Proactive staff help avert patient safety crisis in OR

Quality improvement program encourages employees to proactively report situations. Greasy feel, wrong color in liquid spurs employees into action. When staff have concerns, key phrases will automatically stop a process.     

Improving preventive care at a medical clinic: how can the patient help?

We developed a comprehensive individualized preventive care reminder system and then tested the hypothesis that directly involving patients in the reminder process would lead to greater use of preventive services than involving physicians only. There were three experimental groups of 350 patients each: in group 1 physicians and patients received the reminder; in group 2 physicians only received the reminder; in group 3 neither physicians nor patients received the reminder. Nine preventive care services were studied: blood pressure measurement; dental exam; ocular pressure measurement; stool exam for occult blood; influenza, pneumococcal, and tetanus vaccinations; mammography; and Papanicolaou smears. Need for these services was determined by telephone interview and chart review. To determine whether services were obtained, charts were reviewed after four to eight months of follow-up. For overall compliance with preventive recommendations and for several individual services (stool exam for occult blood, tetanus vaccination, mammography), group 1 patients received significantly more preventive care than group 2. Likewise, group 2 patients received more preventive care than group 3. These data show that involving patients in reminder efforts is an effective means of raising the level of preventive services.     

Surgical malpractice claims in the United States

Despite ongoing reform, there is still significant physician concern regarding the impact of medical claims on their practices. It is important that physicians and healthcare risk management professionals have a good understanding of the outcomes of medical malpractice to participate in its restructuring as needed and to prevent potentially harmful practices. In our study, we reviewed National Practitioner Data Bank (NPDB) paid malpractice claim reports from September 1, 1990, through July 30, 2011, and identified the 10 most common surgery‐related allegations against physicians, excluding those listed as unspecified. Data were collected on the number of claims, the cost of the claims, and physician and patient characteristics.     

International perspectives on the health care crisis in the United States

The American health care system is confronting a crisis: one consisting of severe problems of cost and access, and the other consisting of significant qualitative changes in structure, systemic behavior and operation. Some of these factors may be understood better in comparison with how systems in other nations have responded to similar problems. The United States had adopted solutions which are significantly different from those of other countries, including more limited government involvement in health care and planning, and the development of corporatized medicine. These solutions pose significant ethical and operational problems.     

Harnessing the power of medical malpractice data to improve patient care

Intelligence gleaned from medical malpractice cases helps health care institutions analyze their litigation practices, trend financial outcomes, and even identify clinical services needing attention. But when examined more deeply, medical malpractice data can also be a powerful patient safety tool by revealing clinical patterns that contribute to medical errors and by enabling leadership to more accurately plan investments in patient safety and risk management. This case study describes how one organization, UMass Memorial Health Care in Worcester, Massachusetts, harnesses its deeply coded medical malpractice data and benchmarks its performance against national peers to catalyze clinical improvements. This strategy has proven successful in yielding positive change in such areas as emergency department ultrasound coverage, obstetrics communication, and airway management training. UMass Memorial's ability to embed claims data use into its culture and to share learning across clinical services offers lessons for health care organizations of any size.     

The AIDS crisis: a United States health care perspective

The unanticipated onset of Acquired Immunodeficiency Syndrome in the United States, followed by its gradual progression into a full-blown, uncontrollable epidemic, has had severe economic and organizational consequences for the American health care system. AIDS has taken its toll on the health workforce as well in terms of stress, anxiety and workload demands. In the absence of adequate community-based treatment and care resources for persons with AIDS, hospitals had to assume the major burden for providing basic medical care and developing the needed range of services required. This expansion of responsibilities strained hospitals and other health care agencies beyond their capabilities. Some hospitals have faced economic and allocation dilemmas because of high occupancy rates by AIDS patients since there are no specialized reimbursement rates for the intensive resource utilization required for their care. These substantial burdens underscored the need for coordinated long-term planning for a continuum of in-patient, out-patient and community support services. A major response to the epidemic has been a restructuring of the health and social service delivery systems. Hospitals have had to maintain patients beyond their need for an acute level of care, develop infrastructures to manage the increasing numbers of patients, alter physical facilities, provide educational programs and support groups to increase staff's knowledge and decrease fears of AIDS, consider alternatives to in-patient medical management, and lobby with local, state and federal governments to obtain increased public monies for AIDS treatment and care. In the past year, there has been a discernible shift to widening the network of ambulatory medical services and community-based social and health care supports. A major focus of this paper is the social and organizational impact of this epidemic on the hospital and health care system and the systems' responses. Alternatives to an acute care treatment locus for persons with AIDS are explored. Recommendations for future directions for a comprehensive, coordinated health and social services delivery network are presented.     

Telemedicine can help to ensure that patients receive timely medical care

We describe a case illustrating that telephone consultations can help to lower the psychological threshold for accessing medical care in people who are not aware of the seriousness of their symptoms, or who might otherwise be reluctant to access face-to-face care. A 69-year-old male patient called a teleconsultation service at the weekend because of acute fever. The patient was scheduled to have a hip replacement and the usual pre-operative check-up done the day before had been normal. However, a careful medical history taken during the teleconsultation revealed potentially serious symptoms. We therefore referred the patient to the emergency room immediately with the suspicion of severe infection, possibly due to colon cancer. The patient was subsequently diagnosed with septicaemia and adenocarcinoma of the sigmoid. This demonstrates that teleconsultation is not only a powerful tool for triage and diagnosis, but can also help to reduce delay in diagnosing severe diseases in primary health care.     

Learning from malpractice claims about negligent, adverse events in primary care in the United States

Background: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care.

Methods: Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care.

Results: Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer).

Conclusions: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

     

Globalization of health care delivery in the United States through medical tourism

This study highlights some of the inefficiencies in the U.S. health care system and determines what effect medical tourism has had on the U.S. and global health care supply chains. This study also calls attention to insufficient health communication efforts to inform uninsured or underinsured medical tourists about the benefits and risks and determines the managerial and cost implications of various surgical procedures on the global health care system into the future. This study evaluated 3 years (2005, 2007, and 2011) of actual and projected surgical cost data. The authors selected 3 countries for analysis: the United States, India, and Thailand. The surgeries chosen for evaluation were total knee replacement (knee arthroplasty), hip replacement (hip arthroplasty), and heart bypass (coronary artery bypass graft). Comparisons of costs were made using Monte Carlo simulation with variability encapsulated by triangular distributions. The results are staggering. In 2005, the amount of money lost to India and Thailand on just these 3 surgeries because of cost inefficiencies in the U.S. health care system was between 1.3 to 2 billion dollars. In 2011, because many more Americans are expected to travel overseas for health care, this amount is anticipated to rise to between 20 and 30.2 billion dollars. Therefore, more attention should be paid to health communication efforts that truly illustrate the benefits/risks of medical travel. The challenge of finding reliable data for surgeries performed and associated surgical cost estimates was mitigated by the use of a Monte Carlo simulation of triangular distributions. The implications from this study are clear: If the U.S. health care industry is unable to eliminate waste and inefficiency and thus curb rising costs, it will continue to lose surgical revenue to foreign health providers.     

Continuing constraints to a preventively-oriented medical care system in the United States

In this paper the author focuses on the structure of, and trends in, our nation's medical care system, as they relate to preventive maternal and child health needs. Continuing barriers to appropriate utilization of medical care, effects of recent federal actions, and possible directions for future change are discussed.