The problem of medical error is becoming ever more prominent, thanks to recent reports that show an estimated 251,000 deaths from medical error in 2016, making it the third most common cause of death in the United States. This represents a substantial increase from previous reports, one of the most commonly cited of which being a 1999 Institute of Medicine paper which reported 44k-98k deaths from medical error per year.
However, since that time, much has changed in the way that these statistics are recorded, and the consensus now is that rather than representing an increase in medical error incidence and severity, this represents an improvement in our record-keeping and statistical analysis. Yet this does not mitigate our need to further explore the roots of this issue and strive to improve it while simultaneously improving our statistical analysis and record-keeping.
Defining Medical Error
While it is accepted that errors will occur in any arena which relies on human decision-making and task completion, those errors will clearly fall into a wide range when it comes to severity. As in other high risk professions (aviation, military, law) it can be difficult in medicine to determine which errors will lead to which outcomes. Errors that are large in terms of scope (wrong-sided surgery, widely inaccurate drug amounts) can result in negligible consequences, while seemingly small errors (tiny dose changes, forgetting to schedule follow-ups, missed physical exam findings) can result in permanent complications including death. The effect of these errors is magnified by a host of factors, including allergies, patient sensitivity to medication, drug-drug interactions, and the layers of support surrounding an individual patient. A specific error can have no effect on a patient for thousands of cases but then lead to death under perfectly unfortunate circumstances.
For this reason, it is important to collect a record of as many medical errors as possible, and then determine what (if any) the extent of their impact on patient health may have been.
To this end, the British Medical Journal defines medical error as:
– an unintended act of omission or commission
– an act that does not achieve its intended outcome
– errors of execution, in which a planned action is not completed as originally intended
– using the wrong plan to achieve a specific goal
– a deviation from standard of care or an established care process.
All of these can be considered medical error whether or not they cause harm to a patient. And with such a broad definition they occur quite frequently.
Systems vs. Individuals
For generations of private practitioners, preventing medical error came down to the provider. And while the onus of safe medical care often remains with providers due to their face-to-face relationship, medical error prevention has now become a major systems issue. With medical systems that span many hospitals, clinics, and thousands of providers, there is now tremendous potential to record and prevent untold cases of medical error.
To this end, it is crucial to face this news of potentially increasing volume of death from medical errors, continue to study it, and use that knowledge toward prevention of future incidents. Now, individual providers have the ability to prevent medical errors on a personal level as well as a systems level through involvement, advocacy and QI research.
The medical community has been slow to wade into the e-cigarette conversation, taking a hesitant stance that often boils down to “let’s wait and see, but we know smoking is bad for your health.” For many clinicians, a lack of scientific data and well-designed clinical trials have prevented them from taking a position on this no-longer-new trend. Now, some experts are saying that it is time to be realistic about the way people are using e-cigarettes to quit smoking, regardless of our amount of clinical knowledge.
Addiction specialists like Ann McNeill, PhD of King’s College London are recommending that “It would be foolish for clinicians to ignore this new technology.” Rather than focusing on the unknown risks of e-cigarettes, it may now be time to harness this option that may patients have already used to quit. In her words, “by encouraging smokers to use whatever support that is available to stop smoking, including e-cigarettes, clinicians will be helping to ensure that tobacco cigarettes and smoking and the associated massive mortality and morbidity burden become obsolete within our lifetime.”
What We do Know
In a realm of such wild confusion and aggressive advertising, it can be hard to wade into the piles of information and focus in on what we do know about e-cigarettes. A 2015 Cochrane review did show that e-cigarettes were significantly better at helping patients quit than placebo e-cigarettes. They are also the most popular method of smoking cessation in many countries.
While it is not yet possible to know the long-term effects of using these products, the currently postulated relative risk is about 5% that of smoking tobacco cigarettes. Much of this benefit comes from the delivery method, which involves the use of water vapor rather than smoke, eliminating many of the particulates which are carcinogenic and produce inflammation. This delivery method also offers the benefit of adjustability, as these devices may be able to be improved to reduce health risk as more research is conducted.
