Hardeep Singh

BACKGROUND: Inadequate supervision is a significant contributing factor to medical errors involving trainees, but supervision in high‐risk settings such as the intensive care unit (ICU) is not well studied.OBJECTIVE: We explored how residents in the ICU experienced supervision related to medication safety, not only from supervising physicians but also from other professionals.DESIGN, SETTING, MEASUREMENTS: Using qualitative methods, we examined in‐depth interviews with 17 residents working in ICUs of three tertiary‐care hospitals. We analyzed residents' perspectives on receiving and initiating supervision from physicians within the traditional medical hierarchy, and from other professionals, including nurses, staff pharmacists, and clinical pharmacists (“interprofessional supervision”).RESULTS: While initiating their own supervision within the traditional hierarchy, residents believed in seeking assistance from fellows and attendings, and articulated rules of thumb for doing so; however, they also experienced difficulties. Some residents were concerned that their questions would reflect poorly on them; others were embarrassed by their mistaken decisions. Conversely, residents described receiving interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Residents relied on nurses and pharmacists for nonjudgmental answers to their queries, especially after‐hours. To enhance both types of supervision, residents emphasized the importance of improving interpersonal communication skills.CONCLUSIONS: Residents depended on interprofessional supervision when making decisions regarding medications in the ICU. Improving interprofessional supervision, which thus far has been underrecognized and underemphasized in graduate medical education, can potentially improve medication safety in high‐risk settings. Journal of Hospital Medicine 2011;6:448–456. © 2011 Society of Hospital Medicine

Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

If implemented correctly, the patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care. One highly relevant but

Objectives Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC. Methods The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time. Results Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with ‘positive faecal occult blood test’ (92 days, pConclusions Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response.

Communication breakdown is consistently identified as a preventable factor in studies of adverse events^1-6 and a significant contributor to outpatient diagnostic errors from a lack of follow-up of abnormal test results.^7-12 The volume of outpatient care and nature of high-risk transitions between health care practitioners/providers (HCPs), settings, and systems of care makes timely communication particularly challenging.¹³ For example, a patient referred for diagnostic workup for respiratory symptoms by a primary care provider (PCP) may undergo several laboratory and imaging tests and a pulmonary consultation. Any abnormal findings such as a possible lung mass would need to be communicated rapidly and effectively to the treating HCPs to ensure adequate follow-up.

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may arise: (1) the provider–patient encounter, (2) performance and interpretation of diagnostic tests, (3) follow-up of patients and diagnostic test results, (4) subspecialty consultation, and (5) patients seeking care and adhering to their instruction/appointments, i.e. patient behaviors. We presented these risk domains to conference participants to elicit their views about sources of and solutions to diagnostic errors in ambulatory care. In this paper, we present a summary of discussion in each of these risk domains. Many novel themes and hypotheses for future research and interventions emerged.

Several studies have found that computerized physician order entry (CPOE) systems reduce medication errors and overall patient harm.^1-4 However, computerization may introduce new error pathways.^5-10 Errors facilitated by CPOE have received increasing attention in the literature, yet the true frequency of the problem is unknown.^9,11,12 Most medication errors are related to the ordering process,¹³ and many types of CPOE-related errors have been described in recent years.^5-10 For instance, a study using both qualitative and quantitative methods to study house staff interaction with a CPOE system at a tertiary care facility identified 22 different types of medication errors, including fragmented CPOE displays and inflexible ordering formats.⁹