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Pimentel MPT, Chung S, Ross JM, Wright D, Urman RD. Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers. Anesth Analg 2024:00000539-990000000-00814. [PMID: 38640080 DOI: 10.1213/ane.0000000000006700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
BACKGROUND As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. METHODS Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. RESULTS Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). CONCLUSIONS This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.
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Affiliation(s)
- Marc Philip T Pimentel
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott Chung
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline M Ross
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Daniel Wright
- Department of Patient Safety and Risk Management, The Doctors Company, Napa, California
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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Schultz TJ, Zhou M, Gray J, Roseleur J, Clark R, Mordaunt DA, Hibbert PD, Haysom G, Wright M. Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature. Syst Rev 2024; 13:104. [PMID: 38594759 PMCID: PMC11003134 DOI: 10.1186/s13643-024-02501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/20/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised. METHODS We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis. RESULTS From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results. CONCLUSION Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.
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Affiliation(s)
- Timothy J Schultz
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia.
| | - Michael Zhou
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Jodi Gray
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Jackie Roseleur
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Richard Clark
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
- HealthFX, Melbourne, Australia
| | - Dylan A Mordaunt
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
- Southern Adelaide Local Health Network, Adelaide, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | | | - Michael Wright
- Avant Mutual, Sydney, Australia
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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Methangkool E, Slade IR, Rangrass G, Harbell M. Best practices for addressing adverse event analysis: a scoping review. Int Anesthesiol Clin 2024; 62:16-25. [PMID: 38282451 DOI: 10.1097/aia.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Affiliation(s)
- Emily Methangkool
- Department of Anesthesiology, Olive View-UCLA Medical Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ian R Slade
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Govind Rangrass
- Department of Anesthesiology, St. Louis University School of Medicine, St. Louis, Missouri
| | - Monica Harbell
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona
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Finkelstein A, Brezis M, Taub A, Arad D. Disclosure following a medical error: lessons learned from a national initiative of workshops with patients, healthcare teams, and executives. Isr J Health Policy Res 2024; 13:13. [PMID: 38462624 PMCID: PMC10926562 DOI: 10.1186/s13584-024-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/27/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops. METHODS Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines. RESULTS We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties. CONCLUSION The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.
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Affiliation(s)
- Adi Finkelstein
- Department of Nursing, Faculty of Life and Health Sciences, Jerusalem College of Technology (JCT), Beit Hadfus 7 St., 9548307, Jerusalem, Israel.
| | - Mayer Brezis
- School of Public Health, Hebrew University Hadassah Medical Center, Ein-Kerem, PO Box 12000, 91120, Jerusalem, Israel
| | - Amiad Taub
- 'Ofek Back to Life' Organization, Sderot H'areches 13, 7178441, Modi'in, Israel
| | - Dana Arad
- Patient Safety Division, Ministry of Health, 39 Yeremiahu, 9101002, Jerusalem, Israel
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5
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Kusumoto F, Ross J, Wright D, Chazal RA, Anderson RE. Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors. Risk Manag Healthc Policy 2024; 17:411-422. [PMID: 38440254 PMCID: PMC10910983 DOI: 10.2147/rmhp.s403710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/24/2023] [Indexed: 03/06/2024] Open
Abstract
Objective Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship. Study Design A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019. Results Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties. Discussion Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.
