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author:("Singh, hardee")
1.  Corner store purchases in a low-income urban community in NYC1 
Journal of community health  2015;40(6):1084-1090.
We assessed purchases made, motivations for shopping, and frequency of shopping at four New York City corner stores (bodegas).
Surveys and purchase inventories (n= 779) were collected from consumers at four bodegas in Bronx, NY. We use chi-square tests to compare types of consumers, items purchased and characteristics of purchases based on how frequently the consumer shops at the specific store and the time of day the purchase was made.
Most consumers shopped at the bodega because it was close to their home (52%). The majority (68%) reported shopping at the bodega at least once per day. The five most commonly purchased items were sugary beverages, (29.27%), sugary snacks (22.34%), coffee, (13.99%), sandwiches, (13.09%) and non-baked potato chips (12.2%). Nearly 60% of bodega customers reported their purchase to be healthy.
Most of the participants shopped at the bodega frequently, valued its convenient location, and purchased unhealthy items. Work is needed to discover ways to encourage healthier choices at these stores.
PMCID: PMC4620064  PMID: 25910485
choice behavior; diet; food; obesity; New York City
2.  Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial 
Journal of Clinical Oncology  2015;33(31):3560-3567.
We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer.
We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months.
We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58).
Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.
PMCID: PMC4622097  PMID: 26304875
3.  Development and Validation of Electronic Health Record–based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings 
Radiology  2015;277(1):81-87.
An electronic health record–based trigger algorithm was developed to identify patients who are at risk for delayed follow-up of abnormal imaging findings. The trigger achieved a positive predictive value of 57.3% and shows promise in detecting diagnostic delays in patients with imaging findings suspicious for lung cancer.
To develop an electronic health record (EHR)–based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data.
Materials and Methods
The local institutional review board approved the study. A “trigger” algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being “suspicious for malignancy.” The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40–70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics.
The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years.
EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed.
© RSNA, 2015
PMCID: PMC4613876  PMID: 25961634
4.  Graphical display of diagnostic test results in electronic health Records: a comparison of 8 systems 
Accurate display and interpretation of clinical laboratory test results is essential for safe and effective diagnosis and treatment. In an attempt to ascertain how well current electronic health records (EHRs) facilitated these processes, we evaluated the graphical displays of laboratory test results in eight EHRs using objective criteria for optimal graphs based on literature and expert opinion. None of the EHRs met all 11 criteria; the magnitude of deficiency ranged from one EHR meeting 10 of 11 criteria to three EHRs meeting only 5 of 11 criteria. One criterion (i.e., the EHR has a graph with y-axis labels that display both the name of the measured variable and the units of measure) was absent from all EHRs. One EHR system graphed results in reverse chronological order. One EHR system plotted data collected at unequally-spaced points in time using equally-spaced data points, which had the effect of erroneously depicting the visual slope perception between data points. This deficiency could have a significant, negative impact on patient safety. Only two EHR systems allowed users to see, hover-over, or click on a data point to see the precise values of the x–y coordinates. Our study suggests that many current EHR-generated graphs do not meet evidence-based criteria aimed at improving laboratory data comprehension.
PMCID: PMC4482275  PMID: 25792704
diagnostic tests; user computer interface; electronic health records; national health policy
5.  A Socio-Technical Approach to Preventing, Mitigating, and Recovering from Ransomware Attacks 
Applied Clinical Informatics  2016;7(2):624-632.
Recently there have been several high-profile ransomware attacks involving hospitals around the world. Ransomware is intended to damage or disable a user’s computer unless the user makes a payment. Once the attack has been launched, users have three options: 1) try to restore their data from backup; 2) pay the ransom; or 3) lose their data. In this manuscript, we discuss a socio-technical approach to address ransomware and outline four overarching steps that organizations can undertake to secure an electronic health record (EHR) system and the underlying computing infrastructure. First, health IT professionals need to ensure adequate system protection by correctly installing and configuring computers and networks that connect them. Next, the health care organizations need to ensure more reliable system defense by implementing user-focused strategies, including simulation and training on correct and complete use of computers and network applications. Concomitantly, the organization needs to monitor computer and application use continuously in an effort to detect suspicious activities and identify and address security problems before they cause harm. Finally, organizations need to respond adequately to and recover quickly from ransomware attacks and take actions to prevent them in future. We also elaborate on recommendations from other authoritative sources, including the National Institute of Standards and Technology (NIST). Similar to approaches to address other complex socio-technical health IT challenges, the responsibility of preventing, mitigating, and recovering from these attacks is shared between health IT professionals and end-users.
