Cherri Hobgood

The American health care system has recently come under intense scrutiny for its response to an unac-ceptably high level of medical errors.1 The Institute of Medicine (IOM) has identified ''effective physi-cian communication'' of medical errors and ''unfet-tered patient access to ...

The American Board of Emergency Medicine (ABEM) convened a summit of stakeholders in Emergency Medicine (EM) to critically review the ABEM Maintenance of Certification (MOC) Program. The newly introduced American Board of Medical Specialties (ABMS) 2015 MOC Standards require that the ABMS Member Boards, including ABEM, "engage in continual quality monitoring and improvement of its Program for MOC …" ABEM sought to have the EM community participate in the quality improvement process. A review of the ABMS philosophy of MOC and requirements for MOC were presented, followed by an exposition of the ABEM MOC Program. Roundtable discussions included strengths of the program and opportunities for improvement; defining, teaching, and assessing professionalism; identifying and filling competency gaps; and enhancing relevancy and adding value to the ABEM MOC Program. Several suggestions to improve the ABEM MOC Program were discussed. ABEM will consider these recommendations when developing its next revision of the ABEM MOC Program.

Safety experts contend that to make incident reporting work, healthcare organizations must establish a "just" culture-that is, an organizational context in which health professionals feel assured that they will receive fair treatment when they report safety incidents. Although healthcare leaders have expressed keen interest in establishing a just culture in their institutions, the patient safety literature offers little guidance as to what the term "just culture" really means or how one goes about creating a just culture. Moreover, the safety literature does not indicate what constitutes a just incident reporting process in the eyes of the health professionals who provide direct patient care. This gap is unfortunate, for knowing what constitutes a just incident reporting process in the eyes of front-line health professionals is essential for designing useful information systems to detect, monitor, and correct safety problems. In this article, we seek to clarify the conceptual meaning of just culture and identify the attributes of incident reporting processes that make such systems just in the eyes of health professionals. To accomplish these aims, we draw upon organizational justice theory and research to develop a conceptual model of perceived justice in incident reporting processes. This model could assist those healthcare leaders interested in creating a just culture by clarifying the multiple meanings, antecedents, and consequences of justice.

... Department of Center for Care Innovation and Research Children's Hospitals and Clinics of Minnesota Minneapolis, Minnesota Amy C. Blackwell ... Anesthesiology and Program in Trauma University of Maryland School of Medicine Baltimore, Maryland Michael J. Yeoh, MBBS, DA ...

To determine if perceptions of interpersonal aspects of care in the emergency department (ED) vary by patient race/ethnicity. Patients in a tertiary care academic ED responded to a 22-question survey focusing on interpersonal care aspects: affiliation, satisfaction, trust and participation. Scores for each of the four generated scales were compared in terms of race, ethnicity and other basic demographics. African-American patients demonstrated significantly lower mean scores for trust of healthcare providers than Caucasians and significantly lower levels of participation. African-American race/ethnicity continued to be a significant predictor of lower levels of trust (but not participation) after accounting for age, gender, education, household income, health insurance, healthcare received in last six months and route of referral to the ED. Preliminary evidence suggests that African Americans may feel less trust toward their ED providers. Understanding this phenomenon and teaching providers how to reduce distrust may translate into better patient compliance/outcomes and reduce healthcare disparities.

Medical school faculty members who specialize in the scholarship of teaching have unique requirements for academic advancement in universities with clinician-educator series. While excellence in teaching is the cornerstone of achievement, attention to traditional academic pursuits improves the likelihood of a favorable review by the institution's promotion and tenure committee. The teaching portfolio is an effective means to document performance. Ongoing faculty development and sound mentoring relationships facilitate the academic advancement of clinician-educators.

This 2012 Academic Emergency Medicine consensus conference breakout session was devoted to the task of identifying the history and current state of faculty development in education research in emergency medicine (EM). The participants set a future agenda for successful faculty development in education research. A number of education research and content experts collaborated during the session. This article summarizes existing academic and medical literature, expert opinions, and audience consensus to report our agreement and findings related to the promotion of faculty development.

To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p < 0.01). Nurses were less likely to disclose an error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p < 0.01). For all provider and error types, identification, disclosure, and reporting increased with increasing severity. Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

The disparities in health care and health outcomes between the majority population and cultural and racial minorities in the United States are a problem that likely is influenced by the lack of culturally competent care. Emergency medicine and other primary-care specialties remain on the front lines of this struggle because of the nature of their open-door practice. To provide culturally appropriate care, health care providers must recognize the factors impeding cultural awareness, seek to understand the biases and traditions in medical education potentially fueling this phenomenon, and create a health care community that is open to individuals' otherness, thus leading to better communication of ideas and information between patients and their health care providers. This article highlights the rationale for and current problems in teaching cultural competency and examines several different models implemented to teach and promote cultural competency along the continuum of emergency medicine learners. However, the literature addressing the true efficacy of such programs in leading to long-lasting change and improvement in minority patients' clinical outcomes remains insufficient.

