JAMA Performance Improvement: Do No Harm

Homeless patients with chronic medical conditions who need long-term care often repeatedly present to emergency departments to receive treatment. Following a performance improvement analysis, clinicians at UCSF developed an emergency department–based team who work with the community to provide care for this challenging population. Hemal Kanzaria, MD, and Jack Chase, MD, discuss how UCSF has addressed this clinical problem. Related Article(s) available here

There are hundreds of thousands of liver transplant patients, all of whom will be seen in general clinical practices. It is common for them to develop elevated liver enzymes—a potentially serious problem that may be a sign that the transplanted liver is failing. Traditionally, patients with these findings are sent to a liver transplant center for an inpatient workup. A new protocol facilitating management of most of these patients in routine outpatient clinics has been developed, greatly improving the efficiency of managing patients with this clinical problem. Fady Kaldas, MD, director of the Dumont-UCLA transplant center, discusses how to manage elevated liver function results in liver transplant patients on an outpatient basis. Related Article(s): Outpatient Management of Liver Function Test Abnormalities in Patients With a Liver Transplant

As physicians age, they experience the inevitable decline of cognitive and physical function. It is not clear how that affects clinical practice. Jeffrey Saver, MD, vice chair of neurology at UCLA and a JAMA Associate Editor, discusses how to best assess the clinical performance of aging physicians. The Aging Clinician: When Should Older Clinicians' Cognitive Abilities Be Evaluated?, Part 1 Read the article: Cognitive Testing of Older Clinicians Prior to Recredentialing

More than a third of the physician workforce is older than 60 years, and 10% are older than 70 years. Cognitive abilities may decline with age but how cognition affects clinical practice is unknown. It is also not clear how clinicians’ cognitive ability can be measured and acted upon when diminished without committing age discrimination. Two major academic hospitals launched programs to test cognitive abilities in older physicians applying for renewal of their medical staff privileges. It went well for one and not well for the other hospital. Yet, in the hospital where the testing program was carried out, several clinicians who were not suspected of having any problems had profoundly affected cognition. Leo Cooney, MD, from Yale-New Haven Medical Center, and Anne Weinacker, MD, from Stanford Health Care, discuss their experiences in dealing with these difficult issues. The Aging Clinician: When Should Older Clinicians' Cognitive Abilities Be Evaluated?, Part 2 Read the article: Cognitive Testing of Older Clinicians Prior to Recredentialing

Chaos in the emergency department is common. How to fix it is not always clear. Mary P. Mercer, MD, MPH, from the University of California, San Francisco, discusses how they successfully fixed their long dwell times at the emergency department at San Francisco General Hospital. Their solution was to create a fast-track unit that managed low-acuity patients separately from the rest of the emergency department cases. The most important aspect of this quality improvement effort was the ongoing and regular engagement of executives from the medical center with frontline staff. Read the article: Reducing Emergency Department Length of Stay

Electronic health records are the bane of most clinicians’ existence. They were supposed to help us but not only have they made life more difficult for clinicians, they are the cause of medical errors. Described here is a case of the patient receiving an unnecessary procedure because an order was not canceled in an EHR where it had disappeared from the clinicians’ view. A second theme in this case that is consistent in nearly all of the JAMA Performance Improvement articles to date is inadequate communication among clinicians.

One promise of electronic medical records (EMRs) was to reduce medication errors. That may not have occurred since one type of error, illegible orders, has been replaced by another: Order sets may incorrectly match a patient and necessary treatments. In this JAMA Performance Improvement podcast, we review a case in which guideline-based care was incorporated into an order set, then the guideline changed but the order set did not, resulting in a post-STEMI patient receiving β-blockers when they were contraindicated. Interviewees included Arjun Gupta, MD, University of Texas Southwestern Medical Center, and Jennifer L. Rabaglia, MD, MSc, Parkland Health and Hospital System, Dallas, Texas. Learning Objectives: To understand the role of β-blocker treatment in patients with acute myocardial infarction; to understand how EMR order sets should be developed and maintained. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2018.0845

