Hospital Risk Management Research Articles

An Innovative Approach for Familiarizing Surgeons with Malpractice Litigation

Familiarize surgery residents with medicolegal knowledge and skills required when facing the prospect of being sued through a simulation session. The general surgery residency, hospital risk management, and malpractice attorneys collaboratively organized an educational intervention, consisting of an introductory lecture followed by a mock lawsuit. Two medical malpractice attorneys acted as defense and plaintiff attorneys while an attending surgeon experienced in litigation acted as defendant. Experience, attitudes, and preintervention/postintervention competency were evaluated via retrospective self-assessment. Weekly departmental educational conference. Forty residents and attending surgeons. Among the participants, 27.5% had been named in a law suit before. Most surgeons (70.0%) are worried about malpractice. Physicians who had been sued were no more likely to worry about malpractice (18.6 vs 25.0%, p = 0.82) than their colleagues who had never been sued. Results from the retrospective preintervention/postintervention competency assessmentsdemonstrated significant improvement in all measured competencies after the mock lawsuit. In comparison with attending faculty, residents obtained greater improvements in understanding the essential elements of a medical claim (1.9 vs 1.1, p = 0.03), gaining confidence doing a deposition for medical litigation (1.9 vs 0.9, p < 0.01) and understanding the do's and don'ts when named in a lawsuit (2.0 vs 1.1, p = 0.01). The novel educational format effectively familiarized surgery faculty and residents with the process of litigation and improved their confidence and mental preparedness when facing the prospect of a lawsuit. It is a valuable educational tool that can be incorporated in residency training and faculty development curricula.

Maturity Levels of Quality and Risk Management at the University Hospital Schleswig-Holstein

Quality and risk management in hospitals are not only required by law but also for an optimal patient-centered and process-optimized patient care. To evaluate the maturity levels of quality and risk management at the University Hospital Schleswig-Holstein (UKSH), a structured analytical tool was developed for easy and efficient application. Four criteria concerning quality management - quality assurance (QS), critical incident reporting system (CIRS), complaint management (BM) and process management (PM) - were evaluated with a structured questionnaire. Self-assessment and external assessment were performed to classify the maturity levels at the UKSH (location Kiel and Lübeck). Every quality item was graded into four categories from "A" (fully implemented) to "D" (not implemented at all). First of all, an external assessment was initiated by the head of the department of quality and risk management. Thereafter, a self-assessment was performed by 46 clinical units of the UKSH. Discrepancies were resolved in a collegial dialogue. Based on these data, overall maturity levels were obtained for every clinical unit. The overall maturity level "A" was reached by three out of 46 (6.5%) clinical units. No unit was graded with maturity level "D". 50% out of all units reached level "B" and 43.5% level "C". The distribution of the four different quality criteria revealed a good implementation of complaint management (maturity levels "A" and "B" in 78.3%), whereas the levels for CIRS were "C" and "D" in 73.9%. Quality assurance and process management showed quite similar distributions for the levels of maturity "B" and "C" (87% QS; 91% PM). The structured analytical tool revealed maturity levels of 46 clinical units of the UKSH and defined the maturity levels of four relevant quality criteria (QS, CIRS, BM, PM). As a consequence, extensive procedures were implemented to raise the standard of quality and risk management. In future, maturity levels will be reevaluated every two years. This qualitative maturity level model enables in a simple and efficient way precise statements concerning presence, manifestation and development of quality and risk management.

Electronic medical records and risk management in hospitals of Saudi Arabia

ABSTRACTObjective: Electronic medical records systems and the associated risks have been well studied in developed countries; the same cannot be said for systems in developing countries. Previous research in Saudi Arabian health-care organizations has shown a low level of quality in hospital services due to ineffective risk management. The objective of this research is to apply the Systems Theoretic Accident Modelling and Processes (STAMP) risk management technique in Saudi Arabia and evaluate its implementation. Participants: The participating organization is a health-care organization in Saudi Arabia Methods: A two-phase case study was conducted. The first phase implemented the STAMP technique to identify and manage risks to the system. For the second phase, the STAMP technique was extended to include a checklist, to increase STAMP’s capability to mitigate risks, and the process reapplied. Results and Conclusion: The results demonstrated that the inclusion of the STAMP Checklist reduced errors and prevented system failures compared to regular STAMP.

