Extensivists and near miss programs: Readers respond to December issue

Readers respond to articles on extensivists and near miss programs.

Hospitalists outside the hospital

Perhaps at some point, as more and more patients have to be seen on an outpatient basis by the same physicians who provided inpatient care (“Hospitalists outside the hospital, “ ACP Hospitalist, December 2011), someone in the medical education hierarchy will realize that the best model for efficient patient care is a modification of the traditional model that has existed in internal medicine for decades. There is simply no way for physicians without a vested long-term interest in their patients to care for them in the same seamless fashion that traditional, outpatient physicians do. Furthermore, patients select their outpatient physicians because they trust their abilities and knowledge; this choice is often taken away once they enter the hospital.

I suggest that ACP propose and stand behind a modification of the traditional model, with well-trained internists or family physicians as the hub of a model that would work cooperatively with physician assistants and/or nurse practitioners to serve patients' needs in both in- and outpatient arenas. In this model, doctors would move back and forth between in- and outpatient settings each day, both in person and virtually (through technology). This would allow patients to be seen by someone on the same team each day, and one well-trained physician to monitor the care of a large number of acutely and chronically ill persons. It would create a true medical home for people, as opposed to the current proposed model, which separates inpatient care from the “home's” responsibility set. ACP should push graduate medical education in this direction, before we are splintered into a mishmash of disconnected care that no electronic medical record, or any other supposedly uniting device, will be able to repair.

Joseph G. Weigel, FACP
Somerset, Ky.

Near misses

We were thrilled to read the cover article in the December 2011 edition of ACP Hospitalist (“Good catch!”) on the efforts at the Mayo Clinic to record and monitor “near miss” events. The New York Chapter of the American College of Physicians has been administering the only statewide near miss registry since 2007. It was reported in this magazine in 2008.

The registry has been funded by the New York State Department of Health and is still supported by the Department of Health with a research waiver that allows data to be collected without risk of legal discovery or regulatory investigation. Monitoring near misses helps health care agencies to design safe systems for patients without waiting for patients to first suffer adverse events. The study of near misses gives us information not only about our vulnerabilities but also about the barriers that protected patients from the errors that were avoided. Finally, it is clear that for every medical error that is committed, there are many other near misses which avoided that sort of error.

To date hundreds of reports have been filed by health care workers across the state and thousands of workers have been trained about the anatomy of medical errors, the effect of human factors on safety and the use of the online anonymous survey. Residency programs have used the survey as a way to document competency in Systems-Based Practice. Many of our hospitals have been recognized as promoting patient safety through this project and webinars have been conducted across the state to highlight safety programs affecting such potentially dangerous therapies as anticoagulation and to promote the use of such barriers to error as regular medication reconciliation.

Today we are poised to publish our first set of findings. Data analysis statistically confirms that in hospitals that have well- developed safety systems, those systems act as effective barriers to error. Hospitals that do not feature many safety systems tend to rely on human barriers to errors. Furthermore, evidence is mounting that more hospitals in New York State are using a variety of safety systems including computerized physician order entry, electronic health records and bar coding.

We applaud the efforts of ACP to support patient safety and congratulate the group at Mayo on their efforts to address near misses to guide patient safety planning.

Steven Walerstein, MD, FACP, President
New York Chapter, American College of Physicians, Inc.
Terence Brady, MD, FACP, President
New York Chapter, American College of Physicians Services, Inc.
Ethan D. Fried, MD, MS, MACP
New York State Near Miss Registry, Principal Investigator
New York Near State Miss Advisory Committee, Chair