Orientador: Thomas Patrick Dwyer / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Filosofia e Ciências Humanas / Made available in DSpace on 2018-08-17T03:36:02Z (GMT). No. of bitstreams: 1 Moliani_MariaMarce_D.pdf: 2474438 bytes, checksum: 21f53ff10257b2a7c6a4b32eebec64f0 (MD5) Previous issue date: 2010 / Resumo: O objetivo desta tese é analisar as causas de erros médicos junto aos profissionais de saúde e os pacientes, vitimas de erros médicos a fim de compreender os condicionantes sociais dos erros e efeitos adversos do processo de tratamento medico, verificando a influência de fatores tais como: os condicionantes profissionais, através da identidade do sujeito social com a profissão e com os papéis sociais desempenhados; formação medica e condições de trabalho. Esse trabalho utilizou como referencial Teórico-metodológico aportes da fenomenologia de Alfred Schutz, a fim de compreender os critérios de relevância mobilizados pelo sujeito social no curso de sua ação. A pesquisa foi elaborada utilizando metodologia qualitativa, através de entrevistas e apreensão dos condicionantes da ação / Abstract: The aim of this thesis is to analyze the causes of medical errors, involving health professionals and patients, the victims of medical errors, in order to understand the social conditions of the errors, as well as the adverse effects of the medical treatment process, checking the influence of factors such as: professional conditions, through the social subject's identity in the profession and the social roles played, as well as medical training and work conditions. This work was based on the theoretical and methodological contributions of Alfred Schutz's phenomenology, in order to understand the relevance criteria raised by the social subject in the course of action. The methodology used in the research was qualitative, through interviews and by understanding the action determinants / Doutorado / Doutor em Ciências Sociais

The criminal law has been critiqued as an unsuitable system to regulate adverse medical events (AME) because the unintentional nature of AME renders it incompatible with the penal objectives of the criminal law. This project uses an interpretivist approach to examine how blameworthiness is constructed in criminal cases involving AME. Situated within a contextual constructionist paradigm, and utilizing a theoretical framework that draws on legal pragmatism, symbolic interactionism, Habermasian thought, and Goffmanian frame analysis, this project employs a case study approach to explore how appellate courts construct AME as a product of fate or agency. The British case of Bawa-Garba v. R. (2016) and the Canadian case of R. v. Javanmardi (2019) are analysed using thematic analysis. It is concluded that the majority of the Supreme Court of Canada in Javanmardi constructed the AME within the realm of fate, contrasting the minority in Javanmardi and full panel of the England and Wales Court of Appeal in Bawa-Garba which constructed the AME within the realm of agency. It is also concluded that the majority in Javanmardi utilised pragmatic adjudication to determine blameworthiness. It is suggested that these findings could reduce fear of criminal liability among Canadian health care professionals. Future research is suggested to examine the legal cultures underlying this variation, critically explore the intersection of race and criminal prosecution of AME, and apply structural violence as a theoretical frame to further interrogate AME as a systemic failure.

No / Estimates show that as many as one in 10 patients are harmed while receiving hospital care. Previous strategies to improve safety have focused on developing incident reporting systems and changing systems of care and professional behaviour, with little involvement of patients. The need to engage with patients about the quality and safety of their care has never been more evident with recent high profile reviews of poor hospital care all emphasising the need to develop and support better systems for capturing and responding to the patient perspective on their care. Over the past 3 years, our research team have developed, tested and refined the PRASE (Patient Reporting and Action for a Safe Environment) intervention, which gains patient feedback about quality and safety on hospital wards. Methods/design A multi-centre, cluster, wait list design, randomised controlled trial with an embedded qualitative process evaluation. The aim is to assess the efficacy of the PRASE intervention, in achieving patient safety improvements over a 12-month period. The trial will take place across 32 hospital wards in three NHS Hospital Trusts in the North of England. The PRASE intervention comprises two tools: (1) a 44-item questionnaire which asks patients about safety concerns and issues; and (2) a proforma for patients to report (a) any specific patient safety incidents they have been involved in or witnessed and (b) any positive experiences. These two tools then provide data which are fed back to wards in a structured feedback report. Using this report, ward staff are asked to hold action planning meetings (APMs) in order to action plan, then implement their plans in line with the issues raised by patients in order to improve patient safety and the patient experience. The trial will be subjected to a rigorous qualitative process evaluation which will enable interpretation of the trial results. Methods: fieldworker diaries, ethnographic observation of APMs, structured interviews with APM lead and collection of key data about intervention wards. Intervention fidelity will be assessed primarily by adherence to the intervention via scoring based on an adapted framework. Discussion This study will be one of the largest patient safety trials ever conducted, involving 32 hospital wards. The results will further understanding about how patient feedback on the safety of care can be used to improve safety at a ward level. Incorporating the ‘patient voice’ is critical if patient feedback is to be situated as an integral part of patient safety improvements.

