OBJECTIVE:To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS:Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge.DESIGN: Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS:Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit.MAIN RESULTS: Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION:We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.KEY WORDS: medical errors; continuity of care; discharge plan; discharge summary. J GEN INTERN MED 2003;18:646±651. A dverse events in hospitalized patients have been associated with the discontinuity of care that occurs during the handoff of patient care from one hospital-based physician to another, 1 and there is evidence that improved communication between hospital-based physicians may decrease adverse events. 2 However, relatively little attention has been given to the spectrum of medical errors and adverse events that are caused by inadequate communication between hospital-based physicians and outpatient primary care providers (PCPs). Physicians caring for hospitalized patients often formulate discharge plans that include medication regimens that are to be continued after discharge, scheduled outpatient tests and procedures, and test results that are pending at discharge and that need to be followed up by the outpatient PCP. The Institute of Medicine defines a medical error as``failure of a planned action to be completed as intended. '' 3 Based on this definition, failure to implement the intended discharge plan for a recently hospitalized patient constitutes a medical error, assuming the PCP concurs with the plan or, if not, fails to change the plan. However, studies have shown that less than half of all PCPs are provided information about the discharge medications and plans for their recently hospitalized patients, 4±6 this despite evidence that access to relevant discharge in...

Key Points Question Is enhanced usability of an electronic health record system associated with physician cognitive workload and performance? Findings In this quality improvement study, physicians allocated to perform tasks in an electronic health record system with enhancement demonstrated statistically significantly lower cognitive workload; those who used a system with enhanced longitudinal tracking appropriately managed statistically significantly more abnormal test results compared with physicians allocated to use the baseline electronic health record. Meaning Usability improvements in electronic health records appear to be associated with improved cognitive workload and performance levels among clinicians; this finding suggests that next-generation systems should strip away non–value-added interactions.

Background and objectives Over 35% of patients on maintenance dialysis are readmitted to the hospital within 30 days of hospital discharge. Outpatient dialysis facilities often assume responsibility for readmission prevention. Hospital care and discharge practices may increase readmission risk. We undertook this study to elucidate risk factors identifiable from hospital-derived data for 30-day readmission among patients on hemodialysis.Design, setting, participants, & measurements Data were taken from patients on maintenance hemodialysis discharged from University of North Carolina Hospitals between May of 2008 and June of 2013 who received inpatient hemodialysis during their index hospitalizations. Multivariable logistic regression models with 30-day readmission as the dependent outcome were used to identify readmission risk factors. Models considered variables available at hospital admission and discharge separately.Results Among 349 patients, 112 (32.1%) had a 30-day hospital readmission. The discharge (versus admission) model was more predictive of 30-day readmission. In the discharge model, malignancy comorbid condition (odds ratio [OR], 2.08; 95% confidence interval [95% CI], 1.04 to 3.11), three or more hospitalizations in the prior year (OR, 1.97; 95% CI, 1.06 to 3.64), $10 outpatient medications at hospital admission (OR, 1.69; 95% CI, 1.00 to 2.88), catheter vascular access (OR, 1.82; 95% CI, 1.01 to 3.65), outpatient dialysis at a nonuniversity-affiliated dialysis facility (OR, 3.59; 95% CI, 2.03 to 6.36), intradialytic hypotension (OR, 3.10; 95% CI, 1.45 to 6.61), weekend discharge day (OR, 1.82; 95% CI, 1.01 to 3.31), and serum albumin ,3.3 g/dl (OR, 4.28; 95% CI, 2.37 to 7.73) were associated with higher readmission odds. A decrease in prescribed medications from admission to discharge (OR, 0.20; 95% CI, 0.08 to 0.51) was associated with lower readmission odds. Findings were robust across different model-building approaches.Conclusions Models containing discharge day data had greater predictive capacity of 30-day readmission than admission models. Identified modifiable readmission risk factors suggest that improved medication education and improved transitions from hospital to community may potentially reduce readmissions. Studies evaluating targeted transition programs among patients on dialysis are needed.

Background: Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.Methods: This controlled clinical trial (April 1, 2002, to February 28, 2003 involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1-or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.Results: Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; PϽ.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; PϽ.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; PϽ.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.Conclusions: A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.

Factors shown to have an adverse affect on opioid prescribing disproportionately impact on the attitudes of internists compared with geriatricians. Further research is needed to determine if there is also a differential impact on how internists care for their elderly patients with chronic pain.