Explore the vast range of titles available.

ABSTRACT BACKGROUND Collection of data on race, ethnicity, and language preference is required as part of the “meaningful use” of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities. OBJECTIVE Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients. DESIGN/SUBJECTS/MAIN MEASURES Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics ( n  = 569). KEY RESULTS Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p  < 0.001) and African American race (27.0 % vs. 20.4 %, p  < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p  < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking. CONCLUSION We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.

The diagnosis section in hospital discharge summaries is critical for continuity of care and patient safety, yet it varies widely in quality, format, and content due to a lack of standards. This study aims to develop a cross-specialty standard for the structure and content of the diagnosis section, based on the preferences of German physicians. The study examines physicians' satisfaction with the diagnosis section, their rating of its importance, and their preferences for its specific elements, comparing perspectives between inpatient and outpatient physicians. This mixed-methods study integrated a scoping review, focus group discussion, and a nationwide survey of 602 physicians (317 outpatient primary care and 285 inpatient physicians; 4.1% response rate), most trained in internal medicine. Quantitative analyses evaluated physician satisfaction and preferences, while qualitative feedback provided deeper insights regarding preferred content and format. Although 95.7% of physicians considered the diagnosis section crucial for follow-up care, only 36.9% were satisfied with its current content and format. 91.2% supported standardizing the diagnosis section, identifying 18 content elements to be included for every current treatment diagnosis. Strong consensus (> 95.0% agreement) was reached for \"name of the diagnosis,\" \"severity/stage/classification/TNM,\" \"localization/extent/pattern of involvement,\" \"course e.g., acute, chronic, recurrent,\" \"expression,\" \"complications,\" \"date of initial diagnosis,\" and \"etiology/cause.\" 86.4% preferred separating current and chronic/prior diagnoses with headings. Outpatient physicians were more likely than inpatient physicians to rate \"ICD-10 codes\" as mandatory (46.2% vs. 14.8%, p < 0.001) and to consider \"recommendations for further procedures\" (76.6% vs. 63.6%, p < 0.001) and \"follow-up appointments\" (77.3% vs. 63.5%, p < 0.001) as necessary. Additionally, a list of practical recommendations for clinicians to better document diagnoses was derived. This study proposes a cross-specialty standard for the diagnosis section based on physician preferences for a clearly structured format and 18 key content elements.

Analgesic trials frequently fail to demonstrate efficacy of drugs known to be efficacious. Poor pain reporting accuracy is a possible source for this low essay-sensitivity. We report the effects of Accurate-Pain-Reporting-Training (APRT) on the placebo response in a trial of Pregabalin for painful-diabetic-neuropathy. The study was a two-stage randomized, double-blind trial: In Stage-1 (Training) subjects were randomized to APRT or No-Training. The APRT participants received feedback on the accuracy of their pain reports in response to mechanical stimuli, measured by R-square score. In Stage-2 (Evaluation) all subjects entered a placebo-controlled, cross-over trial. Primary (24-h average pain intensity) and secondary (current, 24-h worst, and 24-h walking pain intensity) outcome measures were reported. Fifty-one participants completed the study. APRT patients (n = 28) demonstrated significant (p = 0.036) increases in R-square scores. The APRT group demonstrated significantly (p = 0.018) lower placebo response (0.29 ± 1.21 vs. 1.48 ± 2.21, mean difference ± SD = -1.19±1.73). No relationships were found between the R-square scores and changes in pain intensity in the treatment arm. In summary, our training successfully increased pain reporting accuracy and resulted in a diminished placebo response. Theoretical and practical implications are discussed.

ObjectiveTo describe the associations between patient-to-nurse staffing ratios and rates of mortality, process of care events and vital sign documentation.DesignSecondary analysis of data from the evaluating processes of care and outcomes of children in hospital (EPOCH) cluster-randomised trial.Setting22 hospitals caring for children in Canada, Europe and New Zealand.ParticipantsEligible hospitalised patients were aged>37 weeks and <18 years.Primary and secondary outcome measuresThe primary outcome was all-cause hospital mortality. Secondary outcomes included five events reflecting the process of care, collected for all EPOCH patients; the frequency of documentation for each of eight vital signs on a random sample of patients; four measures describing nursing perceptions of care.ResultsA total of 217 714 patient admissions accounting for 849 798 patient days over the course of the study were analysed. The overall mortality rate was 1.65/1000 patient discharges. The median (IQR) number of patients cared for by an individual nurse was 3.0 (2.8–3.6). Univariate Bayesian models estimating the rate ratio (RR) for the patient-to-nurse ratio and the probability that the RR was less than one found that a higher patient-to-nurse ratio was associated with fewer clinical deterioration events (RR=0.88, 95% credible interval (CrI) 0.77–1.03; P (RR<1)=95%) and late intensive care unit admissions (RR=0.76, 95% CrI 0.53–1.06; P (RR<1)=95%). In adjusted models, a higher patient-to-nurse ratio was associated with lower hospital mortality (OR=0.77, 95% CrI=0.57–1.00; P (OR<1)=98%). Nurses from hospitals with a higher patient-to-nurse ratio had lower ratings for their ability to influence care and reduced documentation of most individual vital signs and of the complete set of vital signs.ConclusionsThe data from this study challenge the assumption that lower patient-to-nurse ratios will improve the safety of paediatric care in contexts where ratios are low. The mechanism of these effects warrants further evaluation including factors, such as nursing skill mix, experience, education, work environment and physician staffing ratios.Trial registration numberEPOCH clinical trial registered on clinical trial.gov NCT01260831; post-results.

