Error Disclosure Training and Organizational Culture

Objective. Our primary objective was to determine whether, after training was offered to participants, those who indicated they had received error disclosure training previously were more likely to disclose a hypothetical error and have more positive perceptions of their organizational culture pertaining to error disclosure, safety, and teamwork. Methods. Across a 3-year span, all clinical faculty from six health institutions (four medical schools, one cancer center, and one health science center) in The University of Texas System were offered the opportunity to anonymously complete an electronic survey focused on measuring error disclosure culture, safety culture, teamwork culture, and intention to disclose a hypothetical error at two time points—both before (baseline) and after (follow-up) disclosure training was conducted for a subset of faculty. Results. There were significant improvements (all p-values \u3c .05) in the follow-up surveys compared with the baseline surveys for the following domains (percent refers to percent positives before and after, respectively): minor error disclosure culture (33 percent vs. 52 percent), serious error disclosure (53 percent vs. 70 percent), safety culture (50 percent vs. 63 percent), and teamwork culture (62 percent vs. 73 percent). Follow-up survey data revealed significant differences (all p-values \u3c .001) between faculty who had previously received any error disclosure training (n = 472) and those who had not (n = 599). Specifically, we found significant differences in culture (all p-values \u3c .001) between those who received any error disclosure training and those who did not for all culture domains: minor error disclosure (61 percent vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure (61 percent vs. 51 percent), safety (73 percent vs. 51 percent), and teamwork (78 percent vs. 66 percent). Significant differences also existed for intent to disclose an error (t = 4.1, p \u3c .05). We also found that error disclosure culture was significantly associated with intent to disclose for those who received previous error disclosure training, whereas all types of culture we measured were significantly associated with intent to disclose for those who did not receive error disclosure training. Conclusions. Error disclosure, teamwork, and safety culture all improved over a 3-year period during which disclosure training was provided to key faculty in these six institutions. Self‑reported likelihood to disclose errors also improved. The precise impact of the training on these improvements cannot be determined from this study; nevertheless, we present an approach to measuring error disclosure culture and providing training that may be useful to other institutions

What\u27s going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process

OBJECTIVES: Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a good diagnostic process (DxP). METHODS: We evaluated patient/family feedback on what\u27s going well as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words. RESULTS: In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %). CONCLUSIONS: Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP

Partnering with Patients and Families to Improve Diagnostic Safety through the OurDX Tool: Effects of Race, Ethnicity, and Language Preference

BACKGROUND: Patients and families at risk for health disparities may also be at higher risk for diagnostic errors but less likely to report them. OBJECTIVES: This study aimed to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage patients and families in the diagnostic process (DxP). METHODS: Cross-sectional study of 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, codeveloped and tested with patients and families. Prior to each visit, patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns. We used logistic regression to determine factors associated with patient-reported diagnostic concerns. We conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note. RESULTS: Participants provided a similar mean number of contributions regardless of patient race, ethnicity, or language preference. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70; 95% confidence interval [CI]: [1.18, 2.43]) or other race (OR: 1.48; 95% CI: [1.08, 2.03]) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53; 95% CI: [1.78, 3.59]. There were no significant differences in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference. CONCLUSION: Participants self-identifying as Black or other race, or those who prefer a language other than English were 1.5 to 2.5 times more likely than their counterparts to report potential diagnostic concerns when proactively asked to provide this information prior to a visit. Actively engaging patients and families in the DxP may uncover opportunities to reduce the risk of diagnostic errors and potential safety disparities

Partnering With Patients and Families Living With Chronic Conditions to Coproduce Diagnostic Safety Through OurDX: A Previsit Online Engagement Tool

