Clinical inertia in hospitals and 24-7-365 care: a limited series, part 1
Introduction
The “To Err Is Human” report by the Institute of Medicine (IOM) (Kohn et al., 1999) attributed adverse health care events of up to 98,0000 deaths and 1.3 million injuries per year in the US. This data suggests that health care errors are the cause of more fatalities per year in the US than those dying from AIDS, breast cancer, and car crashes combined (Kohn et al., 1999). The Harvard Medical Practice Study (Brennan et al., 2004) evaluated adverse events to occur at a rate of 3.7% of hospitalizations. Adverse Drug Events (ADE) alone are estimated to occur at a rate of 1 in 100 medication administrations (Bates et al., 1999). (Kozer et al., 2002) reported prescription errors in 10.1% of charts reviewed. In Australia, Runciman et al. (2003) reported adverse drug events in 1% of hospital admissions and errors occurring in 15-20% of drug administrations of ward stock systems and 5-8% when individual patient systems are used. In the Netherlands, Baines et al. (2015) reported a corrected and standardized adverse event rate of 5.7% and preventable adverse events of 1.4% of patient admissions. In Ireland, Rafter et al. (2017) reported adverse event rates of 12.2%, with 70% preventable and 6.7% contributing to death. More recently, Bates et al. reported US rates of adverse events to be 23.6% with 22.7% preventable and 0.2% resulting in death.
What is behind these adverse events?
While there are many potential reasons for these rates, communication is frequently identified as a contributing factor to error occurrence (Alvarez and Coiera, 2006). Potential consequences of ineffective communication and failures are poor utilization of resources, interruptions, extended hospital stays, lower patient satisfaction and increased complications of care (Kuziemsky and Varpio, 2010, van Leijen-Zeelenberg et al., 2015). Agarwal et al. (2010) estimated that a 500-bed hospital loses over $4 million annually as a result of communication inefficiencies. Communication ‘errors’ can take several forms, but can primarily be codified according to Hollnagel (1998) as shown in Table 1.
Table 1. Communication Error Types
van Leijen-Zeelenberg et al. (2015) highlight that failures in handover communication alone have been shown to lead to interruptions in continuity of care, with the potential to harm. Jeffcott et al. (2009) emphasized that poor clinical handovers potentially “create discontinuities in care”, with consequences manifesting as patient harm. In response, they proposed a resilience based framework for clinical handovers. Resilience according to Jeffcott et al. (2009) has three interconnected levels outlined in Table 2.
Table 2. Levels of resilience
Resilience can therefore be associated with an individual, a team or an organization as a whole.
The role of clinical handovers
Clinical handovers play a key role in advancing patient progress, tasks for completion, or recommendations for the next shift. Effective information transfer can be the information super-highway of hospitals: pertinent information successfully transferred from shift-to-shift should form the foundation on which to build teamwork, decision-action cycles and collaborative decision-making. Too much information, and particularly the wrong type of information, can lead to cognitive overload, a state of mental exhaustion when demands on the working memory exceed capacity. In studies, decision density and decision fatigue frequently result in information prioritization, as increasingly more information is provided and in times of high-cognitive load, the individual’s ability to assimilate and interpret the information decreases (Sweller, 1988, Harry and Sweller, 2016, Young et al., 2016). Consequently, decisions to ‘do nothing’ can occur.
This ‘do nothing’ decision has been related to the concept of clinical inertia, which we'll explore in detail in the next post.
References:
Agarwal, R., Sands, D.Z. & Schneider, J.D., 2010. Quantifying the economic impact of communication inefficiencies in US hospitals. Journal of Healthcare Management, 55, 265.
Alvarez, G. & Coiera, E., 2006. Interdisciplinary communication: An uncharted source of medical error? Journal of Critical Care, 21, 236-242.
Baines, R., Langelaan, M., De Bruijne, M., Spreeuwenberg, P. & Wagner, C., 2015. How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. BMJ Quality & Safety, 24, 561-571.
Bates, D.W., Levine, D.M., Salmasian, H., Syrowatka, A., Shahian, D.M., Lipsitz, S., Zebrowski, J.P., Myers, L.C., Logan, M.S., Roy, C.G., Iannaccone, C., Frits, M.L., Volk, L.A., Dulgarian, S., Amato, M.G., Edrees, H.H., Sato, L., Folcarelli, P., Einbinder, J.S., Reynolds, M.E. & Mort, E., 2023. The Safety of Inpatient Health Care. New England Journal of Medicine, 388, 142-153.
Brennan, T.A., Leape, L.L., Laird, N.M., Hebert, L., Localio, A.R., Lawthers, A.G., Newhouse, J.P., Weiler, P.C. & Hiatt, H.H., 2004. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. Quality and Safety in Health Care, 13, 145-151.
Harry, E. & Sweller, J., 2016. Cognitive load theory and patient safety. In K.J. Ruskin, M.P. Stiegler & S.H. Rosenbaum (eds.) Quality and safety in anesthesia and perioperative care. Oxford, UK: Oxford University Press.
Hollnagel, E., 1998. Cognitive Reliability and Error Analysis Method (CREAM). Oxford, UK; New York, USA: Elsevier Science Ltd.
Jeffcott, S.A., Ibrahim, J.E. & Cameron, P.A., 2009. Resilience in healthcare and clinical handover. Quality and Safety in Health Care, 18, 256-260.
Kohn, K.T., Corrigan, J.M. & Donaldson, M.S. (eds.) (1999) To Err is Human: Building a Safer Health System., Washington, DC: National Academy Press: Institute of Medicine.
Kozer, E., Scolnik, D., Macpherson, A., Keays, T., Shi, K., Luk, T. & Koren, G., 2002. Variables associated with medication errors in pediatric emergency medicine. Pediatrics, 110, 737-742.
Kuziemsky, C.E. & Varpio, L., 2010. Describing the Clinical Communication Space through a Model of Common Ground: ‘you don’t know what you don’t know’. AMIA Annual Symposium. Washington, DC: American Medical Informatics Association, 407-411.
Rafter, N., Hickey, A., Conroy, R.M., Condell, S., O'Connor, P., Vaughan, D., Walsh, G. & Williams, D.J., 2017. The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study. BMJ Quality & Safety, 26, 111-119.
Runciman, W.B., Roughead, E.E., Semple, S.J. & Adams, R.J., 2003. Adverse drug events and medication errors in Australia. Int J Qual Health Care, 15, i49-59.
Sweller, J., 1988. Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science, 12, 257-285.
Van Leijen-Zeelenberg, J.E., Van Raak, A.J., Duimel-Peeters, I.G., Kroese, M.E., Brink, P.R. & Vrijhoef, H.J., 2015. Interprofessional communication failures in acute care chains: How can we identify the causes? Journal of interprofessional care, 29, 320-330.
Young, J.Q., Wachter, R.M., Ten Cate, O., O'Sullivan, P.S. & Irby, D.M., 2016. Advancing the next generation of handover research and practice with cognitive load theory. BMJ Qual Saf, 25, 66-70.
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