Risk Watch e-column
March 2005

A monthly update of risk management news, issues and items of interest

• Many Patient Files Missing Important Data
  
• Docs Silent on Colleagues’ Behaviors
  
• Interactive Website Teaches Patient Safety
  

Many Patient Files Missing Important Data

Important clinical information — including laboratory and radiology results, letters and medical history — is missing from medical records in nearly 14% of patient visits, according to a new study. And in 44% of the cases, the missing information has the potential to adversely affect a patient’s well-being, physicians said.

Researchers examined the records of more than 1,600 patient visits at 32 Colorado primary care clinics. Their report was published in the February 2, 2005, Journal of the American Medical Association (JAMA).

The types of missing data, in order of frequency, include the following:

An editorial in JAMA recommends that physicians give copies of reports to patients so they can take them to a hospital or a specialist. The editorial also suggests that staff ensure patient files are complete.

(Sources: AMNews, Reuters)

Docs Silent on Colleagues’ Behaviors

Most physicians and healthcare workers routinely witness risky and potentially dangerous behavior by their colleagues, but few do anything about it, according to a new study.

Researchers visited 19 hospitals and observed and interviewed more than 1,700 physicians, nurses, clinical-care staff and administrators. Their findings include the following:

• 84% of physicians said they have seen coworkers “repeatedly taking shortcuts that could endanger patients.”
• 88% of physicians said about 10% of their colleagues “show poor clinical judgment.”
• 20% of physicians said they have seen patients harmed by such behaviors.
• Fewer than 10% of physicians and other clinical staff directly confront their colleagues about their concerns.

The study was cosponsored by the American Association of Critical-Care Nurses and VitalSmarts, a company specializing in leadership training and organizational performance. For more information, go to www.rxforbettercare.org.

(Sources: American Association of Critical-Care Nurses, BCBS HealthIssues)

Interactive Website Teaches Patient Safety

The National Patient Safety Foundation has launched an interactive, web-based educational tool to help physicians increase their knowledge of patient safety issues and adopt safe healthcare procedures in their practices.

The website has several modules that offer continuing medical education credits on various topics, including physician-patient communication, medication safety, disclosure of errors, learning from errors, pediatric care, medical device safety and anesthesia.

For example, the Physician-Patient Communication module covers the following:

• how to recognize the differences between errors and complications
• the necessity of providing clear and concise information to patients about procedures and potential complications
• how to identify elements of informed consent.

The website also contains an interactive education module for nurses and one for patients. For more information, go to www.npsf.org/html/mcw/physicians.html.

(Sources: American Medical News, National Patient Safety Foundation)