Appropriate Standard Of Care Research Articles

On being an expert witness in sexual and reproductive health

A new generation of expert witnesses in sexual and reproductive health is needed, including those in nursing as well as medical roles. Being an expert witness is a significant commitment...

Medico-legal risk, clinical negligence and the practice of travel medicine.

Traditionally a small number of clinical specialties, such as obstetrics and gynaecology, have been regarded as particularly high-risk areas of medical practice in terms of medical negligence litigation. Increasing evidence is emerging to substantiate the view that clinical negligence litigation is becoming prevalent in primary and ambulatory care settings.1–3 In common with other specialist areas of clinical practice, travel medicine presents medico-legal risks. The potential for unrecognised medico-legal risk and a lack of risk management practices in travel medicine merit consideration. In order for an allegation of negligence to be proven, four principle facts must be individually established.4 In the first instance, the travel health professional must have a duty of care to the patient. Second, that professional must have failed to reach an accepted standard of practice in the course of providing that care. Third, the patient must have suffered physical, financial, psychological and/or another form of loss. Finally, the loss must have been legally caused by the failure to provide an accepted standard of care. The onus is upon the plaintiff (i.e. the patient) to prove that negligence has occurred, and unless evidence of all four aspects is accepted by the court, the allegation of negligence will not be upheld. Travel health professionals owe a duty of care to any patient who consults them. Within that duty of care, there is an obligation to provide a standard of care that must be approved by a reputable body of opinion within the specialist area of practice. In this way, variation in clinical practice and differences in opinion between practitioners are taken into account. If there is a reasonable body of opinion to support the course of action taken, then the professional will likely be considered to have provided an appropriate standard of care. Duty of care begins …

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Social determinants of health: from the concept to the practice in outcomes of unintended pregnancies which result in induced abortion

The present research is a continuation of another one previously developed about unsafe abortion, associated socio-demographic characteristics and morbidity, and goes further in its analysis of the social determinants of health that influence this occurrence, generating inequities in health. This study compared data of three groups of 51 women (total of 153) submitted to induced abortion, as per situation and site of the procedure: one with “unsafe abortion” (Slum), one with “legal and safe” induced abortion (Public hospital) and a third group with “illegal and safe” induced abortion (Private clinics with appropriate standard of care). Univariate and multiple analyses of multiple multinomial logistic regression analyses were performed for the three categories with Private as reference. In the final model, the variables that proved to have a statistically significant association with induced abortion (CI=95%; p<0.05) were: income, level of schooling, ethnicity/color and place of birth for Slum and, for the Hospital location, the variable ethnicity lost significance. Morbidity, resulting from the outcome, showed a highly significant discrepancy between the first sample (Slum), with 94.12% of women who reported post-abortion complications, and the other two samples (Hospital and Private) in which no case of complication was identified or reported. A critical analysis was also made on the influence of the social determinants of health implied in abortion in all samples, and on the degree of inequity generated in each one (intra-group) and among them. We aimed to better understand social determinants of health concepts in practice. Proposals of action/intervention related to the “entry points” and findings were also suggested.

What Does the Excised Stomach from Sleeve Gastrectomy Tell us?

Staple-line leak and haemorrhage are the most serious complications following sleeve gastrectomy. The operation is often performed without prior endoscopy. Given that gastric inflammatory conditions are common, could they predispose patients to suffering a serious complication following sleeve gastrectomy? Consecutive patients undergoing laparoscopic sleeve gastrectomy from March 2007 to May 2014 were included in the study. All final histologic reports were coded and investigated against whether or not the patient had a post-operative leak and/or haemorrhage. Associations were explored using Fisher's exact test. Over this period, 976 laparoscopic sleeve gastrectomies were performed with a pre-operative gastroscopy rate of 2.2%. Over half of the specimens demonstrated a histopathologic abnormality. Helicobacter pylori infection occurred in 8.6%, and the most common histopathologic abnormality was chronic gastritis in 38.9%. There was no association between H. pylori infection or inflammation and staple-line leak and/or haemorrhage. We conclude that inflammatory gastric conditions are unlikely to predispose patients to staple-line leaks or haemorrhages following sleeve gastrectomy and that selective pre-operative gastroscopy may be an appropriate standard of care.

