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Patient Safety Findings: Part 2: Communication


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Patient Safety Findings: Part 2: Communication

By Tom A. Augello, CRICO

Related to: Ambulatory, Clinical Guidelines, Communication, Diagnosis, Surgery

A look at tools like electronic reminders for test follow-up and simulation for resident orientation.


  • Gila Kriegel, MD; Beth Israel Deaconess Medical Center; Boston, MA
  • David Roberson, MD; Children’s Hospital; Boston, MA
  • Peter Weinstock, MD; Children’s Hospital; Boston, MA


Dr. Kachalia was followed at the Harvard Patient Safety Grant Symposium by Dr. Gila Kriegal. Dr. Kriegal’s team used its CRICO/RMF grant to create an electronic reminders system to help providers follow up with abnormal cancer screening tests. They were converting a large hospital-based primary care practice from paper-based follow-up of breast, colon, and cervical cancer tests.

“So, why is it, do we think, that these kind of tests are such a high risk for failure to follow up.  One reason is that there is often a long lag time from when you order one of these tests to when you get the results.  So, for example at the BI [Beth Israel Deaconess Medical Center], I can do a Pap smear and maybe not get the results for maybe two weeks or even a month afterwards. Sometimes these kinds of tests are not done at the time of the appointment.  You give the patient stool guaiac cards and they send them back weeks/months later.  In Massachusetts, a woman can call and schedule their own mammogram so they can initiate that test without the provider even knowing that it has been done. And then even if the provider gets these results back, they may not be aware of changes in the algorithms for what the appropriate follow-up is.”

Dr. Kriegal’s team believed an electronic reminder system would be more reliable than paper, more timely, and less intensive administratively. They interviewed the primary care physicians, the specialty labs, and consulted guidelines and algorithms to develop the appropriate intervals. Pap smears involved the most complex reminder system, because the algorithm has the most branch points. Then the team worked with its computer department to embed the reminders in the electronic medical record system.

“In order to do what the providers asked us, which is ‘don’t bother me if I did the follow up,’ we had asked the computer to check.  Did the patient have follow-up?  Which meant looking in visit histories, looking for colposcopy results and pathology, looking for repeat Pap smears.  So, we said to the computer, ‘tell us, the patient had ASCUS, did they have a colposcopy?’  Okay, we’re done.  If not, well then did they have HPV testing? If they did and it was high risk, did they have a colposcopy?  If not, ‘alert.’ And that means the provider is going to get an alert saying ‘hey, you should have done this’ and these are basically the same thing.  We’re looking if they didn’t have HPV, did they have a repeat PAP smear?  If they did, was it normal?  Was it abnormal, etc.?  So, you just get a sense of the complexity of what we were dealing with before we even got to testing this.”

When physicians log onto the system, the first thing they see is an alert if follow-up is due. Options are presented to go to an algorithm, the patient chart, or even a prepared letter to send to the patient. Physicians can forward a note to another clinician, request a reminder in three months or tell the administrator the task is complete.

“In August we generated 18 reminders to people who, as best we could tell, had not followed up on an abnormal mammogram, and eight on fecal occult blood. And you can see in the last column there it is taking about two weeks on average for our providers to take some sort of action in the electronic system.  I’ll compare that with our old paper system that would take weeks and weeks and weeks sometimes before we got results back.”

Another research team tested the efficacy of using simulation training in the orientation of residents at a children’s hospital. Dr. David Roberson  works at Children’s Hospital in Boston.

“The object of this pilot project was to develop and demonstrate the feasibility of a simulator-based orientation for rotating surgical residents, feeling that the rotating surgical resident who works in an adult hospital and comes to our hospital for a short period of time is uniquely vulnerable for a variety of reasons and their patients may also be vulnerable.”

Roberson noted that the turnover of medical knowledge in pediatrics is accelerated. Rotating surgical residents are vulnerable in understanding the basic principles of pediatric physiology and management, including diseases, interventions, and complications that simply aren’t present with adult patient populations.

“And we think that a better orientation may be part of the solution to enable the surgical resident who starts on Monday and is on call on Monday night and has to see somebody in the ER, schedule them for surgery, get a CT, and make seven phone calls at two in the morning that first night he or she’s on call might do a better job.”

The pilot included a four-hour orientation program for pairs of residents, with learning objectives that were mapped onto scenarios that could be simulated using interactive videos requiring the residents to make decisions.

“No human being can retain everything we’d like them to get to know before they start. No matter how good your orientation is you cannot learn 1,000 things in a four hour period and one of the big goals very consciously of this orientation program is not to make them memorize this information, but to make sure they know where it is on their pocket card, where they can access it quickly if they needed it to in the morning. And you’ll see at several points during our simulation scenarios they are forced to use their house officer card to access important information.”

Dr. Peter Weinstock, who works in the surgical ICU, was part of Dr. Roberson’s research team. Dr. Weinstock explained that the overarching goal is to reproduce the feeling that a resident in a new rotation will have when a critical situation arises. The learning objectives came from interviews with medical, surgical, anesthesia faculty, rotating residents, chief residents and fellows in otolaryngology.

“So, we start with goals.  We decide how we are going to construct it as a simulation. We decide what kind of actors we’re going to need, what kind of support staff we’re going to need, and then we develop the scenario.”

Dr. Weinstock says that simulation allows the residents to learn orientation issues within a clinical context. The beauty of simulation are the didactic breaks made possible by the “pause” button.

“You’re going to see this in the vignettes.  Patient is not going to get any worse, not any better, and we have a moment now to really think about what just happened and what’s the best way to go forward and have them pull out their house officer cards or look at some slides in context.  Some of the examples that we use is that pediatric cardiac physiology will stop, take a pause, and go through that a little bit; pediatric respiratory exam, show some slides of patients in various degrees of respiratory distress and how to obtain even just systematic issues like how to get x-rays. And these are just some of the slides that we would show;  these would come up on the LCD screen;  you can just go straight through these.  And so these would come up as the patient was in distress.  We’d say ‘this is what you actually see.  What do you think and what would you do next?’”

According to Dr. Roberson, the residents even learn how to communicate better, including ways to challenge decisions and orders by attendings and other senior clinicians that they are uncomfortable with. Dr. Roberson says the simulation project has demonstrated a more effective orientation process, covering more ground that is better retained than a four-hour lecture.

More ideas for improving patient care and preventing error will get another boost from CRICO/RMF as the next half-million dollar round of CRICO/RMF patient safety grants in the Harvard system has already begun.

November 1, 2006
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