November 5, 2007, Issue No. 38
Patient Safety Quote of the Month
“We have found that technical errors resulting in serious injury to surgical patients occur most often in routine operations conducted by experienced surgeons but with complex patients and/or circumstances.”
—from a new AHRQ-funded study, reported by Dr. Scott Regenbogen and his colleagues in the November 2007 issue of the Annals of Surgery.
For more information on the study by Dr. Regenbogen and his colleagues, select Item No. 1.
Today's Headlines:
1. New AHRQ-Funded Study Finds Technical Errors Are Pervasive in Surgical Procedures
2. Many Errors by Medical Residents Caused by Teamwork Breakdowns, Lack of Supervision
3. AHRQ Audio Podcast Discusses Medical Errors and Trainees and How to Ask Doctors Tough Questions
4. AHRQ Receives Special Award for Excellence in the Advancement of Patient-Centered Care
5. AHRQ Director Helps Consumers Navigate the Health Care System in a New Advice Column on the Web
6. AHRQ Director Testifies on AHRQ's Role in Health IT and Improving the Quality of Care for Underserved Populations
7. Special Journal Issue on Working Conditions—“Improving the Health Care Work Environment to Promote Quality and Safety”
8. Latest Issue of AHRQ WebM&M Available Online
1. New AHRQ-Funded Study Finds Technical Errors Are Pervasive in Surgical Procedures
Most surgical adverse events are a result of technical errors, such as manual errors and errors in judgment and knowledge, and primarily involve experienced surgeons during routine operations, according to a new AHRQ-funded study in the November issue of the Annals of Surgery.
Forty-nine percent of the 140 malpractice claims that involved technical errors examined in the study caused permanent disability, and an additional 16 percent resulted in death. Of the technical errors studied, 73 percent involved fully trained and experienced surgeons operating within their area of expertise, and 84 percent occurred in routine operations. The most common types of operations associated with the errors were general or gastrointestinal surgery (31 percent), spine surgery (15 percent), gynecologic surgery (12 percent), and non-spine orthopedic surgery (9 percent). Researchers recommend that surgical safety research should focus on improving decision-making and performance in routine operations for complex patients and circumstances.
The study was led by Scott E. Regenbogen, M.D., Postdoctoral Fellow, Department of Health Policy and Management, Harvard School of Public Health, Boston, and Resident in Surgery, Massachusetts General Hospital; and Atul Gawande, M.D., Associate Professor of Surgery at Harvard Medical School, Boston, and a general and endocrine surgeon at Brigham and Women's Hospital and Dana Farber Cancer Institute. Select to review an abstract of the study, “Patterns of Technical Error Among Surgical Malpractice Claims: An Analysis of Strategies to Prevent Injury to Surgical Patients.”
2. Many Errors by Medical Residents Caused by Teamwork Breakdowns, Lack of Supervision
A new AHRQ-funded study shows physicians-in-training are highly vulnerable to making medical errors that stem from teamwork breakdowns, especially a lack of supervision by experienced staff. Teamwork breakdowns involving medical residents, fellows, and interns (first-year residents) also caused a significant number of errors to occur during patient handoffs, researchers found.
The study, “Medical Errors Involving Trainees: A Study of Closed Malpractice Claims from 5 Insurers,” appears in the October 22 issue of the Archives of Internal Medicine. Select to access our press release and to review an abstract of the study.
3. AHRQ Audio Podcast Discusses Medical Errors and Trainees and How to Ask Doctors Tough Questions
In this week's Healthcare 411 audio podcast, Hardeep Singh, M.D., of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, discusses his research published in the October 22 issue of Archives of Internal Medicine about physicians-in-training and medical errors. He found that breakdowns in teamwork contributed to 70 percent of medical errors by medical trainees, and he found a lack of supervision by a more experienced physician in over half of the medical error cases reviewed.
In another interview, AHRQ Director Carolyn M. Clancy, M.D., provides advice to consumers about how to ask their doctors tough questions, such as questions about getting a second opinion or obtaining copies of records. Select to access the 9-minute program and to review the transcript. To access any of AHRQ's podcasts, visit our Healthcare 411 series main page.