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Affiliation(s)
- Fred Kusumoto
- Heart Rhythm Service, Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL, USA
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Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care 2023; 35:mzad096. [PMID: 38060672 DOI: 10.1093/intqhc/mzad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Defensive medicine, characterized by physicians' inclination toward excessive diagnostic tests and procedures, has emerged as a significant concern in modern healthcare due to its high prevalence and detrimental effects. Despite the growing concerns among healthcare providers, policymakers, and physicians, comprehensive synthesis of the literature on the prevalence and determinants of defensive medicine among physicians has yet been reported. A comprehensive literature search was conducted to identify eligible studies published between 1 January 2000 and 31 December 2022, utilizing six databases (i.e. Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library). A meta-analysis was conducted to determine the prevalence and determinants of defensive medicine. Of the 8892 identified articles, 64 eligible studies involving 35.9 thousand physicians across 23 countries were included. The overall pooled prevalence of defense medications was 75.8%. Physicians engaged in both assurance and avoidance behaviors, with the most prevalent subitems being increasing follow-up and avoidance of high-complication treatment protocols. The prevalence of defensive medicine was higher in the African region [88.1%; 95% confidence interval (CI): 80.4%-95.8%] and lower-middle-income countries (89.0%; 95% CI: 78.2%-99.8%). Among the medical specialties, anesthesiologists (92.2%; 95% CI: 89.2%-95.3%) exhibited the highest prevalence. Further, the pooled odds ratios (ORs) of the nine factors at the individual, relational, and organizational levels were calculated, and the influence of previous experience in medical-legal litigation (OR: 1.65; 95% CI: 1.13-2.18) should be considered. The results of this study indicate a high global prevalence of defensive medicine among physicians, underscoring the necessity of implementing targeted interventions to reduce its use, especially in certain regions and specialties. Policymakers should implement measures to improve physicians' medical skills, enhance physician-patient communication, address physicians' medical-legal litigation fears, and reform the medical liability system. Future research should focus on devising and assessing interventions to reduce the use of defensive medicine and to improve the quality of patient care.
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Affiliation(s)
- Junyao Zheng
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Yongbo Lu
- School of Public Policy and Administration, Xi'an Jiaotong University, 28 West Xianning Road, Xi'an 710049, China
| | - Wenjie Li
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
| | - Bin Zhu
- School of Public Health and Emergency Management, Southern University of Science and Technology, 1008 Xueyuan Road, Shenzhen, Guangdong 518005, China
| | - Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Jie Shen
- Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200030, China
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7
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Daniels L, Marneffe W, Bielen S. Virtual reality evidence on the impact of physicians' open versus defensive communication on patients. HEALTH ECONOMICS, POLICY, AND LAW 2023:1-20. [PMID: 38037812 DOI: 10.1017/s1744133123000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.
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Affiliation(s)
- Lotte Daniels
- Faculty of Business Economics, Hasselt University, 3500 Hasselt, Belgium
| | - Wim Marneffe
- Faculty of Business Economics, Hasselt University, 3500 Hasselt, Belgium
| | - Samantha Bielen
- Faculty of Business Economics, Hasselt University, 3500 Hasselt, Belgium
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8
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Bilal M, Feld LD, Hernandez LV, Feld AD, Anderson JC, Bloomfeld RS. Professionalism in the Management of Endoscopic Adverse Events: Consensus Document From the American College of Gastroenterology Professionalism Committee. Am J Gastroenterol 2023; 118:1725-1730. [PMID: 37589497 DOI: 10.14309/ajg.0000000000002474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Mohammad Bilal
- Division of Gastroenterology & Hepatology, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lauren D Feld
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lyndon V Hernandez
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- GI Associates, Racine, Kenosha, and Milwaukee, Wisconsin, USA
| | - Andrew D Feld
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Division of Gastroenterology, Kaiser Permanente, Seattle, Washington, USA
| | - Joseph C Anderson
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center, The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Richard S Bloomfeld
- Section of Gastroenterology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
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9
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Lambert BL, Schiff GD. RaDonda
Vaught, medication safety, and the profession of pharmacy: Steps to improve safety and ensure justice. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bruce L. Lambert
- Department of Communication Studies Northwestern University Chicago Illinois USA
| | - Gordon D. Schiff
- Center for Patient Safety Research and Practice Brigham and Women's Hospital Boston Massachusetts USA
- Center for Primary Care and Associate Professor of Medicine Harvard Medical School Boston Massachusetts USA
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10
