jueves, 29 de septiembre de 2011

Research Activities, October 2011: Patient Safety and Quality

Patient Safety and Quality

Simpler drug warning labels are easier to understand

Many drugs are off limits to pregnant women because they can harm fetuses. But not all drug labels state this warning clearly enough for some women to understand it. When researchers tested the standard drug label that warns pregnant women to avoid a drug against a new text version and a text-and-icon version of the label, most women best understood the combination version.

Researchers interviewed 132 women at outpatient care clinics in Shreveport, LA, and Chicago, IL. Ninety-four percent of the women were able to understand the message of the enhanced text (Do not use if you are pregnant, think you are pregnant, or breast feeding) when it accompanied an icon that was a silhouette of a pregnant woman with a slash through it. In contrast, just 76 percent of women comprehended the standard label and 79 percent understood the enhanced text alone.

Because care providers do not often explain that the medicine they are prescribing may cause birth defects, warning labels may be the best line of defense in providing that information. Standardizing the labels and testing them with consumers may make them easier to understand so they do their job better. This study was funded in part by the Agency for Healthcare Research and Quality (T32 HS00078).

See "Improving pregnancy drug warnings to promote patient comprehension," by Whitney B. You, M.D., William Grobman, M.D., M.B.A., Terry Davis, Ph.D., and others in the April 2011 American Journal of Obstetrics and Gynecology, 204(4), pp. 318.e1-318.e5.
Research Activities, October 2011: Patient Safety and Quality: Simpler drug warning labels are easier to understand

Patient Safety and Quality

Medical students, interns, and residents need training to disclose medical errors

Although patients say they want health care providers to promptly disclose and apologize for errors made while patients are under their care, surveys suggest that a minority of harmful errors are disclosed to patients. What's more, disclosure conversations often fail to meet patients' expectations. In fact, a recent survey reveals that the disclosure content chosen by 758 medical students, interns, and residents falls short of current disclosure guidelines.

The researchers surveyed medical students in various stages of training at two universities that did not require error-disclosure training. The survey used two hypothetical scenarios, one involving an obvious insulin overdose, and the other involving hyperkalemia (excessively high potassium levels in the blood), an error less apparent to the patient. Questions focused on how likely the medical trainee would be to disclose the error and what they would most likely say.

Most trainees (85 percent) agreed that their scenario represented a serious error. A majority (78 percent) felt that, as the doctor, they would be very or extremely responsible for the error in the scenario. Trainees reported their intent to disclose the error as "definitely" (43 percent), "probably" (47 percent), "only if asked by the patient" (9 percent), and "definitely not" (1 percent). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognize (55 vs. 30 percent). Respondents were split between conveying a general expression of regret (53 percent) and making an explicit apology (46 percent). More experienced respondents were less likely to provide an explicit apology.

The information respondents would disclose largely mirrored that chosen by doctors surveyed by the researchers in prior studies. Yet, only a minority of medical students receive training in error disclosure. The researchers conclude that the current training environment may not encourage an approach to error disclosure that is consistent with patient expectations and national guidelines. This study was supported by the Agency for Healthcare Research and Quality (HS14012).

See "How trainees would disclose medical errors: Educational implications for training programmes," by Andrew A. White, M.D., Sigall K. Bell, M.D., Melissa J. Krauss, M.P.H., and others in Medical Education 45, pp. 372-380, 2011.

Patient Safety and Quality

Certain factors increase risk of medication errors in the neonatal intensive care unit (NICU)

Babies in neonatal intensive care units (NICUs), like patients in other critical care environments, are at increased risk for medication errors. In fact, these errors are eight times more likely to take place in the NICU than an adult setting in the hospital. Given their small size, infants in the NICU are particularly vulnerable to the consequences of medication errors. A new study profiled risk factors for medication errors in the NICU. It found that human factors were behind most medication errors in the NICU, with half of them the result of mistakes during the drug administration phase.
The researchers looked at 6,749 NICU medication-error reports from 163 health care facilities. All were reported to MEDMARX, an independent Internet-based error-reporting system, between 1999 and 2005. The majority of medication errors, (3,725) were errors that reached the patient but did not cause harm. Another 1,529 errors took place but never actually reached the patient. Overall, 72 percent of errors that reached the patient did not result in harm. Four percent of actual errors resulted in permanent harm or death.

