3/24/21

For this post, the Department of Quality and Safety asked two members of the Department of Radiology, Taj Qureshi, MPH, CPHRM, program manager of Quality, Safety and Experience, and Neena Kapoor, MD, director of Diversity, Equity and Inclusion and Quality and Patient Safety officer, to report on one of the major patient safety initiatives underway in Radiology.

According to the American College of Radiology, “Radiologists are medical doctors that specialize in diagnosing and treating injuries and diseases using medical imaging.¹” Medical imaging are tests that scan the body to help detect certain diseases or conditions. For example, an X-ray is a test that helps radiologists diagnose patients with broken bones.

Many times, a radiologist will review a patient’s test results and recommend follow-up tests be performed within a certain amount of time. It is important that the need for this follow-up is clearly communicated to patients and the patient’s care team so that tests are completed within the appropriate timeframe.

For example, a radiologist may identify a mass on an image of a patient’s lung that they believe is cancer. However, before diagnosing the patient, a radiologist may recommend the patient have a follow-up test performed in three months to review any changes or improvements to the patient’s images. If the recommended follow-up test is not performed, the cancer diagnosis may be missed, and the patient may not receive the treatment they need in a timely manner.

At the Brigham, whenever there is an opportunity to improve a process to ensure patient safety, we do everything possible to directly address the issue.

In October 2019, the Department of Radiology at Brigham Health launched a program called “Addressing Radiology Recommendations Collaboratively,” or (ARRC), to help reduce missed and delayed diagnoses in both the outpatient and inpatient hospital care settings.

ARRC helps ensure radiology tests with any findings that require follow-up or additional imaging have a collaborative care plan communicated and completed between the radiologist and the patient’s care team. The program includes several follow-up options to ensure no patient “falls through cracks.” Using these follow up methods, ARRC ensures all recommended follow-up tests are ordered, scheduled, and tracked to completion.

ARRC is on pace to track approximately 10,000 follow-up test recommendations across 10 radiology divisions per year at the Brigham, with initial data showing that 87 percent of tests reviewed as part of this program have been performed on time. For patients who are not imaged on time, a Safety Net Team sends letters to patients and their providers to notify them of imaging findings and the need for subsequent imaging.

Through innovation and collaboration, we believe ARRC will help us continue to improve the quality of radiology reports and patient safety at the Brigham.

References:

1. American College of Radiology. What is a Radiologist?

 https://www.acr.org/Practice-Management-Quality-Informatics/Practice-Toolkit/Patient-Resources/About-Radiology.

2/25/21

In a July 2020 Safety Matters post, “A Near Miss, an Important Reminder,” we discussed how one of our General Surgery residents identified a glitch in our electronic medical record that resulted in the option to order significantly more opioids for patients than were necessary.

The post below, written by one of our team members, Scott Weiner, MD, MPH, emergency physician, medical director of the Brigham Comprehensive Opioid Response and Education Program (B-CORE) and assistant professor of Emergency Medicine at Harvard Medical School, continues to explore how technology and innovation can be used to reduce the risk of medication abuse and overdoses.

The federal government’s name for the group of medications that can lead to abuse or have high risk of overdose is “controlled substances.” These are strong medications, including opioid painkillers (like oxycodone and morphine), benzodiazepine sedatives (like lorazepam and diazepam) and other drugs (like stimulants), and prescribers must be careful when prescribing them to avoid patient harm.

One of the biggest challenges to safety occurs when patients either mix controlled substances or obtain them from more than one provider. For example, if I am going to prescribe a brief course of oxycodone for a patient after a broken leg, I need to know if they are already getting opioids from another prescriber to ensure they are not receiving an unsafe number of pills that may lead to an addiction, or even overdose. Furthermore, some patients with a substance-use disorder may seek prescriptions for controlled substances from different health care providers concurrently. Unfortunately, these duplicate prescriptions are not easily detected.

