Current issues in patient adherence and persistence: focus on anticoagulants for the treatment and prevention of thromboembolism

Warfarin therapy reduces morbidity and mortality related to thromboembolism. Yet adherence to long-term warfarin therapy remains challenging due to the risks of anticoagulant-associated complications and the burden of monitoring. The aim of this paper is to review determinants of adherence and persistence on long-term anticoagulant therapy for atrial fibrillation and venous thromboembolism. We evaluate what the current literature reveals about the impact of warfarin on quality of life, examine warfarin trial data for patterns of adherence, and summarize known risk factors for warfarin discontinuation. Studies suggest only modest adverse effects of warfarin on quality of life, but highlight the variability of individual lifestyle experiences of patients on warfarin. Interestingly, clinical trials comparing anticoagulant adherence to alternatives (such as aspirin) show that discontinuation rates on warfarin are not consistently higher than in control arms. Observational studies link a number of risk factors to warfarin non-adherence including younger age, male sex, lower stroke risk, poor cognitive function, poverty, and higher educational attainment. In addition to differentiating the relative impact of warfarin-associated complications (such as bleeding) versus the lifestyle burdens of warfarin monitoring on adherence, future investigation should focus on optimizing patient education and enhancing models of physician–patient shared-decision making around anticoagulation

Hazardous to your health: a novel approach to facilitating resident error reporting

BACKGROUND: Medical errors are frequently encountered by trainees but there is currently no standard curriculum for educating residents about medical errors. Morning report is a case-based peer-facilitated conference in which residents learn concepts in general internal medicine. We used our standard Chief Resident facilitated morning report to enhance resident learning about medical errors. PURPOSE: Evaluate house staff experiences with medical errors and to facilitate resident discussion, understating and reporting of medical errors using a morning report format. DESCRIPTION: Our Quality Chief Resident designed and led a 50-minute morning report by selecting 3 cases of medical errors that had occurred recently on the teaching service: (1) a missed diagnosis that did not result in harm, (2) a delay in initiation of antibiotic therapy due to prolonged administrative approvals, and (3) discovery of a previously unrecognized error by a colleague when the patient was transferred to another service. For each instance, relevant clinical aspects of the case were presented, followed by resident-lead small group discussions about the seriousness of the error, reporting obligations, patient disclosure, and provider emotions. A more formal discussion was then led by the Quality Chief and an attending hospitalist that included the following principles of patient safety and just culture: differentiating adverse events from medical error; harm and near miss; reporting obligations; ethics of disclosure; and the concept of second victim. 17/19 residents and 4/5 faculty attendees completed a voluntary anonymous survey at the end of the session. 88% of residents reported being involved in patient care when an error had occurred and 50% involved in an error with serious patient harm. 75% of residents had experienced emotional distress and 71% reported feelings of guilt related to patient errors. Only 47% reported any previous education about medical errors. Respondents self-reported confidence in reporting errors rose from 31% before the session to 77% reported after the conference. 88% of respondents found the session useful or very useful, and 93% recommended continuing these sessions in the future. CONCLUSIONS: Residents commonly encounter patient care errors which frequently result in feelings of emotional distress and guilt. A peer-led case-based morning report improved resident confidence in error reporting and was felt to be useful to surveyed attendees.\u2

Hazardous to your health: a novel approach to facilitating resident error reporting

Presented at Society of Hospital Medicine, 03/30/2015, National Harbor, MD.BACKGROUND: Medical errors are frequently encountered by trainees but there is currently no standard curriculum for educating residents about medical errors. Morning report is a case-based peer-facilitated conference in which residents learn concepts in general internal medicine. We used our standard Chief Resident facilitated morning report to enhance resident learning about medical errors. PURPOSE: Evaluate house staff experiences with medical errors and to facilitate resident discussion, understating and reporting of medical errors using a morning report format. DESCRIPTION: Our Quality Chief Resident designed and led a 50-minute morning report by selecting 3 cases of medical errors that had occurred recently on the teaching service: (1) a missed diagnosis that did not result in harm, (2) a delay in initiation of antibiotic therapy due to prolonged administrative approvals, and (3) discovery of a previously unrecognized error by a colleague when the patient was transferred to another service. For each instance, relevant clinical aspects of the case were presented, followed by resident-lead small group discussions about the seriousness of the error, reporting obligations, patient disclosure, and provider emotions. A more formal discussion was then led by the Quality Chief and an attending hospitalist that included the following principles of patient safety and just culture: differentiating adverse events from medical error; harm and near miss; reporting obligations; ethics of disclosure; and the concept of second victim. 17/19 residents and 4/5 faculty attendees completed a voluntary anonymous survey at the end of the session. 88% of residents reported being involved in patient care when an error had occurred and 50% involved in an error with serious patient harm. 75% of residents had experienced emotional distress and 71% reported feelings of guilt related to patient errors. Only 47% reported any previous education about medical errors. Respondents’ self-reported confidence in reporting errors rose from 31% before the session to 77% reported after the conference. 88% of respondents found the session useful or very useful, and 93% recommended continuing these sessions in the future. CONCLUSIONS: Residents commonly encounter patient care errors which frequently result in feelings of emotional distress and guilt. A peer-led case-based morning report improved resident confidence in error reporting and was felt to be useful to surveyed attendees

Perspectives on patient experience: A national survey of hospitalists

Despite efforts to improve patient experience (PX), little is known about the perspective of hospitalists regarding PX initiatives and priorities. A survey was distributed to hospitalist groups across the country assessing involvement in PX initiatives and their perceived effectiveness, what PX means to providers, and facilitators/barriers in improving PX. Ninety-nine percent of respondents had encountered some improvement activity around PX. The most prevalent were communication training, group Hospital Consumer Assessment of Healthcare Providers and Systems data, and interdisciplinary bedside rounding. Respondents rated most initiatives a 5 to 6 out of 10 for their effectiveness, with the perception of effectiveness increasing with respondents\u27 assessment of patient experience priority. Learning about others\u27 experiences in improving PX and learning about potential collaborations for quality improvement or research in these areas were areas of interest for future work. Qualitative work highlighted potential barriers in improving PX such as workload and staffing constraints, uncontrollable environmental factors, and unrealistic patient expectations. Improving PX is a priority, and there are many initiatives in place with perceived variable success and perceived barriers in improving PX