Estimates of the number of U.S. deaths each year resulting from medical errors range from 44,000 (Institute of Medicine, 1999) to 195,000 (HealthGrades, 2004). Additionally, instances of medical harm are estimated to occur at a rate of approximately 15 million per year in the U.S., or about 40,000 per day (Institute for Healthcare Improvement, 2007). Although several organizational behavior management (OBM) intervention techniques have been used to improve particular behaviors related to patient safety, there remains a lack of patient-safety-focused behavioral interventions among healthcare workers. OBM interventions are often applied to needs already identified within an organization, and the means by which these needs are determined vary across applications. The current research addresses gaps in the literature by applying a broad needs-assessment methodology to identify patient-safety intervention targets in a hospital and then translating OBM intervention techniques to identify and improve the prevention potential of responses to reported medical errors. A content analysis of 17 months of descriptions of follow-up actions to error reports for nine types of the most-frequently-occurring errors was conducted. Follow-up actions were coded according to a taxonomy of behavioral intervention components, with accompanying prevention scores based on criteria developed by Geller et al. (1990). Two error types were selected for intervention; based on the highest frequency of reporting and lowest average follow-up prevention score. Over a three-month intervention period, managers were instructed to respond to these two error types with active communication, group feedback, and positive reinforcement strategies. Results indicate improved prevention potential as a consequence of improved corrective action for targeted errors. Future implications for identifying and classifying responses to medical error are discussed. / Ph. D.

This thesis investigates the impact of apology hesitance on medical relationships after an error occurs. Literature suggests that medical personnel are reluctant to apologize because an apology suggests legal liability, violates the drive to provide perfect care that is expected of medical personnel and reinforced during medical education, and violates the certainty over bodies and maladies expected of medical personnel. I suggest that a culture of silence, a pattern of conduct embedded in medical culture, encourages apprehensiveness towards apology and responsibility in the face of error. Despite the fear of litigation, ‘Apology Act’ legislation shields apologizers from having their apology used against them in court, and literature suggests that apologizing following an error benefits doctors by restoring conscience and confidence, assists in the healing of patients and families and restores trust in their relationship with their health care provider, and refines the practice of medicine by addressing how the error occurred. I present two arguments in this thesis. First, I argue that a culture of silence has serious negative impacts on medical relationships and the safe provision of medical care as a whole by obstructing responsibility, apology, and preventing the discussion and correction of conduct that led to the error. Medical personnel who refuse to apologize, or provide an apology that is conditional, instrumental or otherwise of poor-quality leaves their relationship with patients and families in jeopardy. Further, by not apologizing, medical personnel obstruct their own ethical and moral development and obscure the origin and conditions surrounding the error, potentially jeopardizing the safety of future patients. Second, I argue that the medical culture of silence should be replaced by a culture that embraces apology. Doing so would permit medical culture to draw from care ethics, the principles of which are appropriate to responding to, maintaining, and repairing relationships that have experienced damage. The emphasis that care ethics places on maintaining and repairing relationships is especially coherent with apologies that seek to morally engage with the victim, promise non-repetition, and establish a proper record of events. Further, care ethics offers normative recommendations for conduct to respond to and repair relationships, provides inroads to refining notions of human security and safety, and is particularly attuned to interrogating dynamics of power within relationships, dynamics that can limit the potential for and impact of apology. This thesis offers the Tainted Blood Scandal of the 1980s and 90s as a case study. The provision of contaminated blood and blood product resulted in thousands of Canadians becoming infected with Human Immunodeficiency Virus and Hepatitis C. Through this case, I show that the actions of public health officials, the Red Cross, and healthcare providers reflected a culture of silence that sought to avoid and dispute attributions of responsibility by victims, blood activists, and the public. This is the culture that this thesis in its advocacy of apology seeks to challenge. / Graduate

No description available.