The discourse surrounding medical error and its ethical implications has become a pivotal focus within healthcare. Thus, this thesis aims to delve into the multifaceted aspects of and influences on medical error and its disclosure, with each chapter progressively shedding light on their complexities and ethical considerations. The overarching argument posits that despite society’s general intolerance for errors and a recognized aim for perfection, error remains an unavoidable and inevitable aspect of the practice of medicine and medical training. There exists an inherent fallibility in healthcare juxtaposed against the gravity of the profession and its consequent medical and legal ramifications when something goes awry. The following ten chapters collectively highlight the intricacies of error management in healthcare through discussions on societal expectations, medical training, error analysis, accountability, systemic influences, patient-provider relationships, legal implications, and bioethical tenets. Ultimately, advocating for a cultural shift towards greater transparency, collective accountability, systemic quality improvement, and support for healthcare professionals to address errors effectively while upholding patient safety and trust. This thesis also recognizes the ethical imperative of error disclosure and the importance of fostering a balanced approach that acknowledges both the inevitability of errors in healthcare and the significant physical, emotional, and financial burdens caused by medical errors. / Urban Bioethics

Made available in DSpace on 2016-04-26T20:22:51Z (GMT). No. of bitstreams: 1 Patricia Rizzo Tome.pdf: 956478 bytes, checksum: 8b7745d8862516a4b7bf24746a07067a (MD5) Previous issue date: 2014-04-22 / Conselho Nacional de Desenvolvimento Científico e Tecnológico / Our research aims to analyze the liability of the physician for injuries caused on account of errors made during his/her professional practice. These errors may result from their own acts or third parties ones, such as injuries caused by nurses working in compliance with doctors' demands. In this dissertation, the study of the contractual relationship of compromise established between doctor and patient is essential. Of special note here is the approach for full compliance of medical duties. This refers especially to the duty to provide full and clear information on an individual basis, considering each patient and his/her respective sickness. Thus, patients would be made fully aware about their particular situation and would be able to better decide whether they consent on performing surgeries or risky treatments / Nossa pesquisa tem por objetivo analisar a responsabilidade civil do médico por danos efetivamente causados em virtude de erros cometidos durante a atuação profissional. Erros estes que podem decorrer de atos próprios ou de atos de terceiros, como é o caso de danos ocasionados por enfermeiros que atuam em cumprimento de ordens médicas. Nesta dissertação, o estudo da relação contratual de meio estabelecida entre o médico e o paciente é fundamental. Destaca-se, sobretudo, o enfoque do cumprimento integral dos deveres médicos, em especial, o dever de prestar a informação completa e transparente de maneira individualizada, considerando cada paciente em relação a sua doença, para que as pessoas possam daí sim, amplamente esclarecidas, consentirem sobre a realização de cirurgias ou tratamentos de risco

The Institute of Medicine report "To Err is Human," released in late 1999, raised the issue of human error in medicine to a new level of attention. This study examines the frequency, severity, and type (FST) of errors associated with postoperative surgical complications at a tertiary care, university-based medical center, addressing the intersection of three domains: patient safety, graduate medical education, and simulation-based training. The study develops and validates a classification system for medical error that is specific to surgery, affirming reliability internally and externally. Baseline data on the FST of errors is collected over a 12-month period. A hybrid, simulation based training session is developed, validated, and applied to a cohort of surgical residents, focusing on the three most common types of errors identified from pilot data, namely judgment error, incomplete understanding of the problem, and inattention to detail, all human factor errors. The impact of the training is evaluated by measuring the FST of errors occurring during the 6-month period following the training sessions. The study demonstrates that there is a continuous decrement in the incidence of postoperative complications and a proportional decrease in error, which starts at the beginning of the baseline data collection and continues linearly throughout the 12 baseline months and subsequent 6 post-training months. There is no additional decrement in the rate of change following training, and no change in the rate of the index errors following the training. This study suggests that surgical error is frequent (>2%) and principally due to human factors rather than systems or communication. This study demonstrates that creating an environment where residents are continuously involved in identifying and characterizing errors results in a significant and sustained decrease in postoperative complications and the errors specifically associated with them. Contrary to expectations, a validated, well-designed, active-learning training module does not result in an additional identifiable improvement in patient outcome or in the incidence of index errors. These results are at variance with many recent studies addressing medical error and, if verified by additional studies, challenge several strongly held ideas related to patient safety training.