PMCID: PMC4941865  PMID: 27437066
Health information technology; electronic health record; socio-technical; cybersecurity; ransomware
6.  Online public reactions to frequency of diagnostic errors in US outpatient care 
Diagnosis (Berlin, Germany)  2016;3(1):17-22.
Diagnostic errors pose a significant threat to patient safety but little is known about public perceptions of diagnostic errors. A study published in BMJ Quality & Safety in 2014 estimated that diagnostic errors affect at least 5% of US adults (or 12 million) per year. We sought to explore online public reactions to media reports on the reported frequency of diagnostic errors in the US adult population.
We searched the World Wide Web for any news article reporting findings from the study. We then gathered all the online comments made in response to the news articles to evaluate public reaction to the newly reported diagnostic error frequency (n=241). Two coders conducted content analyses of the comments and an experienced qualitative researcher resolved differences.
Overall, there were few comments made regarding the frequency of diagnostic errors. However, in response to the media coverage, 44 commenters shared personal experiences of diagnostic errors. Additionally, commentary centered on diagnosis-related quality of care as affected by two emergent categories: (1) US health care providers (n=79; 63 commenters) and (2) US health care reform-related policies, most commonly the Affordable Care Act (ACA) and insurance/reimbursement issues (n=62; 47 commenters).
The public appears to have substantial concerns about the impact of the ACA and other reform initiatives on the diagnosis-related quality of care. However, policy discussions on diagnostic errors are largely absent from the current national conversation on improving quality and safety. Because outpatient diagnostic errors have emerged as a major safety concern, researchers and policymakers should consider evaluating the effects of policy and practice changes on diagnostic accuracy.
PMCID: PMC4917213  PMID: 27347474
diagnostic error burden; public perceptions
7.  The Burden of Inbox Notifications in Commercial Electronic Health Records 
JAMA internal medicine  2016;176(4):559-560.
PMCID: PMC4860883  PMID: 26974737
electronic health records; health information technology; alerts; notifications; medical informatics; primary care; efficiency; patient safety; health services research
8.  Replantation in scapulothoracic avulsion amputation of the right upper limb in a 3-year-old child- A preliminary report 
Replantations for major amputations of upper extremity have been widely performed. We report a unique case of successful replantation of scapulothoracic avulsion amputation in a child. In this manuscript, we discuss the various challenges faced during the procedure and chances of neural recovery.
PMCID: PMC5053008  PMID: 27833298
Replantation; scapulothoracic avulsion; upper extremity amputation
9.  Measuring and improving patient safety through health information technology: The Health IT Safety Framework 
BMJ Quality & Safety  2015;25(4):226-232.
Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement. The HITS framework follows both Continuous Quality Improvement (CQI) and sociotechnical approaches and calls for new measures and measurement activities to address safety concerns in three related domains: 1) concerns that are unique and specific to technology (e.g., to address unsafe health IT related to unavailable or malfunctioning hardware or software); 2) concerns created by the failure to use health IT appropriately or by misuse of health IT (e.g. to reduce nuisance alerts in the electronic health record (EHR)), and 3) the use of health IT to monitor risks, health care processes and outcomes and identify potential safety concerns before they can harm patients (e.g. use EHR-based algorithms to identify patients at risk for medication errors or care delays). The framework proposes to integrate both retrospective and prospective measurement of HIT safety with an organization's existing clinical risk management and safety programs. It aims to facilitate organizational learning, comprehensive 360 degree assessment of HIT safety that includes vendor involvement, refinement of measurement tools and strategies, and shared responsibility to identify problems and implement solutions. A long term framework goal is to enable rigorous measurement that helps achieve the safety benefits of health IT in real-world clinical settings.
PMCID: PMC4819641  PMID: 26369894
Information technology; Patient safety; Performance measures; Quality measurement; Quality improvement methodologies
10.  Communication breakdowns and diagnostic errors: a radiology perspective 
Diagnosis (Berlin, Germany)  2014;1(4):253-261.
