Checklist to meet ethical and legal obligations to critically ill patients at the end of life

Despite improvements in communication, errors in end-of-life care continue to be made. For example, healthcare professionals may take direction from the wrong substitute decision-maker, or from family members when the patient is capable; permit families to propose treatment plans; conflate values and beliefs with prior expressed wishes or fail to inquire about prior expressed wishes. Sometimes healthcare professionals know what prior expressed wishes are but do not respect them; others do not believe they have enough time to have an end-of-life discussion or lack the confidence, willingness and skills to manage one. As has been shown in initiatives to improve in surgical safety, the use of a checklist presents opportunities to potentially minimize common mistakes and errors. When engaging in end-of-life care, a checklist can help focus on what needs to be communicated rather than how it needs to be communicated. We propose a checklist to support healthcare professionals in meeting their ethical and legal obligations to patients at the end of life. The checklist should minimize common mistakes, and in situations where irreconcilable conflict is unavoidable, it will ensure that both healthcare teams and family members are informed and prepared.     

Morally managing executive mistakes

Medical errors have been the subject of extensive discussion for many years. In contrast, management mistakes have not received the same scrutiny. Why is this true, and what are some of the factors contributing to management mistakes? What constitutes a mistake or error? How do mistakes in management compare with those in medicine? When and how should mistakes be disclosed? What are appropriate options for dealing with them productively and ethically? How can the incidence of mistakes be reduced? This article is intended to stimulate discussion about a critical topic--one that has received inadequate attention by both healthcare administration and the field of organizational ethics--with important implications for improving executive and organizational performance.     

Physicians' role in managing emotionally distressed patients already in psychotherapy

Much has been written on how physicians should manage patients in emotional distress, including recommendations for making successful referrals to mental health providers. Little has been written, however, on the management of distressed patients who are already in psychotherapy. This article, drawing on three cases, a review of the literature, and systems theory, presents recommendations for managing these patients. Physicians are encouraged to assess these patients for risk of suicide or homicide, substance abuse, and indications for psychotropic medication. They are advised to seek a patient's permission to speak to his or her therapist when the patient may be in immediate danger, when psychotropic medications, hospitalization, or psychiatric consultation is considered, and when the patient fails to respond to ongoing treatment. For patients whose therapists are not psychiatrists, psychiatric consultation is recommended when there are questions about psychotropic medications, when psychiatric and substance abuse disorders coexist, and when hospitalization is considered. Therapists skilled in applying systems theory should be consulted when the patient, psychotherapist, and physician agree that the patient is not making sufficient progress. In most cases, however, physicians should reassure patients about distressing symptoms, avoid expressing opinions about the therapist and psychosocial issues, and encourage patients to renew or to expand their commitment to their psychotherapy.     

Evidence-based management reconsidered

Reports of medical mistakes have splashed across newspapers and magazines in the United States. At the same time, instances of overuse, underuse, and misuse of management tactics and strategies receive far less attention. The sense of urgency associated with improving the quality of medical care does not exist with respect to improving the quality of management decision making. A more evidence-based approach would improve the competence of the decision-makers and their motivation to use more scientific methods when making a decision. The authors of this article consider a study of 68 U.S. health services managers that found a low level of evidence-based management behaviors. From the findings, four strategies are suggested to increase health systems managers' use of research evidence to improve decision making: focusing evidence-based decision making on strategically important issues, developing committees and other structures to diffuse management research throughout the organization, building a management culture that values research, and training managers in the competencies required to apply research evidence to health services management decisions. To aid the manager in understanding and applying an evidenced-based approach to decision making, the article provides practical tools, techniques, and resources for immediate use.     

Operations research in intensive care unit management: a literature review

The intensive care unit (ICU) is a crucial and expensive resource largely affected by uncertainty and variability. Insufficient ICU capacity causes many negative effects not only in the ICU itself, but also in other connected departments along the patient care path. Operations research/management science (OR/MS) plays an important role in identifying ways to manage ICU capacities efficiently and in ensuring desired levels of service quality. As a consequence, numerous papers on the topic exist. The goal of this paper is to provide the first structured literature review on how OR/MS may support ICU management. We start our review by illustrating the important role the ICU plays in the hospital patient flow. Then we focus on the ICU management problem (single department management problem) and classify the literature from multiple angles, including decision horizons, problem settings, and modeling and solution techniques. Based on the classification logic, research gaps and opportunities are highlighted, e.g., combining bed capacity planning and personnel scheduling, modeling uncertainty with non-homogenous distribution functions, and exploring more efficient solution approaches.     

