James S. Todd Memorial Research Award

Understanding Medical Errors in Hospital Psychiatry

Steven C. Marcus, University of Pennsylvania School of Social Policy and Practice

There are over one million discharges from inpatient psychiatric units of acute care hospitals annually, yet knowledge about critical patient-safety events is notably deficient for mental health care settings because major studies on the topic have systematically excluded patients with mental disorders. Our award from the National Patient Safety Foundation has allowed us to begin to characterize patient safety events in inpatient mental health care by: 1) designing a medical record screening form to detect potential adverse incidents that occur on psychiatric inpatient units, 2) having a team of medical records administrators use that form to screen all discharges for one year from the inpatient psychiatric units at two urban medical centers, 3) assessing the reliability and feasibility of the screening form and making changes to it based on the review process, 4) using the revised screening orm to review one year of discharges from both hospitals,5) designing and testing an extensive physician review form to measure the incidence, nature, and preventability of inpatient psychiatric incidents, 6) using this physician review form to carefully examine a large sample of charts screened positive by the medical records administrators, and 7) assessing the reliability and feasibility of the physician review form and making changes to it based on the review process.

Our results indicate that patient safety events are common in psychiatric inpatient settings, that they differ from those found in general medicine/surgery, and that the patient safety event rates vary by hospital. When events occur, they cause harm and are often the result of error, but are largely preventable. We used the tools and results of this pilot work as the foundation or a recently awarded R01 from the National Institute of Mental Health to examine the patient, provider, and psychiatric unit actors associated with the incidence, nature and preventability of patient safety events occurring in a large random sample of patients from Pennsylvania inpatient psychiatric units of general hospitals. Our goal is to build prevention strategies for inpatient mental health care that enhance the provision of safe clinical care for this vulnerable patient population.

Patient Safety in After Hours Telephone Medicine

Dr. Shersten Killip, University of Kentucky Department of Family and Community Medicine

The overall objective of this study is to explore the nature and extent of errors in telephone medicine encounters between physicians and patients. There are over 50 million after hours telephone encounters per year in the United States. This qualitative study is intended to determine the incidence and types of errors and/or threats to patient safety which result from after-hours telephone medicine. Using interviews with patients, the researchers intend to generate the first detailed taxonomy of errors in after-hours telephone medicine, and the first large-scale report of the harms and potential harms related to telephone medicine.