Record linkage as a research tool for office-based medical care.
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OBJECTIVE: To explore the feasibility of linking records to study health services and health outcomes for primary care patients. DESIGN: A cohort of patients from the Family Medicine Centre at Mount Sinai Hospital was assembled from the clinic's billing records. Their health numbers were linked to the Ontario Hospital Discharge Database. The pattern of hospital admission rates was investigated using International Classification of Diseases (ICD) codes for primary discharge diagnosis. A pilot case-control study of risk factor management for stroke was nested in the cohort. SETTING: Family medicine clinic based in a teaching hospital. PARTICIPANTS: A cohort of 19,654 Family Medicine Centre patients seen at least once since 1991. MAIN OUTCOME MEASURES: Admission rates by age, sex, and diagnosis. Numbers of admissions for individual patients, time to readmission, and length of stay. Odds ratios for admission for cerebrovascular disease. RESULTS: The 19,654 patients in the cohort had 14,299 discharges from Ontario hospitals in the 4 years from 1992 to 1995, including 3832 discharges following childbirth. Some patients had many discharges: 4816 people accounted for the 10,467 admissions excluding childbirth. Excluding transfers between institutions, there were 4975 readmissions to hospital during the 4 years, 1392 (28%) of them within 28 days of previous discharge. Admissions for mental disorders accounted for the greatest number of days in hospital. The pilot study of risk factor management suggested that acetylsalicylic acid therapy might not be effective for elderly primary care patients with atrial fibrillation and that calcium channel blocker therapy might be less effective than other therapies for preventing cerebrovascular disease in hypertensive primary care patients. CONCLUSIONS: Record linkage combined with data collection by chart review or interview is a useful method for studying the effectiveness of medical care in Canada and might suggest interesting hypotheses for further investigation. (+info)
Ward pharmacy: a foundation for prescribing audit?
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OBJECTIVES: To determine the extent and nature of prescription monitoring incidents by hospital pharmacists and to derive a performance indicator to allow prescription monitoring to be compared among hospitals in North West Thames region. DESIGN: Survey of all self recorded prescription monitoring incidents for one week in June 1990. SETTING: All (31) acute hospitals in the region with pharmacy departments on site, covering 10,337 beds. SUBJECTS: 210 pharmacists. MAIN MEASURES: Number of prescription monitoring incidents recorded, their nature, and outcome; a performance indicator of prescription monitoring (incidents/100 beds/week) and its variation according to specialty and site. RESULTS: 3273 prescription monitoring incidents were recorded (median 89 per hospital, range 3-301), the most common being related to the dose and frequency of administration of the drug (933 incidents, 29%). These incidents led to alterations of prescriptions on 1611 occasions; the pharmacist's advice was rejected on 81. The greatest number of prescription monitoring incidents/100 beds/week by specialty was recorded for intensive therapy units (median 75); the medians for medicine and surgery were 32 and 21 respectively. This performance indicator varied 20-fold when analysed by site, values ranging from 3.6 to 82.1 (median 29.8). CONCLUSIONS: Hospital pharmacists play a large part in monitoring and improving prescribing, and most of their interventions are related to the basics of prescribing. They therefore have a role in medical audit, working with clinicians to identify prescribing problems, and to set standards and monitor practice. A performance indicator of prescription monitoring incidents/100 beds/week allows comparison of pharmacists' activities among sites and may be a valuable tool in auditing them. (+info)
Clinical complaints: a means of improving quality of care.
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OBJECTIVES: To establish the reasons for clinical complaints, complainants' feelings about the original incident, and their motivation in complaining. DESIGN: Postal questionnaire survey. SETTING: 24 hospitals in North West Thames region. SUBJECTS: 1007 complainants who had written to 20 hospitals between 1 January 1992 and 30 June 1993 about a complaint involving a clinical incident. MAIN MEASURES: Personal details, the nature of the complaint, the complainant's reaction to the original incident, the quality of the explanation at the time of the incident, the reasons for making a complaint, and what would have prevented the incident. RESULTS: 491 completed questionnaires were received (response rate 49%). Complaints arose from serious incidents, generally a clinical problem combined with staff insensitivity and poor communication. Clinical complaints were seldom about a clinical incident alone (54; 11%); most (353; 72%) included a clinical component and dissatisfaction with personal treatment of the patient or care. In all, 242(49%) complainants reported a need for additional medical treatment, 206(42%) reported that the patient's condition had worsened as a result of treatment, and 175(36%) that side effects had been experienced. In 26(5%) cases the patient had died. Complainants' primary motive was to prevent recurrence of a similar incident. Lack of detailed information and staff attitude were identified as important criticisms. CONCLUSIONS: The emphasis must be on obtaining a better response to complaints at the clinical level by the staff involved in the original incident, not simply on adjusting the complaints procedure. Staff training in responding to distressed and dissatisfied patients is essential, and monitoring complaints must form part of a more general risk management programme. (+info)
Understanding adverse events: human factors.