Timely and accurate communication is essential to safe and effective health care. Despite increased awareness over the past decade of the frequency of medical errors and greater efforts directed towards improving patient safety, patient harm due to communication breakdowns remains a significant problem. Communication problems related to diagnostic testing may account for nearly half of all errors made by typical primary care physicians in their medical practices. This article provides an overview of communication breakdowns in the context of radiology related diagnostic errors. In radiology, communication breakdowns between radiologists, referring clinicians, and patients can lead to failure of critical information to be relayed, resulting in delayed or missed diagnosis. New technologies, such electronic health records (EHRs), contribute to the increasing complexity of communication in health care, but if used correctly, they can provide several benefits to safe and effective communication. To address the complexity of communication breakdowns, a multifaceted sociotechnical approach is needed to address both technical and non-technical aspects of health care delivery. The article also provides some future directions in reducing communication breakdowns related to diagnostic testing, including proactive risk assessment of communication practices using recently released SAFER self-assessment guides.
PMCID: PMC4799783  PMID: 27006890
electronic communication; electronic health records; health information technology; medical informatics; primary care; radiology; test results
11.  Developing checklists to prevent diagnostic error in Emergency Room settings 
Diagnosis (Berlin, Germany)  2014;1(3):223-231.
Checklists have been shown to improve performance of complex, error-prone processes. To develop a checklist with potential to reduce the likelihood of diagnostic error for patients presenting to the Emergency Room (ER) with undiagnosed conditions.
Participants included 15 staff ER physicians working in two large academic centers. A rapid cycle design and evaluation process was used to develop a general checklist for high-risk situations vulnerable to diagnostic error. Physicians used the general checklists and a set of symptom-specific checklists for a period of 2 months. We conducted a mixed methods evaluation that included interviews regarding user perceptions and quantitative assessment of resource utilization before and after checklist use.
A general checklist was developed iteratively by obtaining feedback from users and subject matter experts, and was trialed along with a set of specific checklists in the ER. Both the general and the symptom-specific checklists were judged to be helpful, with a slight preference for using symptom-specific lists. Checklist use commonly prompted consideration of additional diagnostic possibilities, changed the working diagnosis in approximately 10% of cases, and anecdotally was thought to be helpful in avoiding diagnostic errors. Checklist use was prompted by a variety of different factors, not just diagnostic uncertainty. None of the physicians used the checklists in collaboration with the patient, despite being encouraged to do so. Checklist use did not prompt large changes in test ordering or consultation.
In the ER setting, checklists for diagnosis are helpful in considering additional diagnostic possibilities, thus having potential to prevent diagnostic errors. Inconsistent usage and using the checklists privately, instead of with the patient, are factors that may detract from obtaining maximum benefit. Further research is needed to optimize checklists for use in the ER, determine how to increase usage, to evaluate the impact of checklist utilization on error rates and patient outcomes, to determine how checklist usage affects test ordering and consultation, and to compare checklists generally with other approaches to reduce diagnostic error.
PMCID: PMC4799784  PMID: 27006889
checklist; clinical reasoning; diagnosis; diagnostic error; emergency medicine
12.  Breakdowns in communication of radiological findings: an ethical and medico-legal conundrum 
Diagnosis (Berlin, Germany)  2014;1(4):263-268.
Communication problems in diagnostic testing have increased in both number and importance in recent years. The medical and legal impact of failure of communication is dramatic. Over the past decades, the courts have expanded and strengthened the duty imposed on radiologists to timely communicate radiologic abnormalities to referring physicians and perhaps the patients themselves in certain situations. The need to communicate these findings goes beyond strict legal requirements: there is a moral imperative as well. The Code of Medical Ethics of the American Medical Association points out that “Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties.” Thus, from the perspective of the law, radiologists are required to communicate important unexpected findings to referring physicians in a timely fashion, or alternatively to the patients themselves. From a moral perspective, radiologists should want to effect such communications. Practice standards, moral values, and ethical statements from professional medical societies call for full disclosure of medical errors to patients affected by them. Surveys of radiologists and non-radiologic physicians reveal that only few would divulge all aspects of the error to the patient. In order to encourage physicians to disclose errors to patients and assist in protecting them in some manner if malpractice litigation follows, more than 35 states have passed laws that do not allow a physician’s admission of an error and apologetic statements to be revealed in the courtroom. Whether such disclosure increases or decreases the likelihood of a medical malpractice lawsuit is unclear, but ethical and moral considerations enjoin physicians to disclose errors and offer apologies.
PMCID: PMC4799785  PMID: 27006891
case law; communication; disclosure; malpractice; medical ethics; radiology
14.  The challenges in defining and measuring diagnostic error 
Diagnosis (Berlin, Germany)  2015;2(2):97-103.