Odious Debt and Jus Post Bellum

Odious debt concerns the repudiation and cancellation of debt accrued by a State for ‘odious’ purposes. This article argues that odious debt can play a role in jus post bellum in lessening the financial burden placed on States who experience conflict and generate a clear standard for investors who seek to enforce a State’s obligations to repay its debts and other financial obligations after conflict. This article highlights several challenges inhibiting the translation of the proposal of odious debt into an international legal principle. It offers a conception of odious debt that seeks to resolve these challenges by aligning with other areas of public international law which operate concurrently. This article considers how international human rights law could give clear meaning to the contested term ‘odious’, how to conceive of the appropriate standard of care for creditors and examines potential institutions for debt resolution and potential incentives of relevant actors.

Circumcision and the best interests of the child.

Circumcision and the best interests of the child.

Analysis of anesthesia-related medical disputes in the 2009-2014 period using the Korean Society of Anesthesiologists database.

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status ≤ II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.

Avoiding the Deadly Sins of Humanitarian Missions: How to Do Good Better

Program Description: Humanitarian surgical trips provide an opportunity to deliver care that would otherwise be unavailable. However, there is significant variability among humanitarian missions. This variability has contributed to some unfortunate patient outcomes. This miniseminar will explore “deadly sins” common to medical humanitarian efforts and issues that are unique to surgical humanitarian missions. Panelists with extensive humanitarian experience will discuss available data and areas with a lack of data concerning humanitarian efforts. Best practices will be discussed with respect to appropriate standard of care, duration, follow-up, research, role of the media, and integration with local care systems. Educational Objectives: (1) Critically evaluate the existing literature and identify gaps in knowledge regarding humanitarian efforts in otolaryngology. (2) Recognize “best practices” including appropriate standard of care, duration, follow-up, conduct of research, role of the media, and integration with local care systems. (3) Critically evaluate and devise methods to improve existing humanitarian efforts in otolaryngology.

Preventing stillbirths through improved antenatal recognition of pregnancies at risk due to fetal growth restriction

Most stillbirths used to be categorized as ‘unexplained’ and were considered, by implication, unavoidable. Recent evidence indicates that they represent a combined challenge for public health and for clinical services. Independent case reviews have found that many deaths are associated with a failure to recognize risk factors and to afford them the appropriate standard of care. The majority of normally formed fetal deaths had preceding, unrecognized intrauterine growth failure. Improved training and adoption of standardized protocols has led to increased antenatal detection of fetal growth restriction, and this in turn has resulted in significant reductions in stillbirths in areas with high uptake of the training programme. A comprehensive, evidence-based growth assessment protocol (GAP) is currently being rolled out across the NHS to implement this strategy for stillbirth prevention.

Stakeholder views of ethical guidance regarding prevention and care in HIV vaccine trials.

BackgroundSouth Africa is a major hub of HIV prevention trials, with plans for a licensure trial to start in 2015. The appropriate standards of care and of prevention in HIV vaccine trials are complex and debated issues and ethical guidelines offer some direction. However, there has been limited empirical exploration of South African stakeholders’ perspectives on ethical guidance related to prevention and care in HIV vaccine trials.MethodsSite staff, Community Advisory Board members and Research Ethics Committee members involved with current HIV vaccine trials in South Africa were invited to participate in an exploration of their views. A questionnaire listed 10 care and 10 prevention recommendations drawn from two widely available sets of ethical guidelines for biomedical HIV prevention trials. Respondents (n = 98) rated each recommendation on five dimensions: “Familiarity with”, “Ease of Understanding”, “Ease of Implementing”, “Perceived Protection”, and “Agreement with” each ethical recommendation. The ratings were used to describe stakeholder perspectives on dimensions for each recommendation. Dimension ratings were averaged across the five dimensions and used as an indication of overall merit for each recommendation. Differences were explored across dimensions, between care-oriented and prevention-oriented recommendations, and between stakeholder groups.ResultsBoth care and prevention recommendations were rated highly overall, with median ratings well above the scale midpoint. In general, informed consent recommendations were most positively rated. Care-related recommendations were rated significantly more positively than prevention-related recommendations, with the five lowest-rated recommendations being prevention-related. The most problematic dimension across all recommendations was “Ease of Implementing,” and the least problematic was “Agreement with,” suggesting the most pressing stakeholder concerns are practical rather than theoretical; that is, respondents agree with but see barriers to the attainment of these recommendations.ConclusionsWe propose that prevention recommendations be prioritized for refinement, especially those assigned bottom-ranking scores for “Ease of Implementing”, and/ or “Ease of Understanding” in order to assist vaccine stakeholders to better comprehend and implement these recommendations. Further qualitative research could also assist to better understand nuances in stakeholder reservations about implementing such recommendations.

