Emotional Harm in the Radiology Department: Analysis of an Underrecognized Preventable Error.

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.

The Practice of Respect in the ICU.

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Development of a framework to describe patient and family harm from disrespect and promote improvements in quality and safety: a scoping review.

PURPOSE: Patients and families may experience 'non-physical' harm from interactions with the healthcare system, including emotional, psychological, socio-behavioral or financial harm, some of which may be related to experiences of disrespect. We sought to use the current literature to develop a practical, improvement-oriented framework to recognize, describe and help prevent such events. DATA SOURCES: Searches were performed in PubMed, Embase, PsychINFO, CINAHL, Health Business Elite and ProQuest Dissertations & Theses: Global: Health & Medicine, from their inception through July 2017. STUDY SELECTION: Two authors reviewed titles, abstracts, full texts, references and cited-by lists to identify articles describing approaches to understanding patient/family experiences of disrespect. DATA EXTRACTION: Findings were evaluated using integrative review methodology. RESULTS OF DATA SYNTHESIS: Three-thousand eight hundred and eighty two abstracts were reviewed. Twenty three articles were identified. Components of experiences of disrespect included: (1) numerous care processes; (2) a wide range of healthcare professional and organizational behaviors; (3) contributing factors, including patient- and professional-related factors, the environment of work and care, leadership, policies, processes and culture; (4) important consequences of disrespect, including behavioral changes and health impacts on patients and families, negative effects on professionals' subsequent interactions, and patient attrition from organizations and (5) factors both intrinsic and extrinsic to patients that can modify the consequences of disrespect. CONCLUSION: A generalizable framework for understanding disrespect experienced by patients/families in healthcare may help organizations better prevent non-physical harms. Future work should prospectively test and refine the framework we described so as to facilitate its integration into organizations' existing operational systems.

Surveying Care Teams after in-Hospital Deaths to Identify Preventable Harm and Opportunities to Improve Advance Care Planning.

BACKGROUND: Reviewing in-hospital deaths is one way of learning how to improve the quality and safety of care. Postdeath surveys sent to the care team for patients who died may have a role in identifying opportunities for improvement. As part of a quality improvement initiative, a postdeath care team survey was developed to explore how it might augment the existing process for learning from deaths. METHODS: A survey was sent to the care team for all inpatient deaths on the hospital medicine and medical ICU services at one institution. Survey responses were reviewed to identify cases that required further investigation. An iterative process of inductive coding was used to create a coding taxonomy to classify survey response free-text comments. RESULTS: During the distribution period (September 25, 2015-December 28, 2015), 82 patients died, and 191 care team members were surveyed. Responses (138; 72.3% response rate) were collected through January 28, 2016. Based on the survey responses, 5 patients (6.1%) not identified by other review processes were investigated further, resulting in the identification of several important opportunities for improvement. The free-text comment analysis revealed themes around the importance of advance care planning in seriously ill patients, as well as evidence of the emotional and psychological strain on clinicians who care for patients who die. CONCLUSION: Postdeath care team surveys can augment mortality review processes to improve the way hospitals learn from deaths. Free-text comments on such surveys provide information not otherwise identified during traditional mortality review processes, including the importance of advance care planning and the strain on clinicians whose patients die.

A Road Map for Advancing the Practice of Respect in Health Care: The Results of an Interdisciplinary Modified Delphi Consensus Study.

BACKGROUND: Most health care organizations' efforts to reduce harm focus on physical harm, but other forms of harm are both prevalent and important. These "nonphysical" harms can be framed using the concepts of respect and dignity: Disrespect is an affront to dignity and can cause harm. Organizations should strive to eliminate disrespect to patients, to families, and among health care professionals. METHODS: A diverse, interdisciplinary panel of experts was convened to discuss strategies to guide health care systems to embrace an expanded definition of patient harm that includes nonphysical harm. Subsequently, using a modified Delphi process, a guide was developed for health care professionals and organizations to improve the practice of respect across the continuum of care. RESULTS: Five rounds of surveys were required to reach predefined metrics of consensus. Delphi participants identified a total of 25 strategies associated with six high-level recommendations: "Leaders must champion a culture of respect and dignity"; with other professionals sharing the responsibility to "Promote accountability"; "Engage and support the health care workforce"; "Partner with patients and families"; "Establish systems to learn about and improve the practice of respect"; and "Expand the research agenda and measurement tools, and disseminate what is learned." CONCLUSION: Harm from disrespect is the next frontier in preventable harm. This consensus statement provides a road map for health care organizations and professionals interested in engaging in a reliable practice of respect. Further work is needed to develop the specific tactics that will lead health care organizations to prevent harm from disrespect.

Associations Between Organizational Communication and Patients' Experience of Prolonged Emotional Impact Following Medical Errors.