The Importance of PCP Interaction
Primary care providers play a huge role in many patients’ decisions to eventually quit smoking cigarettes. Studies have shown that the advice of their clinicians is a major factor for many patients. As provider know, just a few minutes can arm their patients with the tools needed to quit smoking, often considered one of the most important choices patients can make to improve their health.
While we are still far from having the necessary years of data to establish true safety and risk profiles for e-cigarettes, the preliminary research shows that the risk is drastically lower that continuing to use tobacco. Furthermore, patients have already shown a strong interest in this cessation method without the recommendations of the medical community. By wading into the discussion and possibly even embracing e-cigarettes as a powerful cessation tool, providers may be able to help patients who would not respond to traditional cessation devices. Each provider will need to evaluate the data for themselves and decide how they would like to approach this undeniable new aspect to the tobacco conversation.
For most mental health providers, one of the hardest aspects of caring for patients is gaining their trust. These patients have concerns that are often much harder to discuss openly than patients managing other chronic diseases like diabetes or hypertension. It is in this area that primary care providers have an immense advantage with their established patients: they have already earned a trusted role. Patients may feel comfortable with quickly jumping into deep waters thanks to a long-term clinical relationship, rather than building trust over the course of several appointments with a new provider.
With this trusted relationship comes an obligation for screening and appropriate referral to mental health specialists. For many patients, seeing a specialist outside a family practitioner feels like a big step, and knowing when to recommend that service is an important part of the primary care provider role.
An Invaluable Screening Step
Many patients attach stigma to seeing a mental health provider, but will more comfortably discuss their mental health concerns with a primary care provider. “Just” talking to your PCP can feel much less overwhelming than it might to talk with a specialist. “Patients who would never go to a counselor or a psychiatrist may trust their family physician with their mental health problems,” attests J. McBride, PhD, MPH, who serves as the director of behavioral medicine at Floyd Medical Center Family Medicine Residency in Rome, Georgia. “I think most family physicians have an orientation toward incorporating the mental health care of their patients and have had to become the mental health providers in our health care system.”
However, this can represent a significant challenge for the busy PCP. Rather than having an entire 20 or 40 minute appointment to discuss mental health issues, PCPs often feel like they are shoehorning in the depression and anxiety discussions around other chief complaints. And many patients are hesitant to schedule follow-up appointments specifically for these mental health concerns because they don’t want them to be that important.
The One-Minute Mental Health Checkup
Taking the time in each visit to check in with your patient’s mental health can have a major impact in the long run. This is one area in which the primary care provider can take advantage of their strengths – multiple visits over the span of many years for a variety of reasons. Checking in about any known issues (depression, anxiety, suicidality) can mean a lot to patients and helps providers and patients alike grow more comfortable discussing these issues.
For patients without a known history of mental health concerns, screening can easily take the form of getting to know patients better. Asking about home life, work life, current stressors can help you get to know patients more intimately and also screen for depression, anxiety, PTSD, or a history of abuse. And as always, documenting these discussions is absolutely crucial to growing your knowledge about a patient’s situation, and makes it so much easier to reference at the next appointment which reviewing their chart.
Two of the most commonly used medications in the world may have a new and surprising risk when used together. Widely considered safe, NSAIDs (aspirin, ibuprofen and naproxen) represent some of the most commonly used and prescribed medications in modern medicine. Likewise, antidepressants (such as Prozac, Zoloft and Paxil) are taken by millions of Americans with excellent results. Yet newer research may show that taking these medications together greatly increases your risk of a brain bleed, also known as a hemorrhagic stroke. And the damage from these bleeds can range from temporary to deadly.
The Danger Window
A study performed by Dr. Byung-Joo Park in South Korea shows that there is a significant increase in the number of brain bleeds patients experienced within the first thirty days of taking these two types of medication in combination. This study was particularly powerful, as it was able to draw from South Korea’s nation-wide health database of more than four million patients. It also showed men also had twice the risk of developing these bleeds as women.