Nursing Associated Medication Errors: Are Internationally Educated Nurses Different from U.S. Educated Nurses?

Medication errors can be detrimental to patient safety and contribute to additional costs in healthcare. The United States has seen a steady increase in internationally-educated nurses (IENs) entering the nursing workforce. The current study builds upon the existing research examining the relationship between IENs and medication errors by controlling for confounding factors and testing whether IENs were more likely to make multiple medication errors compared to USENs. This study was a quasi-case control study. The 2006 and 2010 medication error incident data from hospital risk management departments were used. The final sample was 1,773, representing 788 registered nurse in the case group and 985 registered nurses in the control group. Multivariable analyses were conducted to examine single medication error, multiple errors, and consequence of medication errors, in comparing the IENs to USENs. IENs tended to have multiple errors more often than USENs in 2006 (31.7% for IENs and 20.5% for USENs, p = 0.03), but these differences became marginally significant after combining both years of data and completing the multivariable models adjusting for covariates (Odds ratio = 1.38, p = 0.06). No significant differences in making a single error and medication error consequences were observed between IENs and USENs. Although no significant differences between IENs and USENs in having medication error incidents were observed, IENs might be more likely to have multiple medication error incidents in a year compared to USENs. Policies that encourage targeted orientation addressing implicit belief systems about the nursing role and explains patient safety expectations as well as procedures for medication administration may be beneficial for IENs. Supportive leadership that is culturally competent, ensures ongoing continuing education in pharmacology, and provides culturally appropriate incentives for self-reporting medication errors are important.

The function of patient-centered care in mitigating the effect of nursing shortage on the outcomes of care.

The shortage of nursing staff is a national and international issue. Inadequate number of hospital nurse staff leads to poor health care services. Yet the effects of patient-centeredness between the relationships of nursing shortage on the quality of care (QC) and patient safety (PS) have not been explored. The aim of this study was to examine the mediating effects of patient-centeredness on the relationship of nursing shortage on the QC and PS in the Medical and Surgical Wards, in Malaysian private hospitals. A descriptive, cross-sectional study was carried out on 12 private hospitals. Data was gathered, through a self- administered questionnaire, from 652 nurses, with a 61.8% response rate. Stratified simple random sampling was used to allow all nurses to participate in the study. Hayes PROCESS macro-regression analyses were conducted to explore the mediating effects of patient-centeredness on the relationships of hospital nurse staffing on the QC and PS. Patient-centeredness mediated the relationships of hospital nurse staffing on both the QC (F=52.73 and P=0.000) and PS (F=31.56 and P=0.000). Patient-centeredness helps to mitigate the negative associations of nursing shortage on the outcomes of care. The study provides a guide for hospital managers, leaders, decision-makers, risk managers, and policymakers to maintain adequate staffing level and instill the culture of patient-centeredness in order to deliver high quality and safer care.

Identification of health, safety, and environment aspects and hazards in loghman hospital and manage of their risks using analytical hierarchy process technique

Aims: The present study was conducted to identify and prioritize Health, Safety, and Environment (HSE) risk in Loghman hospital. Risk management of hospitals represents a critical issue owing to special safety, health, biological and infection risks, and hospital wastes. Materials and Methods: This study is, in terms of the purpose, an applied research. Statistical population includes 68 managers and experts of risk management in Loghman hospital of Iran. A targeted sampling method was used for sampling. Five points were selected to identify and evaluate the risks at which field visits were made and the checklists were completed. The identified risks were extracted from the checklists and worksheets for identification and evaluation of the risks were completed based on failure mode and effect analysis (FMEA) method. Priority of risks obtained by analytical hierarchy process technique was quiet close to that achieved by FMEA approach. Results: Occurrence probability, severity, and detectability of HSE risks were identified using FMEA technique. According to the results, lack of emergency exit with normal weight of 0.143 has the highest priority, followed by lack of building strength (normal weight of 0.114), electricity (0.113), and biological contamination (0.107). Inconsistency rate was estimated close to zero (

