2002-2003 Grant Awards
James S. Todd Memorial Award for Patient Safety Research of 2002
Transitions in Care: Sign-overs in the Emergency Department
Shawna Perry, MD, FACEP (Principal Investigator), P.G. Croskerry, MD, PhD, M. Shapiro, MD, C. Beach, MD, R.L Wears, MD, M. Vanderhoef, RN, MSN, R. Behara, PhD, A. Murphy, PhD, and E. Eisenberg, PhD
The need for continuous 24-hour care in the emergency department (ED) requires nurses and physicians to transfer patients to a new group of caregivers at the end of a shift. These transitions are critically important to the quality and safety of ED care but have received little attention. Authority, responsibility, and information are all transferred through a process of co-construction in which both the oncoming and the offgoing parties are active participants. To date, attempts to improve handovers in the ED have generally failed. This study demonstrated that this failure may in part be due to a lack of deep understanding of the multidimensional nature of transitions—resulting in a one-size-fits-all approach that does not support medical dynamics. The researchers on this team propose a conceptual framework to characterize signovers which may help clarify future studies and assist in crafting interventions to better fit the context of clinical work.
Talking to Patients about Medical Errors
Kathleen Mazor, EdD (Principal Investigator), Jerry Gurwitz, MD and George Reed, PhD
When medical errors do occur, effective physician-patient communication is critical. Prompt and candid disclosure of errors is important not only for the patients, families and providers involved, but also for the wider medical community—open discussion of error is prerequisite to the identification of causes of error, and subsequent improvements to the health care system. Such discussions cannot occur without including patients and families. In spite of its importance, there has been little empirical work on disclosure of medical errors. This study brought a patient-focused, evidence-based approach to discussions of disclosure of medical error.
To better understand patients’ views, we developed a series of video-vignettes. Each vignette described a medical error, and portrayed a physician talking with a patient about the error. The video-vignettes varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome. After viewing a video, participants reported how they would feel if they were the patient or family member involved. Dependent measures included patient satisfaction, trust, emotional response, likelihood of changing physicians, and likelihood of seeking legal advice. Results led us to conclude that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients’ responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error, remains uncertain.
The paper reporting findings from this study was published in the Journal of General Internal Medicine. Dr. Mazor and her team have continued to work in this area. She recently completed a study of parents’ views on medical errors, which has been published in the Journal of Patient Safety.
A Clinical Decision Support Tool to Improve Quality of Transition Care: A Pilot Trial of Process
James O. Judge, MD (Prinicipal Investigator), Jane LaPrino, Barbara Banning, Pharm D, Kathy White, RPh, Donna Galluzo, Cheryl Leslie, RN, MPH and Cora Zombrzuski, RN, MS
Improving the accurate flow of information in transitions of care is a critical quality issue for older patients with multiple conditions. This pilot study tested one strategy of improving the quality and timeliness of information flow to the Primary Care Physician following a hospital stay (with or without a stay in a post acute facility). Intake nurses requested key laboratory results in addition to medical diagnoses and medication. Following the initial reconciliation process for medications, a consulting pharmacist entered the laboratory data and medications and diagnoses into geriatrics clinical decision support (CDS) system- 55 algorithms that assessed for choice and dosage of medications, medication interactions, and need for laboratory follow-up. Following editing by the consultant pharmacist for redundancy, the Primary Care Physician received a fax containing the reconciled medication list, diagnoses, lab results, and CDS messages, with a request that they respond by phone or fax.
Hospitals and Post Acute centers provided key laboratory data on 170 of the 206 patients. The CDS system generated 630 messages that might warrant action by the physician- a median of 3 messages per patient. 282 messages suggested a modification in the medication regimen (179 messages to change or D/C drug, 103 messages to add a medication). 325 messages suggested a follow-up laboratory test. In addition, 303 messages suggesting close monitoring were generated, but required action primarily by the home care nurses. Physicians initiated 90 actions in response to the messages—45 medication changes (16% response rate) and 50 lab tests ordered (15% response rate).
A key process measure—providing the Primary Care Physician with key laboratory results at the initiation of home care—was achieved for 84% of the patients. The Clinical Decision Support tool generated a median of 3 messages that might warrant action by the primary care physician at the start of home care following a non elective hospital admission. These messages were in addition to the usual initial medication reconciliation process.
The relatively low response rate to CDS suggestions suggests either that refinement in the CDS messaging and in methods of communicating to the Primary Care Physician is needed or that Clinical Decision Support tools, no matter how well designed, will serve only as warning flags for physician consideration.