One-third of the US population is obese. Obesity is a major risk factor for obstructive sleep apnea. This condition is very common, and patients with sleep apnea are at risk of major complications from sedation. This JAMA Performance Improvement podcast reviews a case of a patient who did poorly after he was sedated for a medical procedure. Interviewees include Joshua Pevnick, MD, MSHS, from Cedars-Sinai Medical Center, and Jason R. Farrer, MD, from Northwestern Medical Faculty Foundation. Related article: Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging

It is very easy to confuse drug concentrations and vials containing different amounts of drugs in the hospital setting. It is not uncommon to have dosing errors occur. In this podcast, we discuss how to manage an overdose of insulin and also how to implement preventive measures in the hospital environment to minimize the risk of drug dosing errors. Interviewees include Cynthia Barnard, PhD, MBA, MSJS, from Northwestern Memorial HealthCare, Lara K. Ellinger, PharmD, BCPS, from Northwestern Memorial Hospital, and Keith Hemmert, MD, from Northwestern Memorial HealthCare. Read the article: Insulin Dosing Error in a Patient With Severe Hyperkalemia

There are about 500 wrong-site surgeries performed in the United States every year. Simple maneuvers can minimize the risk for these occurring. This JAMA Performance Improvement podcast reviews a case of wrong-site surgery and discusses potential ways to avoid it. Interviewees include Armando Giuliano, MD, Harry Sax, MD, Kathryn Englehart, MD, and David Baker, MD, from The Joint Commission. Read the article: Wrong-Site Surgery Author Affiliations: Armando Giuliano, MD, Executive Vice Chairman, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles Harry C. Sax, MD, Executive Vice Chair, Administration Department of Surgery, Cedars-Sinai Medical Center, Los Angeles Kathryn Englehart, MD, Research Fellow, Department of Surgery, Northwestern University David Baker, MD, Executive Vice President, Division of Health Care Quality Evaluation, The Joint Commission

A patient was admitted to the hospital and got three times their normal dose of phenytoin resulting in phenytoin toxicity and a long hospital stay. Analysis of the error revealed problems with hospital organization, supervision issues and having an environment that facilitates errors. Errors don’t occur simply because one clinician makes a mistake—rather they occur because the hospital system fails to prevent them. Related article: Phenytoin Toxicity—A Significant Adverse Drug Event

A resident is asked to remove a drain that was placed in the lumbar space during an operation. Having never seen this sort of drain before not having removed one, the resident proceeded to remove the catheter. Several days later, the patient complained of persistent drainage. An 11-cm segment of retained catheter was removed. This JAMA Performance Improvement article discusses how to avoid this sort of problem as well as how to ensure that resident physicians have sufficient skills to perform procedures on their own. We talk with Drs Cynthia Barnhard, John DeLancey, authors of Retained Lumbar Catheter Tip, and Dr Aaron Reynolds and Dr David Baker. Related article: Retained Lumbar Catheter Tip

Latex allergy is common and usually benign but at times can be life-threatening. What can clinicians do to minimize the risk of serious complications attributable to latex allergy? We interview Cynthia Barnard, PhD, MBA, MSJS, and Erin Slade-Smith, MSN, RN, CNOR, both from Northwestern Memorial Hospital in Chicago, Illinois, and David W. Baker, MD, MPH, FACP, from The Joint Commission, to shed light on this serious issue. Article discussed in this episode: Management of a Patient With a Latex Allergy

Violence against health care workers is increasing. With fewer mental health services available, health care workers have disproportionate exposure to potentially dangerous patients. This article reviews the experience of one nurse who was severely injured by a patient and the lessons learned by the hospital where the incident occurred regarding minimizing the risk of staff injury when providing care for potentially violent patients. We interview Robert P. Roca, MD, MPH, MBA; Antonio DePaolo, PhD; Ernestine Cosby, RN; and Bolarin Kehinde, RN, to shed light on this serious issue. Article discussed in this episode: Ensuring Staff Safety When Treating Potentially Violent Patients

What to do when the wrong procedure is performed? In this first installment of JAMA Performance Improvement: Do No Harm we explore the options for dealing with this very difficult problem with Tami Minnier, RN, MSN, Paul Phrampus, MD, Linda Waddell, RN, MSN, and David Baker, MD, MPH, FACP. Air traffic audio courtesy of LiveATC.net, used with permission.