Objective To identify features of clinical decision support systems critical for improving clinical practice. Design Systematic review of randomised controlled trials. Data sources Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice. Data extraction Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. Results Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P Conclusions Several features were closely correlated with decision support systems9 ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.

https://www.bmj.com/content/bmj/330/7494/765.full.pdf

Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

/pdf/the-canadian-adverse-events-study-the-incidence-of-adverse-4ip66k5tbq.pdf

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

Introduction: Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on inhospital adverse events. Methods: A formal search of Embase, Cochrane and Medline was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and endpoints. Primary endpoints were incidence of in-hospital adverse events and percentage of preventability. Secondary endpoints were adverse event outcome and subdivision by provider of care, location and type of event. Results: Eight studies including a total of 74 485 patient records were selected. The median overall incidence of inhospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority. We present a summary of evidence-based interventions aimed at these categories of events. Conclusions: Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference.

https://qualitysafety.bmj.com/content/qhc/17/3/216.full.pdf

The incidence and nature of in-hospital adverse events: a systematic review

http://www.atulgawande.com/documents/Analysisoferrorsreportedbysurgeonsatthreeteachinghospitals.pdf

Analysis of errors reported by surgeons at three teaching hospitals

Objective To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors

Design Prospective cohort study

Setting Three urban freestanding children’s hospitals in the United States

Participants 123 residents in three paediatric residency programmes

Main outcome measures Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month

Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout Active surveillance yielded 45 errors made by participants Depressed residents made 62 times as many medication errors per resident month as residents who were not depressed: 155 (95% confidence interval 057 to 422) compared with 025 (014 to 046, P<0001) Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 045 (020 to 098) compared with 053 (021 to 133, P=02)

Conclusions Depression and burnout are major problems among residents in paediatrics Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors

https://www.bmj.com/content/bmj/336/7642/488.full.pdf

Rates of medication errors among depressed and burnt out residents: prospective cohort study.

Aim To determine whether foundation year 1 (FY1) doctors reflect upon patient safety incidents (PSIs) within their portfolios and the potential value of such reflections for quality of care. Methods A cross-sectional retrospective review of every ‘reflective practice’ portfolio entry made by all FY1 doctors within an Acute Teaching Hospital Trust was conducted in February 2010. Entries were reviewed by two independent blinded researchers to determine whether they related to a PSI that is, any unintended or unexpected incident that could have or did lead to patient harm. For all entries rated positive by both reviewers, a content analysis approach was used to code PSI into incident type, contributing factors and patient outcome according to validated frameworks developed by the National Patient Safety Agency. Results 139 reflective practice entries were completed by 30 trainees (15 men, 15 women, mean age 24 years). Of the 139 entries, 49% reflected on a PSI. Of these, 22% were due to errors in clinical assessment; 22% were due to delayed access to care; 18% were due to infrastructure/staffing deficiencies; and 16% were due to medication errors. The most common contributing factors were team/social factors (23%), patient factors (22%), communication and task factors (both 17%). The majority of PSIs led to no harm. Six entries described PSIs resulting in patient death, the majority of which were attributable to diagnostic errors. Conclusions FY1 doctors commonly reflect on PSIs within their professional portfolios. Such critical reflection can encourage learning but may also promote patient safety and the quality of healthcare across all medical specialties.

https://pmj.bmj.com/content/postgradmedj/88/1037/125.full.pdf

Junior doctors' reflections on patient safety

Editor—It was brave to devote a whole issue to medical error1—how to recognise, how to investigate, how to analyse, and how to change systems to improve patient safety.1 However, we regret that the edition was dominated by American studies, ignoring the British contribution of confidential inquiries and analyses of closed claims, which have significantly improved safety in some well defined areas of medical practice.

In the United States the insurance industry provided the impetus for the study of adverse events,2 and in Australia the government funded a similar study3 because it was considering “no fault” compensation.3 In the United Kingdom, for 25 years the Department of Health has financed all successful claims against NHS hospitals and their staff. As a result the need to take a British study beyond the pilot phase may not be supported.4

Be that as it may, an important issue was not addressed in the BMJ. Behind each adverse event there is a patient, a doctor, and a doctor-patient relationship. A patient must be told when things have gone wrong. Every effort must be made to minimise the after effects, including financial compensation where necessary. Most patients wish to know in detail what happened and what is being done to reduce the possibility of a recurrence. And members of healthcare teams need mechanisms to come to terms with their fallibility. It is to be hoped that clinical governance will make a difference.