Medical error and patient safety have become important issues. It is clear that medical error is more influenced by systemic factors rather than human characteristics. Communication patterns, in particular interruptive communication, maybe one of the systemic factors that contribute to the burden of medical error. Objective: An exploratory study to examine interruptive communication patterns of healthcare staff within an intensive care unit during ward rounds. Methods: The study was conducted in a tertiary hospital in Sydney, Australia. Nine participants were observed individually, for a total of 24 hours, using the Communication Observation Method (COM). The amount of time spent in conversation, the number of conversation initiating and number of turn-taking interruptions were recorded. Results: Participants averaged 75% [95% confidence interval 72.8-77.2] of their time in communication events during ward rounds. There were 345 conversation-initiating interruptions (C.I.I.) and 492 turn-taking interruptions (T.T.I.). C.I.I. accounted for 37% [95%CI 33.9-40.1] of total communication event time (5hr: 53min). T.T.I. accounted for 5.3% of total communication event time (56min). Conclusion: This is the first study to specifically examine turn-taking interruptions in a clinical setting. Staff in this intensive care unit spent the majority of their time in communication. Turn taking interruptions within conversations occurred at about the same frequency as conversation initiating interruptions, which have been the subject of earlier studies. These results suggest that the overall burden of interruptions in some settings may be significantly higher than previously suspected.

Iatrogenic vascular injuries (IVIs) and injuries associated with vascular surgery can cause severe morbidity and death. The aims of this thesis were to study those injuries in the Swedish vascular registry (Swedvasc), the Swedish medical injury insurance where insurance claims are registered, the Population and Cause of death registries, and in patient records, in order to explore preventive strategies. Among 87 IVIs during varicose vein surgery 43 were venous, mostly causing bleeding in the groin. Among 44 arterial injuries, only 1/3 were detected intraoperatively. Accidental arterial stripping predominated, with poor outcome. Four patients died, all after venous injuries. IVIs increased over time, and constitute more than half of the vascular injuries registered in the Swedvasc. Lethal outcome was more common (4.9%) among patients suffering IVIs than among non-iatrogenic vascular injuries (2.5%). Risk factors for death were age, diabetes, renal insufficiency and obstructive lung-disease. Fifty-two patients died within 30 days after IVI. The most common lethal IVIs were puncture during endovascular procedures (n=24, 46%), penetrating trauma during open surgery (11) and occlusion after compression (6). Symptoms were peripheral ischemia (n=19), external bleeding (14), and hypovolemic chock without external bleeding (10). Most died within two weeks (n=36, 69%). After >2 weeks the IVI as a cause of death was uncertain. Among 193 insurance claims after vascular surgery during 2002-2007, nerve injuries (91) and wound infections (22) dominated. Most patients suffered permanent injuries, three died. Patients with insurance claims were correctly registered in the Swedvasc in 82%. In 32 cases of popliteal artery injury during knee arthroplasty symptoms were bleeding (n=14), ischaemia (n=7) and false aneurysm formation (n=11). Only twelve injuries (38%) were detected intraoperatively. Patency at 30 days was 97%, but only seven (22%) patients had complete recovery. Six of those had intraoperative diagnosis of popliteal injury and immediate vascular repair. In conclusion, registration of IVIs is increasing and outcome is often negatively affected by diagnostic and therapeutic delay. Not all fatalities after IVIs are attributable to the injury itself. The most common causes of insurance claims after vascular surgery were nerve injuries, and 82% were correctly registered in Swedvasc.

This thesis evaluated the effects of two types of training on nurses’ ability to safely and efficiently administer IV medications using a smart infusion pump. A high fidelity simulated nursing unit was created in which nurses recruited from the University Health Network programmed a series of infusions after receiving training. A training script modeled after the pump vendor’s training sessions was created and tested first on 24 nurses. The results were analyzed for deficiencies in safety and efficiency from a human factors and education perspective and a new training script was created and tested on a group of 23 nurses. No significant differences were found between training groups on measures related to safety, but significant differences were found in nurse efficiency and behaviour in some aspects of pump programming. This study sets a precedent for human factors evaluation being used in tandem with existing training practices and lays the groundwork for further exploration on this topic.

This thesis evaluated the effects of two types of training on nurses’ ability to safely and efficiently administer IV medications using a smart infusion pump. A high fidelity simulated nursing unit was created in which nurses recruited from the University Health Network programmed a series of infusions after receiving training. A training script modeled after the pump vendor’s training sessions was created and tested first on 24 nurses. The results were analyzed for deficiencies in safety and efficiency from a human factors and education perspective and a new training script was created and tested on a group of 23 nurses. No significant differences were found between training groups on measures related to safety, but significant differences were found in nurse efficiency and behaviour in some aspects of pump programming. This study sets a precedent for human factors evaluation being used in tandem with existing training practices and lays the groundwork for further exploration on this topic.