The impact of Computerized Physician Order Entry (CPOE) on the dependent variables of medication-order compliance and time to first dose of antibiotic was investigated in this quasi-experimental study of a naturally-occurring CPOE intervention. The impact of CPOE on compliance and time to first dose was assessed by comparing measures of these variables from the intervention site and a non-equivalent control before and during intervention phases. Medication orders placed using CPOE were significantly more compliant than paper-based medication orders (p<.001), and first doses of antibiotic ordered using CPOE were delivered significantly faster than antibiotic orders placed using the paper-based system (p<.001). Findings support previous research indicating the positive impact of CPOE on patient safety as well as justify and enable future interventions to increase CPOE adoption and use among physicians. Additionally, data collected in this study will be used to provide behavior-based feedback to physicians as part of CPOE adoption and use intervention strategies to be explored in the forthcoming research. / Master of Science

Background: Hospitals face an increasing pressure towards efficiency and cost reduction while ensuring patient safety. This warrants a closer examination of the trade-off between production and protection posited in the literature for a high-risk hospital setting (intensive care). Purposes: Based on extant literature and concepts on both safety management and organizational/safety culture, this study investigates to which extent production pressure (i.e., increased staff workload and capacity utilization) and safety culture (consisting of safety climate among staff and safety tools implemented by management) influence the occurrence of medical errors and if/how safety climate and safety tools interact. Methodology / Approach: A prospective, observational, 48-hour cross-sectional study was conducted in 57 intensive care units. The dependent variable is the incidence of errors affecting those 378 patients treated throughout the entire observation period. Capacity utilization and workload were measured by indicators such as unit occupancy, nurse-/physician-to-patient ratios, levels of care, or NEMS scores. The safety tools considered include Critical Incidence Reporting Systems, audits, training, mission statements, SOPs/checklists and the use of barcodes. Safety climate was assessed using a psychometrically validated four-dimensional questionnaire. Linear regression was employed to identify the effects of the predictor variables on error rate, as well as interaction effects between safety tools and safety climate. Findings: Higher workload has a detrimental effect on safety while safety climate - unlike the examined safety tools - has a virtually equal opposite effect. Correlations between safety tools and safety climate as well as their interaction effects on error rate are mostly nonsignificant. Practice Implications: Increased workload and capacity utilization increase the occurrence of medical error; an effect that can be offset by a positive safety climate but not by formally implemented safety procedures and policies. (authors' abstract)