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Medical Dispute Committees in the Netherlands: a qualitative study of patient expectations and experiences. BMC Health Serv Res 2022; 22:650. [PMID: 35570286 PMCID: PMC9109360 DOI: 10.1186/s12913-022-08021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health care incidents, such as medical errors, cause tragedies all over the world. Recent legislation in the Netherlands has established medical dispute committees to provide for an appeals procedure offering an alternative to civil litigation and to meet the needs of clients. Dispute committees incorporate a hybrid procedure where one can file a complaint and a claim for damages resulting in a verdict without going to court. The procedure is at the crossroads of complaints law and civil litigation. This study seeks to analyze to what extent patients and family members' expectations and experiences with dispute committees match the goals of the new legislation. METHODS This qualitative, retrospective research includes in-depth, semi-structured, face-to-face interviews with patients or family members who filed a complaint with a dispute committee in the Netherlands. The researchers conducted an inductive, thematic analysis of the qualitative data. RESULTS A total of 26 interviews were held with 30 patients and family members. The results showed that participants particularly felt the need to be heard and to make a positive impact on health care. Some wished to be financially compensated, for others money was the last thing on their mind. The results demonstrated the existence of unequal power relationships between participants and both the defendant and dispute committee members. Participants reported the added value of (legal) support and expressed the need for dialogue at the hearing. Participants sometimes experienced closure after the proceedings, but often did not feel heard or felt a lack of a practical outcome and a tangible improvement. CONCLUSIONS This study shows that participants' expectations and experiences were not always met by the current set up of the dispute committee proceedings. Participants did not feel heard, while they did value the potential for monetary compensation. In addition, some participants did not experience an empowered position but rather a feeling of a power misbalance. The feeling of a power misbalance and not being heard might be explained by existing epistemic injustice, which is a concept that should be carefully considered in processes after health care incidents.
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Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221097422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Julia Adler-Milstein
- Department of Medicine, University of California, San Francisco, CA, USA
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco, CA, USA
| | - Urmimala Sarkar
- Department of Medicine, University of California, San Francisco, CA, USA
- Division of General Internal Medicine, Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Robert M Wachter
- Department of Medicine, University of California, San Francisco, CA, USA
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12
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Dijkstra RI, Roodbeen RTJ, Bouwman RJR, Pemberton A, Friele R. Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration. Health Expect 2021; 25:264-275. [PMID: 34931415 PMCID: PMC8849248 DOI: 10.1111/hex.13376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies. BACKGROUND In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies. SEARCH STRATEGY AND INCLUSION CRITERIA To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles. MAIN RESULTS AND SYNTHESIS The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support and desired outcomes. PATIENT CONTRIBUTION This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.
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Affiliation(s)
- Rachel I Dijkstra
- Department of Criminal Law, Tilburg Law School, Tilburg University, Tilburg, The Netherlands.,Netherlands Institute for the Study of Crime and Law Enforcement, Amsterdam, The Netherlands
| | - Ruud T J Roodbeen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands.,Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, The Netherlands
| | - Renée J R Bouwman
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Antony Pemberton
- Department of Criminal Law, Tilburg Law School, Tilburg University, Tilburg, The Netherlands.,Netherlands Institute for the Study of Crime and Law Enforcement, Amsterdam, The Netherlands.,Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands.,Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, The Netherlands.,Leuven Institute of Criminology, KU Leuven, Leuven, Belgium
| | - Roland Friele
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands.,Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, The Netherlands
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13
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Gu X, Deng M. The Impacts of Disclosure and a Proactive Compensation Offer on Chinese Patients' Actions After Medical Errors. J Patient Saf 2021; 17:e745-e751. [PMID: 34009870 DOI: 10.1097/pts.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aims to obtain evidence of the impacts of error disclosure and the impacts of a proactive compensation offer on Chinese patients' actions after medical errors. METHODS A total of 915 responses were collected from a questionnaire survey. Two fictitious cases (entailed moderate and severe harm) that involved error disclosure were described. One of 5 disclosure and compensation types was randomly provided to each participant. The 5 types were combinations of 3 disclosure types (no disclosure, partial disclosure, and full disclosure) and 2 proactive compensation offer categories (no offer and an offer), with the exception of no disclosure but a proactive compensation offer. The respondents were asked about their willingness to take actions if they were the affected patient. RESULTS The generalized ordinal logit regression model showed that error disclosure did not increase the likelihood of the patients taking action, such as changing physicians, complaining, or filing lawsuits. A proactive compensation offer decreased the patients' willingness to file lawsuits but had no significant influence on the other action choices. In addition, the patients' actions were affected by other factors, such as the severity of the error, age, sex, education level, being religious, prior error experience, and health insurance. CONCLUSIONS We suggest that "disclosure and compensation" programs are developed in China. To ensure their implementation, it is recommended that appropriate training is provided and that the disclosure culture in health care organizations is improved. Furthermore, laws or regulations are required that govern error disclosure and provide support for health care professionals and organizations.