PP156 Risk Assessment Of Equipment Used In Intensive Care Units

Introduction:Knowledge and proper use of hospital equipment are essential for preventing adverse events associated with their use. The risks controls for medical devices and equipment are of major importance in ensuring patient safety and the quality of care delivered by healthcare professionals. Monitoring equipment (ME), infusion pumps (IP), and mechanical ventilators (MV) are frequently used in intensive care units, but they are subject to technical, human, and process failures that may pose harm to and even cause the death of patients. The aim of this study was to evaluate the risks related to the use of ME, IP, and MV in the adult intensive care unit (AICU) of a public hospital in Brazil, and to investigate the causes of technical complaints and the adverse events associated with them. We hope the outcomes may serve as a basis for the facility to create mechanisms to diminish the risk and increase the safety and quality of care delivered to critical patientsMethods:A 12-month prospective, observational descriptive study was conducted using an active and passive search of processes related to: hospital medical equipment use; available human and material resources; training programs and continuing professional education; equipment disinfection, sterilization, and assembly processes; and the hospital risk management measures regarding the reports and actions for technical, human, and process failures and the adverse events and incidents related to them. All the data collected were checked against current Brazilian legislation and the equipment technical manuals. The root cause of every failure and adverse event was investigated.Results:The active search identified seventy-five reports on technical complaints in the study period: sixty-five were related to IP, six to ME, and four to MV. The reasons for the complaints included: deficiencies in the quantity, qualification, training, and capacity of professionals handling the devices; inadequate disinfection of MV accessories; absence of or difficulty in accessing the equipment technical manuals; and a lack of preventive and corrective maintenance programs. One single adverse event caused by an IP medication error was attributed to a programing error.Conclusions:Failures and deficiencies in the knowledge and management of hospital equipment can potentially increase risks to patients and healthcare professionals. Increasing compliance with Brazil's current legislation related to the technical and operational norms of hospital equipment might create safer practices and improve care quality for critical patients.

Risk management training programme: A perspective from the European side of the Atlantic

• Nowadays, there has been an improvement in hospital safety but risk management is still not a priority for academia.

A methodology to estimate seismic vulnerability of health facilities. Case study: Mexico City, Mexico

We developed a model to estimate seismic vulnerability of health facilities in Mexico City, Mexico, following these steps: (1) designing a theoretical framework (TF) to measure structural, non-structural, functional, and administrative-organizational vulnerabilities; (2) measurement of the vulnerability conditions of the analyzed facility by using the TF; and (3) estimation of the hospital’s seismic vulnerability by comparing the measured vulnerability to the TF’s vulnerability indicators by taking into account the optimal case. The TF was developed considering a scoring system and international standards for risk management in hospitals. The methodology establishes the degree of vulnerability of the analyzed institution as well as its interrelations with external infrastructure systems. This tool also identifies existing failures to estimate expected damage. The methodology was applied to the National Cardiology Hospital, the Children’s Hospital “Dr. Federico Gomez,” and the “Hospital de Jesus” of Mexico City. The vulnerability problems in these three hospitals are common within them, and some of the main causes of vulnerability found are: (1) the lack of technology to resistant seismic shaking; (2) the need to develop or update disaster response plans; (3) the need of periodic and proper maintenance to hospitals’ buildings; (4) the lack of sufficient financial resources for vulnerability reduction projects and autonomous operations of the hospital during 3–5 days after a disaster occurs. We believe that vulnerability in these health facilities can be reduced with low-cost procedures and that the methodology developed here will support the decision-making processes to reduce seismic risk in Mexico City.