This increased risk was seen in patients who were taking chronic NSAIDs and then started a new antidepressant, as well as those who were on a chronic antidepressant and then started taking NSAIDs. They monitored the number of people who were admitted to the hospital within a 30 day period after patients started taking the two drugs in combination. This effect is believed to be due to the way that the two drugs interact with each other, as they can increase each other’s effects. NSAIDs are well known to cause gastric (stomach and intestinal) bleeding with long-term use, and to slow down the blood’s ability to clot, but these effects on brain bleeds have not been as well described.
What Does it Mean for Patients?
One of the hardest aspects of this finding is that patients who chronically take pain medications like NSAIDs often suffer from depression, and vice versa. According to one study, as many as 65% of those with depression suffer from chronic pain, and the numbers are likely even higher going the other way. This makes it particularly difficult for those patients who would truly benefit from using both of these medications.
While this may not prevent patients from taking either of these medications given their prevalence and effectiveness, it may make providers consider other options. For those requiring depression management, other pain control methods may be pursued, such as Tylenol, physical therapy or osteopathic manipulation therapy. Behavioral health and individual therapy are also highly effective alternatives. In addition, it may mean that providers will need to be more thorough about taking a bleeding risk history as patients begin these medications in conjunction. Those with other risk factors, such as a family history of bleeding or clotting, current anticoagulation, or a personal history of a bleeding event may not be good candidates for these therapies at all.
Long heralded anecdotally as “the best medicine,” laughter maintains a nebulous position in the medical literature. While it is unlikely to be able to cure cancer, as some proponents have maintained, it does seem to be connected to health, and most certainly has an impact on a person’s stress and anxiety levels. So while it won’t necessarily let you stop taking your daily medications, adding a little more laughter to your day may be helpful in improving your overall health.
The Known Benefits of Laughter
According to the Mayo Clinic, laughter does more than just make you “feel good.” It actually improves your health in the process through a series of physical changes. One of the main ways this can be felt is through the release of extra endorphins, the hormonal pleasure chemicals normally sent by your brain during sex, eating or other pleasurable activities. This chemical release is one of the main reasons that people enjoy laughing, and contributes to the urge to watch comedy movies or attend comedy events. These endorphins can also contribute to pain relief, helping those with pain feel better with less need for pain medicine.
In addition, the act of laughing makes your body’s stress response engage and then release, which contributes to a feeling of relief and relaxation. Your heart rate and blood pressure increase and then return to normal, giving you the sensation of something exciting happening to you. This activation and release actually reduces overall stress, promoting circulation and improving your overall muscle relaxation. It can decrease the effects of depression and anxiety and help you navigate the world around you with greater control. It can also improve your immune system response through the release of neuropeptides that fight stress but also protect you from more serious illnesses.
Laughter has been the subject of much research and many unresearched claims. While the benefits listed above have been well proven, other claims may have only anecdotal evidence behind them. While laughter alone is not able to cure cancer, as some suggest, it may be very effective at improving a patient’s outlook during their cancer treatment, and can strengthen their immune system and improve their treatment response.
One very famous example of the anecdotal benefits of laughter is Norman Cousins’ book Anatomy of an Illness: as Perceived by a Patient, in which he treats his pain successfully with Marx Brothers comedies and Vitamin C in 1964. This has been proven in the scientific literature, including in one study which showed that patients who watch a comedy had improved pain tolerance afterwards, while those who were exposed to a drama or a documentary actually had a reduced pain tolerance. Food for thought during Oscar season…
The research community has made it clear: the ambulatory clinic setting is full of opportunities to improve quality and safety. And while it may be difficult for many budget-conscious clinics to embrace recommendations with no immediate financial incentives, the benefits of improved safety and quality of care include long-term financial benefits. By keeping patients safer and improving the quality of their care, visit numbers and reimbursements should continue to improve.
Keeping it Simple
Addressing all the problems present in the ambulatory care environment is an overwhelming task in any clinic. Additionally, each clinic has its own unique set of problems, which may or may not be apparent initially. By breaking this overwhelming load of issues into manageable chunks, each clinic can take control of its own quality. In this way, clinic employees and management can feel optimistic and inspired about the way that they are taking control of the future of their own clinic.
