Errors In Patient Management Research Articles

Malpractice Claims Data as a Quality Improvement Tool. I. Epidemiology of Error in Four Specialties

Objective. —To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology. Design. —Retrospective review of physician malpractice claim records. Setting. —Large New Jersey physician malpractice insurer. Participants. —Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, and radiology and covered by the insurance carrier during any portion of 1977 through 1989. Main Outcome Measures. —Proportion of claims due to negligence associated with errors in (1) patient management, (2) technical performance, and (3) medical and nursing staff coordination and the clinical and financial consequences of such errors. Results. —Among 1371 claims ascribed to negligence, patient management errors were cited most frequently in all four specialties (48% to 75%) and, compared with performance and coordination problems, were generally associated with a higher frequency of serious injury and higher median payments. Coordination problems accounted for about 9% of claims. In obstetrics and gynecology, newborn delivery claims usually arose from management errors (57% to 68%), whereas gynecologic procedure claims were most often associated with performance errors (55% to 73%). Underperformance of cesarean section was cited more frequently than overperformance (31% vs 3%). General surgery claims were about equally divided between management and performance types regardless of procedure. Failure to perform appropriate diagnostic testing or monitoring was the main problem in 3% to 8% of claims. Conclusion. —Malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence. (JAMA. 1991;266:2087-2092)

Malpractice Claims Data as a Quality Improvement Tool

--To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology. --Retrospective review of physician malpractice claim records. --Large New Jersey physician malpractice insurer. --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, and radiology and covered by the insurance carrier during any portion of 1977 through 1989. --Proportion of claims due to negligence associated with errors in (1) patient management, (2) technical performance, and (3) medical and nursing staff coordination and the clinical and financial consequences of such errors. --Among 1371 claims ascribed to negligence, patient management errors were cited most frequently in all four specialties (48% to 75%) and, compared with performance and coordination problems, were generally associated with a higher frequency of serious injury and higher median payments. Coordination problems accounted for about 9% of claims. In obstetrics and gynecology, newborn delivery claims usually arose from management errors (57% to 68%), whereas gynecologic procedure claims were most often associated with performance errors (55% to 73%). Underperformance of cesarean section was cited more frequently than overperformance (31% vs 3%). General surgery claims were about equally divided between management and performance types regardless of procedure. Failure to perform appropriate diagnostic testing or monitoring was the main problem in 3% to 8% of claims. --Malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence.

Common artifacts of pulmonary artery and pulmonary artery wedge pressures: recognition and interpretation.

Bedside measurement of pulmonary artery pressure and pulmonary artery wedge pressure has an important role in the management of critically ill patients. Unfortunately, waveform abnormalities and artifacts commonly distort numeric values and lead to incorrect therapeutic decisions. The clinical impact of these artifacts is magnified by the digital pressure displays used in most intensive care units. We present here an atlas and an analysis of the artifacts that commonly occur. Use of analog rather than digital pulmonary artery wedge pressure data, when combined with an understanding of the physiological characteristics of patients, can prevent critical errors in patient management.

Current concepts of thyroiditis

• Thyroiditis refers to a diverse group of disorders that produce distinct pathologic abnormalities of the thyroid gland. The clinical course, diagnosis, and treatment of the individual types of thyroiditis are reviewed herein. Some of these conditions may be associated with only transient abnormalities of thyroid function. When faced with a hyperthyroid or hypothyroid patient, care must be exercised to establish the correct origin of the condition so that errors in patient management will be avoided. (<i>Arch Intern Med</i>1983;143:1952-1956)

Current Concepts of Thyroiditis

Thyroiditis refers to a diverse group of disorders that produce distinct pathologic abnormalities of the thyroid gland. The clinical course, diagnosis, and treatment of the individual types of thyroiditis are reviewed herein. Some of these conditions may be associated with only transient abnormalities of thyroid function. When faced with a hyperthyroid or hypothyroid patient, care must be exercised to establish the correct origin of the condition so that errors in patient management will be avoided.

Perioperative Management of Patients with Pituitary Microadenoma

A systematic method for the perioperative management of routine cases of pituitary microadenoma treated by transsphenoidal microsurgery is presented. These methods have evolved over a 7-year period and have been utilized in the management of more than 750 patients with pituitary tumors and related problems treated by trans-sphenoidal surgery. The goals in this joint neurosurgical, endocrinological, and otorhinolaryngological team effort are to eliminate errors in patient management, to assure the safety of the patient in the perioperative period, and to make the therapy as efficient and as cost-effective as possible.

Pseudodysrhythmias in Ambulatory ECG Monitoring

Artifacts mimicking a variety of dysrhythmias occur relatively frequently in ambulatory ECG (Holter) monitoring records. Proper interpretation is imperative if serious therapeutic errors are to be avoided. Two-channel recording systems may facilitate recognition of some, but not all, of these artifacts. Pseudodysrhythmias may mimic paroxysmal supraventricular tachycardia and atrial fibrillation, atrial dissociation, extrasystoles, and sinus pauses. There are several causes of pseudodysrhythmias. Failure to recognize these patterns may result in serious errors in patient management.

Errors in management of patients dying of chronic obstructive lung disease

Errors in management of patients dying of chronic obstructive lung disease

LIVER SCANNING IN THE DIAGNOSIS OF HEMATOBILIA.

The diagnosis of traumatic hematobilia, which is often obscure, can be aided by scintillation scanning of the liver after the administration of a suitably labeled radioactive compound. The physician who examines a patient with gastrointestinal bleeding following abdominal trauma must consider hemorrhage from the biliary system among other possibilities. The correct diagnosis is especially important because of the treacherous course of this disease: failure to consider hematobilia may lead to a false sense of security, and fatal errors in patient management may occur. Although only 27 cases have been reported in the literature (1) since Sandblom's (2) original description of this entity, interest in the condition has stimulated some discussion (3–5). Emphasis has been placed on clinical suspicion of hematobilia in the absence of another demonstrable bleeding site, following appropriate roentgen studies. Two special procedures are suggested by Schatzki (6) as potential means of identifying liver hemorrhage. These are selective arteriography and scintillation scanning of the liver. Recently we studied 2 cases of traumatic hematobilia by scintillation scanning. This method proved an effective means of confirming the diagnosis and may provide an excellent opportunity for following progress of the disease. The cases to be presented showed a fairly typical clinical course. Case I: K. D., an 8-year-old white male, was struck by a truck on Feb. 10, 1962, and brought immediately to Cincinnati General Hospital. He had suffered a contusion to the abdomen and a fracture of the clavicle. Hematocrit was 29 per cent, the vital signs were good, and the patient was sent home. On Feb. 17, the child began to complain of generalized abdominal pain and vomited blood-stained material. On readmittance, an abdominal paracentesis revealed blood in the abdomen. At laparotomy a laceration of the right lobe of the liver was sutured. The boy improved postoperatively, and was discharged. On March 8, the patient vomited bright red blood. He was readmitted to the hospital where transfusions were given. On March 9, 64 microcuries of rose bengal was injected intravenously. A scintillation scan demonstrated a filling defect along the right lateral border of the liver (Fig. 1). Intermittent bouts of colicky pain, jaundice, and melena occurred. On March 31, a mass developed in the right upper quadrant. Laparotomy revealed a gallbladder filled with blood and bile, and a large clot was removed from the right hepatic duct. Following this, a massive hemorrhage occurred, and a right hepatic lobectomy was attempted. The hemorrhage could not be controlled, and the patient died. The portion of the liver removed showed a large area of hemorrhage and necrosis along the right lateral border as shown in a postmortem radiograph of the liver (Fig. 2).