ASH Clinical News ACN_4.14_Full Issue_web | Page 154

FEATURE Medical Mistakes unexpected happens, they are prepared.” He antici- pates that a majority of institutions will have a CRP in place within the next few years. The Errors of Others Standardized CRPs among health-care facilities may help solve the problem of “pre-referral errors” or “interfacility medical errors” – mistakes that are picked up by downstream providers from different organizations. When errors are identified by providers who work in the same facility, there are clear ways of revealing and managing these issues: incident reporting, patient safety committees, root cause analyses, etc. Those mechanisms simply don’t exist between different facilities; there are no clear profes- sional norms regarding disclosure when physicians discover errors that were made at other institutions. “This is really not a problem that’s ever been explicitly defined or described in the literature, and there are no guidelines for what to do in these scenarios,” said Lesly Dossett, MD, MPH, assis- tant professor of surgery in the division of surgical oncology at the University of Michigan. Dr. Dossett has been exploring this gray area in her research. Her interest in this type of medi- cal error was born during her clinical fellowship at a major cancer center, when she noticed how often cases of mismanagement and misdiagnosis would come up during tumor boards. “Everyone would sit around discussing cases and say things like, ‘Wow, who would ever do that?’” she related to ASH Clinical News. “And I noticed that nobody disclosed the conversations to the patient or provided feedback to the referring physician. That bothered me.” When she delved deeper, she found that special- ists, in particular, seem to struggle with these conver- sations because they are unsure about what to do and they are uncomfortable providing negative feedback. Dr. Dossett said she was most intrigued by the fact that surgeons felt reticent to “project superior- ity,” according to interviews of cancer specialists from two National Cancer Institute–designated Cancer Centers. 10 “We’re specialists, which means we have years of extra training to be able to deal with those rare problems, and that’s why the patient was referred to us in the first place,” she said. “Yet, we don’t want to alienate our referral base, even when dealing with rare problems that generalists would not be expected to have much experience with.” Most specialists who participated in the interviews also expressed the belief that disclosure of medical errors “provided no benefit to patients and might un- necessarily add to their anxiety about their diagnoses or prognoses.” They often did not reveal mistakes to patients or only partially revealed mistakes. “Some participants expressed the belief that disclosure should come from the responsible physi- cian,” the authors reported. But, paradoxically, most respondents also noted that, “in many cases, they did not believe the responsible physician was aware of the error.” Interfacility errors aren’t just misses by referring physicians; they can take many forms, Dr. Dossett con- tinued. “It can happen when, say, I operate on some- body and forget to restart the anticoagulant before I discharge him or her. The patient has a stroke and ends up in an outside emergency department,” she said. “It’s the same type of problem and somebody needs to provide feedback to me that we made an error.” When Dr. Dossett and colleagues queried 30 specialists heavily reliant on external referrals about this issue, they learned that few respondents prac- ticed regular, explicit feedback, despite recognizing its importance. 11 Some cited time limitations and other structural barriers as obstacles, but the main barriers to providing feedback involved psychologi- cal discomfort, like fear of conflict, negativity, and jeopardizing future referrals. Medico-legal uncer- tainty and risk were also cited as hindering factors. “After conducting a comprehensive review of all the federal and state laws in Michigan to see if there would be any case law that would support a requirement for feedback, [we] found no case law that would justify a requirement for disclosure,” she added. Joseph Jacobson, MD, MSc, chief quality officer at the Dana-Farber Cancer Institute, said he only occasionally sees examples of pre-referral error of the type Dr. Dossett is studying but agreed that there is no structure or requirement for reporting such an event. “As far as I know, it doesn’t trigger a report to our board of registration in medicine or our depart- ment of public health,” he said. Dr. Dossett’s team also reviewed 130 ethics codes from large health-care societies like the American Medical Association and found that medical error was not included in their guidelines. “You are obligated to report a physician if you be- lieve he or she is acting fraudulently – overbilling and things like that – or is impaired,” Dr. Dossett said, “but, if he or she made an error, there is no obligation to report.” 