A Database Innovation

To address this problem, Massachusetts, like nearly every other state in the U.S., instituted a special website, called the Massachusetts Prescription Awareness Tool (MassPAT), to enable secure access to its Prescription Drug Monitoring Program database. The database allows prescribers to see a patient’s complete controlled substance prescription history by licensed providers in Massachusetts regardless of who wrote the prescription, or where it was filled. This safety check is so important that Massachusetts now requires prescribers to check the database prior to issuing any new opioid or benzodiazepine prescriptions.

However, accessing this database is not easy. Prescribers need to register to use the site and then log in to the database using a different URL. It’s a cumbersome process that can take several minutes¹ to complete, preventing providers from performing all necessary steps due to their busy schedules and competing priorities. In 2018, Brigham and Women’s Hospital became the first health care system in the state to provide a direct connection to that data. Now, providers can enter our electronic medical record (EMR) system and within a few seconds can access the controlled substance prescription history for each of their patients.

A study of this innovation was recently published in the journal Pain Medicine. In the study, we found that the number of MPAT searches by Mass General Brigham providers in the EMR increased from about 209,000 in the six months before the integration to approximately 298,000 in the six months following integration — an increase of 43 percent. The study also discovered that the quantity of opioids prescribed decreased by about 5 percent, possibly reflecting times when the prescriber thought it might be safer to prescribe fewer opioids.²

A team at the Brigham was pleased to be able to help the state complete this integration for the first time, paving the way for other health care systems to use this same technology by integrating their own EMRs with MPAT, as we all strive to prescribe these medications as safely as possible.

References:

1. Poon et al. Usability of the Massachusetts Prescription Drug Monitoring Program in the Emergency Department: A Mixed-methods Study. Academic Emergency Medicine. 2016 January. PMID: 26806310.
2. Weiner et al. Opioid Prescribing after Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System’s Electronic Health Record. Pain Medicine. 2021 February. PMID: 33561288.

2/9/21

With the approval and distribution of both Pfizer and Moderna’s COVID-19 vaccines hopefully ushering in “the beginning of the end” of the COVID-19 pandemic, we would like to reflect on one of the most significant challenges our hospital faced in 2020—a year full of trials and tribulations.

Last September, the Brigham identified a cluster of COVID-19 infections that ultimately affected 52 individuals on 3 units, including 38 employees and 14 patients. An infectious disease cluster is an “aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even though the expected number may not be known.¹” Meaning, based on the number of cases and a thorough investigation into their potential sources, it is likely that these cases were associated with one other, possibly being transmitted from employee-to-patient, patient-to-patient, or employee-to-employee.

As experts in patient safety whose priority it is to keep our patients and staff safe and healthy, our primary goal was to understand the cluster as quickly as possible and prevent it from growing.  At the same time, we recognized that this cluster could also serve as an opportunity for significant learning about the disease, that would not have been possible otherwise.  Famously, John Snow, considered by many to be “the Father of Epidemiology,” was able to use a cluster of cholera cases to become the first person to identify how this infectious disease was transmitted.² (You can learn more about this discovery here.)

The investigation of our COVID-19 cluster revealed that the cluster began with a highly infectious, highly symptomatic patient who tested negative on arrival to the hospital, and then spread infection to several staff members and roommates before being diagnosed with COVID-19.  Factors that may have contributed to the further spread of the virus to other patients and staff included very high viral loads amongst infected individuals (making them more likely to spread their infection to others), patients rarely wearing their masks during encounters with staff, low rates of eye protection use by providers, and providers eating in small, enclosed spaces close together. The cluster ultimately ended through the use of an array of intensive interventions, including extensive contact tracing and repeated testing of all patients and staff on the impacted hospital floors.

Since identifying the contributing factors, we have worked to improve our practices and share our learnings broadly so those at our hospital and beyond can avoid a similar cluster in the future.  New measures implemented include increased testing of all inpatients (on arrival, again 72 hours after arrival, and every 3 days thereafter for patients receiving aerosol generating procedures); easy access to on-site testing for employees; a redoubling of efforts to improve staff compliance with eye protection and patient compliance with masking; and de-densification of staff work rooms and eating spaces.

