What Attributes of Patients Affect Their Involvement in Safety? A Key Opinion Leaders’ Perspective

OBJECTIVE: Little is known about which attributes the patients need when they wish to maximise their capability to partner safely in healthcare. We aimed to identify these attributes from the perspective of key opinion leaders. DESIGN: Delphi study involving indirect group interaction through a structured two-round survey. SETTING: International electronic survey. PARTICIPANTS: 11 (65%) of the 17 invited internationally recognised experts on patient safety completed the study. OUTCOME MEASURES: 50 patient attributes were rated by the Delphi panel for their ability to contribute maximally to safe health care. RESULTS: The panellists agreed that 13 attributes are important for patients who want to maximise the role of safe partners. These domains relate to: autonomy, awareness, conscientiousness, knowledge, rationality, responsiveness and vigilance; for example, important attributes of autonomy include the ability to speak up, freedom to act and ability to act independently. Spanning seven domains, the attributes emphasise intellectual attributes and, to a lesser extent, moral attributes. CONCLUSIONS: Whereas current safety discourses emphasise attributes of professionals, this study identified the patient attributes which key opinion leaders believe can maximise the capability of patients to partner safely in healthcare. Further research is needed that asks patients about the attributes they believe are most important

Missing Clinical Information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care

In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK.Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information.Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care

Using the ecology model to describe the impact of asthma on patterns of health care

BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

The free child health care scheme : implications for New Zealand general practice

xv, 260 leaves :ill. ; 30 cm. Includes bibliographical references.Background: The Free Child Health Care Scheme was introduced on July 1, 1997. It provided increased government subsidies for general practice consultations and fully subsidised doctor-prescribed medicines for children aged less than six years old. Thesis: The central thesis of this work is that health policy affecting general practice cannot be adequately understood by analysis from a single academic approach but requires transdisciplinary research, integrating historical, economic, epidemiologic, and policy perspectives. This thesis is examined by evaluating the Free Child Health Care Scheme and analysing its implications for New Zealand general practice. Objectives: 1. To assess the need for health policy specifically directed at young children. 2. To review the significance of fee-paying to general practice. 3. To understand the implications of the Free Child Health Care Scheme in an historical context. 4. To evaluate the Free Child Health Care Scheme using: a. A researcher-initiated plan funded by the Health Research Council (HRC). b. A project plan commissioned by the Transitional Health Authority (THA). c. A household survey commissioned by the THA. 5. To investigate the symbolic and practical implications of the Free Child Health Care Scheme for New Zealand general practice. Methods: A review of literature documenting the development of medicine, general practice, and general practice in New Zealand provided material to assess the symbolic significance of fee-paying in general practice. A further literature review established existing knowledge of the effect of changes in copayment on utilisation of health services. The researcher-initiated and THA-commissioned evaluations used a controlled before-and-after framework to examine utilisation during one-year periods before and after the start of the Free Child Health Care Scheme. The researcher-initiated evaluation used only the Dunedin RNZCGP Research Unit databases for the same purpose. All available relevant routine data sets were used for the THA evaluation. The THA-commissioned survey provided a consumer's view of the policy. Standard survey analysis techniques were used. Descriptive statistics were first computed. Bi-variable analyses tested associations between key variables and logistic regression analyses identified factors significantly associated with important outcomes. Results: Patient payments to doctors have been symbolically important in establishing the primacy of doctors' accountability to patients. The Social Security Act 1938, the Accident Compensation Corporation Act 1974, and the Free Child Health Care Scheme 1997 encapsulate the different philosophies of general practitioners and politicians regarding accountability for health services and health outcomes. The HRC and THA evaluations identified no significant impact of the Free Child Health Care Scheme on the workload of general practitioners. The household survey showed that most carers of children under six years old received the Scheme favourably. To a disproportionate degree, the Scheme failed to reach North Island families and children with private health insurance. Conclusion: Regulations affecting patient fees are of central interest to New Zealand general practitioners for reasons related to the philosophy of their profession. The Free Child Health Care Scheme had little impact on the workload of general practitioners but held many implications for the core general practice philosophy of professional independence. Evaluations of the Scheme commissioned by the THA had little utility for the organisation but were used by the Health Funding Authority and probably influenced a political decision to retain the Scheme. The household survey suggested that the Scheme may systematically exclude some of the country's most disadvantaged children