Chronic illness management and health literacy: an overview

Poor literacy skills can severely compromise effective chronic illness management by the patient. Practitioners' awareness of the prevalence of low health literacy, or the ability to understand and appropriately act on healthcare instructions, among their patients is a first step toward making changes in the practice to ensure patients understand how to manage their chronic illnesses. Researchers and clinicians in the health literacy field gathered recently at a national health literacy conference and shared techniques used and studied in their practices to aid in more effective provider-patient communications and to help improve outcomes and successful patient management of their chronic illnesses.     

Caregivers of Children With Disabilities: A Comparison of Those Managing "OK" and Those Needing More Help

A survey was mailed to caregivers of children with disabilities to ascertain how they were managing caregiving. Caregivers reporting they were managing "OK" were compared to those who reported they needed more help or could not manage much longer ("not OK"). Results showed the not OK group of caregivers had children who were more severely impaired and functionally dependent. Their mothers were in poorer physical and mental health, had greater demands placed on their time and finances, and received less emotional support from friends and family. Special programs provided some assistance but not enough to meet their needs.     

Managing critical pathway variances

As the use of critical pathways expands at an increasing rate, we are faced with the issue of how to manage variances from the pathway. Variance management is not clearly defined in the literature, and many institutions search for the best approach. We have implemented a number of different techniques for variance management at Fletcher Allen Health Care. Our success benefits both patients and providers.     

From antiseptics to antibiotics – and back?

There is no straight line to trace the trajectory of antiseptics; rather, this has been manifested more as a fluctuating line, a backwards and forwards movement, seen in the wake of major discoveries but of colossal mistakes too. While today no one would allow their prophylactic policies to be guided by miasma or contagia, there continues to be some uncertainly about how to manage anti-infectives effectively even today.When in 1941 the first human being was successfully treated with penicillin, interest in antiseptics gradually waned. From that time onwards, everything was treated with antibiotics, unleashing a race for the discovery of novel antibiotics, as witnessed decades earlier in the case of antiseptics. The significance of antiseptics declined to such an extent that among physicians they were associated merely with cleaning agents or sanitary disinfection. Today, at the beginning of the 21^st century we know that the euphoria generated by antibiotics was just another station along the pathway of discoveries. Bacterial infections and new, hitherto unknown infectious diseases continue to play a major role. Several viral infections continue to be refractory to successful treatment and bacterial antibiotic resistance has become a problem worldwide. The most effective countermeasures no longer entail only the development of new antibiotics but above all responsible management of antibiotics and strict observance of infection control measures in the hospital setting. Set against that background, interest in antiseptics has been rekindled. In that spirit we can look eagerly forward over the coming years to further developments in antisepsis.     

Understanding adverse events: human factors.

(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.     

Management of depression in the elderly by general practitioners: I. Use of antidepressants

Depression is a common problem in the elderly but studies havesuggested that it is often in-adequately treated by generalpractitioners (GPs). This study aims to investigate how GPsmanage depression in the elderly. A national questionnaire studyon the management of depression in the elderly was carried out.Case vignettes were used to investigate how GPs manage depressionand what influenced their decision making process. Each casevignette had a factor complicating the use of the older tricyclics.The questionnaire was completed by 407 out of 667 GPs (61%).Many GPs chose the newer antidepressants but a substantial proportionpreferred the older tricyclics. Many GPs selected subtherapeuticdoses, particularly of the older tricyclics. Few GPs said theymaintained patients on antidepressants for more than 3 monthsafter recovery and only 1 in 12 continued antidepressants forover 6 months. If these results reflect GPs practice there isa danger that many patients will be inadequately treated andalso at risk of relapse because of their antidepressants beingstopped too soon after recovery.     

The shared burden: when physicians and families decide to forego life-sustaining treatment

Family physicians are being called upon to make decisions regarding whether to forego life-sustaining treatment. These decisions are made based on consultation with the family of the patient but are complicated by problematic family interactions. The family physician can manage difficult family reactions and assist the family in making a decision by understanding that there are common reactions to loss and bereavement on the part of family members such as anger, denial, and feelings of helplessness; assessing whether problems arise from chronic family conflicts (marital, parent-child, or previous unresolved mourning) or are situation related (unexpressed feelings, how to tell others, need to feel they have done everything, overwhelming other stresses); and incorporating several specific techniques into their practices such as family conferences, accepting anger, involving anxious members in treatment planning, referral to self-help family groups, reframing the decision in terms of the patient's wishes, and negotiating mutually acceptable solutions when patient or family members disagree.     

