UNTANGLING VARIATION IN EHRs & HIE: A COMPLEX PATIENT SAFETY ISSUE

by Gwen O’Keefe, MD, FACP | Principal, GO Healthcare Strategy Imagine you’ve just spent a harrowing 4 days in the hospital with sudden onset of heart problems, had many tests, and are sent home with multiple appointments and new medications. The conversations with hospital staff passed in a blur. You don’t understand what the results of some of the tests showed, but you are confident that at your appointment with your primary care doctor, Dr. Sue Caring, all will be explained. Now, imagine you are Dr. Caring, about to see one of your favorite patients. You are dismayed that he has developed a severe cardiac condition and know he will have many questions. You prepare for the visit by reviewing the discharge summary from the hospital but are frustrated with the amount of data presented in the 15 screens of that particular hospital’s discharge summary. It looks very different than the one from a different hospital you read earlier in the day. It’s nearly impossible to quickly comb through the overwhelming amount of data to find the key 5 pieces of information you need to really make sense of what happened. You have a nagging sense of unease that you may be missing a key follow-up item and could end up dropping the ball and harming your patient.     THE PROBLEM: HOW DID IT GET THIS WAY? Nationally, most hospitals and physician practices have adopted Electronic Health Records (EHR). At the same time, national health information standards continue to mature and a variety of options exist to facilitate electronic health information exchange (HIE). This ready access to standardized electronic clinical information offers great promise to enhance care coordination, improve patient safety, and simplify both administrative and clinical workflows. However, to date, this promise has not been realized to the degree it should. While there are a variety of factors responsible for this diminished return on investment, one key issue relates to variability across EHR vendors and clinical organizations in how clinical information standards are being implemented. Of particular concern are the diverse approaches taken to implement the national standard for clinical information exchange, the Consolidated Clinical Document Architecture (C-CDA). The C-CDA was designed as the vehicle to extract, summarize, and transmit clinical information from a certified EHR. Regional clinical and informatics leaders have recognized that the wealth of variations in C-CDA exchange across EHR vendors and clinical organizations makes...

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THE CASE FOR A CARE FOR THE COLLEAGUE PROGRAM

by Kit Hoffman, PsyD | BESIDE Program Coach, Confluence Health In the year 2000, a physician named Albert Wu coined the term “second victim” to describe the experience of physicians, and other medical care providers, who make a medical mistake. The patient, of course, is the first victim of a medical mistake. The medical care provider, who feels guilt, shame, anger, and helplessness following a medical mistake is the second victim. Following a medical error, research shows that physicians, in particular, may also experience anxiety about making another error, loss of confidence in their abilities, difficulty sleeping, decreased job satisfaction, and harm to their reputation among other things. THE 6 STAGES OF A SECOND VICTIM Sue Scott and colleagues (2009) identified a traditional 6-stage trajectory to the process a provider goes through when involved in a medical error: (1) chaos and accident response (2) intrusive reflections (3) restoring personal integrity (4) enduring the inquisition (5) obtaining emotional first aid (6) moving on After the last stage, Sue Scott and her colleagues (2009) found that the second victim will either go on to drop out, survive, or thrive. Dropping out includes leaving the profession or practice. Surviving is when the second victim is doing well enough to function but still has difficult memories, thoughts, or emotions related to the event. Finally, thriving includes finding some meaning in the event and possibly even growing from it. THE PITFALLS OF PERFECTIONISM “Systems that realize that health care providers are human and fallible have a better chance of catching and fixing errors before they reach the patient.” Wu (2000) describes how a societal expectation for perfection not only increases shame when a medical mistake occurs, but also makes it difficult to report and remedy systemic errors, as people are hesitant to admit that they are not conforming to expectations of perfection. Even when a healthcare professional realizes that expectations of perfection are unrealistic, the societal pressure to perform at such high levels is immense. Of course, perfect patient care is a worthy aspiration. This is not the same, however, as expecting perfect performance. To achieve this self-correcting system, healthcare professionals must feel comfortable reporting and talking about mistakes. THE IMPACT OF PROACTIVE SUPPORT To help healthcare professionals feel safe talking about their own mistakes, providing organizational support is essential. Ideally, this organizational support should include some form of emotional support, with an understanding that...

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HITTING THE BULLSEYE: THE IMPORTANT ROLE OF DIAGNOSTIC ACCURACY IN PATIENT SAFETY

by Karen M. Markwith RN, MJ, CPHRM, CHPS | Director of Quality and Patient Safety, Virginia Mason In our January 2018 strategic planning session, diagnostic error rose to the top of the discussion and became one of the two key areas we voted to devote WPSC efforts to this year, the other being patient safety culture. To that end, we’ve split our Action Planning Subcommittee into two groups: Diagnostic Error and Patient Safety Culture, in an effort to divide and conquer. Below, Karen Markwith of Virginia Mason, one of the members of the Diagnostic Error group chaired by Randy Moseley, explains the importance of diagnostic accuracy as it pertains to patient safety and why we’ve chosen it as a focus. There are two decisions you need to make when first taking up archery: Which type of archery are you interested in, and which bow will work best for you? These two decisions will provide you with an increased chance of accuracy in hitting the target or bullseye. The goal of accurately diagnosing a patient’s condition is similar to an archer’s goal of hitting the bullseye. The Institute of Medicine’s (IOM) committee’s definition of diagnostic error is as follows: The failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient (NAS). Unfortunately the lack of an accurate diagnosis is more common than we realize and can result and serious harm; even death.   WHAT THE RESEARCH SAYS Using varied methodologies, studies have found the following: Major diagnostic errors that may have contributed to the patient death have been detected in 10% of autopsies[1] In hospitals, an estimated 7%-17% of adverse events result from diagnostic errors, based on studies of retrospective record reviews[2] At least 1 in 20 adults experiences a diagnostic error each year, based on studies in U.S. outpatient settings[3] Inaccurate or delayed diagnoses can also have repercussions beyond a single episode of care and cause ripple effects in the form of inaccurate treatment plans, adverse health events, and psychological and financial consequences. TARGETS TO AIM TOWARD The IOM published a report in 2015 on diagnostic errors and the need to improve diagnosis.[4] According to the report, to improve diagnosis is a “moral, professional, and public health imperative.”  The report identified eight overarching goals and many supporting recommendations. I am not going to go in-depth on each...

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