Purpose Free text reports (FTR) of head and neck ultrasound studies are currently deployed in most departments. Because of a lack of composition and language, these reports vary greatly in terms of quality and reliability. This may impair the learning process during residency. The purpose of the study was to analyze the longitudinal effects of using structured reports (SR) of head and neck ultrasound studies during residency. Methods Attending residents ( n  = 24) of a tripartite course on head and neck ultrasound, accredited by the German Society for Ultrasound in Medicine (DEGUM), were randomly allocated to pictures of common diseases. Both SRs and FTRs were compiled. All reports were analyzed concerning completeness, acquired time and legibility. Overall user contentment was evaluated by a questionnaire. Results SRs achieved significantly higher ratings regarding completeness (95.6% vs. 26.4%, p  < 0.001), description of pathologies (72.2% vs. 58.9%, p  < 0.001) and legibility (100% vs. 52.4%, p  < 0.001) with a very high inter-rater reliability (Fleiss’ kappa 0.9). Reports were finalized significantly faster (99.1 s vs. 115.0 s, p  < 0.001) and user contentment was significantly better when using SRs (8.3 vs. 6.3, p  < 0.001). In particular, only SRs showed a longitudinally increasing time efficiency (− 20.1 s, p  = 0.036) while maintaining consistent completeness ratings. Conclusions The use of SRs of head and neck ultrasound studies results in an increased longitudinal time-efficiency while upholding the report quality at the same time. This may indicate an additive learning effect of structured reporting. Superior outcomes in terms of comprehensiveness, legibility and time-efficiency can be observed immediately after implementation.

AimTo assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials.MethodsThe PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1 mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors.ResultsEight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0–4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolvedConclusionThe overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.

ABSTRACT BACKGROUND Poor communication of tests whose results are pending at hospital discharge can lead to medical errors. OBJECTIVE To determine the adequacy with which hospital discharge summaries document tests with pending results and the appropriate follow-up providers. DESIGN Retrospective study of a randomly selected sample PATIENTS Six hundred ninety-six patients discharged from two large academic medical centers, who had test results identified as pending at discharge through queries of electronic medical records. INTERVENTION AND MEASUREMENTS Each patient’s discharge summary was reviewed to identify whether information about pending tests and follow-up providers was mentioned. Factors associated with documentation were explored using clustered multivariable regression models. MAIN RESULTS Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries. CONCLUSION Discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers.

Background Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance. Methods From July 2015 through November 2015, patients aged ≥18 years undergoing elective colorectal cancer surgery were prospectively included in a single-institution trial. Video recording of key moments was performed peroperatively and analyzed for adequacy. The study cases were compared with a historic cohort. Video was compared with the operative note using the amount of adequate steps and a scoring system. Results This study compared 15 cases to 32 cases from the historic control group. Compared to the written operative note alone, significant differences in availability of information were seen in favor of video as well as using a combination of video plus the operative note (N adequate steps p  = .024; p  = <.001. Adequacy score: p  = .039; p  = <.001, both respectively). Conclusions Systematic video registration is feasible and seems to improve the availability of essential information after colorectal cancer surgery. In this respect, combining video with a traditional operative note would be the best option. A multicenter international study is being organized to further evaluate the effect of operative video capture on surgical outcomes.

Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs). To evaluate whether a peer comparison email intervention that communicates an oncologist's performance on documenting cancer stage relative to that of peer physicians was associated with increased likelihood that stage was documented in the EHR. This 12-month, randomized quality improvement pilot study aimed to increase oncologist staging documentation in the EHR. The pilot study was performed at Massachusetts General Hospital Cancer Center from October 1, 2018, to September 30, 2019. Participants included 56 oncologists across 3 practice sites who treated patients in the ambulatory setting and focused on diseases that use standardized staging systems. Data were analyzed from July 2, 2019, to March 5, 2020. Peer comparison intervention with as many as 3 emails to oncologists during 6 months that displayed the oncologist's staging documentation rate relative to all oncologists in the study sample. The primary outcome was patient-level documentation of cancer stage, defined as the likelihood that a patient's stage of disease was documented in the EHR after the patient's first (eg, index) ambulatory visit during the pilot period. Among the 56 oncologists participating (32 men [57%]), receipt of emails with peer comparison data was associated with increased likelihood of documentation of cancer stage using the structured field in the EHR (23.2% vs 13.0% of patient index visits). In adjusted analyses, this difference represented an increase of 9.0 (95% CI, 4.4-13.5) percentage points (P = .002) in the probability that a patient's cancer stage was documented, a relative increase of 69% compared with oncologists who did not receive peer comparison emails. The association increased with each email that was sent, ranging from a nonsignificant 4.0 (95% CI, -0.8 to 8.8) percentage points (P = .09) after the first email to a statistically significant 11.2 (95% CI, 4.9-17.4) percentage points (P = .003) after the third email . The association was concentrated among an oncologist's new patients (increase of 11.8 [95% CI, 6.2-17.4] percentage points; P = .001) compared with established patients (increase of 1.6 [95% CI, -2.9 to 6.1] percentage points; P = .44) and persisted for 7 months after the email communications stopped. In a quality improvement pilot trial, peer comparison emails were associated with a substantial increase in oncologist use of the structured field in the EHR to document stage of disease.

IntroductionIt is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being.Methods and analysisPragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be ≥18 years screened as potentially having palliative care needs and at risk of dying in 6–12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient’s health-related quality-of-life and quality of chronic disease care; (ii) caregiver’s health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff’s self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention.Ethics and disseminationApproved by South-East Sydney Local Health District Human Research Ethics Committee and NSW Population and Health Services Research Ethics Committee. Results will be disseminated via conference presentations, journal publications, seminars and invited talks.Trial registration numberACTRN12617000280303.