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Affiliation(s)
- Xiuzhu Gu
- From the Department of Industrial Engineering and Economics, School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Mingming Deng
- School of Management, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Medico-legal considerations in the context of neonatal encephalopathy and therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101266. [PMID: 34301500 DOI: 10.1016/j.siny.2021.101266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neonatal encephalopathy (NE) is a significant complication of the peripartum period. It can lead to lifelong neurologic disabilities, including cerebral palsy, cognitive impairments, developmental delays, and epilepsy. Induced hypothermia is the first therapy, which has shown promise in improving the outcomes for neonates with moderate to severe NE following a presumed intrapartum insult. NE is also a frequent source of medical malpractice litigation. In this paper, we will review salient features of the American Tort System as it pertains to medical malpractice. We will discuss the obstetric medico-legal implications of therapeutic hypothermia and suggest a five-step approach to analyzing neonatal cases for causation, etiology, timing of occurrence, responsibility, and liability. We will close with three illustrative clinical cases.
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Bass GD, Zhao FS, Schweickert WD, Manaker S. A Retrospective Analysis of Malpractice-Related Procedure Rates for Internal Medicine Specialists at an Academic Medical Center. Jt Comm J Qual Patient Saf 2021; 47:704-710. [PMID: 34456152 DOI: 10.1016/j.jcjq.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although malpractice litigation is common in the United States, the risk of a malpractice claim for procedures performed by internal medical practitioners is unknown. This study determined the frequency of malpractice claims related to procedures in a large department of medicine at an academic medical center over a five-year period. METHODS Researchers retrospectively reviewed all malpractice claims and procedures performed by internal medicine practitioners of all specialties between July 1, 2014, and June 30, 2019, in a department of medicine at a large academic medical center. A list of all procedures and Current Procedural Terminology codes performed by internal medicine practitioners was compiled. Active procedure-related malpractice claims and the total number of procedures performed during the study period were counted. RESULTS During the study period, 353,661 procedures were performed by internal medicine practitioners. During the same period, 76 active malpractice claims were identified, of which only 13 (17.1%) were procedure-related. For 2 different malpractice claims, a single patient had 2 procedures; thus 13 total claims related to the performance of 15 procedures. The proportion of procedure-related claims per total number of procedures performed was 0.37 claims/10,000 cases. The frequency of procedure-related malpractice claims per number of procedures performed ranged from 1 in 38 for pulmonary artery thrombolytic therapy to 1 in 137,325 for colonoscopy. CONCLUSION Procedure-related malpractice claims against internal medicine practitioners at a large academic medical center over a five-year period were infrequent despite significant procedural volume. Contextualizing procedure-related malpractice claims in terms of procedure-specific volume reframes the reporting of malpractice risk.
