Eric J Thomas

Publications of Eric J Thomas

• Error disclosure: a new domain for safety culture assessment.

  Authors: Jason M Etchegaray, Thomas H Gallagher, Sigall K Bell, Ben Dunlap, Eric J Thomas

  BMJ quality & safety. 05/2012;

  OBJECTIVE: To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establishOBJECTIVE: To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture. METHOD: All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure. RESULTS: The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05). CONCLUSIONS: The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.

• Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

  Authors: Jason M Etchegaray, Eric J Thomas

  BMJ quality & safety. 04/2012;

  ObjectiveTo examine the reliability and predictive validity of two patient safety culture surveys-Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPS)-whenObjectiveTo examine the reliability and predictive validity of two patient safety culture surveys-Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPS)-when administered to the same participants. Also to determine the ability to convert HSOPS scores to SAQ scores.MethodEmployees working in intensive care units in 12 hospitals within a large hospital system in the southern United States were invited to anonymously complete both safety culture surveys electronically.ResultsAll safety culture dimensions from both surveys (with the exception of HSOPS's Staffing) had adequate levels of reliability. Three of HSOPS's outcomes-frequency of event reporting, overall perceptions of patient safety, and overall patient safety grade-were significantly correlated with SAQ and HSOPS dimensions of culture at the individual level, with correlations ranging from r=0.41 to 0.65 for the SAQ dimensions and from r=0.22 to 0.72 for the HSOPS dimensions. Neither the SAQ dimensions nor the HSOPS dimensions predicted the fourth HSOPS outcome-number of events reported within the last 12 months. Regression analyses indicated that HSOPS safety culture dimensions were the best predictors of frequency of event reporting and overall perceptions of patient safety while SAQ and HSOPS dimensions both predicted patient safety grade. Unit-level analyses were not conducted because indices did not indicate that aggregation was appropriate. Scores were converted between the surveys, although much variance remained unexplained.ConclusionsGiven that the SAQ and HSOPS had similar reliability and predictive validity, investigators and quality and safety leaders should consider survey length, content, sensitivity to change and the ability to benchmark when selecting a patient safety culture survey.

• Acceptability of narratives to promote colorectal cancer screening in an online community.

  Authors: Kevin O Hwang, Amber W Trickey, Amanda L Graham, Eric J Thomas, Richard L Street, Jennifer L Kraschnewski, Sally W Vernon

  Preventive medicine. 03/2012;

  OBJECTIVE: To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community. METHOD: Members of online weight loss communityOBJECTIVE: To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community. METHOD: Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives. RESULTS: Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65). CONCLUSIONS: Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.

• The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU.

  Authors: Jochen Profit, Jason Etchegaray, Laura A Petersen, J Bryan Sexton, Sylvia J Hysong, Minghua Mei, Eric J Thomas

  Archives of disease in childhood. Fetal and neonatal edition. 03/2012; 97(2):F127-32.

  Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unitNeonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting. To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure. Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others. There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture. A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

• Electronic health record-based surveillance of diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Samuel N Forjuoh, Michael D Reis, Steven Kosmach, Myrna M Khan, Eric J Thomas

  BMJ quality & safety. 02/2012; 21(2):93-100.

  Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary careDiagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer. Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)). While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

• Structural social support predicts functional social support in an online weight loss programme.

  Authors: Kevin O Hwang, Jason M Etchegaray, Christopher N Sciamanna, Elmer V Bernstam, Eric J Thomas

  Health expectations : an international journal of public participation in health care and health policy. 01/2012;