OBJECTIVE: Patients and families are key partners in diagnosis, but methods to routinely engage them in diagnostic safety are lacking. Policy mandating patient access to electronic health information presents new opportunities. We tested a new online tool ( OurDX ) that was codesigned with patients and families, to determine the types and frequencies of potential safety issues identified by patients/families with chronic health conditions and whether their contributions were integrated into the visit note. METHODS: Patients/families at 2 US healthcare sites were invited to contribute, through an online previsit survey: (1) visit priorities, (2) recent medical history/symptoms, and (3) potential diagnostic concerns. Two physicians reviewed patient-reported diagnostic concerns to verify and categorize diagnostic safety opportunities (DSOs). We conducted a chart review to determine whether patient contributions were integrated into the note. We used descriptive statistics to report implementation outcomes, verification of DSOs, and chart review findings. RESULTS: Participants completed OurDX reports in 7075 of 18 129 (39%) eligible pediatric subspecialty visits (site 1), and 460 of 706 (65%) eligible adult primary care visits (site 2). Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. In total, probable DSOs were identified by 7.5% of pediatric and adult patients/families with underlying health conditions, respectively. The most common types of DSOs were patients/families not feeling heard; problems/delays with tests or referrals; and problems/delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. CONCLUSIONS: OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients/families identified DSOs and most of their OurDX contributions were included in the visit note

Erosion of Digital Professionalism During Medical Students’ Core Clinical Clerkships

Background: The increased use of social media, cloud computing, and mobile devices has led to the emergence of guidelines and novel teaching efforts to guide students toward the appropriate use of technology. Despite this, violations of professional conduct are common. Objective: We sought to explore professional behaviors specific to appropriate use of technology by looking at changes in third-year medical students’ attitudes and behaviors at the beginning and conclusion of their clinical clerkships. Methods: After formal teaching about digital professionalism, we administered a survey to medical students that described 35 technology-related behaviors and queried students about professionalism of the behavior (on a 5-point Likert scale), observation of others engaging in the behavior (yes or no), as well as personal participation in the behavior (yes or no). Students were resurveyed at the end of the academic year. Results: Over the year, perceptions of what is considered acceptable behavior regarding privacy, data security, communications, and social media boundaries changed, despite formal teaching sessions to reinforce professional behavior. Furthermore, medical students who observed unprofessional behaviors were more likely to participate in such behaviors. Conclusions: Although technology is a useful tool to enhance teaching and learning, our results reflect an erosion of professionalism related to information security that occurred despite medical school and hospital-based teaching sessions to promote digital professionalism. True alteration of trainee behavior will require a cultural shift that includes continual education, better role models, and frequent reminders for faculty, house staff, students, and staff

Developing the Improving Post-event Analysis and Communication Together (IMPACT) Tool to Involve Patients and Families in Post-Event Analysis

The analysis of harmful errors is typically led by a team within the hospital and includes clinicians and staff who were involved at the time of the event. However, the patient and family are often left out of this process and are not asked to participate in the investigation. Because little guidance is available for facilitating patient input, an interprofessional team convened to develop a semi-structured tool to be used in eliciting patient feedback. Some 72 persons who had experienced adverse events were interviewed. Using a thematic analysis approach, the team learned that 51% of the interviewees preferred to participate in event analysis directly through an interview and 47% recommended that patients and families should be offered the opportunity to provide their views immediately (within 24-48 hours of the event). The resulting tool, IMPACT, incorporates a conversational flow of questions that allows patients to tell their story, focus their attention on specific causative factors, and give recommendations to improve healthcare in their institutions or to prevent further harm