Addressing Occupational Fatigue in Nurses: Current State of Fatigue Risk Management in Hospitals, Part 2.

The aim of this article is to describe the current state of fatigue risk management systems (FRMSs) to address nurse fatigue in hospitals. Little is known about the current state of FRMS implementation and adoption of national recommendations in nursing work systems. This study used a sequential exploratory mixed-methods design including a survey of nurse leaders from across the United States. Adoption of evidence-based policies to address fatigue is both limited and variable depending on the policy. Nurse leaders indicate that while nurse fatigue is an important issue and has negative consequences, the social norms of fatigue have not allowed the elevation of this topic to trigger sweeping organizational change. This study provides a framework for implementation of FRMSs as an innovation, highlighting the critical role of nurse leaders in adoption and dissemination. Raising the visibility of fatigue across the organization is a critical 1st step.

Cops and docs: The challenges for ED physicians balancing the police, state laws, and EMTALA.

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers.

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Extravasation injury in a paediatric population.

Extravasation occurs when a drug is inadvertently administered outside of the vein. Depending on the substance involved, this may lead to tissue necrosis with significant long-term morbidity. Children, particularly neonates, are particularly susceptible to extravasation with up to 70% of children in neonatal intensive care unit having some form of extravasation injury. These injuries are commonly referred to plastic surgeons for ongoing management. We prospectively collected information on all extravasation injuries referred to the plastic surgery department in a children's hospital over an 18-month period. Data collected included the agent involved in the extravasation, treatment and outcomes. In total, there were 43 extravasation injuries recorded on the hospital risk management system during the period of this study. All of these were referred to the plastic surgery team for ongoing management. Five patients (11%) underwent washout of their injuries. Three patients (7%) suffered injuries, which led to significant tissue necrosis, delayed healing and prolonged morbidity. Smaller infants, particularly those being cared for in an intensive care setting, are at increased risk for extravasation injury. Early referral and treatment of high-risk extravasation injuries may reduce the incidence of tissue loss and morbidity.

Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management.

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.

Nurses’ Perception toward the Effectiveness of Using Risk Fall Prevention Protocol of Hospitalized Patients.

Background: Falls are a widespread concern in hospitals setting. Fall is an unexpected event in which an individual comes to rest on the ground floor or lower level. Fall prevention is a very pressing hospital risk management and patient safety challenge due to many of in-patient admitted for mobility problems, falls, or injury from falls making. Aim : the study aimed to assess nurses’ perception of the effectiveness of using fall prevention protocol of risk fall hospitalized patients. Research design the study is quantitative descriptive cross-sectional design. Sample: A convenience sample of 204 nurse from KAUH. Tools: Assessment of the injurious fall risk factors and fall prevention intervention questionnaire''. It consist of three parts: part I includes socio demographic data, part II includes 44 potential factors that may lead to an injurious fall in adult inpatients. Part II of the tool consists of 40 interventions for preventing injurious falls in adult inpatients. Result There was a weak significant positive linear relationship between perceived fall risks and the perceived preventability of risks of fall , the adopted Nursing Intervention and effectiveness of nursing Interventions were correlated strongly .Nurses who coming from the General Units perceived significantly higher frequently perceived fall-risks, greater Perceived preventable risks of fall. Conclusion: It is concluded that nurses’ approaching the nurses’ perception was to figure out the relationship between what nurses consider to be high risk of falls and what they perceive as preventable of those risk factors. On the other hand, it is also an achievable objective of the current study for finding the most frequent interventions as perceived by nurses that are preventing falls to occur on daily practices. Recommendation: all nurses should be motivated and encouraged to attend regular continuous education of programs every six months for risk fall and prevention measures. Key Words: nurses perception, fall prevention, risk factors and hospitalized patients.