12 Her team is now working on developing guide- lines to manage interfacility errors. “It’s a complex problem and I don’t have the answer yet, but I can tell you that every time I tell people this is what I’m doing, they launch into a story about a patient they saw the other week.” The Role of Health IT Beyond the mistakes of other providers, the poten- tial for system failures – especially during the refer- ral process – concerns Dr. Jacobson. Collecting all the primary data necessary for making an informed treatment recommendation can be challenging, and there is often a lingering worry that an important piece of clinical information isn’t available at the consultation. “When I speak to patients, one of their greatest fears is that many different specialists are involved in their care and they aren’t sure, for example, that the surgeon who told them they need an operation reached the recommendation based on review of all the data and input from the whole team,” Dr. Jacob- son recounted. While he doesn’t doubt that system failures occur, he said he lacks the information to speak about that risk with patients because those data are not collected. “We have not come up with reliable systems for communicating key data across institutions, and I think it’s possible that this can put patients at risk, either because of inadequate data available to make the treatment recommendation or inordinate delays that could adversely affect an outcome,” he said. Like checklists, electronic health records (EHRs) were once expected to revolutionize patient safety by eliminating medication errors and other communications failings. However, the benefits seen in earlier studies are not being borne out in real-world clinical settings. EHR usability is a major concern for patient safety, as shown in a recent study conducted in a pe- diatric patient population. 13 Of 9,000 patient safety reports from three health-care institutions made between 2012 and 2017 that were likely related to EHR use, 36 percent had “usability challenges” that contributed to a patient safety event, like a system defaulting to an incorrect date and time for a medi- cation order, which led to a missed dose. Research- ers estimated that nearly 19 percent of these might have resulted in patient harm. “EHRs in their current iteration, even within an organization, are inadequate communication tools,” said Dr. Jacobson. “EHRs can go either way,” said Lisa Hicks, MD, MSc, a staff hematologist at St. Michael’s Hospital and assistant professor at the University of Toronto and chair of ASH’s Committee on Quality. “Certainly, for standardization of medical order entry and drug order entry, we think they improve patient safety.” However, she added, “when EHRs are too oner- ous and create an increasing burden for physicians, there is a potential for them to increase burnout and increase the medical error rate.” Researchers from Pascal Metrics, a patient safety organization, found that EHRs could be used to predict patient harm before it happens. 14 They tested a method of extracting safety indicators from EHRs to identify harm and its precursors in two large commu- nity hospitals, finding that the EHR-based analytics tool detected and predicted harm in real time. Dr. Jacobson’s dream is a bit simpler. “At the top of my wish list is a simple, asynchronous, closed- loop communication system between key providers who have to weigh in on a therapeutic decision,” he commented. “In this type of system, I would know that when I sent Mrs. Jones to Dr. X my question would be answered, and that Dr. X had access to all the data that he needed at the time of the consulta- tion to render an opinion. We could all agree on the pathology and the imaging and sign off on the final treatment decision.” Ideally, he added, there would also be a means of sharing some details of the process with the patient. Human Error or System Failure? The topic of medical error got a big boost in the popular press with the publication of The Checklist Manifesto by Atul Gawande, MD, MPH, in 2009. Dr. Gawande – a surgeon, writer, researcher, and now CEO of the recently formed health-care ven- ture from Amazon, Berkshire Hathaway, and JP Morgan – differentiates two types of errors: errors of ignorance, or mistakes made because science has given us only a partial understanding; and errors of ineptitude, where the knowledge exists but was not applied appropriately. As science advances, he sug- gested, the balance has shifted from ignorance to ineptitude, leaving clinicians with simply too much to remember. It is the errors of ineptitude that Dr. Gawande targeted with checklists – tools long used in the avia- tion industry (and advocated for in the health-care industry) to avoid overreliance on memory, improve team communication, and formalize workflow. The approach reframes the discussion about medical mistakes, from one about “bad actors” to one about how systems can be made safer. In an expansion of the concept, in 2009, Dr. Gawande and colleagues tested implementation Continued on page 154 152 ASH Clinical News December 2018