  Background  Online weight loss programmes allow members to use social media tools to give and receive social support for weight loss. However, little is known about the relationship between the useBackground  Online weight loss programmes allow members to use social media tools to give and receive social support for weight loss. However, little is known about the relationship between the use of social media tools and the perception of specific types of support. Objective  To test the hypothesis that the frequency of using social media tools (structural support) is directly related to perceptions of Encouragement, Information and Shared Experiences support (functional support). Design  Online survey. Participants  Members of an online weight loss programme. Methods  The outcome was the perception of Encouragement (motivation, congratulations), Information (advice, tips) and Shared Experiences (belonging to a group) social support. The predictor was a social media scale based on the frequency of using forums and blogs within the online weight loss programme (alpha = 0.91). The relationship between predictor and outcomes was evaluated with structural equation modelling (SEM) and logistic regression, adjusted for sociodemographic characteristics, BMI and duration of website membership. Results  The 187 participants were mostly female (95%) and white (91%), with mean (SD) age 37 (12) years and mean (SD) BMI 31 (8). SEM produced a model in which social media use predicted Encouragement support, but not Information or Shared Experiences support. Participants who used the social media tools at least weekly were almost five times as likely to experience Encouragement support compared to those who used the features less frequently [adjusted OR 4.8 (95% CI 1.8-12.8)]. Conclusions  Using the social media tools of an online weight loss programme at least once per week is strongly associated with receiving Encouragement for weight loss behaviours.

• Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

  Authors: Michal Tamuz, Traber Davis Giardina, Eric J Thomas, Shailaja Menon, Hardeep Singh

  Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 10/2011; 6(8):445-52.

  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. WeInadequate 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. 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"). 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. 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.

• Neonatal intensive care unit safety culture varies widely.

  Authors: Jochen Profit, Jason Etchegaray, Laura A Petersen, J Bryan Sexton, Sylvia J Hysong, Minghua Mei, Eric J Thomas

  Archives of disease in childhood. Fetal and neonatal edition. 09/2011; 97(2):F120-6.

  Background Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giverBackground Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics. Methods NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU. Results There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%-80% positive; mean 33.3%) and stress recognition (18%-61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel. Conclusion There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.

• Exploring situational awareness in diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Laura A Petersen, Michael W Smith, Lindsey Wilson Paul, Key Dismukes, Gayathri Bhagwath, Eric J Thomas

  BMJ quality & safety. 09/2011; 21(1):30-8.

  Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs),Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research. A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process. Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management. A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.

• Improving erythropoietin-stimulating agent administration in a multihospital system through quality improvement initiatives: a pre-post comparison study.

  Authors: Mano S Selvan, Dean F Sittig, Eric J Thomas, Cody C Arnold, Robert E Murphy, M Michael Shabot

  Journal of patient safety. 06/2011; 7(3):127-32.

  : Erythropoietin-stimulating agent (ESA) use is associated with serious adverse events in patients with hemoglobin levels of 12 g/dL or higher at the time of administration. Our aim was to determine: Erythropoietin-stimulating agent (ESA) use is associated with serious adverse events in patients with hemoglobin levels of 12 g/dL or higher at the time of administration. Our aim was to determine whether inappropriate ESA use has changed over time since the implementation of new drug warning alerts and local quality improvement initiatives. : We performed a retrospective review of ESA administration practices at Memorial Hermann Healthcare System (Houston, Tex). Our primary outcome measure was the proportion of inpatient encounters (one entire inpatient hospital stay) with 1 or more inappropriate uses of ESA (defined as ESA administration for a patient with hemoglobin ≥12 g/dL). We analyzed the potential influence of local and national interventions on ESA utilization patterns. : Between May 1, 2006, and May 31, 2009, 15,642 inpatients were treated with ESAs in our system. We classified inpatients as before intervention (n = 6350) and after intervention (n = 9292) based on the date of implementation of a synchronous alert in the electronic medical record. We found a significant decrease in inappropriate ESA administration before to after intervention (9.03%-6.21%; P < 0.001), which can be translated into a 31.25% (05% CI, 21.93%-40.75%) relative risk reduction. Reduced odds ratios for inappropriate ESA use changed little after controlling for relevant demographic variables and clinical characteristics. : Following several quality improvement interventions to improve patient safety related to ESA use, we found a significant reduction in inappropriate ESA administration to inpatients in a large health care system.

• Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system.

