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IIR 04-107 – HSR&D Study

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IIR 04-107
Identifying and Predicting Contextual Errors in Medical Decision Making
Saul J. Weiner MD
Jesse Brown VA Medical Center, Chicago, IL
Chicago, IL
Funding Period: October 2006 - August 2009

BACKGROUND/RATIONALE:
This study was undertaken to explore the problem of "contextual error," a term used to characterize situations in which physicians fail to attend to elements of their patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient specific, contextual errors represent a failure to individualize care.

OBJECTIVE(S):
To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes.

METHODS:
This study was conducted at fourteen practices including two academic clinics, two community based primary care networks with multiple sites, a core safety net provider and three Veteran Administration facilities. An incomplete randomized block design whereby unannounced standardized patients visited 111 internal medicine attending physicians (April 2007-2009) and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and biomedical red flag. Responses to probing about flags varied in revealing either no underlying complicating condition or an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. Primary outcomes were the proportions of visits in which physicians probed for contextual and biomedical factors in response to hints or "red flags" and the proportion of visits with error-free treatment plans. In addition this study includes a qualitative component based on a ROTER interaction analysis as well as an ethnographic content analysis with theme coding to identify elements of the physician patient interaction that could account for variation in rates of error.

FINDINGS/RESULTS:
Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.

IMPACT:
Recent publication: Contextual Errors and Failures in Individualizing Patient Care
A Multicenter Study. Annals of Internal Medicine (July 2010). Widely disseminated within VHA and externally. Impact is on demonstrating need for broader approach to assessing physician performance and addressing performance gaps related to failures to individualize care.

PUBLICATIONS:

Journal Articles

  1. Weiner SJ, Schwartz A. Contextual Errors in Medical Decision Making: Overlooked and Understudied. Academic Medicine. 2016 May 1; 91(5):657-62.
  2. Weiner SJ, Schwartz A. Directly observed care: can unannounced standardized patients address a gap in performance measurement? Journal of general internal medicine. 2014 Aug 1; 29(8):1183-7.
  3. Schwartz A, Weiner SJ, Binns-Calvey A. Comparing announced with unannounced standardized patients in performance assessment. Joint Commission Journal on Quality and Patient Safety. 2013 Feb 1; 39(2):83-8.
  4. Weiner SJ, Schwartz A, Cyrus K, Binns-Calvey A, Weaver FM, Sharma G, Yudkowsky R. Unannounced standardized patient assessment of the roter interaction analysis system: the challenge of measuring patient-centered communication. Journal of general internal medicine. 2013 Feb 1; 28(2):254-60.
  5. Schwartz A, Weiner SJ, Weaver F, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Jordan N. Uncharted territory: measuring costs of diagnostic errors outside the medical record. BMJ quality & safety. 2012 Nov 1; 21(11):918-24.
  6. Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Persell SD, Jacobs E, Abrams RI, Schapira MM. Contextual errors and failures in individualizing patient care: a multicenter study. Annals of internal medicine. 2010 Jul 20; 153(2):69-75.
  7. Weiner SJ, Schwartz A, Yudkowsky R, Schiff GD, Weaver FM, Goldberg J, Weiss KB. Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making. Medical Decision Making. 2007 Nov 1; 27(6):726-34.
Journal Other

  1. Weiner SJ, Schwartz A. Author's Reply Re: The need for biomedically and contextually sound care plans in complex patients: thoughts on creating a better practice environment. Annals of internal medicine. 2010 Sep 15.
Books

  1. Weiner SJ, Schwartz AJ.
Book Chapters

  1. Weiner SJ. Contextual Error. In: Encyclopedia of Medical Decision Making. Thousand Oaks, CA: Sage Publications; 2009.
Magazine/Popular Press Articles

  1. Weiner SJ. Preventing Contextual Errors in Clinical Practice. Chicago Medicine. 2016 Aug 15; 1(1):20-23.
VA Cyberseminars

  1. Weiner SJ. Listening for What Matters: Lessons about Caring from Concealed Recordings of Medical Encounters. Compassion in Action Series [Cyberseminar]. The Schwartz Center. 2016 Sep 13.
Conference Presentations

  1. Weiner SJ. This Visit May be Recorded: Direct Assessment of the Clinical Encounter for Attention to Patient Context. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 16; Minneapolis, MN.
  2. Weiner SJ, Schwartz AJ. Learning to Avoid “Contextual Errors” when Planning Patient Care. Paper presented at: American College of Physicians Annual Meeting; 2015 May 1; Boston, MA.
  3. Binns-Calvey A, Yudkowsky R, Weiner SJ, Dolley F, Brown J, Schwartz AJ. Assessing Unannounced Standardized Patients' Accuracy in Real Practice Compared with SP Accuracy in a Clinical Performance Center. Poster session presented at: Association of Standardized Patient Educators Annual Conference; 2011 Jun 5; Nashville, TN.
  4. Weiner SJ, Schwartz A, Harris I. A randomized trial of an educational intervention to reduce contextual errors in medical decision making. Paper presented at: Society of General Internal Medicine Midwest Regional Annual Meeting; 2009 Sep 17; Chicago, IL.
  5. Weiner SJ, Schwartz A, Weaver FM, Schapira M, Jacobs E, Goldberg J, Yudkowsky R, Jordan N. Contextual errors lead to avoidable cost: A multi-site unannounced standardized patient trial. Paper presented at: Society of General Internal Medicine Midwest Regional Annual Meeting; 2009 Sep 17; Chicago, IL.
  6. Weiner SJ, Schwartz A, Weaver FM, Schapira M, Yudkowsky R, Jordan N. Overlooking Contextual Information when Planning Patient Care: A Source of Medical Error and Avoidable Cost. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  7. Weiner SJ, Schwartz A, Harris IB. Learning to Individualize Care: An Educational Intervention to Reduce Contextual Errors in Medical Decision Making. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 14; Miami Beach, FL.
  8. Weiner SJ, Schwartz A, Weaver FM, Schapira M, Jacobs E, Goldberg J, Yudowsky R, Jordan N. Overlooking Contextual Information when Individualizing Care: A Source of Medical Error and Avoidable Cost. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 14; Miami Beach, FL.
  9. Weiner SJ, Schwartz A, Weaver FM, Goldberg J, Schapira MM, Yudkowsky R, Sharma G, Preyss B, Jordan N, Kaestner R. Overlooking Contextual Information in Medical Decision Making: A Source of Medical Error and Avoidable Cost. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  10. Binns-Calvey A, Maddox S, Weiner SJ, Sharma GS. Strategies for Avoiding Medical Testing and Procedures for Unannounced Standardized Patients. Poster session presented at: Association of Standardized Patient Educators Annual Conference; 2008 Jun 29; San Antonio, TX.


DRA: Health Systems
DRE: none
Keywords: Safety, Adverse events, Decision support
MeSH Terms: none

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