Diagnostic errors have emerged as a serious patient safety problem but they are hard to detect and complex to define. At the research summit of the 2013 Diagnostic Error in Medicine 6th International Conference, we convened a multidisciplinary expert panel to discuss challenges in defining and measuring diagnostic errors in real-world settings. In this paper, we synthesize these discussions and outline key research challenges in operationalizing the definition and measurement of diagnostic error. Some of these challenges include 1) difficulties in determining error when the disease or diagnosis is evolving over time and in different care settings, 2) accounting for a balance between underdiagnosis and overaggressive diagnostic pursuits, and 3) determining disease diagnosis likelihood and severity in hindsight. We also build on these discussions to describe how some of these challenges can be addressed while conducting research on measuring diagnostic error.
PMCID: PMC4779119  PMID: 26955512
clinical decision-making; cognitive errors; diagnostic error; judgment; patient safety
15.  Insight into thermophiles and their wide-spectrum applications 
3 Biotech  2016;6(1):81.
The deconstruction of biomass is a pivotal process for the manufacture of target products using microbial cells and their enzymes. But the enzymes that possess a significant role in the breakdown of biomass remain relatively unexplored. Thermophilic microorganisms are of special interest as a source of novel thermostable enzymes. Many thermophilic microorganisms possess properties suitable for biotechnological and commercial use. There is, indeed, a considerable demand for a new generation of stable enzymes that are able to withstand severe conditions in industrial processes by replacing or supplementing traditional chemical processes. This manuscript reviews the pertinent role of thermophilic microorganisms as a source for production of thermostable enzymes, factors afftecting them, recent patents on thermophiles and moreso their wide spectrum applications for commercial and biotechnological use.
PMCID: PMC4764608
Thermophilic microorganisms; Thermostable enzymes; Heat tolerance and biomass
16.  Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care 
Diagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement.
We aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews.
We gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (n = 389), with and without previously identified diagnostic errors (n = 129 and n = 260, respectively).
The final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient–provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84 %, sensitivity of 71 %, specificity of 90 %, negative predictive value of 86 %, and positive predictive value of 78 %. All 11 items correlated significantly with the instrument’s error outcome question (all p values ≤ 0.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach’s alpha coefficients 0.93, 0.92, and 0.38, respectively).
The Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-016-3601-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4870415  PMID: 26902245
diagnostic error; measurement; patient safety; diagnostic safety; primary care; quality improvement
17.  Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses: An Evaluation of CrowdMed 
Despite visits to multiple physicians, many patients remain undiagnosed. A new online program, CrowdMed, aims to leverage the “wisdom of the crowd” by giving patients an opportunity to submit their cases and interact with case solvers to obtain diagnostic possibilities.
To describe CrowdMed and provide an independent assessment of its impact.
Patients submit their cases online to CrowdMed and case solvers sign up to help diagnose patients. Case solvers attempt to solve patients’ diagnostic dilemmas and often have an interactive online discussion with patients, including an exchange of additional diagnostic details. At the end, patients receive detailed reports containing diagnostic suggestions to discuss with their physicians and fill out surveys about their outcomes. We independently analyzed data collected from cases between May 2013 and April 2015 to determine patient and case solver characteristics and case outcomes.
During the study period, 397 cases were completed. These patients previously visited a median of 5 physicians, incurred a median of US $10,000 in medical expenses, spent a median of 50 hours researching their illnesses online, and had symptoms for a median of 2.6 years. During this period, 357 active case solvers participated, of which 37.9% (132/348) were male and 58.3% (208/357) worked or studied in the medical industry. About half (50.9%, 202/397) of patients were likely to recommend CrowdMed to a friend, 59.6% (233/391) reported that the process gave insights that led them closer to the correct diagnoses, 57% (52/92) reported estimated decreases in medical expenses, and 38% (29/77) reported estimated improvement in school or work productivity.
Some patients with undiagnosed illnesses reported receiving helpful guidance from crowdsourcing their diagnoses during their difficult diagnostic journeys. However, further development and use of crowdsourcing methods to facilitate diagnosis requires long-term evaluation as well as validation to account for patients’ ultimate correct diagnoses.