BACKGROUND: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood. METHODS: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year). Based on their reported experience with communication about the error, patients' experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact (> 1 month, > 1 year). RESULTS: Of all survey respondents, 17.8% (451/2,536) reported an error occurring ≥ 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5-2.9]); low socioeconomic status (SES; 1.7 [1.1-2.7]); physical impact (7.3 [4.3-12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03-2.3]); communication contrary to guidelines (4.0 [2.1-7.5]); and mixed communication (2.2 [1.3-3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2-2.5]; low SES, 2.2 [1.3-3.6]; physical impact, 6.8 [3.8-12.5]; no disclosure/reporting, 1.9 [1.2-3.2]; communication contrary to guidelines, 4.6 [2.2-9.4]; mixed communication, 2.1 [1.1-3.9]). CONCLUSION: Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.

Putting the "Action" in RCA2: An Analysis of Intervention Strength After Adverse Events.

BACKGROUND: Safety event reporting and review is well established within US hospitals, but systems to ensure implementation of changes to improve patient safety are less developed. METHODS: Contributing factors and corrective actions for events brought to a tertiary care academic medical center's multidisciplinary hospital-level safety event review meeting were prospectively collected from 2020 to 2021. Corrective actions were tracked to completion through 2023. The authors retrospectively coded corrective actions by category and strength using the US Department of Veterans Affairs/Institute for Healthcare Improvement Action Hierarchy Tool. RESULTS: In the analysis of 67 events, 15 contributing factor themes were identified and resulted in 148 corrective actions. Of these events, 85.1% (57/67) had more than one corrective action. Of the 148 corrective actions, 84 (56.8%) were rated as weak, 36 (24.3%) as intermediate, 15 (10.1%) strong, and 13 (8.8%) needed more information. The completion rate was 97.6% (for weak corrective actions), 80.6% (intermediate), and 73.3% (strong) (p < 0.0001). CONCLUSION: Safety events were often addressed with multiple corrective actions. There was an inverse relationship between intervention strength and completion, the strongest interventions with the lowest rate of completion. By integrating action strength and completion status into corrective action follow-up, health care organizations may more effectively identify and address those barriers to completing the strongest interventions that ultimately achieve high reliability.

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

BACKGROUND: Patients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician's view. We aimed to develop a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning. METHOD: A multi-stakeholder advisory group including patients, families, clinicians, and experts in diagnostic error, patient engagement and safety, and user-centred design, co-developed a framework for PRDBs in ambulatory care. We tested the framework using standard qualitative analysis methods with two physicians and one patient coder, analysing 2165 patient-reported ambulatory errors in two large surveys representing 25 425 US respondents. We tested intercoder reliability of breakdown categorisation using the Gwet's AC1 and Cohen's kappa statistic. We considered agreement coefficients 0.61-0.8=good agreement and 0.81-1.00=excellent agreement. RESULTS: The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The frequency of PRDBs was 6.4% in one dataset and 6.9% in the other. Intercoder reliability showed good-to-excellent reliability in each dataset: AC1 0.89 (95% CI 0.89 to 0.90) to 0.96 (95% CI 0.95 to 0.97); kappa 0.64 (95% CI 0.62, to 0.66) to 0.85 (95% CI 0.83 to 0.88). CONCLUSIONS: The PRDB framework, developed in partnership with patients/families, can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.

Defining Best Practices for Interhospital Transfers.

INTRODUCTION: Interhospital transfers (IHT) are important yet high-risk transitions in care. Variable IHT processes and a lack of clarity around best practice may contribute to risk. To define the best practice principles for IHTs and identify improvement opportunities in the transfer process to our hospital's Cardiology services. METHODS: Through literature review, interviews with experts and key stakeholders, a survey of health care professionals at our institution, and a failure modes effect analysis, we identified themes in IHT best practices and improvement opportunities. RESULTS: We identified six critical elements of IHT: (1) initiation of transfer request; (2) the management of transfer request and information exchange; (3) updates between transfer acceptance and patient transport; (4) transport; (5) patient admission and information availability; and (6) measurement, evaluation, and feedback. Improvement opportunities were found in all elements. CONCLUSIONS: The standardization of these six critical elements may improve the safety of IHTs.

CE: A Prone Positioning Protocol for Awake, Nonintubated Patients with COVID-19.

ABSTRACT: Prone positioning of critically ill patients with acute respiratory distress syndrome is an accepted therapy done to improve oxygenation and promote weaning from mechanical ventilation. But there is limited information regarding its use outside of the ICU. At one Boston hospital, the influx of patients with suspected or confirmed COVID-19 strained its resources, requiring sweeping systems changes and inspiring innovations in clinical care. This article describes how an interdisciplinary team of clinicians developed a prone positioning protocol for use with awake, nonintubated, oxygen-dependent patients with suspected or confirmed COVID-19 on medical-surgical units, with the hope of hastening their recovery and avoiding deterioration and ICU transfer. A protocol implementation plan and staff educational materials were disseminated via the hospital incident command system and supported through daily leadership huddles. Patient eligibility criteria, including indications and contraindications, and a clear nursing procedure for the implementation of prone positioning with a given patient, were key elements. Nurses' feedback of their experiences with the protocol was elicited through an e-mailed survey. Nearly all respondents reported improvements in patients' oxygen saturation levels, while few respondents reported barriers to protocol implementation. The prone positioning protocol was found to be both feasible for and well tolerated by awake, nonintubated patients on medical-surgical units, and can serve as an example for other hospitals during this pandemic.