A evolução tecnológica e a inovação dos recursos médicos tornaram crescentes e impulsionaram a busca por procedimentos realizados pela Medicina no Brasil e, como consequência, o número de erros médicos também aumentou. O erro médico advém de uma conduta inadequada, capaz de produzir dano à vida ou agravo à saúde do seu paciente, por ação ou omissão do profissional médico, mediante a imperícia, imprudência ou negligência. Essa situação tem se tornado cada vez mais comum nos cenários nacional e internacional. No Brasil, não se tem uma dimensão exata do número de pessoas acometidas pelo erro médico, como também, não se têm pesquisas aprofundadas envolvendo a subjetividade e o sofrimento das vítimas na literatura nacional. O objetivo desta tese foi investigar o sentido dado pelas vítimas de erro médico a essa sua condição existencial e também analisar o sofrimento psíquico implicado nesse processo, à luz da perspectiva fenomenológico-existencial e das contribuições de Walter Benjamin. Foi conduzida uma entrevista semiestruturada com uma questão inicial disparadora, realizada com 12 pessoas vítimas de erro médico. Os dados foram tratados a partir da análise de sentido. Pôde-se observar, dentre outros aspectos, que as vítimas inicialmente demoram para acreditar no que estão vivenciando, ficando perplexas e indignadas diante do erro médico do qual foram vítimas. Verificou-se que algumas souberam por outros profissionais da ocorrência do erro, e nenhum dos médicos que cometeu o erro foi o responsável pelo suporte e condução da correção. Assumir que errou foi pouco visto nos 1 É preciso destacar que esta pesquisa não tem o propósito e nem a finalidade de gerar conflito de interesse. discursos e atitudes dos médicos envolvidos. Os sentimentos de ódio, raiva e desespero tomam conta da vivência das vítimas. A rotina de vida se modifica, e as vítimas se tornam, muitas vezes, dependentes e impossibilitadas de continuar com suas responsabilidades e afazeres. As narrativas das vítimas indicaram que cada indivíduo tem seu modo subjetivo de enfrentar e reagir ao erro, e o sofrimento é um elemento peculiar a esse processo. O conceito de erro médico, formulado pelas vítimas, apresenta uma conotação negativa e representa uma atuação profissional sem qualidade, retratando a realidade do contexto sanitário que o País vive, sem respeito e consideração pelo paciente. Sobre o julgamento dos casos, as vítimas destacaram a demora na deliberação do processo e sentiram-se surpresas quanto às brandas punições aplicadas aos médicos condenados. Com base nas reflexões, é possível apontar que o estigma do erro médico tem uma forte ligação com os juízos de valores e culturais impostos no País, o que dificulta a sua aceitação tanto para a vítima quanto para o profissional. A relação médico e paciente tem se mostrado desgastada, sem haver o respeito e consideração à individualidade da pessoa como paciente, distanciando o médico de uma prática humanizada e dos aspectos bioéticos. As narrativas permitem um pensar sobre o sofrimento psíquico das vítimas e ajudam a compreender melhor os aspectos emocionais, comportamentais e sociais de uma vítima de erro médico no Brasil. A partir das análises, identificou-se a necessidade de um olhar mais cauteloso e atento da Psicologia para o cuidado à saúde mental dos envolvidos no erro / The technological evolution and the innovation of medical resources increased and boosted the search for medical procedures in Brazil, and, as a consequence, the number of medical errors has also raised. The medical error results from an inadequate procedure than can either damage the patient´s life or worsen his/her health, and that follows an action or omission of the doctor, because of his/her malpractice, imprudence or negligence. Such a situation has become more and more common both in the national and in the international scene. In Brazil, there is not an exact dimension of the number of people affected by medical errors, nor there is depth research about the victims´ subjectivity and suffering in the national literature. The aim of this thesis was to investigate the meaning the victims of medical errors give to their current existential condition, as well as to analyze the psychic suffering involved in such a process, in the light of the phenomenological-existential perspective and of Walter Benjamin´s contributions. We conducted a semi-structured interview in which there was an initial triggering question with 12 people who were victims of medical error. The data were treated from the analysis of meaning. Among other aspects, we could observe that first it takes a long time for the victims to believe what they are experiencing. They are astonished and indignant as they stand before the error they fell victims to. We found out that some of the victims were informed by other professionals of the occurrence of the error, and that none of the doctors who made the error became responsible for supporting and performing the correction. To assume the error was something that was hardly verified in the speech and attitudes of the doctors involved in the error. Hate, anger and despair are experienced by the victims. The daily routine changes, and a lot of times the victims become dependent and incapable of taking over their previous responsibility and tasks. The victims´ narratives show that each individual has his/her subjective way to face and react to the error, and suffering is a peculiar element of such a process. The victims´ concept of medical error has a negative connotation, and it stands for professional performance without any quality, which portrays the reality of the country´s health context, without any respect or consideration for the patient. As for the judgement of the cases, the victims highlighted the slow process of deliberation, and they were surprised with the light punishment inflicted on the doctors condemned. From our study, we can state that the medical error stigma is strongly tied with the country´s culture and value judgements, which makes it more difficult for the victim and the professional to accept it. The relation between doctor and patient has worn out, without any respect or consideration for the patient´s individuality, which distances the doctor from a humanized practice and bioethical issues. The narratives let us think about the victims´ psychic suffering, and they help us understand better the emotional, social and behavior issues of a victim of medical error in Brazil. From the analyses undertaken, it was identified the need for a more cautious and attentive look of Psychology to the mental health care of the people involved in the error

A presente dissertação busca aproximar o compliance penal ao cotidiano do profissional da medicina. Será analisada a possibilidade de o instituto, que tem por foco a pessoa jurídica, ser aplicado diretamente a pessoas físicas. As questões penais que envolvem a medicina também serão levantadas, com foco nos principais tipos penais que podem se apresentar no dia a dia do profissional. Será discutido se a adoção de normas de compliance consistiria uma assunção de culpa em caso de violação destas, e como esta implementação pode ser vista à luz da teoria da imputação objetiva. Estudaremos a teoria do erro de James Reason e os conceitos de Cultura Justa, ambos ferramentas que auxiliam na criação de normas preventivas. Forneceremos um delineamento geral dos elementos que devem, idealmente, compor o compliance para os profissionais da medicina. Analisaremos acórdãos do Tribunal de Justiça do Estado de São Paulo, com breve apontamentos acerca do atual panorama dos processos criminais que envolvem questões médicas. A conclusão busca responder se a adoção do compliance se justifica frente a todo o analisado, e se é benéfica para os profissionais. / This work tries to approximate the criminal compliance to the medical professional\'s daily life. It analyses the possibility of applying the institute, which is focused on corporations, directly to individuals. Criminal issues involving the field of medicine will also be raised, focusing on main crimes that can arise on daily activities. We will discuss if the adoption of standards of compliance would be seem as an assumption of guilt in case of violations of those, and how this implementation can be seen in light of the Theory of Objective Imputation. We will study the errors theory of James Reason and the concepts of Just Culture, both tools that assist in the creation of preventive standards. We provide a general outline of the elements that should ideally comprise the compliance program to medical professionals. We will analyze decisions of the Court of Justice of the State of São Paulo, with brief notes about the current situation of litigations involving medical issues. The conclusion seeks to answer whether the adoption of compliance methods can be justified at all, and if it is beneficial for the professionals.