PMCID: PMC4731679  PMID: 26769236
crowdsourcing; diagnosis; diagnostic errors; patient safety; World Wide Web
18.  What happens to the hemodynamic responses for laryngeal mask airway insertion when we supplement propofol with butorphanol or fentanyl for induction of anesthesia: A comparative assessment and critical review 
There is a delicate balance between respiratory tract anatomy, its physiology, physiological response to anesthetic agents, and airway management. The traditional gadgets to secure airway are face masks or endotracheal tubes. Recently, laryngeal mask airway (LMA) is gaining popularity. It does not require laryngoscopy thereby minimizing hemodynamic responses. For LMA placement, propofol is the induction agent of choice. Propofol, when used alone, requires large doses and leads to undesirable cardiorespiratory depression. To culminate its dose, various adjuncts are combined with it.
Comparison of hemodynamic response of LMA using either butorphanol or fentanyl (according to group allocated) in combination with propofol.
Hundred patients scheduled for various surgical procedures were randomly selected and divided into two groups of 50 patients each, Group F (propofol and fentanyl) and Group B (propofol and butorphanol). One minute after giving intravenous (IV) opioids, induction was achieved with IV propofol 2.5 mg/kg. Depth of anesthesia was assessed, and LMA was inserted. Hemodynamic variables were measured before premedication, after premedication; 1, 3, and 5 min after insertion and after extubation of LMA.
After insertion of LMA, statistically significant drop in mean heart rate, systolic blood pressure (BP), diastolic BP, and mean BP was noted in Group F as compared to Group B (P < 0.05).
The use of propofol-butorphanol combination produces stable hemodynamics as compared to propofol-fentanyl combination.
PMCID: PMC4795361  PMID: 27051621
Butorphanol; fentanyl; hemodynamics; insertion conditions; laryngeal mask airway; propofol
19.  A case series of flow-through free anterolateral thigh flap to augment the vascularity of ischaemic limbs with soft tissue defect 
In a world of fast moving vehicles, heavy machinery and industries crush injury to limbs with vascular compromise and soft tissue defect is common. The traditional treatment is a 2 step one dealing with vascular repair and soft tissue cover separately, in the same operation. We report a series of single step vascular repair and soft tissue cover with flow through anterolateral thigh flap (ALT) flap for limb salvage.
Materials and Methods:
Ten patients with soft tissue defect and vascular injury were included in this study. A two team approach was used to minimise operative time, team one prepared the vessels and team 2 harvested the flap.
Observations and Results:
Of the ten patients operated (8 males), eight flaps were done for upper limb and two for lower limb salvage. Six anastomosis were done with ulnar vessels, two with radial and two with posterior tibial vessels. Nine extremities could be salvaged while one patient developed progressive thrombosis leading to amputation.
The ALT flow-through flap is a versatile single step procedure that can be used to salvage an ischemic limb with soft tissue loss avoiding the need for interpositional vein graft.
PMCID: PMC4878242  PMID: 27274120
Flow through flap; vascular compromise; Salvage
20.  Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records 
On September 30th, 2014, the Centers for Disease Control and Prevention (CDC) confirmed the first travel-associated case of US Ebola in Dallas, TX. This case exposed two of the greatest concerns in patient safety in the US outpatient health care system: misdiagnosis and ineffective use of electronic health records (EHRs). The case received widespread media attention highlighting failures in disaster management, infectious disease control, national security, and emergency department (ED) care. In addition, an error in making a correct and timely Ebola diagnosis on initial ED presentation brought diagnostic decision-making vulnerabilities in the EHR era into the public eye. In this paper, we use this defining “teachable moment” to highlight the public health challenge of diagnostic errors and discuss the effective use of EHRs in the diagnostic process. We analyze the case to discuss several missed opportunities and outline key challenges and opportunities facing diagnostic decision-making in EHR-enabled health care. It is important to recognize the reality that EHRs suffer from major usability and inter-operability issues, but also to acknowledge that they are only tools and not a replacement for basic history-taking, examination skills, and critical thinking. While physicians and health care organizations ultimately need to own the responsibility for addressing diagnostic errors, several national-level initiatives can help, including working with software developers to improve EHR usability. Multifaceted approaches that account for both technical and non-technical factors will be needed. Ebola US Patient Zero reminds us that in certain cases, a single misdiagnosis can have widespread and costly implications for public health.