As mentioned in previous articles in this series, the core of the ambulatory quality/safety philosophy is establishing ownership within small teams. These teams are expected to watch for, suggest, discuss, implement, and monitor initiatives for quality and safety improvement. This can dramatically impact each area of the clinic, and also fundamentally shift the culture of the clinic itself. As employees get used to watching for improvement opportunities, they will feel connected to the success of the clinic itself at each level. This is also protective against burnout and indifference toward portions of clinic operation that are broken or dysfunctional.
Watching for Common Safety Stumbling Blocks
Previous articles have discussed the many common safety and quality concerns that are most frequently seen in the ambulatory setting. Thanks to this ongoing research from the Department of Defense and others, we now know many of the areas that clinics can monitor initially to make the most dramatic improvement on safety and quality. These include delays in diagnosis, diagnoses that are missed altogether, medication errors, adverse drug events, issues with communication within teams and between patients and providers, and delays in patient care and preventative services.
Another important way to approach common errors is to think about the entire chain of care that patients experience, from the time they first hear about the clinic until they pay their final bill. Errors that contribute to decreased quality of care and patient safety can occur at any point along this chain of care. The best way to prevent these errors is to study each point of the chain specifically, utilizing those who are most familiar with the way that it operates. This study can be used to label the most common errors that occur at that point of care, and predict other possible errors to be avoided. By utilizing these and other preventative measures, clinics can take control of the quality and safety of their ambulatory care center.
As further study is done on the improvement of efficiency and safety in ambulatory care, the Department of Defense and other institutions have been able to identify several proven ways of enhancing care across a range of clinic types and specialties. Here are six of the most helpful:
SBAR: the Structured Handoff: One of the areas of greatest risk for patient care is the handoff from provider to provider. Whether occurring between specialties, across shifts or at the end of a provider’s career, the handoff is a crucial area where patient details can fall through the cracks. By adopting a structured handoff option, these risks can be mitigated and the process can even be streamlined. SBAR (Situation, Background, Assessment, Response) can be used to rapidly express the following: Situation: their current clinic presentation, Background: their relevant medical health history, Assessment: their current differential diagnosis, Response: their current plan of active medical care.
Team Briefs: Just as pilots give a brief before each flight, medical care teams can benefit from a team message when a new week begins, before a specific shift, or before a specific procedure. This standardized message template can cover all the important topics of the day, and can be updated as needed for each unique situation. This can help ensure that fewer things fall through the cracks, and that there is a standardized method of information distribution.
Team Huddles: Team huddles are a crucial aspect of patient care when there are a range of patient and providers involved with varying levels of experience. A provider may not have met a patient, but the patient care staff may be very familiar with them and can offer some insight. These huddles can be done at the start of the shift with the entire patient care staff in a particular clinic team, and can also be very helpful between each provider and their patient care staff for that particular shift. This can help things get done in advance and avoid delays.
Team Debriefs: Regular, scheduled debrief time is crucial for the distribution of relevant feedback. If there is time built in for debrief after every shift or every week, it becomes much easier for perceived concerns to be voiced and addressed in a timely manner. When things have to be addressed only at an individual’s discretion, only the most serious concerns will be voiced, and often after much time has passed. Scheduled debrief sessions can help suss out feedback of various levels of importance and with greater clarity and detail.
Closed loop communication: As the medical environment advances with technology, it has become standard for most orders and much of the communication to be sent electronically. Though this is quite convenient, it is important for these communication loops to be closed, meaning that the person sending the information receives a response from the person receiving it to know that it will be carried out. This can take many forms, but must be adopted in a variety of ways throughout the clinic environment for the best possible care.
Clinical team leaders and mentors: One of the most important aspects of long-term health and vitality of an ambulatory clinic is the establishment of clinic leaders and mentors. These leaders will often naturally emerge, but they may need to be assigned as well when there is no clear leader for an initiative or aspect of clinic management. Supporting these leaders is crucial, and mentorship may be an excellent way to ensure this. Both informal and formal mentorship relationships should be encouraged, and having an established mentorship program which participants may opt out of is often considered the standard.