4. AHRQ Receives Special Award for Excellence in the Advancement of Patient-Centered Care
AHRQ has been selected as a recipient of this year's Picker Awards for Excellence® in the Advancement of Patient-Centered Care. The Picker Institute, an independent, nonprofit organization dedicated to the advancement of the principles of patient-centered care and the global patient-centered care movement, honored the recipients during the recent “Celebrating Quality” event at the annual International Society for Quality in Health Care conference in Boston. To learn more about the award and the awardees, go to the Picker Institute's press release.
5. AHRQ Director Helps Consumers Navigate the Health Care System in a New Advice Column on the Web
AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in new, brief, easy-to-understand columns. The biweekly columns will help consumers better navigate the health care system. Select to access Dr. Clancy's two new advice columns.
6. AHRQ Director Testifies on AHRQ's Role in Health IT and Improving the Quality of Care for Underserved Populations
AHRQ's initiative on health IT is a key element of the nation's 10-year strategy to bring health care into the 21st century by advancing the use of information technology, AHRQ Director Carolyn M. Clancy, M.D., told members of the House Subcommittee on Management, Organization, and Procurement on November 1.
Dr. Clancy testified about the role AHRQ plays in health IT and improving the quality of health care for underserved populations through the funding of more than $166 million in grants and contracts that support and stimulate investment in health IT in 41 states, especially in rural and underserved areas.
Through these projects, AHRQ and its partners will: 1) identify challenges to health IT adoption and use as well as solutions and best practices for making health IT work; and 2) encourage viewing health IT as a normal cost of doing business and using market-based tools that will help hospitals and clinicians successfully incorporate new IT. Select to review Dr. Clancy's complete testimony.
7. Special Journal Issue on Working Conditions—“Improving the Health Care Work Environment to Promote Quality and Safety”
An AHRQ-sponsored supplement to the November issue of the Joint Commission Journal on Quality and Patient Safety reviews evidence on the effects of health care working conditions on the quality of health care. The papers cite persistent threats to patient safety in hospital work environments and present improvement options.
Six papers, five of them written by AHRQ-funded researchers or staff members, synthesize the evidence on key elements in the hospital work environment. Among the topics are the potential for harm in conditions prevailing in many hospital inpatient settings, such as excessive work hours, inadequate nurse staffing, and crowding. Other papers examine the effects on safety and quality of the built environmental and organizational climate.
The issue also includes recommendations covering the breadth and depth of future research, additional features of the work environment deserving attention, practices for implementing and sustaining improvements in work environments, and the need for syntheses of practical implementation experience. The special issue follows AHRQ's funding of more than 22 studies beginning in 2002 to identify gaps in knowledge about the effects of health care working conditions on care quality. Single copies of the November supplement to the journal are available by sending an E-mail to ahrqpubs@ahrq.hhs.gov.
8. Latest Issue of AHRQ WebM&M Available Online
The October issue of AHRQ WebM&M is now available. This month, the Perspectives on Safety section features an interview with David Marx, J.D., on the concept of “Just Culture,” which has been increasingly embraced as a way to balance the desire to create a “no blame” environment and the clear need for accountability.You can listen to an excerpt of the interview via an audio podcast. In the accompanying perspective, Alison Page, chief safety officer of Fairview Health Services, discusses how one organization has worked to implement Just Culture.
In the Spotlight Case, a woman on a patient-controlled analgesia pump following surgery is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismissed the patient's symptoms and chastised the nurse for the late call. F. Daniel Duffy, M.D., of the University of Oklahoma and the American Board of Internal Medicine (ABIM), and Christine Cassel, M.D., president of ABIM, discuss professionalism and the challenges it raises in training and in practice. In the second case, a code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. House staff covering the code team did not know where the service was located, and when the team arrived they found their equipment to be incompatible with the leads on the patient. The discussion focuses on the approach to out-of-hospital code blues. In the third case, an elderly woman was admitted with severe abdominal pain and tachycardia. After 3 days in the hospital with no clear etiology discovered for these symptoms, a level of a thyroid-stimulating hormone was found to be undetectable and the patient was diagnosed with thyrotoxicosis.
Now you can easily share AHRQ WebM&M articles by using the “E-mail a colleague” feature. As always, you can receive CME, CEU, or trainee certification by taking the Spotlight Quiz. All previously published commentaries are available under “Case Archive.” Please submit cases to AHRQ WebM&M via the “Submit Case” button.
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Current as of November 2007
Internet Citation:
Patient Safety E-Newsletter. November 5, 2007, Issue No. 38. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews38.htm
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