The need for medical interpreters: a questionnaire survey of municipal hospitals in Japan

Objectives This study aimed to investigate the need for medical interpreters, in relation to hospital size, the number of foreign patients accepting, and risk management in municipal hospitals in Japan.Methods In 2016, we conducted a questionnaire survey at 894 municipal hospitals in Japan. The questionnaire included hospital characteristics, the number of foreign patients, the need for medical interpreters, and the respondents' background. We used the incident classification of the Safety Management Council of National University Hospitals (0-5 levels and others). We applied pairwise analysis to hospital size: small hospitals (20-99 beds), medium hospitals (100-399 beds), and large hospitals (400 or more beds).Results The response rates of the small, medium, and large hospital were 30.1%, 32.5%, and 32.8%, respectively. The percentage of hospitals that had accepted foreign patients over the previous year ranged from 84.9% to 97.6%, a higher with larger hospitals. Larger hospitals attended to emergencies, hospitalization, and surgical patients more frequently than the smaller hospitals. Hospital staff who communicated with non-Japanese-speaking foreign patients via ad-hoc interpreters accompanying the patients ranged from 84.3% to 86.7% in larger hospitals. Of the staff at small, medium, and large hospitals, 66.7%, 58.5%, and 44.7%, respectively, considered the interpretations of the ad-hoc interpreters accompanying the patient to be accurate. Of the small, medium, and large hospitals, 31.6%, 76.5% and 92.3% claimed that they would use interpreting services if the interpretation costs were covered by the National Health Insurance System (P<0.001). When foreign patients are accepted, 75.7%, 84.7% and 94.6% of small, medium and large hospitals require trained medical interpreters, respectively (P=0.014). Hospital staff reporting that the most common reason for using an interpreter was to reduce medical risks ranged from 81.1% to 94.3%. Of the 274 hospital staff surveyed, 4.7% had experiences of incidents due to the language barriers when dealing with foreign patients. The incident classification was as follows: 3 cases with Impact Level 0, including MRI withdrawal; 9 cases with Level 1, including unauthorized discharge and self-extraction of an in-travenous drip; 1 case of precipitate labor; 1 case of Level 5 death; and 3 other cases. Small hospitals have not been reporting incidents, but larger hospitals, despite the small number of foreign patients, have been reporting incidents.Conclusion Large or medium-sized hospitals need medical interpreters more than smaller hospitals because of the greater number of foreign patients being attended to, and diversity and complexity of reasons for seeking hospital services. Our results suggest that language barriers when dealing with foreign patients are a threat to patient safety. The majority of the responding Japanese municipal hospitals believe that they require trained language interpreters to improve risk management.

A whole greater than the sum of the parts: Close collaboration between palliative care and clinical ethics.

53 Background: The disciplines of palliative care (PC) and clinical ethics (CE) share common content but also important distinctions in method, skill set, and clinical role in a given patient encounter. Particularly in cases of advance care planning, complex decision-making, and clarifying goals oncology teams may be challenged to know which consultation service to involve. Methods: Case report and commentary. Results: A 60 year-old man with a 3-year history of glioblastoma multiforme presented with sudden onset right-sided weakness and altered mental status. In the emergency department, a computed tomography (CT) scan demonstrated a left-sided intracranial bleed with concomitant cerebral edema and left-to-right midline shift. The patient was admitted to a surgical intensive care unit (SICU) where neurosurgery declined to operate. Within hours of admission, while the patient’s son (also his durable healthcare power-of-attorney) was considering a do-not-resuscitate order, local police arrived at the hospital, having received a 911 call from the patient’s daughter who claimed her brother and medical providers were attempting to murder her father by shifting to comfort care. The SICU team urgently consulted PC and CE. Within an hour, PC and CE clinicians met with the patient’s family to review the patient’s advance directive, counsel regarding clinical management strategies and prognosis, broach comfort care, introduce hospice, and liaise with a hospice case manager. Additionally, PC collaborated with the SICU to provide best symptom management; CE worked with hospital risk management and security to ethically mitigate escalation of more reactive family members. Within 4 hours of the consults, the patient was being transferred to a local inpatient hospice facility, where he died several days later. Conclusions: As this case demonstrates, models of close collaboration between PC and CE consultative services may swiftly facilitate appropriate transitions in care for patients with advanced cancer and simultaneous de-escalation of hospital risk. Evolving models for quality supportive care should further examine such strategies.

