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Journal Reports: Health Care

The Biggest Mistake Doctors Make

Misdiagnoses are harmful and costly. But they're often preventable.

By Laura Landro, assistant managing editor for The Wall Street Journal

 

Not only are diagnostic problems more common than other medical mistakes—and more likely to harm patients—but they're also the leading cause of malpractice claims, accounting for 35% of nearly $39 billion in payouts in the U.S. from 1986 to 2010, measured in 2011 dollars, according to Johns Hopkins.

 

The good news is that diagnostic errors are more likely to be preventable than other medical mistakes. And now health-care providers are turning to a number of innovative strategies to fix the complex web of errors, biases and oversights that stymie the quest for the right diagnosis.

 

Part of the solution is automation—using computers to sift through medical records to look for potential bad calls, or to prompt doctors to follow up on red-flag test results. Another component is devices and tests that help doctors identify diseases and conditions more accurately, and online services that give doctors suggestions when they aren't sure what they're dealing with.

 

Finally, there's a push to change the very culture of medicine. Doctors are being trained not to latch onto one diagnosis and stick with it no matter what. Instead, they're being taught to keep an open mind when confronted with conflicting evidence and opinion.

 

"Diagnostic error is probably the biggest patient-safety issue we face in health care, and it is finally getting on the radar of the patient quality and safety movement," says Mark Graber, a longtime Veterans Administration physician and a fellow at the nonprofit research group RTI International.

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Software-Guided Insulin Dosing: Tight Glycemic Control and Decreased Glycemic Derangements in Critically Ill Patients
Mayo Clin Proc. n September 2013

 

Objective: To determine whether glycemic derangements are more effectively controlled using softwareguided
insulin dosing compared with paper-based protocols.

Patients and Methods: We prospectively evaluated consecutive critically ill patients treated in a tertiary hospital surgical intensive care unit (ICU) between January 1 and June 30, 2008, and between January 1 and September 30, 2009. Paper-based protocol insulin dosing was evaluated as a baseline during the first period, followed by software-guided insulin dosing in the second period. We compared glycemic metrics related to hyperglycemia, hypoglycemia, and glycemic variability during the 2 periods.

Results: We treated 110 patients by the paper-based protocol and 87 by the software-guided protocol during the before and after periods, respectively. The mean ICU admission blood glucose (BG) level was higher in patients receiving software-guided intensive insulin than for those receiving paper-based intensive insulin (181 vs 156 mg/dL; P¼.003, mean of the per-patient mean). Patients treated with software-guided intensive insulin had lower mean BG levels (117 vs 135 mg/dL; P¼.0008), sustained greater time in the desired BG target range (95-135 mg/dL; 68% vs 52%; P¼.0001), had less frequent hypoglycemia (percentage of time BG level was <70 mg/dL: 0.51% vs 1.44%; P¼.04), and showed decreased glycemic variability (BG level per-patient standard deviation from the mean: 29 vs 42 mg/ dL; P¼.01).

Conclusion: Surgical ICU patients whose intensive insulin infusions were managed using the softwareguided
program achieved tighter glycemic control and fewer glycemic derangements than those managed with the paper-based insulin dosing regimen. More


An Inpatient Hypoglycemia Committee: Development, Successful Implementation, and Impact on Patient Safety
The Ochsner Journal, Volume 13, Number 3, Fall 2013

Hypoglycemia is a major and preventable cause of morbidity and mortality in the hospital setting. Prevention of
hypoglycemia in hospitalized patients relates to the practice climates and prescribing patterns of physicians, the development of safe and effective protocols, and the education of providers and nursing staff on hypoglycemia and its consequences.

Many hospitals use multidisciplinary committees to address issues of healthcare quality and patient safety. This
article describes the creation of a subspecialty Hypoglycemia Committee, its design and function, and the steps taken to reduce hypoglycemia in a large, tertiary acute care hospital.

The committee’s initiatives included a systematic investigation of all severe hypoglycemic events, the development of a standalone hypoglycemia treatment protocol, reduction of sliding scale insulin therapy, revision of insulin order sets, and education of physicians and house staff. Hypoglycemic events have consequently decreased.

The Hypoglycemia Committee is unique in that every case of severe hypoglycemia is reviewed by physicians, endocrinologists, and diabetes specialists. This multidisciplinary approach can effect measurable decreases in preventable hypoglycemic events. More


STATISTICAL TRANSFORMATION AND THE INTERPRETATION OF

INPATIENT GLUCOSE CONTROL DATA

Endocrine Practice September 2013

Objective: To introduce a statistical method of assessing hospital-based non–intensive care unit (non-ICU) inpatient glucose control.

Methods: Point-of-care blood glucose (POC-BG) data from non-ICU hospital units was extracted for January 1 through December 31, 2011. Glucose data distribution was examined before and after Box-Cox transformations and compared to normality. Different subsets of data were used to establish upper and lower control limits, and exponentially weighted moving average (EWMA) control charts were constructed from June, July, and October data as examples to determine if out-of-control events were identified differently in nontransformed vs transformed data.

Results: A total of 36,381 POC-BG values were analyzed. In all 3 monthly test samples, glucose distributions in nontransformed data were skewed but approached normal distribution once transformed. Interpretation of out-of-control events from EWMA control chart analysis also revealed differences. In the June test data, an out-of-control process was identified at sample 53 with nontransformed data, while the transformed data remained in control for the duration of the observed period. Analysis of July data demonstrated an out-of-control process sooner in the transformed data (sample 55) than the nontransformed (sample 111), while for October, transformed data remained in control longer than nontransformed data.

Conclusion: Statistical transformations increase the normal behavior of inpatient non-ICU glycemic data sets. The decision to transform glucose data could influence the interpretation and conclusions about the status of inpatient glycemic control. Further study is required to determine whether transformed vs nontransformed data influence point-of-care decisions or evaluation of interventions. More


Pathways to Quality Inpatient Management of Hyperglycemia and Diabetes:

A Call to Action
Diabetes Care 36:1807–1814, 2013

Currently patients with diabetes comprise up to 25–30%of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (.180 mg/dL) and hypoglycemia (,70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the
hospital.

In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed.We refer to four as system-based issues and four as patient-based issues.We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. More

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