Journal of patient safety
-
Journal of patient safety · Dec 2020
Missed Acute Coronary Syndrome During Telephone Triage at Out-of-Hours Primary Care: Lessons From A Case-Control Study.
Serious adverse events at out-of-hours services in primary care (OHS-PC) are rare, and the most often concern is missed acute coronary syndrome (ACS). Previous studies on serious adverse events mainly concern root cause analyses, which highlighted errors in the telephone triage process but are hampered by hindsight bias. This study compared the recorded triage calls of patients with chest discomfort contacting the OHS-PC in whom an ACS was missed (cases), with triage calls involving matched controls with chest discomfort but without a missed ACS (controls), with the aim to assess the predictors of missed ACS. ⋯ To facilitate learning from serious adverse events in the future, these should also be bundled and carefully assessed without hindsight bias and within the context of "normal" clinical practice.
-
Journal of patient safety · Dec 2020
Liability of Health Care Professionals and Institutions During COVID-19 Pandemic in Italy: Symposium Proceedings and Position Statement.
On May 12, 2020, a symposium titled "Liability of healthcare professionals and institutions during COVID-19 pandemic" was held in Italy with the participation of national experts in malpractice law, hospital management, legal medicine, and clinical risk management. The symposium's rationale was the highly likely inflation of criminal and civil proceedings concerning alleged errors committed by health care professionals and decision makers during the COVID-19 pandemic. Its aim was to identify and discuss the main issues of legal and medicolegal interest and thus to find solid solutions in the spirit of preparedness planning. ⋯ Limitation of the liability to the cases of gross negligence (with an explicit definition of this term), a no-fault system with statal indemnities for infected cases, and a rigorous methodology for the expert witnesses were proposed as key interventions for successfully facing future proceedings.
-
Journal of patient safety · Dec 2020
The Detection, Analysis, and Significance of Physician Clustering in Medical Malpractice Lawsuit Payouts.
There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error. ⋯ There is a clustering of payments in medical malpractice cases among a small group of physicians. These findings point up the need to oppose the negative impact of such outlier physicians on the safety of patients.
-
Journal of patient safety · Dec 2020
Description and Yield of Current Quality and Safety Review in Selected US Academic Emergency Departments.
Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. ⋯ With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.
-
Journal of patient safety · Dec 2020
Essential and Nonessential Blood Testing in the Clinical Teaching Unit.
The aim of the study was to evaluate the essential and nonessential blood tests ordered on the internal medicine clinical teaching units (CTUs) at Kingston General Hospital. Our aim was to establish a baseline performance measure identifying appropriate use of laboratory tests that could be used to inform improvement over time. ⋯ Inadequate use of blood tests for CTU patients is common. Quality improvement initiatives should aim to address the lack of observed consensus between attending physicians' views and the ordered tests and to streamline decision-making and the ordering/communication processes. Clinical standards and guidelines regarding ordering of laboratory tests should be clearly defined.