Keeping Current with the Applied Behavior-Analytic Literature in Developmental Disabilities: Noteworthy Articles for the Practicing Behavior Analyst.

To meet the appropriate standard of care for their clients, practicing behavior analysts must stay in close contact with the scholarly literature. As one step toward this important goal, we provide an annotated bibliography of recent articles that are deemed to have relevance to behavioral practitioners in the area of developmental disabilities.

Liability in the context of misdiagnosis of melanoma in Australia

Malignant melanoma is a serious and relatively common condition, the diagnosis of which may be difficult. In a recent Supreme Court of New South Wales case, misdiagnosis of melanoma occurred, but there was failure to establish causation of the patient's poor prognosis. Aggressive melanomas may grow quickly, fail to conform to standard and commonly taught diagnostic criteria, and frequently escape early detection. In the event of uncertain diagnosis or failed treatment of a lesion, an appropriate standard of care is full excisional biopsy if not previously performed, or referral of the case to an appropriate specialist or melanoma centre. Clinicians should remain aware of the existence of higher-risk, easily misdiagnosed melanomas with a high mortality rate. Therefore, they should aim to identify these at the earliest opportunity.

The SEC's Continuing Quest for a Harmonized Standard of Care Governing Broker-Dealers and Investment Advisers

This document reviews the latest chapter in the long-running and continually evolving debate over the appropriate standard of care for broker-dealers and investments advisers under the federal securities laws. Following the SEC’s report to Congress under the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010 (the “Dodd-Frank Act”) of its Study Regarding a Harmonized Standard of Care for Broker-Dealers and Investment Advisers in January 2012. The U.S. Securities and Exchange Commission (“SEC”) published a Request for Data and Information (RFDI) in March 2013 that elicits input on the costs and burdens of several hypothetical approaches to harmonizing the standards of care governing broker-dealers and investment advisers. This material will highlight the SEC’s Request for Data and Information, summarize public input, and provide context within which to evaluate the FRDI in in view of the many stages of the regulatory examination of broker-dealer and investment adviser standards of care. Collectively, this information should provide a roadmap for evaluating the status of a harmonized standard of care for broker-dealers and investment advisers.Many catalysts for change have contributed to this latest regulatory development on a standard of care, including regulatory solutions galvanized by profound economic turmoil, and competing industry and regulatory initiatives. The document reviews these agents for change that ultimately led to a congressionally mandated SEC study on a harmonized broker-dealer and investment adviser standard of care in the Dodd-Frank Act. The material also charts regulatory and industry positions, addresses various regulatory and legislative solutions that functioned as substantive preludes to the Dodd-Frank Act and provides a framework of statutory and regulatory background.