The problems of quality and safety in the ambulatory care environment have received significant attention from government and non-government research entities in recent years. Some of the major players currently are the Joint Commission, the American College of Physicians, the National Quality Forum, and the Institute of Healthcare Improvement. One of their major findings was that taking a team-based approach to these issues can have a large impact on a clinic’s performance.
Three Ways to Address Quality and Safety with a Team Approach
Teamwork as Science: While perhaps not heavily studied in traditional scientific investigation, the importance of team effectiveness and communication is now coming forward as a scientifically provable and fundamental aspect of knowledge gathering. For example, recent changes in one study of ambulatory centers (the Safety Attitudes Questionnaire) has given researchers additional insight into the dynamics and culture of the medical clinic and office. As a result of these changes, experts in teamwork and workplace dynamics are now partnering with medical professionals, providers and clinic managers. Three major areas of study in this field are team performance, system/reliability theory, and the science of human factors.
Improvement Teams: Rather than tasking the entire clinic with improving the entire clinic, an overwhelming and difficult job, it has been shown to be far more effective to use smaller teams for smaller projects. Interdisciplinary teams composed of team members of all specialities can be used to follow the PDSA model. Plan, Do, Study, Act has been shown to be an effective and repeatable model for improving care in the ambulatory setting. A specific problem is brought before the small group through a brainstorming session, various ideas are suggested, one idea is settled on and discussed, and then a plan is made. This plan is typically implemented in one smaller area of the clinic if possible prior to implementation clinic-wide, to serve as a controlled study environment. These plans can be followed for 3-6 months depending on the specific plan, and then implemented for the whole clinic if found to be helpful.
Care Provision Teams: In addition to the improvement teams, which focus primarily on clinic processes and care plans, care provision teams can be used to focus specifically on patient populations that may benefit from additional attention. Team members of various specialties can come together to focus on improving the care of their clinic’s patients with a specific chronic disease or situation, such as diabetes, heart failure or high-risk OB care. The actions and structure of these teams can vary significantly depending on the specific patient population of focus. Several care provision teams can be used to give the best possible care clinic-wide.
Ambulatory clinics across the country see more than a billion visits each year (+4 visits per person), an incredible volume of patient interactions. Possibly as a result of the low acuity of many of these interactions, the ambulatory setting has not been held to the same sort of quality improvement and standardization expectations as the inpatient environment. And yet, even if the majority of ambulatory visits are fairly specific and low-risk, the incredibly high volume of these visits ensures that even events that occur rarely (missed diagnosis, unexpectedly high acuity presentations) can have a startling impact if not handled properly.
Four of the Most Common Safety and Quality Issues in the Ambulatory Clinic
Delays: Whether they occur due to patient factors, scheduling issues, clinical delays or provider error, delays at the various stages of treatment can have a major impact on patient health. At the most direct level, delays in the waiting room can decrease a patient’s willingness to be open with a provider, can cause the visit to be rushed, can increase the chance of error and can even lead to patients leaving without being seen. At the most extreme, patients who leave this way can be hesitant to seek care at other clinics, and can even be put on “no-show” lists at their home clinic which further delay their seeking care in the future. Delays at other levels of care, whether in scheduling or follow-up, can also cause problems to be missed, to not receive the proper amount of attention, or can lead to serious problems being dismissed through denial.
Missed diagnosis: While no provider is expected to be perfect, missed diagnosis is clearly a source of concern for patients, and with good reason. Over 50% of lawsuits brought as a result of ambulatory care concern the failure to diagnose conditions with significant repercussions, primarily cancer. These issues can occur as the result of poor judgement, inappropriate surveillance, insufficient knowledge, and even unclear handoffs between providers. While this problem in particular may seem overwhelming to understand, let alone address, by breaking it down into several different contributing factors, it becomes easier for clinics to face. In addition to ongoing education for providers, it is important to be aware of systemic issues, communication standards, information recording, and patient communication methods.