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(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole. (+info)
Impact of litigation on senior clinicians: implications for risk management.
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OBJECTIVES: To investigate the impact of litigation on consultants and senior registrars and to establish their views on methods of reducing adverse events and litigation. DESIGN: Postal survey. SETTING: Acute hospitals in the North Thames (West) Regional Health Authority. SUBJECTS: 1011 consultants and senior registrars in acute hospitals. MAIN MEASURES: Perceived causes and effects of adverse events; views on methods of reducing litigation and adverse events. RESULTS: 769 (76%) doctors responded. 288 (37%) had been involved in litigation at some point during their career; 213 surgeons (49%) and 75 (23%) doctors in the medical specialties. Anger, distress, and feeling personally attacked were common responses to litigation. Clinicians' views on reducing litigation emphasised the need for change at the clinical level. Supervision of junior staff, workload, and training in communication skills were to the fore. CONCLUSIONS: The high frequency of doctors who have experienced litigation and the emotional responses described indicate that clinicians require support at several levels. At a personal level, support can be offered to clinicians going through the litigation process or after an adverse event. Also, managerial support is needed by offering financial and practical help in correcting the factors that have been consistently identified as producing high risk situations to minimise the possibility of a reoccurrence. Accidents in medicine are, by their very nature, costly in human and financial terms and the root causes must be tackled. Recommendations are made for clinicians and risk management teams. (+info)
The political economy of capitated managed care.
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Despite the fact that billions of dollars are being invested in capitated managed care, it has yet to be subjected to the rigors of robust microeconomic modeling; hence, the seemingly intuitive assumptions driving managed care orthodoxy continue to gain acceptance with almost no theoretical examination or debate. The research in this paper finds the standard unidimensional model of risk generally used to analyze capitation--i.e., that risk is homogenous in nature, organizationally fungible, and linear in amplitude--to be inadequate. Therefore, the paper proposes to introduce a multidimensional model based on the assumption that phenomenologically unrelated species of risk result from non-homogenous types of socioeconomic activity in the medical marketplace. The multidimensional analysis proceeds to concentrate on two species of risk: probability risk and technical risk. A two-dimensional risk matrix reveals that capitation, far from being a market-oriented solution, actually prevents the formation of a dynamic price system necessary to optimize marketplace trades of medical goods and services. The analysis concludes that a universal attempt to purchase healthcare through capitation or any other insurance mechanism would render the reasonable attainment of social efficiency highly problematic. While in reality there are other identifiable species of risk (such as cost-utility risk), the analysis proceeds to hypothesize what a market-oriented managed care approach might look like within a two-dimensional risk matrix. (+info)
Reducing malpractice risk through more effective communication.
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This activity is designed for physicians, health plan administrators, and other providers. GOAL: To help physicians, health plan administrators, and other providers learn more about the relationship between provider communication behaviors and subsequent negligence litigation and learn how to reduce malpractice risk through improving communication behaviors. OBJECTIVES: 1. To describe research findings concerning the relationship between provider communication behaviors and subsequent claims of negligence. 2. To describe the major interviewing deficiencies that have been identified as precipitants of malpractice litigation. 3. To describe three functions of effective interviewing. 4. To describe training and learning methods that can improve provider-patient relationships, leading to improved clinical outcomes and decreased malpractice risk. (+info)
Impact of managed care on quality of healthcare: theory and evidence.
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Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different incentive structures created by different risk-sharing arrangements, but these incentives differ from those in a fee-for-service environment. With fee-for-service and traditional indemnity insurance, physicians have incentives to provide healthcare services of marginal value to the patient; under managed care, physicians have fewer incentives to provide marginally beneficial services. However, the impact of financial arrangements on quality of care remains ambiguous, because it depends on the strategic behavior of physicians with regard to their informational advantage over their patients. Using the framework of an agency theory model, we surveyed the current scientific literature to assess the impact of managed care on quality of care. We considered three different dimensions of quality of care: patient satisfaction, clinical process and outcomes of care measures, and resource utilization. Although we found no systematic differences in patient satisfaction and clinical process and outcomes between managed care and fee-for-service plans, resource utilization appears to be decreased under managed care arrangements. Given the strengths and weaknesses of fee-for-service and managed care, it is unlikely that either will displace the other as the exclusive mechanism for arranging health insurance contracts. Policy makers may be able to take advantage of the strengths of both fee-for-service and managed care financial arrangements. (+info)