Background: The ED has been cited as one of the top 3-sites for hospital based error, and it is a mandatory rotation site for many medical students. No study has addressed how errors observed by students affect professional behaviors; this study examines that relationship. Methods: We designed, piloted, and administered a 98- item survey to final semester medical students. Students described a single error they observed during their medical school training and answered all subsequent questions. The primary dependent variable was student learning outcomes (4-LO scales: advice seeking, evidence based medicine, data management, avoidance/trust) and emotional reaction (EmoR) (2-scales: remorse and discomposure). Independent variables included: demographic data, error severity, error type, provider behavior change, attending teaching and hospital environment. Statistical tests used SPSS. Regression path analyses included LO-scales and EmoR-Scales serving as the dependent variables. Resul...

Recent studies of compromised or damaged tissues, as well as biomaterials, have shown that they provide a particularly fertile substratum for bacterial colonization. Colonization in these environments is mediated by a process of microbial adhesion to surfaces of the substrata. In this report, we present electron microscopic studies of a portion of damaged and infected tendon. These studies demonstrate colonies of bacteria surrounded by a ruthenium red-staining exopolysaccharide biofilm and adhesion to the surface of the tendon by means of an exopolysaccharide polymer. We suggest that this adhesive form of bacterial colonization may partially explain the resistance of exposed tendon to effective debridement by simple mechanical measures and to coverage with granulation tissue, partial-thickness skin grafts, and vascularized tissue grafts.

Direct scanning electron microscopy of material obtained during surgical debridement of osteomyelitic bone showed that the infecting bacteria grew in coherent microcolonies in an adherent biofilm so extensive it often obscured the infected bone surfaces. Transmission electron microscopy showed this biofilm to have a fibrous matrix, to contain some host cells, and to contain many bacteria around which matrix fibers were often concentrated. Many bacterial morphotypes were present in these biofilms, and each bacterium was surrounded by exopolysaccharide polymers, which are known to mediate formation of microcolonies and adhesion of bacteria to surfaces in natural ecosystems and in infections related biomaterials. The adherent mode of growth may reduce the susceptibility of these organisms to host clearance mechanisms and antibiotic therapy and thus may be a fundamental factor in acute and chronic osteomyelitis.

The chief resident's role encompasses administrative, academic, educational, and social responsibilities and is traditionally filled by a small number of residents who are charged with various administrative and educational duties. These duties lay the groundwork that prepares chief residents to assume future leadership positions.

We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potent...

The study objective was to understand providers' perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults wit...

ABSTRACT Introduction/Background: Breakdowns in communication are the leading cause of sentinel events according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Arguably, patient handoffs, defined by the JCAHO as 'the process of passing information from one person (or team) to another (along with authority and responsibility) for the purpose of ensuring continuity and safety of a patient's care,' are the most prevalent points of communication and information transfer in healthcare. Studies show that ineffective handoffs lead to delays in treatment, increased length of stay, severe adverse events and patient dissatisfaction.1 Additional studies suggest that strictly verbal handoffs result in nearly 100% data loss.2 In response to recognized gaps, JCAHO implemented National Safety Goal 2E, which required a 'standardized approach to handoffs including the opportunity to ask and respond to questions. Despite Goal 2E, no uniform mechanism exists for delivering or teaching handoffs and they continue to present deficits in practice for adequate transfer of patient information. Methods: As part of a semester-long Interprofessional Teamwork and Communication (IPT) Course, focused on patient safety and effective communication, we developed a module for teaching effective handoffs. The elective course is offered to medical, nursing and pharmacy students and focuses on medical error and effective communication using TeamSTEPPS. As part of the module, we included a unique handoff mnemonic, b-SAFER, to assist learners in organizing their thoughts and delivering efficient patient handoffs interprofessionally. For this module, learners began with a two station simulated series of handoffs in mock shift changes while handing off five patients, reviewed from paper-based vignettes, to a classmate. Students were permitted three minutes to review the patient vignettes and take notes before having five minutes to hand off to the next student. Students receiving the patients completed a brief checklist with questions about their new patients before rotating to a new room and handing off a new set of five patients that included a mix of progressed versions of the previous patients and new patients. The conveyed information was captured in the checklist and the loss of any information was shown statistically to the class to begin the 45-minute didactic lecture on patient handoffs, barriers to effective handoffs and to introduce b-SAFER as a model for safer handoffs. The mnemonic represents: brief Background, Situation, Active Issues, Future Plan, Ensuring Understanding, Repeat for Clarity. A small group breakout during the lecture provided opportunity for the students to practice additional handoffs using b-SAFER. Following the didactic session, students rotated again through another round of two simulated shift changes with a new set of patients. Results: Conclusion: Although the data collected from the simulated shift changes was limited, it did provide an opportunity to recognize communication gaps from the first round of handoffs. From the second round of handoffs following the lecture and while using b-SAFER, students (N=17) improved (mean score 43% pre and 77% post) and provided more relevant information during the handoffs. There was also less data loss. The mnemonic b-SAFER is designed as a simpler format to deliver information on multiple patients more efficiently than other existing mnemonics. It showed to be very useful as a teaching and assessment tool and may prove useful as a template for real handoffs. References: 1. Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety Literature Review Report; March 2005. Available http://www.safetyandquality.org/clinhovrlitrev.pdf. 2. Pothier, D, Monteiro, P, Mooktiar, M, Shaw, A 'Pilot study to show the loss of important data in nursing handover'. British Journal of Nursing, 2005, vol14, No. 20. Disclosures: None.