Communication breakdown: Communication is critical to the loose organization of the ambulatory setting. Without the rigid structure found in the hospital or ER, it is all too easy for things to fall through the cracks. Having standardized communication protocols for patient results, referrals, questions, and refills can help prevent these problems. Having a clear and permanently recorded communication chain from patient to staff to primary care provider to specialist can help smooth the flow of this information. In addition, there need to be protocols for communication with specialty laboratories, direct patient admissions to the hospital, and medical record transfers for new or outgoing patients.
Adverse Drug Events: The inappropriate prescription, refilling, or mixing of medications is a constant concern, and can lead to frustrating side effects, poor compliance, unnecessary hospital admissions and even death. One study of these ADEs showed an estimated 50 of these events for every 1,000 patient years in older patients. Though only 11% of these events were considered “preventable” by the study, that still represents a notable burden of care that could be improved for patients. The implementation of safeguards, double-checks and protocols can help prevent these ADEs, but the pressure to circumvent these safety measures to save time remains a strong factor for many providers.
We will discuss these, and many other potentially life-saving topics, in future installments of our Patient Safety Toolkit Series. Stay tuned!
Headaches don’t have to be debilitating or life-threatening when you can identify the cause. For so many patients, once the initial workup to rule out major pathology has been completed, it can be difficult to feel like their symptoms are important to anyone but themselves. After being labeled as “migraine with aura,” “cluster headache” or “atypical tension headache,” there is little incentive to hunt up another diagnosis which might fit the symptom set more completely and offer additional insight. In addition to this being frustrating, it can be deeply dangerous, as these headaches can be life-threatening.
Symptoms that Worsen with Postural Change
One of the headache red flags that healthcare providers may be less familiar with is the presence of an orthostatic component to a patient’s symptoms. These symptoms may be subtle, slowly increasing throughout the day as a person spends more time erect, or they may be dramatic, worsening when standing and improving quickly when laying down. While the dramatic symptoms may be easier to identify, both versions can be indicative of a unique headache cause: cerebrospinal fluid leak.
While far less common than the other worst-case headache scenarios, a CSF leak can have a range of presentations and outcomes. It can last a long time without worsening or can become life-threatening in an instant. When CSF leaks out of the dura through a small tear or hole, this can cause pressure changes in the brain that cause the symptoms of orthostatic headache. The staggering variance of these symptoms from this increased intracranial pressure are part of what makes this diagnosis so difficult, and can include:
These symptoms can also include vague neurological changes like unusual smells without a source, visual disturbances, areas of numbness or tingling on the skin, and metal tastes in the mouth.
Causes and More Confusion
Frustratingly, this CSF leak can occur for many reasons, some of them silent. The most commonly known and easily diagnosed cause is a known piercing of the dura, such as would occur during surgery of the brain or spine, or with an epidural or lumbar puncture. Another common cause is a bone spur or bony change such as occur during spinal damage via trauma or long-term degenerative disk disease. A third known cause is connective tissue disease, which may contribute to the dura being less resistant to damage or stretching from minor trauma. This third cause may be particular difficult for patients, as they may not know they suffer from this connective tissue disease until these symptoms present.
For patients concerned that they may be suffering from these debilitating symptoms as a result of a CSF leak, an expert in the newly growing field, Dr. Ian Carroll at Stanford, recommends spending an entire day laying down. Those with a CSF leak may find that they are symptom free all day as a result, and if the experience is dramatic, it’s a sign of a possible leak. Once diagnosed, these leaks can be repaired with specific patches and even dural glue that are specifically designed to seal these leaks. Dr. Carroll is actively searching for patients who may be suffering from these headaches, and has identified 26 such patients in the last six months alone. In his words, “Having lives derailed by intractable headaches is a tragedy, but it is a much greater tragedy when the person has an undiagnosed CSF leak that could be fixed easily if only recognized. We can help them be back at work and live life more fully.”
In this video Dr. Ian Carroll, discusses an often overlooked diagnosis for migraine, positional headache that can be treated.