Error Disclosure Training and Organizational Culture

Objective. Our primary objective was to determine whether, after training was offered to participants, those who indicated they had received error disclosure training previously were more likely to disclose a hypothetical error and have more positive perceptions of their organizational culture pertaining to error disclosure, safety, and teamwork. Methods. Across a 3-year span, all clinical faculty from six health institutions (four medical schools, one cancer center, and one health science center) in The University of Texas System were offered the opportunity to anonymously complete an electronic survey focused on measuring error disclosure culture, safety culture, teamwork culture, and intention to disclose a hypothetical error at two time points—both before (baseline) and after (follow-up) disclosure training was conducted for a subset of faculty. Results. There were significant improvements (all p-values \u3c .05) in the follow-up surveys compared with the baseline surveys for the following domains (percent refers to percent positives before and after, respectively): minor error disclosure culture (33 percent vs. 52 percent), serious error disclosure (53 percent vs. 70 percent), safety culture (50 percent vs. 63 percent), and teamwork culture (62 percent vs. 73 percent). Follow-up survey data revealed significant differences (all p-values \u3c .001) between faculty who had previously received any error disclosure training (n = 472) and those who had not (n = 599). Specifically, we found significant differences in culture (all p-values \u3c .001) between those who received any error disclosure training and those who did not for all culture domains: minor error disclosure (61 percent vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure (61 percent vs. 51 percent), safety (73 percent vs. 51 percent), and teamwork (78 percent vs. 66 percent). Significant differences also existed for intent to disclose an error (t = 4.1, p \u3c .05). We also found that error disclosure culture was significantly associated with intent to disclose for those who received previous error disclosure training, whereas all types of culture we measured were significantly associated with intent to disclose for those who did not receive error disclosure training. Conclusions. Error disclosure, teamwork, and safety culture all improved over a 3-year period during which disclosure training was provided to key faculty in these six institutions. Self‑reported likelihood to disclose errors also improved. The precise impact of the training on these improvements cannot be determined from this study; nevertheless, we present an approach to measuring error disclosure culture and providing training that may be useful to other institutions

Challenging Conversations in Healthcare: Simulation-Based Interprofessional Learning

Introduction: Interprofessional education is central to the mission of the Institute for Professionalism and Ethical Practice, based at Boston Children's Hospital and affiliated with Harvard Medical School. The Institute’s Program to Enhance Relational and Communication Skills (PERCS) offers simulation-based interprofessional workshops designed to help trainees and practitioners engage in challenging healthcare conversations across situations such as critical care, primary care, parent presence during resuscitation, spiritual distress, adverse medical outcomes, informed consent, organ donation, and others.Objective: To describe the pedagogy, recruitment statistics and sustained participant outcomes of the Program to Enhance Relational and Communication Skills (PERCS).Methods: The pedagogical framework is based on creating safety for learning, emphasizing moral and relational aspects of care, suspending hierarchy to support interprofessional learning, honoring multiple perspectives, and valuing reflection and self-discovery. Programs bring together physicians, nurses, social workers, psychologists, chaplains and other healthcare professionals for a wide range of innovative educational offerings. Core learning occurs through live enactments of challenging conversations with professional actors portraying patients and family members, followed by guided debriefings that support individual and group reflection.Results: Approximately 3000 local, national and international professionals have participated since the program’s inception in 2002. PERCS workshop participants have reported a greater sense of preparation, confidence, improved communication and relational skills, and decreased anxiety when holding challenging healthcare conversations immediately following training and up to 12 months later. Benefits of the training were not related to discipline, level of experience or previous educational opportunities.Conclusions: Participants reported enhanced communication and relational skills. The program strives to develop relational competence in the healthcare world, including qualities of compassion, trust, and respect between clinicians and patients, and increased attention to interprofessional collaboration and knowledge sharing

Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions

Communication-and-resolution programs (CRPs) are intended to promote accountability, transparency, and learning after adverse events. In this article we address five key challenges to the programs’ future success: implementation fidelity, the evidence base for CRPs and their link to patient safety, fair compensation of harmed patients, alignment of CRP design with participants’ needs, and public policy on CRPs. While the field has arrived at an understanding of the core communication-and-resolution practices, limited adherence fuels skepticism that programs are meeting the needs of patients and families who have been injured by care or improving patient safety. Adherence to communication-and-resolution practices could be enhanced by adopting measures of CRP quality and implementing programs in a comprehensive, principled, and systematic manner. Of particular importance is offering fair compensation to patients in CRPs and supporting their right to attorney representation. There is evidence that the use of CRPs reduces liability costs, but research on other outcomes is limited. Additional research is especially needed on the links between CRPs and quality and on the programs’ alignment with patients’ and families’ needs. By honoring principles of transparency, quality improvement, and patient and family empowerment, organizations can use their CRPs to help revitalize the medical profession