  Authors: Luisa Franzini, Kavita R Sail, Eric J Thomas, Laura Wueste

  Journal of critical care. 03/2011; 26(3):329.e1-6.

  The purpose of this study is to estimate the costs and cost-effectiveness of a telemedicine intensive care unit (ICU) (tele-ICU) program. We used an observational study with ICU patients cared forThe purpose of this study is to estimate the costs and cost-effectiveness of a telemedicine intensive care unit (ICU) (tele-ICU) program. We used an observational study with ICU patients cared for during the pre-tele-ICU period and ICU patients cared for during the post-tele-ICU period in 6 ICUs at 5 hospitals that are part of a large nonprofit health care system in the Gulf Coast region. We obtained data on a sample of 4142 ICU patients: 2034 in the pre-tele-ICU period and 2108 in the post-tele-ICU period. Economic outcomes were hospital costs, ICU costs and floor costs, measured for average daily costs, costs per case, and costs per patient. After the implementation of the tele-ICU, the hospital daily cost increased from $4302 to $5340 (24%); the hospital cost per case, from $21,967 to $31,318 (43%); and the cost per patient, from $20,231 to $25,846 (28%). Although the tele-ICU intervention was not cost-effective in patients with Simplified Acute Physiology Score II 50 or less, it was cost-effective in the sickest patients with Simplified Acute Physiology Score II more than 50 (17% of patients) because it decreased hospital mortality without increasing costs significantly. Hospital administrators may conclude that a tele-ICU program aimed at the sickest patients is cost-effective.

• Measuring social support for weight loss in an internet weight loss community.

  Authors: Kevin O Hwang, Allison J Ottenbacher, Joseph F Lucke, Jason M Etchegaray, Amanda L Graham, Eric J Thomas, Elmer V Bernstam

  Journal of health communication. 02/2011; 16(2):198-211.

  Although overweight and obese individuals are turning to Internet communities for social support for weight loss, there is no validated online instrument for measuring the subjective social supportAlthough overweight and obese individuals are turning to Internet communities for social support for weight loss, there is no validated online instrument for measuring the subjective social support experiences of participants in these communities. The authors' objective was to determine whether an online version of a validated paper questionnaire, the Weight Management Support Inventory, is appropriate for measuring social support among members of Internet weight loss communities. The authors administered the paper and online versions of the questionnaire in random, counterbalanced fashion to 199 members of a large Internet weight loss community. Scores for the paper and online versions were comparable in between-subjects and within-subjects comparisons. Convergent validity is suggested by the finding that participants who posted messages on Internet forums several times per day reported more social support than those who posted less frequently. However, the instrumental (tangible) support items did not load significantly on the instrumental support factor, suggesting that instrumental support is not relevant to the social support exchanged among participants in these communities. The authors conclude that the online, modified Weight Management Support Inventory, without items for instrumental support, is an appropriate instrument for measuring social support for weight loss among members of Internet weight loss communities.

• Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3?

  Authors: Derek W Meeks, Kevin P Lally, Matthew M Carrick, Debbie F Lew, Eric J Thomas, Peter D Doyle, Lillian S Kao

  American journal of surgery. 01/2011; 201(1):76-83.

  the purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals. chart review and analysis of laparotomythe purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals. chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ). overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance. interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.

• The reply.

  Authors: Hardeep Singh, Laura A Petersen, Eric J Thomas, Lindsey Wilson, Dean F Sittig

  The American journal of medicine. 10/2010; 123(10):e21.

• A tale of 2 hospitals: a staggered cohort study of targeted interventions to improve compliance with antibiotic prophylaxis guidelines.

  Authors: Lillian S Kao, Debbie F Lew, Peter D Doyle, Matthew M Carrick, Victoria S Jordan, Eric J Thomas, Kevin P Lally

  Surgery. 08/2010; 148(2):255-62.

