Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management最新文献

Root Cause Analysis and Action (RCA² ) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and development of systems-level interventions. We recently integrated a complement of human factors tools into the RCA² process to address this gap. These tools include the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a multiple-criterion decision tool called FACES, for selecting effective HFIX solutions. We describe each of these tools and illustrate how they can be integrated into RCA² to create a robust human factors RCA process called HFACS-RCA² . We also present qualitative results from an 18-month implementation study within a large academic health center. Results demonstrate how HFACS-RCA² can foster a more comprehensive, human factors analysis of serious patient harm events and the identification of broader system interventions. Following HFACS-RCA² implementation, RCA team members (risk managers and quality improvement advisors) also experienced greater satisfaction in their work, leadership gained more trust in RCA findings and recommendations, and the transparency of the RCA process increased. Effective strategies for overcoming implementation barriers, including changes in roles, responsibilities and workload will also be presented.

Background: Identifying characteristics of malpractice claims involving emergency medicine (EM) physicians allows leaders to develop patient safety initiatives to prevent future harm events.

Methods: A retrospective study was performed of paid/unpaid claims closed 2007 to 2016 from Comparative Benchmarking System. Claims were identified by physician specialty involved (EM, internal medicine, general surgery). Various characteristics were compared by physician specialty. Multivariable regression was performed to identify factors associated with claim payment, in which (1) physician specialty was included as a predictor and (2) only the subset involving EM physicians was analyzed.

Results: Of 54,772 claims, 2760 involved EM physicians, 5886 involved internists, and 3207 involved surgeons. Death was the most common severity among EM claims (34%). Diagnosis-related allegations accounted for 58%, higher than 42% and 11% of claims involving internists and surgeons, respectively (P < 0.0001). Thirty-one percent was paid. The median indemnity paid on behalf of any defendant was $206,261 (interquartile range $55,065-527,651). The most common final diagnoses were myocardial infarction (2%), pulmonary embolus (2%), and cardiac arrest (2%). Procedure-related claims were associated with increased payment likelihood (odds ratio 1.21, 95% confidence interval 1.10-1.34).

Conclusion: Malpractice claims in EM are often diagnosis- or procedure related. Our findings suggest that diagnostic accuracy and procedural competency should shape future quality improvement work.

Maternal and obstetrical outcomes vary widely within the United States. The impact of insurance type on health care disparities and its influence on obstetrical care and maternal outcome is not clear. We report the impact of health care insurance on obstetrical and maternal outcomes in a tertiary care health care system. Our maternal quality care database (n = 4199) was queried comparing commercial insurance to government sponsored insurance from July 1, 2015 through June 30, 2018. Parturients with commercial insurance were older, weighed more, presented with less gravidity and parity, had more advanced gestation, and had a higher neonatal 5-minute Apgar score than government insured parturients. Additionally, government insured parturients were less likely to be admitted for induction with oxytocin, receive labor epidural analgesia, and have a primary caesarean delivery. Similarly, government insured parturients were more likely to be of African American descent, be a current known smoker, have a positive urine drug screen, and receive a general anesthetic. We conclude obstetrical and maternal health care disparities exist based on medical insurance type.

Objective: Utilize simulation to evaluate if living wills (LW) or POLST achieves goal concordant Care (GCC) in a medical crisis.

Methods: Nurses and resident-physicians from a single center were randomized to a clinical scenario with a living will (LW), physician orders for life sustaining treatment (POLST) or no document. Primary outcomes were resuscitation decision and time to decision. Secondary outcome was the effect of education.

Results: Total enrollment was 57 and less than 30% received prior training. Types of directives were linked to resuscitation decisions (P = .019). Participants randomized to "No Document" or POLST specifying "CPR" performed resuscitation. If a terminal condition presented with a POLST/ do not resuscitate-comfort measures only (DNR-CMO), 73% resuscitated. The LW or POLST specifying DNR combined with medical support resulted in resuscitations in 29% or more of the scenarios. Documents did not significantly affect median time-to-decision (P = .402) but decisions for "No Document" and POLST/CPR were at least 10 s less than other scenarios. Scenarios involving POLST DNR/Limited Treatment had the highest median time of 43 s. Prior training in LWs and POLST exerted a 10% improvement in decision making (P = .537).

Conclusion: GCC was not always achieved with a LW or POLST. This conclusion supports prior research identifying problems with the interpretation and discordance with LW's and POLST.

COVID-19 outbreak in Saudi Arabia (SA) has placed substantial challenges on its health care system, which raised our concern about the possible influence on patient safety culture. Therefore, this study aimed to provide empirical evidence on how the COVID-19 outbreak impacted patient safety incident reports (PSIRs) among the Qassim Health Cluster (QHC) in SA. This retrospective study assessed a total of 23,481 inpatient PSIRs from 22 medical facilities. We compared data on PSIRs between COVID-19 period (March–July 2020) and a comparable pre-COVID-19 period (March–July 2019). PSIRs were classified according to “Saudi Patient Safety Taxonomy.” In the COVID-19 period: inpatient admissions have significantly dropped by one-fourth, and the median score of PSIRs significantly increased to 30.6/100 inpatients. Nevertheless, there were no changes in PSIRs harm level. The top five areas of reporting were related to: patient care, medication, infection control, staff, and facility maintenance. Furthermore, there were no significant differences in the frequency rate of PSIRs by facility bed capacity. The significant increase in PSIRs at COVID-19 time can be perceived as a positive outcome. Our view considers both the COVID-19 crisis and future health crises. The lessons learned here should be employed to promote sustainable preparedness and responses to subsequent crises.