Patient Safety

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    Patient-Physician Trust
    (2021) Khan, Rija
    Purpose: This literature review explores factors contributing to the patient-physician relationship from the perspective of both patient and physician. Methods: A literature review was created from initial PubMed search of "patient-physician trust." Papers were: 2 qualitative essays, one about patient-physician trust from a surgeon's perspective and another about shared decision-making; a qualitative study with physician interviews and focus groups describing low and high trust relationships; and two studies analyzing data from patient surveys focusing on associations with patient-provide trust and communication scores. Results: 1- Physician trust factors: a) Patient transparency in providing necessary medical information b) Letting physician know about major changes in condition c) Telling physician about all medications/treatments d) Understanding the physician, being actively involved in managing the condition e) Respecting physician's time and boundaries f) Not making unreasonable demands or manipulating office visits for secondary gain g) Keeping appointments 2-Patient trust factors: a) Social trust refers to trust a patient has of the institution itself. b) Patients self-reporting negative attitudes toward the healthcare system demonstrated significantly lower trust scores (p< 0.001). c) Socioeconomic factors: lower income and education (p= 0.01) d) Public health insurance or no coverage compared to private health insurance reported significantly lower provider-patient communication scores (p< 0.001). Conclusions: This review showed that patient-physician trust is complex and multifactorial. Awareness of these factors are critical for developing a successful healthcare delivery model.
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    Fall Risk Screening in the Elderly
    (2021) Scribner, Jacob; Colmenero, Evan; Gibson, John; Hadley, Lesca
    Purpose: The purpose of this project was to increase fall screening for patients over the age of 65. Elderly individuals are at increased risk for falling, and at an increased risk of injury from falls. We set out to investigate if implementing more screening for this vulnerable population would identify those at risk. Methods: We used a simple "yes or no" questionnaire during Medicare annual wellness visits that identifies at-risk individuals based on different attributes that put an individual at higher risk for falling. Based on the answers, we evaluated if a patient is at risk, and, if so, what interventions can be implemented in order to decrease the risk of falling. Results: We were able to identify patients who required intervention to prevent future falls. Because there was no prior method of screening patients over the age of 65 for falls at this clinic, our post-intervention data was able to screen 75% of eligible patients. Conclusions: We found that a simple questionnaire can be a useful tool to determine which patients are at an increased risk. There were some limitations; due to COVID-19, many staff members were out for extended periods of time, thus limiting the amount of data collected. Additionally, as the questionnaire required additional time during a patient encounter, there was not time to survey every eligible patient. Moving forward, a systematic implementation for all Medicare visits would streamline the process and allow for further identification of those at risk for falls.
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    Patient Safety in the Hospital Pharmacy Setting: Overcoming Barriers and Identifying Solutions
    (2021) Bond, Hannah
    Objective: The World Health Organization states that as many as 1 in 10 patients in high income countries are harmed while receiving hospital care. The purpose of this study is to understand the types of structural barriers that exist in the inpatient hospital pharmacy setting, highlight common themes, and identify solutions to overcome the barriers. Methods: A systematic review of the literature was conducted from 2001 to 2020 using PubMed with keywords such as "hospital pharmacy," "patient safety," "hierarchical structures," "organizational barriers," "information technology barriers," "environmental barriers," and "collaboration barriers". A PRISMA flow diagram was used to evaluate the process. Articles were summarized in a table organized by author(s), year published, title, study design, type of barrier, method of studying safety, findings, and solutions. The quality of articles was graded using the Oxford for Evidence-based Medicine scale. Results: One-hundred and four articles were eligible to review. The majority of studies conducted semi-structured interviews to gather pharmacist feedback on medication safety. Some common themes include lack of organizational support, environmental constraints, limited collaboration between healthcare professionals, and lack of information technology infrastructure. Proposed solutions include supporting effective multidisciplinary teams, greater involvement of pharmacists in medication reconciliation, linked prescribing databases and decision support systems, and providing advanced training and certification programs. Conclusions: Fostering organizational support and good communication between healthcare professionals will ultimately lead to improved patient safety and better health outcomes.