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Busch IM, Saxena A, Wu AW. Putting the Patient in Patient Safety Investigations: Barriers and Strategies for Involvement. J Patient Saf 2021; 17:358-362. [PMID: 32195779 DOI: 10.1097/pts.0000000000000699] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In an adverse event investigation, the patients have the potential to add a unique perspective because they can identify contributing factors that providers may miss. However, patients are rarely included in patient safety investigations. We aimed to identify the barriers to patient involvement in patient safety investigations and propose strategies to overcome them. METHODS We reviewed literature on active participation by patients in safety investigations to construct a framework for healthcare institutions to use in approaching patients about a potential role in investigating an error in their care. We searched 3 electronic databases (PubMed, PSNet, Web of Science) for the years 1990 to 2018, without restrictions to language. Search terms included: "patient empowerment, "patient involvement," "patient participation," "patient safety investigation," "root cause analysis," "error analysis." We also examined reference lists of relevant studies to identify additional articles. RESULTS Our electronic search produced 10,624 records with 30 potentially eligible articles. However, we identified only 6 relevant published articles. We used these as the basis for a proposed framework that is predicated on the thoughtful disclosure of adverse events and has 3 main levels (i.e., patient, clinician, and institutional level). For each level, we identify barriers to patient participation and potential strategies to overcome them. CONCLUSIONS The proposed framework can be used as a starting point to promote patient involvement in error investigations. Involving patients in patient safety investigations could increase patient centeredness, patient autonomy, and transparency and make analyses more effective by adding unique and potentially actionable information.
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Affiliation(s)
- Isolde Martina Busch
- From the Section of Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Ankita Saxena
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Albert W Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Fischer IC, Frankel RM. "If your feelings were hurt, I'm sorry…": How Third-Year Medical Students Observe, Learn From, and Engage in Apologies. J Gen Intern Med 2021; 36:1352-1358. [PMID: 33034017 PMCID: PMC8131483 DOI: 10.1007/s11606-020-06263-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Apologies may play a significant role in medical care, especially in the context of patient safety, medical error disclosure, and malpractice. Studies have shown that when state laws, institutional policies, and individual skills align-including the ability to offer a sincere apology-patients and families benefit. However, little is known about how, and under what conditions, physicians offer apologies in day-to-day care. Even less is known about what medical students learn about apologies from observing their superiors in these settings. OBJECTIVE Characterize third-year medical students' experiences of observing and engaging in apologies. DESIGN Qualitative descriptive analysis of student professionalism narratives. PARTICIPANTS Third-year medical students at Indiana University School of Medicine. APPROACH A search of 7,384 unique narratives yielded 238 with apologies. A rubric based on four key elements of genuine apologies ((1) acknowledgement, (2) explanation, (3) regret/remorse, and (4) reparation) was used to classify the kind of apology offered. Apology completeness, impact, and timing were also coded. KEY RESULTS Seventeen percent of all apologies were complete (i.e., contained all four elements). Over 40% were coded as incomplete or "non-apology" apologies (i.e., those with only the first two elements). A significant relationship between apology completeness and positive student experience was found. Most apologies were offered by the attending physician or resident to patients and family members. Students were generally positive about their experiences, but one in five were coded as negative. Some students were distressed enough to offer apologies on behalf of the faculty. Apology timing did not make a significant difference in terms of student experience. CONCLUSIONS Few education programs target apologies in the context of routine practice. With little formal instruction, students may rely on adopting what their seniors do. Faculty have an important role to play in modeling the apology process when harms-both great and small-occur.
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Affiliation(s)
- Ian C Fischer
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Richard M Frankel
- Indiana University School of Medicine, Indianapolis, IN, USA. .,VA Center for Health Information and Communication, Indianapolis, IN, USA. .,Cleveland Clinic, Cleveland, OH, USA.
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Schulz-Moore JS, Bismark M, Jenkinson C, Mello MM. Assessing Patients' Experiences with Medical Injury Reconciliation Processes: Item Generation for a Novel Survey Questionnaire. Jt Comm J Qual Patient Saf 2021; 47:376-384. [PMID: 33836941 DOI: 10.1016/j.jcjq.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many health care organizations want to improve their responses to patients who suffer medical injuries. Their ability to understand how well they meet patients' needs is limited by the lack of suitable instruments for assessing injured patients' experiences. METHODS This study aimed to generate items for a patient experience questionnaire that medical facilities can use to assess how well resolution met patients' needs. The Medical Injury Reconciliation Experiences Survey (MIRES) was based on findings from previous studies of New Zealand and American patients' experiences of non-litigation resolution of medical injuries. The researchers performed a content analysis of 24 transcripts from a stratified random sample of 92 interviews from the prior studies. Themes were extracted to develop a draft questionnaire, which was revised following feedback from experts. Cognitive debriefing interviews were conducted with 24 New Zealand and American injured patients. RESULTS There were 40 items in the following domains: perceptions of communications with health care providers after the injury (15 items), perceptions of remedial gestures (11 items), indicia of the patient's overall satisfaction with the reconciliation process (4 items), the nature and impacts of the injury (5 items), and patients' characteristics (5 items). Participants' feedback about the questionnaire was predominantly positive. Their suggestions led to 37 revisions. CONCLUSION The MIRES was comprehensible and acceptable to this group of post-injury patients. While further testing is desirable, the MIRES offers promise as a practicable approach that health care organizations can use to assess how well their reconciliation processes met patients' needs.