PMCID: PMC4687403  PMID: 26705511
cognition; decision-making; diagnostic error; Ebola; electronic medical records; health information technology; human factors; misdiagnosis; patient safety
21.  Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer 
The pedicle positioning in free tissue transfer is critical to its success. Long thin pedicles are especially prone to this complication where even a slight twist in the perforator can result in flap loss. Pedicles passing through the long tunnels are similarly at risk. Streaking the pedicle with methylene blue is a simple and safe method which increases the safety of free tissue transfer.
Materials and Methods:
Once the flap is islanded on the pedicle and the vascularity of the flap is confirmed, the pedicle is streaked with methylene blue dye at a distance of 6-7 mm. The streaking starts from the origin of the vessels and continued distally on to the under surface of flap to mark the complete course of the pedicle in alignment. The presence of streaking in some parts and not in rest indicates twist in the pedicle.
Observation and Results:
Four hundred and sixty five free flaps have been done at our centre in the last 5 years. The overall success rate of free flaps is 95.3% (22 free flap failures). There has not been a single case of pedicle twist leading to flap congestion and failure.
This simple and novel method is very reliable for pedicle positioning avoiding any twist necessary for successful free tissue transfer.
PMCID: PMC4750259  PMID: 26933280
Free flaps; pedicle; perforator
23.  Were My Diagnosis and Treatment Correct? No News is Not Necessarily Good News 
Journal of General Internal Medicine  2014;29(8):1087-1089.
PMCID: PMC4099464  PMID: 24839058
24.  Missed diagnostic opportunities and English general practice: a study to determine their incidence, confounding and contributing factors and potential impact on patients through retrospective review of electronic medical records 
Patient safety research has focused largely on hospital settings despite the fact that in many countries, the majority of patient contacts are in primary care. The knowledge base about patient safety in primary care is developing but sparse and diagnostic error is a relatively understudied and an unmeasured area of patient safety. Diagnostic error rates vary according to how ‘error’ is defined but one suggested hallmark is clear evidence of ‘missed opportunity’ (MDOs) makes a correct or timely diagnosis to prevent them. While there is no agreed definition or method of measuring MDOs, retrospective manual chart or patient record reviews are a ‘gold standard’. This study protocol aims to (1) determine the incidence of MDOs in English general practice, (2) identify the confounding and contributing factors that lead to MDOs and (3) determine the (potential) impact of the detected MDOs on patients.
We plan to conduct a two-phase retrospective review of electronic health records in the Greater Manchester (GM) area of the UK. In the first phase, clinician reviewers will calibrate their performance in identifying and assessing MDOs against a gold standard ‘primary reviewer’ through the use of ‘double’ reviews of records. The findings will enable a preliminary estimate of the incidence of MDOs in general practice, which will be used to calculate the number of records to be reviewed in the second phase in order to estimate the true incidence of MDO in general practice. A sample of 15 general practices is required for phase 1 and up to 35 practices for phase 2. In each practice, the sample will consist of 100 patients aged ≥18 years on 1 April 2013 who have attended a face-to-face ‘index consultation’ between 1 April 2013 and 31 March 2015. The index consultation will be selected randomly from each unique patient record, occurring between 1 July 2013 and 30 June 2014.
There are no reliable estimates of safety problems related to diagnosis in English general practice. This study will lay the foundation for safety improvements in this area by providing a more reliable estimate of MDOs, their impact and their contributory factors.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-015-0296-z) contains supplementary material, which is available to authorized users.
PMCID: PMC4518650  PMID: 26220545
Patient safety; Primary care; Diagnoses; Missed diagnostic opportunities; Diagnostic error; General practice
25.  Patient access to medical records and healthcare outcomes: a systematic review 
We conducted a systematic review to determine the effect of providing patients access to their medical records (electronic or paper-based) on healthcare quality, as defined by measures of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
Articles indexed in PubMed from January 1970 to January 2012 were reviewed. Twenty-seven English-language controlled studies were included. Outcomes were categorized as measures of effectiveness (n=19), patient-centeredness (n=16), and efficiency (n=2); no study addressed safety, timeliness, or equity.
Outcomes were equivocal with respect to several aspects of effectiveness and patient-centeredness. Efficiency outcomes in terms of frequency of in-person and telephone encounters were mixed. Access to health records appeared to enhance patients’ perceptions of control and reduced or had no effect on patient anxiety.
Although few positive findings generally favored patient access, the literature is unclear on whether providing patients access to their medical records improves quality.
PMCID: PMC4078277  PMID: 24154835
Patient Access; Personal Health Record

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