (132 of 162) for 10-month follow-up survey. Most participants had never participated in an RCA (57%, 89 of 157) and had no prior training (87%, 136 of 157). Following the course, participants reported improved confidence in their ability to interview and participate in an RCA (P<.001, 95% CI 4.4-4.6). This persisted 10 months later (P<.001, 95% CI 4.2-4.4), most prominently among residents/fellows who had the highest rate (38.9%, 23 of 59) of participation in real-world RCAs following the training. Conclusions: The course led to a sustained improvement in confidence participating in RCAs, especially among residents and fellows.

A Standard Set of Value-Based Patient-Centered Outcomes and Measures of Overall Health in Adults.

BACKGROUND: The definition of population-specific outcomes is an essential precondition for the implementation of value-based health care. We developed a minimum standard outcome set for overall adult health (OAH) to facilitate the implementation of value-based health care in tracking, comparing, and improving overall health care outcomes of adults across multiple conditions, which would be of particular relevance for primary care and public health populations. METHODS: The International Consortium for Health Outcomes Measurement (ICHOM) convened an international panel (patients, clinicians, and topic experts). Following the development of a conceptual framework, a modified Delphi method (supported by public consultations) was implemented to identify, in sequence, the relevant domains, the best instruments for measuring them, the timing of measurement, and the relevant adjustment variables. FINDINGS: Outcomes were identified in relation to overall health status and the domains of physical, mental, and social health. Three instruments covering these domains were identified: PROMIS Scale v1.2-Global Health (10 items), WHO Wellbeing Index (5 items), and the WHO Disability Assessment Schedule 2.0 (12 items). Case-mix variables included a range of sociodemographic and biometric measures. Yearly measurement was proposed for all outcomes and most case-mix variables. INTERPRETATION: The ICHOM OAH Standard Set has been developed through consensus-based methods based on predefined criteria following high standards for the identification and selection of high-quality measures The involvements of a wide range of stakeholders supports the acceptability of the set, which is readily available for use and feasibility testing in clinical settings.

Expanding Virtual Health Capabilities Into Trainee Health.

Virtual health and secure messaging gained newfound relevance in medicine during the coronavirus disease (COVID)-19 pandemic. For a military trainee health care clinic located on Joint Base San Antonio, the McWethy Troop Medical Clinic (TMC), implementation of virtual health and secure messaging services meant decreased risk of COVID-19 exposure for trainees and clinical staff. Through ongoing utilization, these services also made impacts to reduce loss of instruction time and improve access to care for the McWethy TMC trainee population. In defining the challenges, successes, and future implications for virtual health and secure messaging at the McWethy TMC, key lessons emerge for other military trainee clinics. The key concepts explored in this article are virtual health and secure messaging.

Development of an international standard set of patient-centred outcome measures for overall paediatric health: a consensus process.

OBJECTIVE: To develop an Overall Pediatric Health Standard Set (OPH-SS) of outcome measures that captures what matters to young people and their families and recognising the biopsychosocial aspects of health for all children and adolescents regardless of health condition. DESIGN: A modified Delphi process. SETTING: The International Consortium for Health Outcomes Measurement convened an international Working Group (WG) comprised of 23 international experts from 12 countries in the field of paediatrics, family medicine, psychometrics as well as patient advisors. The WG participated in 11 video-conferences, through a modified Delphi process and 9 surveys between March 2018 and January 2020 consensus was reached on a final recommended health outcome standard set. By a literature review conducted in March 2018, 1136 articles were screened for clinician and patient-reported or proxy-reported outcomes. Further, 4315 clinical trials and 12 paediatric health surveys were scanned. Between November 2019 and January 2020, the final standard set was endorsed by a patient validation (n=270) and a health professional (n=51) survey. RESULTS: From a total of 63 identified outcomes, consensus was formed on a standard set of outcome measures that comprises 10 patient-reported outcomes, 5 clinician-reported measures, and 6 case-mix variables. The four developmental age-specific packages (ie, 0-5, 6-12, 13-17, 18-24 years) include either five or six measures with an average time for completion of 20 min. CONCLUSIONS: The OPH-SS is a starting point to drive value-based paediatric healthcare delivery from a global perspective for enhancing child and adolescent physical health and psychosocial well-being.

Adopting RCA2: The Interrater Reliability of Safety Assessment Codes.