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Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual Saf 2020; 30:64-67. [PMID: 32561590 DOI: 10.1136/bmjqs-2020-010955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/10/2020] [Accepted: 05/31/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Adam C Fields
- Department of Quality and Safety, Brigham Health, Boston, Massachusetts, USA
| | - Michelle M Mello
- Stanford Law School, Stanford University, Stanford, California, USA.,Stanford Health Policy and Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Allen Kachalia
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Mello MM, Roche S, Greenberg Y, Folcarelli PH, Van Niel MB, Kachalia A. Ensuring successful implementation of communication-and-resolution programmes. BMJ Qual Saf 2020; 29:895-904. [PMID: 31959716 PMCID: PMC7590903 DOI: 10.1136/bmjqs-2019-010296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 01/20/2023]
Abstract
Background Communication-and-resolution programmes (CRP) aim to increase transparency surrounding adverse events, improve patient safety and promote reconciliation by proactively meeting injured patients’ needs. Although early adopters of CRP models reported relatively smooth implementation, other organisations have struggled to achieve the same. However, two Massachusetts hospital systems implementing a CRP demonstrated high fidelity to protocol without raising liability costs. Study question What factors may account for the Massachusetts hospitals’ ability to implement their CRP successfully? Setting The CRP was collaboratively designed by two academic medical centres, four of their community hospitals and a multistakeholder coalition. Data and methods Data were synthesised from (1) key informant interviews around the time of implementation and 2 years later with individuals important to the CRP’s success and (2) notes from 89 teleconferences between hospitals’ CRP implementation teams and study staff to discuss implementation progress. Interview transcripts and teleconference notes were analysed using standard methods of thematic content analysis. A total of 45 individuals participated in interviews (n=24 persons in 38 interviews), teleconferences (n=32) or both (n=11). Results Participants identified facilitators of the hospitals’ success as: (1) the support of top institutional leaders, (2) heavy investments in educating physicians about the programme, (3) active cultivation of the relationship between hospital risk managers and representatives from the liability insurer, (4) the use of formal decision protocols, (5) effective oversight by full-time project managers, (6) collaborative group implementation, and (7) small institutional size. Conclusion Although not necessarily causal, several distinctive factors appear to be associated with successful CRP implementation.
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Affiliation(s)
- Michelle M Mello
- Stanford Law School and Stanford University College of Medicine, Stanford, California, USA
| | - Stephanie Roche
- Health Care Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Yelena Greenberg
- Department of Health Policy & Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Allen Kachalia
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Smulowitz P. The illusion of perfection. BMJ Qual Saf 2019; 29:345-347. [DOI: 10.1136/bmjqs-2019-010501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/04/2022]
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Fanaroff JM, Goldsmith JP. The most common patient safety issues resulting in legal action against neonatologists. Semin Perinatol 2019; 43:151181. [PMID: 31493855 DOI: 10.1053/j.semperi.2019.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Common patient safety issues may result in injuries to babies in the newborn period. A medical malpractice lawsuit is one way in which an injured patient can obtain compensation for the injuries they sustained as the result of an error. There are a number of common areas of malpractice risk for neonatologists including the delivery room, jaundice, hypoglycemia, and late preterm infants. A better understanding of the medical malpractice system and common patient safety issues in neonatology can lead to protective strategies to reduce risk for untoward events and subsequent litigation. Strategies including maintaining competency, following national guidelines, and proper communication and documentation can improve the care and treatment of neonatal patients and their families resulting in less malpractice exposure.