Zabluda i pravne posledice zablude

Misconception, in the field of legal transactions, represents a mistaken idea of the legal facts relevant to the validity of the legal transaction. According to the traditional classification, based on the facts to which the mistake relates, we can differentiate misconceptions about the nature of legal transaction (error in negotio), misconception about the personality (error in personae), misconception about the object of legal transaction (error in corpore), misconception about the qualities or substance of the transaction (error in substantia), misconception about the incentives (error inmotivo), misconception about the purpose or the cause of legal transaction (causafinalis) and misconception caused by the false or misleading transfer of statement of will (falsademonstratio). Depending on whether the false assumption relates to the content of legal regulations or to the state of facts, misconceptions can be classified as mistakes in law (error iuris) or as the mistakes in fact (errorfacti). For a misconception to be legally relevant, it has to be essential, but also unprovoked. Conditions under which the mistaken notion is considered to be essential are prescribed by Articles 61, 62 and 64 of the Law on obligations. The party who agreed to a legal transaction because of such essential misconception can require an annulment, provided that such party exercised appropriate standard of care when making the legal transaction and exercising its subjective rights and obligations. The above condition represents the essence of the rule that the misconception of a party in a legal transaction should not be provoked by the party itself. The deadlines for submitting claims for annulment are preclusive. If they are missed, the voidable legal transaction becomes valid. The judgment by which the transaction is canceled due to an essential misconception has constitutive effect and it is considered that such a legal transaction never existed - in other words, that it was void ab initio. Legal consequence of the annulment of legal transaction due to the existence of an essential misconception is the duty to compensate the damage.

We Finally Learnt to Demand: Consumers’ Access to Rehabilitation Following Traumatic Brain Injury

Clinical care guidelines exist internationally recommending the appropriate standards of care for adults following brain injury. These guidelines recommend a care pathway including acute, inpatient and outpatient rehabilitation and community-based care. However, if and how these guidelines are implemented is largely unknown. The aim of this study was to explore the recollected continuum of care experienced by 202 adults with moderate to severe traumatic brain injury (TBI) in Victoria, Australia. The experiences of participants in this study were investigated using a mixed methods research approach (surveys and in-depth interviews). The results indicated that only 20% of participants in this study recollected receiving care in line with recommendations made in clinical care guidelines. Reasons they identified for their problematic access to services included: a lack of information about the services available, the absence of an advocate and services being restricted by limited funding. The findings of this study indicate that while guidelines provide recommendations regarding standards of care and can serve as a benchmark to improve the quality of services, they do not ensure the equitable delivery of services. Clinicians using these guidelines need to be aware of the factors that restrict clients’ access to services and take these into account when planning the delivery of services.

Vermont Seeks Equality For Psychiatry

Back to table of contents Previous article Next article Professional NewsFull AccessVermont Seeks Equality For PsychiatryAaron LevinAaron LevinSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.11a22AbstractAPA and the Vermont district branch battle with an insurance giant in an effort to get fair play for patients and psychiatrists.Rules put forth by BlueCross BlueShield of Vermont (BCBS/Vermont) requiring prior authorization and setting reimbursement rates for psychiatrists below those for primary care physicians violate the Mental Health Parity and Addiction Equity Act of 2008, according to APA and Vermont Psychiatric Association (VPA) officials. The law requires that health plans provide mental health benefits at parity with other medical benefits.Separate treatment limitations are a violation of the law, said James H. Scully Jr., M.D., then APA’s CEO and medical director, and Margaret Bolton, M.D., VPA president, in a letter to the insurer.As of last spring, BCBS/Vermont permitted patients 10 mental health visits without prior authorization but required preauthorization for any visits beyond that number. “We are not aware of any clinically appropriate standards of care that would permit BCBS to ration services in this manner,” said Scully and Bolton.In addition, BCBS/Vermont violates the federal parity law by paying primary care physicians more than psychiatrists when billing for the same CPT codes and providing similar services, APA and VPA noted. The practice also harms patients, since it discourages treatment by the physicians who specialize in mental health and discourages network participation by psychiatrists.The problems have existed for years but came to the fore when BCBS/Vermont created a new company—Vermont Collaborative Care—to manage mental health benefits in the state, said Bolton in an interview. In addition, APA officials have been looking more closely in all states for potential parity violations.Others see deeper forces at work.“BCBS just doesn’t value what psychiatrists do,” said Alice Silverman, M.D., past president of the VPA, in an interview with Psychiatric News. “As a result, mental health care in Vermont has become a two-tier system. Wealthy patients can pay out of pocket, but working people who depend on their insurance have limited access to psychiatric care.”Worse yet, the burdens of preauthorization coupled with lower reimbursements make early career psychiatrists leery of practicing in the state, she said.After the initial exchange of letters failed to clarify matters for psychiatrists, the two sides held a face-to-face meeting October 2 in Montpelier, Vt. Results of the meeting were mixed, at best, said Colleen Coyle, J.D., APA general counsel.“BCBS agreed that in-network psychiatrists no longer needed prior authorization for evaluation and management or for evaluation and managements plus psychotherapy in the same session,” she said. “But if they do only psychotherapy, they still need prior authorization. The process makes no sense.”Furthermore, members are reporting that the changes did not apply to out-of-network psychiatrists or to any other mental health care providers, said Coyle. This amounts to a “treatment limitation” that also violates the parity act.The insurer agreed to review overall preauthorization requirements, said Bolton. “We will advocate that preauthorization requirements be dropped for all psychiatrists in Vermont, in or out of network.”However, BCBS/Vermont’s responses to the lack of reimbursement parity between primary care providers and psychiatrists were not satisfactory, said Coyle. “We argued that mentally ill patients were better off being seen by psychiatrists, given their specialized training, yet the insurer will pay a primary care physician more for the visit,” she said. “BCBS/Vermont agreed to look at it.”Splitting care between a primary care physician and a psychologist would require two separate office visits and be more costly to patients as well, imposing undue burden and expense on mental health patients.Negotiations will continue with the insurer, said Coyle. “We’re making some progress, and I’m guardedly optimistic.”Bolton agreed and said she will actively maintain contacts with Vermont Collaborative Care and with BCBS to resolve remaining differences. ■The VPA website can be accessed at http://www.vtmd.org/vpa. More information on mental health parity is posted on APA’s website at http://www.psychiatry.org/mental-health/more-topics/insurance-and-parity. ISSUES NewArchived