  The purpose of this prospective study was to determine the effectiveness of targeted interventions to improve compliance with antibiotic prophylaxis guidelines (timing, spectrum, and discontinuation)The purpose of this prospective study was to determine the effectiveness of targeted interventions to improve compliance with antibiotic prophylaxis guidelines (timing, spectrum, and discontinuation) at 2 university-affiliated hospitals. Based on barriers identified previously, hospital-specific interventions were developed such as educational conferences, standardized forms, an extended time-out, and feedback. Guideline compliance and surgical site infection (SSI) data were recorded on all patients who underwent elective laparotomies for colorectal procedures, vascular operations, and hysterectomies during four 6-month study periods. Prestudy data from July to December 2006 served as a baseline. One year later, a prospective cohort study was performed. The interventions were introduced to the 2 hospitals in a staggered fashion with 2-month implementation periods before reassessing compliance during the 6-month study periods. General linear modeling was performed (P < .05 significant). Compliance with all 3 guidelines combined improved during the year preceding the study, after attention only, at both hospitals. Hospital-specific differences were found in the effectiveness of the intervention package on individual guidelines. Hospital 2 but not 1 improved in timing after the interventions; both hospitals improved in spectrum, and neither hospital improved in discontinuation. Overall compliance with all 3 antibiotic prophylactic measures was greater at hospital 1, but hospital 2 had lower SSI rates. Simply increasing attention to a quality problem can result in a significant and sustained improvement. Quality improvement interventions should be evaluated rigorously for effectiveness given hospital-specific differences in effectiveness and for correlation of guideline compliance with outcome.

• Errors of diagnosis in pediatric practice: a multisite survey.

  Authors: Hardeep Singh, Eric J Thomas, Lindsey Wilson, P Adam Kelly, Kenneth Pietz, Dena Elkeeb, Geeta Singhal

  Pediatrics. 07/2010; 126(1):70-9.

  We surveyed pediatricians to elicit their perceptions regarding frequency, contributing factors, and potential system- and provider-based solutions to address diagnostic errors. Academic, community,We surveyed pediatricians to elicit their perceptions regarding frequency, contributing factors, and potential system- and provider-based solutions to address diagnostic errors. Academic, community, and trainee pediatricians (N = 1362) at 3 tertiary care institutions and 109 affiliated clinics were invited to complete the survey anonymously through an Internet survey administration service between November 2008 and May 2009. The overall response rate was 53% (N = 726). More than one-half (54%) of respondents reported that they made a diagnostic error at least once or twice per month; this frequency was markedly higher (77%) among trainees. Almost one-half (45%) of respondents reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination, or chart review was the most-commonly reported process breakdown, whereas inadequate care coordination and teamwork was the most-commonly reported system factor. Viral illnesses being diagnosed as bacterial illnesses was the most-commonly reported diagnostic error, followed by misdiagnosis of medication side effects, psychiatric disorders, and appendicitis. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors. Pediatricians reported making diagnostic errors relatively frequently, and patient harm from these errors was not uncommon.

• Job satisfaction ratings: measurement equivalence across nurses and physicians.

  Authors: Jason M Etchegaray, J Bryan Sexton, Robert L Helmreich, Eric J Thomas

  Western journal of nursing research. 06/2010; 32(4):530-9.

  The measurement equivalence of job satisfaction ratings from physicians and nurses working in intensive care units was tested in the present study. Seventy-two nurses and 72 physicians completed theThe measurement equivalence of job satisfaction ratings from physicians and nurses working in intensive care units was tested in the present study. Seventy-two nurses and 72 physicians completed the Safety Attitudes Questionnaire, which contains five items about job satisfaction. Measurement equivalence across nurses and physicians of the job satisfaction ratings was examined via multiple-group confirmatory factor analysis. The results indicated that physicians and nurses use the same metric when providing ratings for this job satisfaction measure. The primary implication from the present study is that nurses and physicians conceptualize job satisfaction in a similar manner. This implication needs to be extended to other survey measures of interest to health services researchers. Future areas of research are discussed.

• Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

  Authors: Hardeep Singh, Eric J Thomas, Dean F Sittig, Lindsey Wilson, Donna Espadas, Myrna M Khan, Laura A Petersen

  The American journal of medicine. 03/2010; 123(3):238-44.

  Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examinedFollow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions. We studied 4 alerts: hemoglobin A1c > or =15%, positive hepatitis C antibody, prostate-specific antigen > or =15 ng/mL, and thyroid-stimulating hormone > or =15 mIU/L. An alert tracking system determined whether the alert was acknowledged (ie, provider clicked on and opened the message) within 2 weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (eg, patient contact, treatment). Multivariable logistic regression models analyzed predictors for lack of timely follow-up. Between May and December 2008, 78,158 tests (hemoglobin A1c, hepatitis C antibody, thyroid-stimulating hormone, and prostate-specific antigen) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%), and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs 10.1%; P =.13). Of 1163 alerts, 202 (17.4%) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (odds ratio 7.35; 95% confidence interval, 4.16-12.97), whereas alerts related to redundant tests were less likely to lack timely follow-up (odds ratio 0.24; 95% confidence interval, 0.07-0.84). Safety concerns related to timely patient follow-up remain despite automated notification of non-life-threatening abnormal laboratory results in the outpatient setting.

• Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

  Authors: Eric J Thomas, Amber L Williams, Eric F Reichman, Robert E Lasky, Sharon Crandell, William R Taggart

  Pediatrics. 02/2010; 125(3):539-46.

  Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with thePoor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects. Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity-simulated resuscitations for teamwork and resuscitation quality. High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%-37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030). Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.

• Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay.

  Authors: Eric J Thomas, Joseph F Lucke, Laura Wueste, Lisa Weavind, Bela Patel

  JAMA : the journal of the American Medical Association. 12/2009; 302(24):2671-8.

  Telemedicine technology, which can enable intensivists to simultaneously monitor several intensive care units (ICUs) from an off-site location, is increasingly common, but there is little evidence toTelemedicine technology, which can enable intensivists to simultaneously monitor several intensive care units (ICUs) from an off-site location, is increasingly common, but there is little evidence to support its use. To assess the association of remote monitoring of ICU patients (ICU telemedicine [tele-ICU]) with mortality, complications, and length of stay (LOS). Observational study conducted in 6 ICUs of 5 hospitals in a large US health care system to assess the use of tele-ICU. The study included 2034 patients in the preintervention period (January 2003 to August 2005) and 2108 patients in the postintervention period (July 2004 to July 2006). Hospital and ICU mortality, complications, and hospital and ICU survivors' LOS, with outcomes adjusted for severity of illness. Local physicians delegated full treatment authority to the tele-ICU for 655 patients (31.1%) and authority to intervene only in life-threatening events for the remainder. Observed hospital mortality rates were 12.0% (95% confidence interval [CI], 10.6% to 13.5%) in the preintervention period and 9.9% (95% CI, 8.6% to 11.2%) in the postintervention period (preintervention to postintervention decrease, 2.1%; 95% CI, 0.2% to 4.1%; P = .03); observed ICU mortality rates were 9.2% (95% CI, 8.0% to 10.5%) in the preintervention period and 7.8% (95% CI, 6.7% to 9.0%) in the postintervention period (preintervention to postintervention decrease, 1.4%; 95% CI, -0.3% to 3.2%; P = .12). After adjustment for severity of illness, there were no significant differences associated with the telemedicine intervention for hospital mortality (relative risk, 0.85; 95% CI, 0.71 to 1.03) or for ICU mortality (relative risk, 0.88; 95% CI, 0.71 to 1.08). There was a significant interaction between the tele-ICU intervention and severity of illness (P < .001), in which tele-ICU was associated with improved survival in sicker patients but with no improvement or worse outcomes in less sick patients. There were no significant differences between the preintervention and postintervention periods for hospital or ICU LOS. Remote monitoring of ICU patients was not associated with an overall improvement in mortality or LOS.