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Affiliation(s)
- Jonathan M Fanaroff
- Department of Pediatrics, Division of Neonatology, University Hospitals Health System, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Jay P Goldsmith
- Department of Pediatrics, Division of Newborn Medicine, Tulane University School of Medicine, New Orleans, LA, United States
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A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare. J Fungi (Basel) 2019; 5:jof5030069. [PMID: 31344775 PMCID: PMC6787571 DOI: 10.3390/jof5030069] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/04/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022] Open
Abstract
This report serves as a guide for investigating mucormycosis infections in healthcare. We describe lessons learned from previous outbreaks and offer methods and tools that can aid in these investigations. We also offer suggestions for conducting environmental assessments, implementing infection control measures, and initiating surveillance to ensure that interventions were effective. While not all investigations of mucormycosis infections will identify a single source, all can potentially lead to improvements in infection control.
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Medical Malpractice Involving Pulmonary/Critical Care Physicians. Chest 2019; 156:907-914. [PMID: 31102609 DOI: 10.1016/j.chest.2019.04.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Medical malpractice data can be leveraged to understand specialty-specific risk. METHODS Malpractice claims were examined from the Comparative Benchmarking System (2007-2016), a national database containing > 30% of claims data in the United States. Claims were identified with either internal medicine or pulmonary/critical care (PCC) physicians as the primary provider involved in the harm. Claim characteristics were compared according to specialty and care setting (inpatient vs outpatient), and multiple regression analysis was performed to predict claim payment. RESULTS Claims involving PCC physicians differed from those involving internal medicine physicians in terms of harm severity, allegation, final diagnosis, procedure involvement, payment rate, and contributing factors. The majority of claims involving PCC physicians resulted from inpatient care (63%), of which only 26% occurred delivering intensive care. Eighty-one percent were from harm events that resulted in death/permanent injury. The most common diagnosis was laceration during a procedure for inpatient claims (6%) and lung cancer for outpatient claims (28%). Thirty-one percent of claims overall involved procedures. Although only 26% were paid, the median indemnity per paid claim of $285,769 ranked PCC as the twelfth highest of 69 specialties. The two variables associated with indemnity payment were outpatient care (OR, 1.70; 95% CI, 1.01-2.86) and temporary harm (OR, 0.36; 95% CI, 0.15-0.87). CONCLUSIONS Malpractice claims involving PCC physicians were distinct from claims involving internal medicine physicians. Although only one-quarter of claims was paid, the indemnity per claim was high among specialties. Specialty-specific prevention strategies must be developed to mitigate both patient harm and provider malpractice risk.
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Gallagher TH, Mello MM, Sage WM, Bell SK, McDonald TB, Thomas EJ. Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions. Health Aff (Millwood) 2018; 37:1845-1852. [DOI: 10.1377/hlthaff.2018.0727] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Thomas H. Gallagher
- Thomas H. Gallagher is a professor in the Department of Medicine and in the Department of Bioethics and Humanities, University of Washington School of Medicine, in Seattle
| | - Michelle M. Mello
- Michelle M. Mello is a professor of law at Stanford Law School and a professor of health research and policy at Stanford University School of Medicine, in California
| | - William M. Sage
- William M. Sage is the James R. Dougherty Chair for Faculty Excellence, School of Law, and a professor of surgery and perioperative care, Dell Medical School, both at the University of Texas at Austin
| | - Sigall K. Bell
- Sigall K. Bell is an associate professor of medicine in the Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, Massachusetts
| | - Timothy B. McDonald
- Timothy B. McDonald is director of the Center for Open and Honest Communication, MedStar Institute for Quality and Safety, in Washington, D.C
| | - Eric J. Thomas
- Eric J. Thomas is a professor of medicine in the Department of Medicine, McGovern Medical School, University of Texas Health Science Center at Houston
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