O princípio da dignidade humana e da proteção à saúde são decorrentes do direito fundamental à vida. São direitos definidos como prerrogativas mínimas sem as quais o cidadão não existiria dentro do estado democrático de Direito. O pluralismo e os tempos modernos evidenciam outros problemas para a humanidade e, dentre eles, está a obesidade. Trata-se de problema que decorre de um processo histórico, expondo que a alimentação humana mudou substancialmente com a crescente urbanização, somada ao fenômeno da globalização e a disseminação da cultura de consumo, fatores que foram predominantes para o aumento exponencial desta doença. Atualmente é problema grave de saúde pública mundial, que dependendo do país e de acordo com seu desenvolvimento, pode chegar a ser causa de discriminação social, vulnerabilidade e exclusão social. Nesse aspecto, na mesma medida em que a obesidade é crescente em todo mundo, as diversas formas de sanar tal questão também são presentes. Logo, evidencia-se naturalmente constatação do crescimento das chamadas cirurgias bariátricas e, como consequência óbvia de tal aumento, a possibilidade de erros médicos em tais intervenções também é cada vez mais crescente. A medicina é atividade que pela sua própria natureza envolve riscos e lida com o bem mais essencial e fundamental. Assim, o erro médico não pode ser apenado com benevolência. Quaisquer ofensas a tais direitos são repelidas pelo Poder Judiciário que, por meio do instituto da responsabilidade civil, evidencia as premissas básicas de prudência, perícia e diligência, expondo a necessidade de atitudes regulares dos profissionais ligados à atividade médica e o bom senso na apuração de eventual ilícito, bem com condenações justas e igualitárias, pautadas na análise técnica e específica a respeito da conduta do profissional, após a observância de todos os princípios éticolegais e processuais. Assim, neste trabalho busca-se apresentar a tutela jurisdicional da cirurgia bariátrica no que diz respeito a responsabilização do médico por erro, aplicando-se a teoria da responsabilização civil e apontando-se a natureza e a ocorrência dos erros que potencializam e embasam demandas judiciais, bem como os procedimentos regulares e recomendados com o objeto de prevenir a responsabilização. / The principles of human dignity and health protection are derived from the fundamental right to life. They are rights defined as the minimum prerogatives without which citizens could not exist within a democratic state. Pluralism and the modern times point to other issues for mankind, among them, obesity. This is a problem that derives from a historical process, evidenced by changes in human nutrition due to the ever-growing trend of urbanization, in addition to the phenomenon of globalization and we spread culture of consumption, which have been major factors for the exponential growth of this disease. In the present day it presents itself as a serious global public healthcare issue, and depending on which country and stage of development, may become the cause of vulnerability, social prejudice and exclusion. Meanwhile obesity has been shown to be growing worldwide, various means of addressing and solving this matter have also been made available. It may be verified a growth in the number of the so-called bariatric surgeries, and as a direct outcome, the enhanced possibility of medical failure during these procedures. The practice of medicine inherently involves risks while dealing with one´s most fundamental and essential belonging. Hence, medical failure cannot be taken lightly or benevolently. Any offenses to such rights are rebuked by the Judiciary, that bring forth the basic assumptions of prudence, skill and diligence through the institution of civil responsibility, pointing to the need for regular attitudes of medical-related professionals and proper reasoning when examining possible illicit, as well as fair and equal conviction, based on the specific technical analysis regarding the professional´s conduct, whilst observing all procedural, ethical and legal principles. Therefore, this publication intends to present the jurisdictional tutelage of bariatric surgery concerning the physicians accountability for his or her mistake by applying the theory of civil accountability, identifying the nature and occurrence of the errors that provoke or lay grounds for legal action, as well as the regular procedures advised in order to prevent accountability.