Meanwhile a change in the ethos of medical practice is required, and it is to this end that Action for Victims of Medical Accidents has set up a group for doctors. Action for Victims of Medical Accidents is often regarded as dealing solely with compensation and litigation, but its raison d'etre has always been to improve patient care.

In February this year the doctors' group met informally to discuss how best to translate into practice the General Medical Council's requirements of “good medical practice when things go wrong.”5 We are determined to take our discussion forward and would welcome input from others who see the need to change the defensive and exclusive culture of British medicine. Doctors who would like to be involved should contact Dr Anne Savage, who is acting as secretary to the group.

/pdf/reducing-error-improving-safety-defensive-culture-of-british-leyckqjmdr.pdf

Reducing error, improving safety. Defensive culture of British medicine needs to change.

Diagnostic error underlies about 10% of adverse events occurring in hospital practice. However, there have been very few studies considering means of improving the mechanisms of diagnosis. As a result, misdiagnosis has been described as 'the next frontier for patient safety'. In this study of case records of patients admitted to hospital as emergencies, some key factors that may underlie diagnostic errors were assessed. From these observations, possibilities for improving the quality of diagnosis and the planning of subsequent care are explored. This paper shows that cognitive biases, believed to distort diagnostic conclusions, can be applied quite specifically to stages in clinical care. These observations led to the proposal of a clinical assessment with a method designed to encourage analytical reasoning. In addition, minor defects in standard practice are shown to adversely influence diagnosis. The findings of this study offer possible means of improving the quality of diagnosis and subsequent patient care, and perhaps pave the way for prospective studies.

https://www.rcpjournals.org/content/clinmedicine/11/6/626.full.pdf

Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.

Objective To determine incidence and aetiology of diagnostic errors in children presenting with acute medical illness to a community hospital.

Design A three-stage study was conducted. Stage 1: retrospective case note review, comparing admission to discharge diagnoses of children admitted to hospital, to determine incidence of diagnostic error. Stage 2: cases of suspected misdiagnosis were examined in detail by two reviewers. Stage 3: structured interviews were conducted with clinicians involved in these cases to identify contributory factors.

Setting UK community (District General) hospital.

Participants All medical patients admitted to the paediatric ward and patients transferred from the Emergency Department to a different facility over a 90-day period were included.

Main Outcome Measure(s) Incidence of diagnostic error, type of diagnostic error and content analysis of the structured interviews to determine frequency of emerging themes.

Results Incidence of misdiagnosis in children presenting with acute illness was 5.0% (19/378, 95% confidence interval (CI) 2.8–7.2%). Diagnostic errors were multi-factorial in origin, commonly involving cognitive factors. Reviewers 1 and 2 identified a median of three and four errors per case, respectively. In 14 cases, structured interviews were possible; clinicians believed system-related errors (organizational flaws, e.g. inadequate policies, staffing or equipment) contributed more commonly to misdiagnoses, whereas reviewers found cognitive factors contributed more commonly to diagnostic error.

Conclusions Misdiagnoses occurred in 5% of children presenting with acute illness and were multi-factorial in aetiology. Multi-site longitudinal studies further exploring aetiology of errors and effect of educational interventions are required to generalize these findings and determine strategies for mitigation.

/pdf/diagnostic-error-in-children-presenting-with-acute-medical-2lyc5anjxj.pdf

Diagnostic error in children presenting with acute medical illness to a community hospital.

A pilot audit of case records of consecutively discharged patients from a district general hospital was undertaken by specialist registrars, SHOs and senior nurses in order to identify adverse events (AEs) and critical incidents (CIs) related to hospital care. Experienced external assessors taught the clinical staff to use a previously validated structured method of case record review that facilitates analysis. The external assessors audited the same case records in parallel. Aggregated data from 154 case records of patients admitted to the general medical wards were collected for analysis. Fifteen AEs and 41 CIs were identified in the case records covering the hospital admission. In addition, 16 AEs and nine CIs were discovered to have occurred before admission or, for three AEs, shortly after discharge. One-half of the episodes related to problems arising during ward care and for one-half of these issues remained unresolved at the time of discharge. One-third of episodes related to medications or the administration of intravenous fluids--and in these cases there were defects in monitoring the patients' clinical progress. This study led to initiatives to improve care at the host hospital and we believe that further programmes along similar lines are indicated.

/pdf/recognising-adverse-events-and-critical-incidents-in-medical-34gqgjjzhk.pdf

Graham Neale

Papers

Junior doctors' reflections on patient safety

Reducing error, improving safety. Defensive culture of British medicine needs to change.

Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.

Diagnostic error in children presenting with acute medical illness to a community hospital.

Recognising adverse events and critical incidents in medical practice in a district general hospital