By sharing our cluster experience and findings, we are demonstrating our unwavering commitment to transparency regarding patient safety events. Given the heightened concern and media attention on COVID-19 globally, we are proud that our team quickly disclosed the event to all potentially impacted patients and their families, our employees, as well as news organizations for public awareness.³ It is our hope that by sharing our story widely, other organizations will be able to learn from our experiences and that, in some small way, this event can contribute to the global fight against COVID-19.

To learn more, you can read about this work published in Annals of Internal Medicine here.

References:

1. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice, Third Edition- An Introduction to Applied Epidemiology and Biostatistics. https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html.
2. Centers for Disease Control and Prevention. John Snow: A Legacy of Disease Detectives. https://blogs.cdc.gov/publichealthmatters/2017/03/a-legacy-of-disease-detectives/.
3. New York Times. Coronavirus in the US.: Latest Map and Case Count.https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html#clusters.

 

2/2/21

For this post, we are sharing submissions from the Brigham’s #MyWhy campaign. The goal of the campaign is to give our front-line workers the opportunity to share, in their own words, their experience with and motivation for receiving the COVID-19 vaccine.

Below, you will find a collection of the #MyWhy contributions the Brigham has published to date.

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For more information about the COVID-19 vaccine and how its distribution is being planned in your state, please click here.

 

12/16/20

For this post, the Department of Quality and Safety asked George X. Huang, MD, a fellow in the Division of Allergy and Clinical Immunology, and Paige Wickner, MD, MPH, a faculty member and the head of Quality and Safety for the Division of Allergy and Clinical Immunology at Brigham and Women’s Hospital, to provide information about the Pfizer-BioNTech COVID-19 vaccine.

On Dec. 11, 2020, the U.S. Food and Drug Administration (FDA) approved an Emergency Use Authorization for the COVID-19 vaccine produced by Pfizer and BioNTech to be distributed in the United States to those ages 16 and older.¹ This vaccine (which is called BNT162b2) is delivered via two injections to the arm muscle which are given three weeks apart. The vaccine works by using advanced technology to deliver an RNA molecule to the body, which then instructs it to make a modified version of the spike protein of the SARS-CoV-2 virus.

Although researchers have been studying them for many years, this is the first RNA-based vaccine to be approved in the U.S. RNA-based vaccines are generally considered safer than other vaccines as they are not produced using any infectious virus elements, and the benefits of RNA-based vaccines are the same as all other vaccines: those vaccinated gain protection against certain infectious diseases. Moderna, another biotechnology company, has also produced an RNA-based COVID-19 vaccine that is currently under review by the FDA.

To study their vaccine’s safety and efficacy, Pfizer conducted clinical trials which included over 43,000 participants from several different countries including the U.S., Argentina, Brazil, and South Africa. Data from these trials showed that the vaccine prevented 95 percent of COVID-19 infections compared to participants who received a “fake” vaccine, also known as a placebo.²

There will certainly be further developments as other companies’ COVID-19 vaccines undergo review by the FDA. At the Brigham, we are closely following all data related to these vaccines, including their efficacy and safety. We have put measures in place as we begin vaccinations to ensure the safety of our patients and staff. Based on recommendations by the Centers for Disease Control (CDC), and in alignment with the state’s approach to vaccine distribution, we have begun vaccinating eligible health care workers this week.

For additional information on COVID-19 vaccines, please reference the links below in addition to consulting state-specific guidelines:

• https://www.cdc.gov/vaccines/covid-19/index.html 
• https://www.mass.gov/info-details/massachusetts-covid-19-vaccine-information
• https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine

References:

1. 1. U.S. Food & Drug Administration. Pfizer-BioNTech COVID-19 Vaccine. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine
   2. Polack et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N  Engl J Med. 2020. PMID: 33301246