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    Implementation of a Pre-Operative Huddle at a Level 1 Trauma Center
    (2021) Rechter, Griffin; Scofield, Harrison; Webb, Brian
    Purpose: Medical errors resulting in patient harm occur frequently. Surgery is a high-risk specialty that requires standardization of communication and processes to decrease errors. We sought to determine whether the implementation of a pre-operative huddle could improve communication and decrease medical errors. Methods: A pre-operative huddle was developed and implemented at a level 1 trauma center. The hospital database was used to review data before and after the huddle implementation. We analyzed patient surveys and comments, percentage of on-time OR starts, OR turnover times, and number of sentinel events. Statistical analysis was performed using chi-square testing for OR start time differences, and the Mann-Whitney U Test was used to compare turnover time and delayed starts. Results: After implementation, we observed a trend of improvement in patient survey results regarding patients' perception of overall understanding following the explanation of their procedure by the healthcare team, p< 0.001. There was an increase in on-time OR starts from 37% to 42%, p< 0.001. Notably, there was a statistically significant increase in OR turnover time from 38 minutes to 40 minutes. We also observed a decrease in the number of sentinel events. Conclusions: We found that implementing a pre-operative huddle at a large level 1 hospital improves patient safety, on-time OR starts, and communication amongst the healthcare team, without significantly disrupting OR workflow. Use of standardized communication processes may contribute to a decrease in medical errors and assist hospitals in becoming highly reliable organizations.
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    QI project to reduce prescription of high risk medications for type 2 diabetes in patients over 65 years old
    (2021) Philip, Timothy; Cantu, Ramon; Hadley, Lesca; Gibson, John
    Purpose Patients over the age of 65 are at risk of hypoglycemia, which can increase risk of death. The objective of this project is to change high-risk medication (HRM) prescription, in diabetic patients over 65 years old, of long-term sulfonylureas or sliding-scale insulin to medication with less risk of hypoglycemia. Methods Patients over 65 years with non-HRM and HRM diabetes medications prescribed to them were identified. Post-exam, a recommendation was made to change medication from HRM to non-HRM. Results of the encounter will be recorded in data tables. Results After the implementation, only 1 out of 3 possible patients on Glimepiride was changed to an anti-diabetic medication that was not an HRM. This particular patient was prescribed basal-bolus insulin to replace the glimepiride. Conclusions One obstacle in preventing a change from Glimepiride to a non-HRM was cost. Therefore, due to cost of medication, socioeconomic status of the patient, and number of other medications, most patients declined a change. One patient denied the change because he was well-controlled on glimepiride for years. Although the data suggests lower rates of prescribing HRMs, this however is due to natural variability within the patient population and not a significant change caused by the enhancement.
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    Quality Improvement: Examining Reduction of High Risk Medication Use in an Elderly Population
    (2021) Hutton, Sarah; McGaughy, Jennifer; Gibson, John; Hadley, Lesca
    Purpose: The purpose of this project was to decrease the use of high-risk medications in adults age 65 and older. Polypharmacy is a potentially dangerous problem facing older patients in the United States; addressing high risk medication use is important to reduce risk. Methods: A questionnaire and educational handout regarding polypharmacy and high-risk medication were used to address the issue of high-risk medication use. Medication lists were reviewed for every patient meeting the criterion of being over the age of 65. Results: There was no significant reduction in high-rick medication use post-intervention. Those who were prescribed 1 high-risk medication (determined by the Beer's criteria) in the "prior to the enhancement implementation period" was 10.5% compared to the 10.0% of the same category in the "enhancement implementation" period. There was no change in either period for those prescribed 2 or more high-risk medications; these were both 0%. Conclusions: One of the reasons to explain the lack of significant reduction is there is not a large elderly patient population seen at the clinic. Also, a medication review function exists in the EMR that may have already led to a reduction in prescription of high-risk medications. While implementing use of the questionnaire and handout were appropriate, it was difficult to fully address the Beer's criteria extensive list of medications. The next step would be to have the EMR flag high-risk medications and identify those who are at higher risk of drug-drug interactions.