Reflections on the ethical dilemmas involved in promoting self-management

Due to their understanding of self-management, healthcare team members responsible for depressed older persons can experience an ethical dilemma. Each team member contributes important knowledge and experience pertaining to the management of depression, which should be reflected in the management plan. The aim of this study was to explore healthcare team members’ reflections on the ethical dilemmas involved in promoting self-management among depressed older persons. A qualitative design was used and data were collected by means of focus group interviews. The results revealed one main theme: ‘Lack of trust in the community health care system’s commitment to bringing about effectiveness and change, based on three themes; ‘Struggling to ensure the reliable transfer of information about depressed older persons to professionals and family members’, ‘Balancing autonomy, care and dignity’ and ‘Differences in the understanding of responsibility’. Lack of engagement on the part of and trust between the various professional categories who work in the community are extremely counterproductive and have serious implications for patient dignity as well as safety. In conclusion, ethical dilemmas occur when staff members are unable to act in accordance with their professional ethical stance and deliver an appropriate standard of care.

Discovering the untapped benefits of team nursing in an acute haemodialysis unit of a major teaching hospital

Background: Nursing duties in a haemodialysis setting can be performed using two main models which are primary and team nursing. The study sought to determine the most appropriate nursing care model in an acute haemodialysis unit (AHU) of a large metropolitan teaching hospital where primary nursing was replaced by the team nursing model on a trial basis. Methods: Standard questionnaires were administered to nursing staff pre and post the introduction of team nursing to determine the effectiveness of primary and team nursing in our dialysis unit. Clinical charts were audited prior to the introduction of team nursing and three months after to detect deviations in appropriate standards of care. A descriptive statistical analysis of data was conducted to address the purpose of this study. Results: Staff took an average of 37±4 days to review patient needs prior to the utilization of the TNC model and 5±3 days 3 months later. Handing over of patients improved from 25% to 65% and 25% of charts audited prior to the TNC model had errors compared to 13% after the introduction of team nursing. On a score of 0 to 10, the success of the PNC model had a mean of 5.2±2.5 compared to 8.3±0.7 for the TNC model. Conclusion: The team nursing care model can be effectively applied in an acute haemodialysis setting without compromising patient care and the superiority of team nursing over primary nursing in this setting has also been reinforced.

Court to Hear Case Alleging Parity-Law Violation

Court to Hear Case Alleging Parity-Law Violation