In the News

Physician errors, managing STEMI, and more.

Best way to get details on physician errors: Ask

Physician self-reporting may be a valuable, yet underused, source of information on the reasons underlying common diagnostic errors, a national survey suggests.

Researchers administered a six-question survey asking physicians at 22 U.S. institutions to report three cases of diagnostic errors and their perceived causes, seriousness and frequency. Of 583 cases reported, 28% were rated as major, 41% as moderate and 31% as minor or insignificant. Pulmonary embolism and drug reactions or overdose were the most commonly missed or delayed diagnoses (each with 4.5% of the total), followed by lung cancer (3.9%), colorectal cancer (3.3%), acute coronary syndrome (3.1%), breast cancer (3.1%) and stroke (2.6%). The study was in the Nov. 9, 2009 Archives of Internal Medicine.

Physicians surveyed readily reported on errors and shared their experiences, the authors noted, suggesting that tapping into physicians' clinical experience might uncover many errors that are missed by existing error surveillance and reporting systems. The survey gave physicians a venue to share their experiences anonymously in a blame-free setting, they added.

Beyond raising awareness, asking physicians to report on errors has several advantages, the authors said. These include

  • Compelling physicians to reflect on past cases and learn from what went wrong;
  • Revealing patterns in diagnostic errors, such as inadequate follow-up of abnormal imaging studies;
  • Looking beyond individual diagnoses to generic factors that cut across disease areas; and
  • Bringing hidden errors to light in order to encourage institutions to make improvements aimed at minimizing errors.

Update on managing PCI, STEMI

Updated guidelines for managing ST-elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI) call for integrating prasugrel into treatment and for new standards on efficient transfer of patients needing PCI.

The update, compiled by the American College of Cardiology, the American Heart Association and the Society of Cardiovascular Angiography and Interventions, notes new evidence about prasugrel, but does not explicitly endorse its use over clopidogrel. A recent large trial found that prasugrel reduced nonfatal MIs in STEMI patients undergoing PCI, compared with clopidogrel, but also increased the risk of bleeding, the authors said. In addition, there is not yet enough information to guide identification of patients who might do better with prasugrel, they said.

The authors also highlighted the importance of speeding transfer to PCI-capable facilities for patients with high-risk features such as high bleeding risk from fibrinolytic therapy and presentation more than four hours after symptom onset. They urged communities to develop regional systems of STEMI care, such as the AHA's “Mission: Lifeline” initiative, which encourages closer cooperation among pre-hospital emergency services and cardiac care professionals. The update was published Dec. 1, 2009 in the Journal of the American College of Cardiology.

Other recommendations in the update include

  • Use of a glycoprotein IIb/IIIa antagonist cannot be recommended as routine therapy for dual-antiplatelet therapy with UFH or bivalirudin as the anticoagulant, although it can be useful at the time of primary PCI;
  • There is insufficient evidence to recommend the use of dual antiplatelet therapy with proton-pump inhibitors in the setting of acute coronary syndrome; and
  • Bivalirudin is useful as a supportive measure for primary PCI in STEMI whether or not the patient received pretreatment with unfractionated heparin.

Timely hospital report cards didn't improve overall cardiac care

Giving hospitals early publicly reported feedback on their quality scores for cardiac care did not significantly improve composite process-of-care indicators, a study found.

Researchers randomized 86 hospitals in Ontario, Canada, to either early (January 2004) or delayed (January 2005) feedback on their performance scores on a set of 12 measures for acute myocardial infarction (AMI) and six for congestive heart failure (CHF) between 1999 and 2001. There were no significant systemic improvements in the early feedback group on composite process-of-care indicators for AMI or CHF, but 30-day AMI mortality rates were 2.5% lower in the early feedback group during the one-year follow-up period. The study appeared in the Nov. 18, 2009 Journal of the American Medical Association.

Many hospitals in the early feedback group undertook improvement initiatives, but each hospital tended to target different areas depending on its local results. This may explain why significant improvements across two large groups of hospitals and a wide range of indicators weren't found, the authors said.

While individual process-of-care indicators were not significantly improved, the lower mean 30-day AMI mortality rate in the early feedback group suggests that the diverse local improvements collectively may have improved outcomes, the authors said. Almost two-fifths of hospitals in the early feedback group initiated processes to improve timely reperfusion, the authors noted, while five hospitals opened CHF clinics, and early feedback appeared to lead to greater use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers.

While releasing report card data did not result in systemic improvements in cardiac care, it likely triggered important local changes that may have contributed to better outcomes. In the future, developing common improvement strategies across hospitals might make the report cards more effective systemwide, the authors said.