The purpose of this study was to (a) characterise patients' preferences for disclosure of medical errors and reporting, (b) assess patients' responses to disclosure of error and (c) determine how these preferences differ by patient race/ethnicity, gender, age and level of education. A survey was conducted of consecutive patients presenting at any hour to a tertiary care academic emergency department. Inclusion criteria were: >21 years, competent to conduct the interview (ie, conscious, not demented, delirious, intoxicated or undergoing a psychiatric evaluation), initial Glasgow Coma Scale >12, and patient not transferred from another institution and not in state custody. A four-scenario survey was used to assess patients' preferences for: disclosure, reporting and responses to disclosure. The responses to the scenarios were analysed using Somers D. Independent effects of study variables were assessed with a generalised estimating equation. Of 512 eligible patients, 394 (77% response rate) participated, and 238/394 (61%) met the criteria for analysis. Overall, in 902 (98%) responses to the scenarios, participants wanted disclosure, in 404 (45%), they wanted the error reported and in 311 (35%) they were less likely to seek legal action if informed of the error. In all three categories there was no relation with race/ethnicity, gender, age and education, with the exception of an increased desire for reporting in younger patients and those with less education. Interventions that aim to assist doctors with disclosure of medical error must emphasise the uniformity of patient preferences for disclosure and the diminished likelihood of legal action following disclosure.

Emergency medical services (EMS) personnel are rarely trained in death notification despite frequently terminating resuscitation in the field. As research continues to validate guidelines for the termination of resuscitation (TOR) and reputable organizations such as NAEMSP lend support to such protocols, death notification in the field will continue to increase. We sought to test the hypothesis that a learning module, GRIEV_ING, which teaches a structured method for death notification, will improve the confidence, competency, and communication skills of EMS personnel in death notification. The GRIEV_ING didactic session consisted of a 90-minute education session composed of a didactic lecture, small group breakout session, and role-plays. This was both preceded and followed by a 15-minute case role-play using trained standardized survivors. To assess performance we used a pre-post design with 3 quantitative measures: confidence, competency, and, communication. Paramedics from the local EMS agency participated in the education as a part of continuing education. Pre-post differences were measured using a paired t-test and McNemar's test. Thirty EMS personnel consented and participated. Confidence and competency demonstrated statistically significant improvements: confidence (percent change in scores = 11.4%, p < 0.0001) and competency (percent change in scores = 13.9%, p = 0.0001). Communication skill scores were relatively unchanged in pre-post test analysis (percent change in scores = 0.4, p = 0.9). This study demonstrated that educating paramedics to use a structured communication model based on the GRIEV_ING mnemonic improved confidence and competence of EMS personnel delivering death notification.

The direct electron microscopic examination of 15 sutures and 15 staples removed from 10 healed surgical wounds showed, on the intradermal portions, consistent colonization by bacteria growing in adherent biofilms. This clearly demonstrable bacterial colonization of biomaterials within the wound tract had not resulted in infection or perceptible inflammation in any of the wounds. These bacterial cells were of several morphotypes, including gram-positive cocci, and all specimens yielded cultures of the autochthonous (native) skin bacterium, Staphylococcus epidermidis. The bacteria within the wound tracts were enveloped by extracellular material that appeared on scanning electron microscopy to be a condensed amorphous residue and on transmission electron microscopy to be a fibrous extracellular matrix. We suggest that this mode of growth, in which the colonizing bacteria are enveloped in a copious exopolysaccharide glycocalix, protects the bacteria from host defense factors and accounts for their persistence on the suture surfaces until they are removed with the sutures.