Preventability of 30-Day Hospital Revisits Following Admission with COVID-19 at an Academic Medical Center.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have affected the preventability of 30-day hospital revisits, including readmissions and emergency department (ED) visits without admission. This study was conducted to examine the preventability of 30-day revisits for patients admitted with COVID-19 in order to inform the design of interventions that may decrease preventable revisits in the future. METHODS: The study team retrospectively reviewed a cohort of adults admitted to an academic medical center with COVID-19 between March 21 and June 29, 2020, and discharged alive. Patients with a 30-day revisit following hospital discharge were identified. Two-physician review was used to determine revisit preventability, identify factors contributing to preventable revisits, assess potential preventive interventions, and establish the influence of pandemic-related conditions on the revisit. RESULTS: Seventy-six of 576 COVID-19 hospitalizations resulted in a 30-day revisit (13.2%), including 21 ED visits without admission (3.6%) and 55 readmissions (9.5%). Of these 76 revisits, 20 (26.3%) were potentially preventable. The most frequently identified factors contributing to preventable revisits were related to the choice of postdischarge location and to patient/caregiver understanding of the discharge medication regimen, each occurring in 25.0% of cases. The most frequently cited potentially preventive intervention was "improved self-management plan at discharge," occurring in 65.0% of cases. Five of the 20 preventable revisits (25.0%) had contributing factors that were thought to be directly related to the COVID-19 pandemic. CONCLUSION: Although only approximately one quarter of 30-day hospital revisits following admission with COVID-19 were potentially preventable, these results highlight opportunities for improvement to reduce revisits going forward.

Improving Ambulatory Health Care Proxy Completion Rates: Implementing an Interdisciplinary Clinic-Based Process.

All adults should complete a health care proxy (HCP), especially those who are seriously ill or otherwise at increased risk of losing capacity. This study describes the implementation of an interdisciplinary process for helping patients complete HCPs during nonurgent visits at a large urban academic primary care practice between July 2014 and May 2017. The process was mapped using direct observations. Pre- and post-implementation measurement of the percent of patients who completed HCPs during their visit revealed significant improvement (1.4% vs 26.1% in the North Suite, special cause variation). Over the study period, the percentage of patients with HCP information rose significantly across the entire clinic (eg, 37% to 80% in the North Suite, Fisher exact test P < .0001; similar findings in other suites). Key facilitators and barriers to implementation were identified by physician leaders. An interdisciplinary process can sustainably improve the percentage of primary care patients with a completed HCP.

Interhospital transfer patients discharged by academic hospitalists and general internists: Characteristics and outcomes.

BACKGROUND: Prior work suggests interhospital transfer (IHT) may be a risky event. Outcomes for patients transferred from another acute care institution and discharged by hospitalists and general internists at academic health systems are not well described. OBJECTIVE: Investigate the characteristics and outcomes of IHT patients compared with patients admitted from the emergency department (ED) to academic health systems. DESIGN: Retrospective cohort study. SETTING/PATIENTS: A total of 885,392 adult inpatients discharged by hospitalists or general internal medicine physicians from 158 academic medical centers and affiliated hospitals participating in the University HealthSystem Consortium Clinical Database and Resource Manager from April 1, 2011 to March 31, 2012. METHODS: Patient cohorts were defined by admission source: those from another acute care institution were IHTs, and those coming through the ED whose source of origination was not another hospital or ambulatory surgery site were ED admissions. In-hospital mortality was our primary outcome. We analyzed our data using descriptive statistics, t tests, χ(2) tests, and logistic regression. RESULTS: Compared with ED admissions, IHT patients had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%, P < 0.01). After adjusting for patient characteristics and risk of mortality measures, IHT patients had a higher risk of in-hospital death (odds ratio: 1.36, 95% confidence interval: 1.29-1.43). CONCLUSIONS: In this large national sample, IHT status is independently associated with inpatient mortality.

The open-ended comment space for action plans on core clerkship students' encounter cards: what gets written?

BACKGROUND: Written comments on encounter (i.e., feedback) cards have not been well studied. This study's purpose was to characterize written comments on encounter cards with space designated for an action plan. METHOD: In 2006, 127 core clerkship students returned 5,356 cards. Written comments were coded into domains and for the presence of feedback and action plans. Congruence between student-completed checklist domains and written comment domains was determined. RESULTS: Seventy-eight percent of cards had at least one intelligible comment. The mean number of domains per card was 1.8 (SD 1.0, range 1-9). Most cards (85%) had an action plan; fewer (54%) were specific. The prevalence of action plans in specific domains was about equal in instances when the student did and did not check the domain. CONCLUSIONS: Action plans are found on encounter cards but are less frequently specific. Faculty development should consider targeting action plan development.