信息化物资管理的应用与效果评价

探讨采用信息化物资管理方法,通过创建库房管理软件,利用计算机技术和已建成的局域网,对临床科室的物资库房进行信息化管理。通过科学、合理使用库房管理软件,加强了对医用耗材的监督管理,减少了手工记账的工作量,减少了差错,避免浪费,提高了运营质量和效率,从而为临床科室的整体运行提供全面的、自动化的管理及运营成本核算的快捷服务。     

Wellness incentives, equity, and the 5 groups problem

Wellness incentives are an increasingly popular means of encouraging participation in prevention programs, but they may not benefit all groups equally. To assist those planning, conducting, and evaluating incentive programs, I describe the impact of incentives on 5 groups: the "lucky ones," the "yes-I-can" group, the "I'll-do-it-tomorrow" group, the "unlucky ones," and the "leave-me-alone" group. The 5 groups problem concerns the question of when disparities in the capacity to use incentive programs constitute unfairness and how policymakers ought to respond. I outline 4 policy options: to continue to offer incentives universally, to offer them universally but with modifications, to offer targeted rather than universal programs, and to abandon incentive programs altogether.     

网上医嘱处理质量实时控制分析

目的：通过对医院近2年网上医嘱处理质量的分析，探索网上医嘱处理质量的管理方法，促进护理文书的规范化，以适应现代医院的发展和社会的需要。方法：调用与医院信息网实现无缝连接的、医院自行设计的“医嘱处理实时监控系统”网上数据库，对2000年10月—2002年9月，98万余条医嘱中报错医嘱及出错人员，分4个时间段进行对比分析。结果：网上医嘱处理存在的主要问题集中在临时医嘱上，其次是控制时间段内未转抄校对医嘱。对医嘱分类出错频次进行分类分析，2年中报错率呈明显减少趋势；对出错人员工作年限进行分析结果表明：报错率与工作年限呈正相关。结论：在网上运用“医嘱处理实时监控系统”，为及时发现和纠正医嘱处理过程中的错误提供了可能；监控数据库的自动生成也为管理者能正确分析和统计医嘱处理过程中存在的问题，有针对性地解决问题提供了可靠的依据和管理方法。     

Reconciling the theory and reality of shared decision‐making: A “matching” approach to practitioner leadership

Shared decision making (SDM) evolved to resolve tension between patients’ entitlement to make health‐care decisions and practitioners’ responsibility to protect patients’ interests. Implicitly assuming that patients are willing and able to make “good” decisions, SDM proponents suggest that patients and practitioners negotiate decisions. In practice, patients often do not wish to participate in decisions, or cannot make good decisions. Consequently, practitioners sometimes lead decision making, but doing so risks the paternalism that SDM is intended to avoid. We argue that practitioners should take leadership when patients cannot make good decisions, but practitioners will need to know: (a) when good decisions are not being made; and (b) how to intervene appropriately and proportionately when patients cannot make good decisions. Regarding (a), patients rarely make decisions using formal decision logic, but rely on informal propositions about risks and benefits. As propositions are idiographic and their meanings context‐dependent, normative standards of decision quality cannot be imposed. Practitioners must assess decision quality by making subjective and contextualized judgements as to the “reasonableness” of the underlying propositions. Regarding (b), matched to judgements of reasonableness, we describe levels of leadership distinguished according to how directively practitioners act; ranging from prompting patients to question unreasonable propositions or consider new propositions, to directive leadership whereby practitioners recommend options or deny requested procedures. In the context of ideas of relational autonomy, the objective of practitioner leadership is to protect patients’ autonomy by supporting good decision making, taking leadership in patients’ interests only when patients are unwilling or unable to make good decisions.     

Answers to common clinical questions

Again, we present a rich issue with great information to address common clinical questions. A common class of drug (proton pump inhibitors) and insufficiently common diet (high fiber content) are related to improved diabetes control. Four good health habits make a huge difference, especially for obese patients. Meaningful use is just not always that meaningful. Computed tomography scans for common chest complaints probably are overused in emergency rooms. Continuous insurance is important to receipt of prevention services, even for those with access to care when they do not have insurance. Practice-based research can be difficult to accomplish, yet can yield some good results--in this case, improved colon cancer screening rates. Consider hyperaldosteronism in patients with resistant hypertension. Reflect on the mistakes other family physicians report; we often learn from others' mistakes. Surgical mesh migration can cause many things, but would you guess it would cause symptoms of irritable bowel syndrome? A nice primer on what is known about chemoprevention of prostate cancer. And, how to influence care outcomes: high-leverage, not just measurable, activities.     

射频识别技术（RFID）在医疗设备管理中的应用（加速医疗设备信息生命周期管理）

随着先进的医疗设备不断引进和应用，我们对医疗设备管理方面的探索也随之加大了步伐。如何能够科学、高效，合理的对医疗设备进行管理也成为一个崭新的课题，我们一直在探寻一种全新的医疗设备管理摸式．既能在日常管理中实现信息互动化，又能针对每一台设备的使用、维修，保养，不良记录等信息真正做到及时准确掌握，变被动抢修为预防性维护。经多方考核研究决定，我们采用RFID（电子标签技术）的基础上研制开发厂医疗设备信息识别管理系统即（医疗设备电子户口）。