Safety assessment codes (SACs) are one method to evaluate adverse events and determine the need for a root cause analysis. Few facilities currently use SACs, and there is no literature examining their interrater reliability. Two independent raters assigned frequency, actual harm, and potential harm ratings to a sample of patient safety reports. An actual and potential SAC were determined. Percent agreement and Cohen's κ were calculated. Substantial agreement existed for the actual SAC (κ = 0.626, P < .001), fair agreement for the potential SAC (κ = 0.266, P < .001), and low agreement for potential harm (κ = 0.171, P = .002). Although there is subjectivity in all aspects of assigning SACs, the greatest is in potential severity. This presents a problem when using the potential SAC and is in agreement with previous literature showing significant subjectivity in determining potential harm. An operational framework is needed to strengthen reliability.

Acute Coronary Syndrome: Current Treatment.

Acute coronary syndrome continues to be a significant cause of morbidity and mortality in the United States. Family physicians need to identify and mitigate risk factors early, as well as recognize and respond to acute coronary syndrome events quickly in any clinical setting. Diagnosis can be made based on patient history, symptoms, electrocardiography findings, and cardiac biomarkers, which delineate between ST elevation myocardial infarction and non-ST elevation acute coronary syndrome. Rapid reperfusion with primary percutaneous coronary intervention is the goal with either clinical presentation. Coupled with appropriate medical management, percutaneous coronary intervention can improve short- and long-term outcomes following myocardial infarction. If percutaneous coronary intervention cannot be performed rapidly, patients with ST elevation myocardial infarction can be treated with fibrinolytic therapy. Fibrinolysis is not recommended in patients with non-ST elevation acute coronary syndrome; therefore, these patients should be treated with medical management if they are at low risk of coronary events or if percutaneous coronary intervention cannot be performed. Post-myocardial infarction care should be closely coordinated with the patient's cardiologist and based on a comprehensive secondary prevention strategy to prevent recurrence, morbidity, and mortality.

Leveraging Health Information Technology to Improve Quality in Federal Healthcare.

PURPOSE: Healthcare delivery in America is extremely complex because it is comprised of a fragmented and nonsystematic mix of stakeholders, components, and processes. Within the US healthcare structure, the federal healthcare system is poised to lead American medicine in leveraging health information technology to improve the quality of healthcare. We posit that through developing, adopting, and refining health information technology, the federal healthcare system has the potential to transform federal healthcare quality by managing the complexities associated with healthcare delivery. Although federal mandates have spurred the widespread use of electronic health records, other beneficial technologies have yet to be adopted in federal healthcare settings. The use of health information technology is fundamental in providing the highest quality, safest healthcare possible. In addition, health information technology is valuable in achieving the Agency for Healthcare Research and Quality's implementation goals. METHODS: We conducted a comprehensive literature search using the Google Scholar, PubMed, and Cochrane databases to identify an initial list of articles. Through a thorough review of the titles and abstracts, we identified 42 articles as having relevance to health information technology and quality. Through our exclusion criteria of currency of the article, citation frequency, applicability to the federal health system, and quality of research supporting conclusions, we refined the list to 11 references from which we performed our analysis. RESULTS: The literature shows that the use of computerized physician order entry has significantly increased accurate medication dosage and decreased medication errors. The use of clinical decision support systems have significantly increased physician adherence to guidelines, although there is little evidence that indicates any significant correlation to patient outcomes. Research shows that interoperability and usability are continuing challenges for implementation. COMMENT: The Veterans Administration is the only entity within the federal health system that has published research on the use of health information technology to improve quality. The federal healthcare system has existing systems in place with computerized physician order entry systems and clinical decision support systems, but these should be advanced. CONCLUSION: Particular focus and attention should be placed on data mining capabilities, integrating the electronic health record across all aspects of care, using the electronic health record to improve quality at the point of care, and developing interoperable and usable health information technology.

Diagnosis and Management of Foodborne Illness.

The Centers for Disease Control and Prevention estimates that each year, one in six Americans will experience a foodborne illness. The most common causes in the United States are viruses, such as norovirus; bacteria, such as Salmonella, Escherichia coli, Campylobacter, and Listeria; and parasites, such as Toxoplasma gondii and Giardia. Resources are available to educate consumers on food recalls and proper handling, storage, and cooking of foods. Diagnosis and management of a foodborne illness are based on the history and physical examination. Common symptoms of foodborne illnesses include vomiting, diarrhea (with or without blood), fever, abdominal cramping, headache, dehydration, myalgia, and arthralgias. Definitive diagnosis can be made only through stool culture or more advanced laboratory testing. However, these results should not delay empiric treatment if a foodborne illness is suspected. Empiric treatment should focus on symptom management, rehydration if the patient is clinically dehydrated, and antibiotic therapy. Foodborne illnesses should be reported to local and state health agencies; reporting requirements vary among states.