Defining Best Practices for Interhospital Transfers.

Introduction: Interhospital transfers (IHT) are important yet high-risk transitions in care. Variable IHT processes and a lack of clarity around best practice may contribute to risk. To define the best practice principles for IHTs and identify improvement opportunities in the transfer process to our hospital's Cardiology services.

Missed diagnosis of cancer in primary care: Insights from malpractice claims data.

Background: In the ambulatory setting, missed cancer diagnoses are leading contributors to patient harm and malpractice risk; however, there are limited data on the malpractice case characteristics for these cases.

Objective: The aim of this study was to examine key features and factors identified in missed cancer diagnosis malpractice claims filed related to primary care and evaluate predictors of clinical and claim outcomes.

Methods: We analyzed 2155 diagnostic error closed malpractice claims in outpatient general medicine.

On-call transthoracic echocardiographic interpretation by first year cardiology fellows: comparison with attending cardiologists.

Background: Transthoracic echocardiograms (TTE) performed and interpreted by cardiology fellows during off-duty hours are critical to patient care, however limited data exist on their interpretive accuracy. Our aims were to determine the discordance rate between TTEs performed and interpreted by cardiology fellows and National Board of Echocardiography certified attending cardiologists and to identify factors associated with discordance.

Methods: Consecutive on-call TTEs acquired and interpreted by 1st year cardiology fellows over 4.

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?: A 128 Million Dollar Question.

Objective: We aimed to study the contributing factors and costs of malpractice claims involving the surgical management of benign biliary disease given the emotional, physical, and financial toll of these claims on patients, providers, and the healthcare system.

Summary Background Data: Cholecystectomy complications carry significant morbidity and rank among the leading sources of surgical malpractice claims.

Methods: Using the CRICO Strategies' Comparative Benchmarking System database, representing approximately 30% of all paid and unpaid malpractice claims in the United States, 4081 closed claims filed against general surgeons from 1995 to 2015 were reviewed to isolate 745 cholecystectomy-related claims.

Selective Serotonin Reuptake Inhibitors and Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: An Analysis From the ROCKET AF Trial.

Background There is concern that selective serotonin reuptake inhibitors ( SSRI s) substantially increase bleeding risk in patients taking anticoagulants. Methods and Results We studied 737 patients taking SSRI s in the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Embolism and Stroke Trial in Atrial Fibrillation) trial of rivaroxaban compared with warfarin for the prevention of stroke/systemic embolism in patients with atrial fibrillation. These patients were propensity score matched 1:1 to 737 patients not taking SSRI s.

Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk.

Background: Guidelines for anticoagulation in atrial fibrillation (AF) assume that stroke risk scheme point scores correspond to fixed stroke rates. However, reported stroke rates vary widely across AF cohort studies, including studies from the same country. Reasons for this variation are unclear.

Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data.

Background: Diagnostic errors are an underrecognized source of patient harm, and cardiovascular disease can be challenging to diagnose in the ambulatory setting. Although malpractice data can inform diagnostic error reduction efforts, no studies have examined outpatient cardiovascular malpractice cases in depth. A study was conducted to examine the characteristics of outpatient cardiovascular malpractice cases brought against general medicine practitioners.

Wide Variation in Reported Rates of Stroke Across Cohorts of Patients With Atrial Fibrillation.

Background: Oral anticoagulants decrease ischemic stroke rates in patients with atrial fibrillation (AF) but increase the risk of bleeding. For the average patient with AF, the threshold of annual ischemic stroke rate where the benefit of anticoagulation outweighs the bleeding risk (net clinical benefit) has been shown to be ≈1% to 2%. Guideline recommendations for oral anticoagulants in AF are based on the CHADS-VASc stroke risk point scores, assuming that those scores translate to fixed stroke rates.

How Well Do Stroke Risk Scores Predict Hemorrhage in Patients With Atrial Fibrillation?

The decision to use anticoagulants for atrial fibrillation depends on comparing a patient's estimated risk of stroke to their bleeding risk. Several of the risk factors in the stroke risk schemes overlap with hemorrhage risk. We compared how well 2 stroke risk scores (CHADS2 and CHA2DS2-VASc) and 2 hemorrhage risk scores (the ATRIA bleeding score and the HAS-BLED score) predicted major hemorrhage on and off warfarin in a cohort of 13,559 community-dwelling adults with AF.

Effect of selective serotonin reuptake inhibitors on bleeding risk in patients with atrial fibrillation taking warfarin.

Selective serotonin reuptake inhibitor (SSRI) medications have been linked to increased bleeding risk; however, the actual association among warfarin, SSRI exposure, and bleeding risk has not been well-established. We studied the AnTicoagulation and Risk factors In Atrial fibrillation cohort of 13,559 adults with atrial fibrillation, restricted to the 9,186 patients contributing follow-up time while taking warfarin. Exposure to SSRIs and tricyclic antidepressants (TCAs) was assessed from pharmacy database dispensing data.

"Not so fast!" the complexity of attempting to decrease door-to-floor time for emergency department admissions.

Background: Successful quality improvement is fundamental to high-performing health care systems, but becomes increasingly difficult as systems become more complex. Previous attempts at the University of California, San Francisco (UCSF) Medical Center to reduce door-to-floor (D2F) time -the time required to move an ill patient through the emergency department (ED) to an appropriate inpatient bed-had not resulted in meaningful improvement. An analysis of why attempts at decreasing D2F times in the ED had failed, with attention to contextual factors, yields recommendations on how to decrease D2F time.

Atrial fibrillation: stroke prevention in older adults.

Atrial fibrillation (AF) is an increasingly prevalent disease in the elderly. Patients with AF are at increased risk of ischemic stroke, resulting in significant morbidity and mortality. Warfarin is highly effective at reducing stroke risk, with a net clinical benefit favoring treatment in older individuals.

Functional impairment in body dysmorphic disorder: a prospective, follow-up study.

Cross-sectional/retrospective studies indicate that individuals with body dysmorphic disorder (BDD) have markedly impaired psychosocial functioning. However, no study has prospectively examined functioning in BDD. In this study, which is to our knowledge the first prospective study of the course of BDD, psychosocial functioning was assessed at baseline and over 1-3 years (mean=2.

A prospective evaluation of interrupted nitinol surgical clips in arteriovenous fistula for hemodialysis.

Background: The use of a self-closing nitinol surgical clip (Coalescent Surgical U-Clip) is a novel technique of creating an interrupted vascular anastomosis, which also eliminates the knot tying associated with a conventional vascular anastomosis. The purpose of this study was to compare the clinical outcome of arteriovenous fistulae (AVF) for hemodialysis as constructed using interrupted U-Clip devices and conventional continuous polypropylene sutures.

Methods: We prospectively studied the clinical course of 132 patients (149 access) undergoing either forearm autologous arteriovenous fistula (FAVF, n = 69) or upper arm autologous arteriovenous fistula (UAVF, n = 80) or creations during a 39-month period.