Data Omission by Physician Trainees on ICU Rounds

Objectives: Incomplete patient data, either due to difficulty gathering and synthesizing or inappropriate data filtering, can lead clinicians to misdiagnosis and medical error. How completely ICU interprofessional rounding teams appraise the patient data set that informs clinical decision-making is unknown. This study measures how frequently physician trainees omit data from prerounding notes (“artifacts”) and verbal presentations during daily rounds. Design: Observational study. Setting: Tertiary academic medical ICU with an established electronic health record and where physician trainees are the primary presenters during daily rounds. Subjects: Presenters (medical student or resident physician), interprofessional rounding team. Interventions: None. Measurements and Main Results: We quantified the amount and types of patient data omitted from photocopies of physician trainees’ artifacts and audio recordings of oral ICU rounds presentations when compared with source electronic health record data. An audit of 157 patient presentations including 6,055 data elements across nine domains revealed 100% of presentations contained omissions. Overall, 22.9% of data were missing from artifacts and 42.4% from presentations. The interprofessional team supplemented only 4.1% of additional available data. Frequency of trainee data omission varied by data type and sociotechnical factors. The strongest predictor of trainee verbal omissions was a preceding failure to include the data on the artifact. Passive data gathering via electronic health record macros resulted in extremely complete artifacts but paradoxically predicted greater likelihood of verbal omission when compared with manual notation. Interns verbally omitted the most data, whereas medical students omitted the least. Conclusions: In an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. Additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://bit.ly/29S62lw). Supported, in part, by grants from National Institute of Health and Agency of Healthcare Research and Quality R01 HS023793. Dr. Artis received funding from the Agency for Healthcare Research and Quality (AHRQ) (partial salary support paid through the grant), and she received support for article research from the AHRQ. Drs. Mohan and Gold’s institutions received funding from the AHRQ. Dr. Bordley has disclosed that he does not have any potential conflicts of interest. This work was performed at the Oregon Health and Science University, Portland, OR. For information regarding this article, E-mail: artisk@ohsu.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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