Esta dissertação trata da responsabilidade médica decorrente dos danos causados aos pacientes. A questão central do trabalho refere-se a investigar as reais causas para a ocorrência do erro médico que acarreta na geração do dano indenizável. A razão que determinou o interesse pelo estudo da responsabilidade médica foi a constatação nos últimos anos do aumento significativo de demandas judiciais ajuizadas em face dos profissionais da medicina sob alegação de erro médico causador de um dano. Partimos do pressuposto de que os erros médicos muitas vezes ocorrem não por culpa exclusiva do médico que prestou o atendimento, mas sim por outras causas que fogem do controle do médico, tais como a culpa dos hospitais, das operadoras de saúde, do próprio paciente que não seguiu as recomendações médicas, ou até mesmo do Estado, pela falta de investimentos na saúde. Por fim, o trabalho analisa a responsabilidade das operadoras de saúde, dos hospitais e do Estado nas demandas judiciais indenizatórias propostas pelos pacientes. / This thesis will study the medical responsibility regarding the damage caused to the patients. Investigating the real causes of medical errors which lead to compensable damage will be the main purpose of this study. The reason for the interest in the analysis of the medical responsibility is the significant increase in lawsuits filed in recent years against medical professionals alleging a detriment caused by a medical error. We can assume that the so called medical errors dont exclusively occur on account of the medical practitioner who attended the patient but as well very often because of third parts such as hospitals, health insurance companies, patients themselves who did not follow the medical recommendations or even the state through a lack of investment in health. Finally, the responsibility of the aforementioned in lawsuits filed by patients for damages, will be thoroughly analyzed.

Apesar da considerável queda no índice de necrópsias - dado pelo número de necrópsias sobre o número total de mortes - por diferentes motivos tecnológicos, médicos e sociais, esse ainda é o principal exame para conferência de discrepâncias diagnósticas ante-mortem e post-mortem e elaboração de relatórios sobre morbidade e mortalidade e riscos aos pacientes. Nosso estudo compara e descreve diagnósticos ante-mortem e de necrópsia dos pacientes que faleceram no HC-FMRP/USP nos anos de 2010 e 2014. Foram analisadas 1216 necropsias realizadas no HC-FMRP nos anos de 2010 e 2014, sendo pareados os diagnósticos clínico e de necrópsia e classificados segundo o modelo de Goldman (1983) modificado. O índice médio de necrópsias foi de 49%. O percentual médio de discrepâncias diagnósticas maiores foi de 23,4%, com média de 15% de discrepâncias Grau 1 e de 8,3% Grau 2. A faixa etária com maior predomínio de discrepâncias foi de 80 a 100 anos. O diagnóstico de maior prevalência foi a pneumonia, presente em 40% de todos os casos avaliados, dentre os quais 25% apresentaram discrepâncias maiores. Nossos resultados são comparáveis aos registrados na maioria dos estudos mais recentes, em que a porcentagem de discrepâncias maiores em outros hospitais brasileiros se mantém em torno dos 32- 35%, e abaixo dos resultados de estudos internacionais, nos quais a discrepâncias maiores são em torno de 20%. / Although there is a drop on necropsies rates performed in each hospital, which is the number of necropsies by total of deaths, for a number of medical, technological and social reasons, necropsy remains as the main exam to evaluate the discrepancy of premortem and postmortem diagnoses and to estimate, morbidity and mortality and patient risks. Our study compares and describes the diagnoses of patients who died at the HC-FMRP/USP during the years of 2010 e 2014. We analyzed 1216 necropsies performed at he the HC-FMRP in 2010 and 2014, comparing agreement and disagreement between clinical diagnoses and necropsy reports, by the Goldman (1983) modified classification. The mean necropsy rate was 49%. Major discrepancies were 23.4%, with average of 15% for class 1 and 8.3% for Class 2 discrepancies. We found the most common discrepancies occurred at the ages of 80 to 100 years old. The most prevalent diagnostic was \'pneumonia\', found in 40% of all cases studied, among which 25% showed major discrepancies. Our results are compatible with the main recent studies in the field in Brazilian hospitals, in which the major discrepancies are between 32-35% and under the rates of the studies conducted abroad, in which major discrepancies were around 20%.