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    Assessing Fall Events in Geriatric Cancer Patients who are Prescribed an Opioid and/or Benzodiazepine
    (2021) Bhachawat, Neal; Rasu, Rafia; Agbor, Walter
    IRBexempt#2020-013. Purpose: Opioids & benzodiazepines are commonly used in cancer pain treatment however their sedating effects increase a patient's fall risk. BEERS criteria was established to reduce adverse events related to medication use in elderly population. Falls are a leading cause of death in the geriatric population and seniors with cancer confer an estimated 20%increased risk. Objectives:(1)identify the demographics of cancer patients age65+ who experienced a fall,(2)determine fall event trends based on patient-specific factors & medications (3)determine if BEERS criteria was followed. Methods: A cross-sectional study analyzing fall outcomes in cancer patients, age 65+, with analgesic medications used to manage acute/chronic pain. The population data was be compiled from the CDC National Ambulatory Medical Care Survey(NAMCS).Diagnosis was based on ICD9/10 and medication codes. Database findings based on sample of office visits. Results: In the NAMCS database between 2006–2017 was 276,166,738 (weighted freq.) cancer patient visits, age 65+ with 83.16%experiencing a fall. 194,560,411 were taking Benzodiazepine only.31,941,74 5were taking Opioids and 68% were prescribed a benzodiazepine as adjunct therapy. Fall incidence: Opioid group 84.6% (p=.03); Benzodiazepine alone 97.1% (p< .001); Benzodiazepine + opioid 93.2% (p< .001). Of the 83.16% of patients who experienced a fall, majority were white and female; 54% were age 75+; Types of cancers: prostate (12.3%), breast (7.3%), lung (5.2%), colorectal (4.5%) and others (70.7%). Fall incident peaked during 2012-2014 with 41.9% of falls occurring and declined to 8.3% during 2015-2017 (p< 0.001). Conclusion: The fall rates experienced by geriatric cancer patients taking opioids and/or benzodiazepines is far greater than the national average for the general geriatric population: 25%suffering a fall. In 2015 BEERS criteria and FDA advised against concurrent use of benzodiazepines + opioids. Our results indicate clinicians followed these changed guidelines, resulting in a decrease in fall events during data period 2015-2017 and illustrating the crucial role BEERS criteria plays in patient safety.
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    How Dirty is Your Phone?–Evaluating Healthcare Workers' Cell Phone Use & Cleanliness in an Ambulatory Clinic
    (2021) Li, Jeffrey; Reynolds, Conner; Lindsley, Joshua; Sankar, Aparna; Perez, Aaron; Wolstein, Austin; Williams, Trevor; Ingram, Aubrey; Gelinas, Lillee; Jowitt, Janet
    Purpose: Preventable medical errors are the 3rd leading cause of death in the United States, accounting for 251,000 lives annually. Healthcare-acquired infections (HAIs) account for nearly 40% of this population, costing the healthcare system $28.4-33.8 billion each year. Current monitoring efforts have set their focus on device-associated infections. Given the rising prevalence of clinicians using smartphones, these may also be contributing to infectious spread. Phase 1 of this initiative found that health professional students use their phones in the restroom, clean it less than once weekly, and are unlikely to remove the case. These behaviors were associated with surface contamination levels exceeding cleanliness benchmarks by 3-to-17 fold. Phase 2 aims to repeat this paradigm in healthcare workers. Methods: Using an interval sampling model, healthcare workers at the UNTHSC Health Pavilion completed a survey and had their cellphone swabbed during normal business hours. Contamination levels were assessed using ATP Luminometery, an established test for surface cleanliness. Results: Healthcare workers were likely to use their cellphones in clinic. They were unlikely to use their cellphone in patient rooms or restrooms, but also unlikely to clean them at the end of each workday. Healthcare workers were very likely to wash their hands in all instances. Cellphone surfaces exceeded cleanliness benchmarks by 2-to-9 fold. Conclusions: Cellphones may improve care delivery by providing quick access to resources but are easily contaminated and rarely disinfected. Despite their utility, more work is needed to ensure safe cellphone use in healthcare.