Preventing our Caregivers from Becoming Patients – Challenges, Successes, and Trends Faced by Hospital Risk Managers and Ergonomists

Healthcare workers suffer musculoskeletal disorders at rates that exceed most other industries. Despite this, many healthcare facilities do not follow best practices that are proven to reduce risk of injury. This discussion panel will explore the reasons for why the healthcare industry struggles to prevent injuries and will outline successful strategies for protecting workers. The panelists are leaders and advisors for large medical systems and their specialties include ergonomics, safe patient handling, and patient safety. The panelists relate the critical challenges faced when preventing caregiver injuries. Such challenges include underreporting of staff injuries, lack of funding or administrative support, and inability to sell the connections among caregiver safety, caregiver productivity, and patient safety. The panelists also share success stories of when they have achieved positive change and explain the strategies that were effective. Practitioners should gain new insights for implementing successful change, and researchers will be exposed to new and important research questions.

Hospital risk management of cutaneous herpes simplex virus infection.

The epidemiology of cutaneous herpes simplex infection (CHSI) has dramatically changed over the past several decades. Valaciclovir is one of a new generation of antiviral medications that has expanded treatment options for the most common cutaneous manifestations of herpes simplex virus. However, the efficacy and safety of formulations with different doses of valaciclovir remain unclear. To carry out hospital risk management by ascertaining the incidence and risk of CHSI in patients during treatment with varying doses of valaciclovir. The PubMed, MEDLINE and Web of Science electronic databases were systematically searched from database inception to date of searching. Efficacy of drug treatment was measured by average easement score (AES). Safety was characterized as the proportion of patients with drug adverse reactions (DARs) such as fever, dizziness, headache, anxiety, irritability and yellowing of the skin. Outcomes for continuous and dichotomous data were estimated by standard mean difference (SMD) and risk ratio (RR), respectively. Five randomized controlled trials involving 1753 randomized participants for efficacy assessment and 1874 randomized participants for safety assessment were identified. Valaciclovir dose increasing from 1000 mg/day improved AES only moderately, but significantly promoted the incidence of DARs. Twice-daily treatment showed no increase in therapeutic effect but greatly increased DAR incidence. The valaciclovir dose that produced a reduction in AES was 1000 mg/day: SMD = -0.73 (95% CI -0.98 to 0.48; P < 0.01) and RR = 0.95 (95% CI 0.81-1.09; P < 0.002). Increasing the daily dose of valaciclovir does not substantially improve therapeutic efficacy for CHSI but may raise DAR incidence. Drug doses of 1000 and 2000 mg/day show no significant difference in efficacy scores, but the latter exhibits a higher incidence of DARs. The dose-dependent, long-term efficacy and safety of valaciclovir remain to be explored.

Legionella and risk management in hospitals-A bibliographic research methodology for people responsible for built environment and facility management.

An ongoing research project investigates the roles and duties of persons responsible for the built environment with respect to risk management of water systems and Legionella prevention from a facility management's perspective. Our literature review provides an approach for selecting and analysing abstracts of initially 177 journal articles, subjected to certain topic-specific inclusion and exclusion criteria. Different decision strategies of either logic 'yes/no', Boolean operators 'OR' or 'AND' and decisions for single counts or cumulative counts of the identified three principal keywords 'Legionella', 'hospital' and 'water', were completed. A final list of ten principal reference articles from 29 journals was compiled. It suggests that the interconnected perspective of water systems, Legionella and hospitals seems to be underrepresented in the field of the built environment and facility management. The term 'stakeholder', which would refer to decision-makers, was not found more than once. Our result is a useful summary of established sources of information on environmental Legionella research. The results can be helpful for those new to the topic.