Nearly half (48.2 percent) of all reported medication errors occurred during the drug administering phase, followed by drug transcribing/documenting, prescribing, and dispensing. Over a quarter (26.9 percent) of all error types cited involved improper dose or quantity. Other types included omission errors (18.6 percent) and wrong timing (17.6 percent). Human factors were the cause of 68.4 percent of all errors, followed by miscommunication (14.4 percent). Risk factors associated with medication errors included the use of what are called high-alert medications, problems during the prescribing phase, and equipment/delivery device failures. The study was supported in part by the Agency for Healthcare Research and Quality (HS16774).

See "NICU medication errors: Identifying a risk profile for medication errors in the neonatal intensive care unit," by Theodora A. Stavroudis, M.D., Andrew D. Shore, Ph.D., Laura Morlock, Ph.D., and others in the Journal of Perinatology 30, pp. 459-468, 2010.

Patient Safety and Quality

Going "smooth" can help relieve weekday crowding at children's hospitals

Children's hospital beds are often filled to or beyond capacity during the week and under-utilized on the weekend. At least some of this weekday/weekend difference can be reduced by rescheduling elective (prescheduled) admissions, a new study finds. This approach, smoothing inpatient occupancy, would affect the 15 to 30 percent of admissions to children's hospitals that are scheduled days—or even months—in advance, with arrival usually on a weekday.

The researchers analyzed resource-utilization information from 39 freestanding, tertiary-care children's hospitals across the United States. They then applied a retrospective smoothing algorithm to set each hospital's daily occupancy during a week to the hospital's weekly mean occupancy. Scheduled admissions (23.6 percent of hospital admissions in the dataset) represented 26.6 percent of weekday admissions, but only 12.4 percent of weekend admissions. Mean occupancy levels ranged from 70.9-108.1 percent on weekdays and 65.7-94.9 percent on weekends.

After smoothing occupancy over the course of a week using the hypothetical algorithm, the calculated weekly maximum occupancy for the participating hospitals was reduced by 6.6 percentage points. This meant that 39,607 patients at the 39 hospitals would not have been exposed to occupancy rates greater than 95 percent. The researchers calculated that the change would require a median 2.6 percent of patients to be scheduled on a different day of the week. The study was funded in part by the Agency for Healthcare Research and Quality (HS16418).

More details are in "Addressing inpatient crowding by smoothing occupancy at children's hospitals," by Evan S. Fieldston, M.D., M.B.A., M.S.H.P., Matthew Hall, Ph.D., Samir S. Shah, M.D., M.S.C.E., and others in the May 2011 Journal of Hospital Medicine (Epub ahead of print).

Patient Safety and Quality

Transparency enhances physician communication with patients

Good physician-patient communication is the cornerstone of patient-centered care. Patients want information about their condition and treatment in ways they can understand. Yet, patients are reluctant to engage in information-seeking behaviors during visits. What's more, physicians devote relatively little time to proactively helping patients to understand their medical conditions or the pros and cons of treatment options or medications. A new study reveals that transparency in communication by physicians can do a great deal to alleviate patient uncertainty and engender empathy and respect during medical visits.

Lynne Robins, Ph.D., of the University of Washington, and colleagues analyzed audiotapes of 263 patient visits to 33 physicians providing care to adult patients in eight community-based, university-affiliated primary care practices. Communication was defined as transparent if the physician used nine types of conversational phrases. Some phrases communicated the process of the clinical encounter, such as what will be included in the visit or stages of the physical exam. Some phrases clarified the medical content of the visit and demystified medical terms and jargon. Other phrases centered around the patient's subsequent course of action, e.g., what the patient needed to do next or instructions in how to take their medication.

Physicians spent the greatest amount of time during the encounter demystifying medical terms into lay language and concepts. Other types of transparent communication often included sharing emotions and judgments about the patient's condition, giving reasons for treatment rationale, and orchestrating instructions on taking medications or determining the next appointment. Patients prompted their physicians to be more transparent, but relatively infrequently. They averaged around one prompt per visit to ask for clarification about medical jargon. In half of the visits, patients asked their physicians to share their thoughts. Patients only infrequently asked for additional information about treatment and diagnosis. The study was supported in part by the Agency for Healthcare Research and Quality (HS13172).

See "Identifying transparency in physician communication," by Lynne Robins, Ph.D., Saskia Witteborn, Ph.D., Lanae Miner, M.D., and others in Patient Education and Counseling 83, pp. 73-79, 2011.

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