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    Tools to Reduce High-Risk Medication Use in Patients 65 Years and Older
    (2021) Pierce, Victoria
    Purpose: With increased use of medications in the elderly, it is important to conduct a medication review at each visit and review changing recommendations for different patient populations. The purpose of this enhancement is to see if a single page, patient led review of medications before each visit can reduce high-risk medication use in patient populations 65 years and older. Methods: For 4 weeks patients 65 years or older were given a summary of high-risk medications per the Beers Criteria prior to each visit. The medications were organized by disease, and the patients were asked to circle any active medications. The physician then reviewed the medication list and made note of which medications could be discontinued, changed, or would remain the same. The number of high-risk medications were recorded before and after the intervention as 0, 1, or 2+. Results: Through this intervention the use of high-risk medications was reduced overall. The intervention also encouraged a scheduled review of high-risk medication recommendations. A reduction of one high-risk medication occurred in >66% of patients and >57% for patients on 2+ high-risk medications. Conclusion: The results suggest a regular review of changing medication recommendations and full medication reviews at yearly appointments can reduce the use of high-risk medications in elderly populations. While the Beers criteria is not a perfect tool, as some medications are needed and cannot be substituted, it is useful as a way to review high-risk medications in elderly patient populations.
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    A Systematic Review of Concomitant Opioid and Sedative or Skeletal Muscle Relaxant Use on Patient Outcomes in Chronic NON-Malignant PAIN
    (2021) Zerezghi, Semhar; Xavier, Christy; Jodray, Megan; Nelson, Rebecca; Zalmai, Rana; Rasu, Rafia
    Purpose: Multiple studies show risks with concomitant opioid and benzodiazepine use in the general population, but few discusses effect of opioids with other sedatives, when policies are not in consensus. This review is a comprehensive outlook of current evidence analyzing the impact of concomitant opioid and sedative use in chronic non-malignant pain. METHODS: Literature search strategy using phrase "opioid AND CNS depressants OR benzodiazepine OR sedatives OR gabapentinoids NOT cancer" was conducted in PubMed, Embase, Web of Science, and Scopus. Excluded case reports, reviews, pediatric, duplicates, and non-opioid-related outcome studies(N=43,914) for total 14 articles. RESULTS: 12 studies were retrospective. Overall, concomitant use of sedatives or muscle relaxants with opioids was associated with hospitalizations(N=5), mortality(N=4), motor vehicle accidents(N=1), inappropriate drug utilization(N=4), or anxiety and depression(N=2). Higher dosages of opioids(N=4) corresponded to negative outcomes regardless of concomitant medications. South and increasing age had higher prevalence of concomitant use but was not always associated with negative outcomes. CONCLUSIONS: Considering increased incidence of co-prescriptions and adverse outcomes, policy changes recommending avoidance of concomitant opioid and skeletal muscle relaxant/sedative use are needed. All 14 studies are diverse but showed higher age, higher opioid dose, and South with more coprescription-associated negative outcomes. Overall consistency of negative outcomes needs further investigation of interactions despite limitations. Policymakers, clinicians, and patients should know the risks of concomitant prescribing to solidify current policy recommendations, ensure adequate drug monitoring and co-prescribing controls through prior authorization, reduce number of co-prescriptions, and improve clinical outcomes.