The free child health care scheme : implications for New Zealand general practice

xv, 260 leaves :ill. ; 30 cm. Includes bibliographical references.Background: The Free Child Health Care Scheme was introduced on July 1, 1997. It provided increased government subsidies for general practice consultations and fully subsidised doctor-prescribed medicines for children aged less than six years old. Thesis: The central thesis of this work is that health policy affecting general practice cannot be adequately understood by analysis from a single academic approach but requires transdisciplinary research, integrating historical, economic, epidemiologic, and policy perspectives. This thesis is examined by evaluating the Free Child Health Care Scheme and analysing its implications for New Zealand general practice. Objectives: 1. To assess the need for health policy specifically directed at young children. 2. To review the significance of fee-paying to general practice. 3. To understand the implications of the Free Child Health Care Scheme in an historical context. 4. To evaluate the Free Child Health Care Scheme using: a. A researcher-initiated plan funded by the Health Research Council (HRC). b. A project plan commissioned by the Transitional Health Authority (THA). c. A household survey commissioned by the THA. 5. To investigate the symbolic and practical implications of the Free Child Health Care Scheme for New Zealand general practice. Methods: A review of literature documenting the development of medicine, general practice, and general practice in New Zealand provided material to assess the symbolic significance of fee-paying in general practice. A further literature review established existing knowledge of the effect of changes in copayment on utilisation of health services. The researcher-initiated and THA-commissioned evaluations used a controlled before-and-after framework to examine utilisation during one-year periods before and after the start of the Free Child Health Care Scheme. The researcher-initiated evaluation used only the Dunedin RNZCGP Research Unit databases for the same purpose. All available relevant routine data sets were used for the THA evaluation. The THA-commissioned survey provided a consumer's view of the policy. Standard survey analysis techniques were used. Descriptive statistics were first computed. Bi-variable analyses tested associations between key variables and logistic regression analyses identified factors significantly associated with important outcomes. Results: Patient payments to doctors have been symbolically important in establishing the primacy of doctors' accountability to patients. The Social Security Act 1938, the Accident Compensation Corporation Act 1974, and the Free Child Health Care Scheme 1997 encapsulate the different philosophies of general practitioners and politicians regarding accountability for health services and health outcomes. The HRC and THA evaluations identified no significant impact of the Free Child Health Care Scheme on the workload of general practitioners. The household survey showed that most carers of children under six years old received the Scheme favourably. To a disproportionate degree, the Scheme failed to reach North Island families and children with private health insurance. Conclusion: Regulations affecting patient fees are of central interest to New Zealand general practitioners for reasons related to the philosophy of their profession. The Free Child Health Care Scheme had little impact on the workload of general practitioners but held many implications for the core general practice philosophy of professional independence. Evaluations of the Scheme commissioned by the THA had little utility for the organisation but were used by the Health Funding Authority and probably influenced a political decision to retain the Scheme. The household survey suggested that the Scheme may systematically exclude some of the country's most disadvantaged children

No-fault compensation for treatment injury in New Zealand: identifying threats to patient safety in primary care

Background: In 2005, the injury compensation legislation in New Zealand was reformed to extend coverage for medical injury removing both 'error' and 'severity' from eligibility criteria. This led to an increase in claiming and claims acceptance rate, thus enlarging the treatment injury claims database. This database provides an unusual 'no-fault' perspective of patient safety events.Methods: The authors analysed the first 4 years of primary care treatment injury claims data to identify the type, incidence, severity and cause of injury in primary care.Results: There were 6007 primary care treatment injury claims; 64% were accepted as treatment injuries. Most claims arose in general practice (62%), and most claimants were female (62%). Most claims were assessed as minor (83%), 12% major, 4% serious and 1% sentinel. Medication caused most injuries (38%) and most serious and sentinel injuries (60%). Dental treatment caused 16% of injuries; injections and vaccinations combined caused 10%; and venepuncture, cryotherapy and ear syringing combined caused 13.5% of injuries, mostly minor. 'Delay in diagnosis' caused few injuries overall (2%), but a disproportionate number of serious and sentinel injuries (16%) and deaths (50%). Spinal/neck manipulation caused 2% of serious and sentinel injuries.Conclusions: New Zealand's no-fault treatment injury claims database provides information about primary care patient safety events from an unusual 'no-fault' perspective. This analysis reinforces previous research identifying medication as a high-risk primary care activity and further identifies other primary care activities (dental care, injections, venepuncture, cryotherapy and ear syringing) as carrying important risks for patient harm

Assessing patient safety culture in New Zealand primary care: a pilot study using a modified Manchester Patient Safety Framework in Dunedin general practices

INTRODUCTION: Patient safety is a major concern, both in hospitals and in primary care settings. The current focus internationally is on the prospect of improving patient safety through cultural transformation. There are no tools designed to assess and strengthen safety culture in New Zealand ( NZ) general practices, but a United Kingdom (UK) group have developed a tool-the Manchester Patient Safety Framework (MaPSaF)-to assess safety culture in UK Primary Care Trusts. We aimed to modify the MaPSaF and test its acceptability and utility in the NZ primary care settingMETHODS: We modified the MaPSaF to suit the NZ context and then used it in 12 Dunedin general practices at baseline and at three months. Participants were all practice personnel present in the practice on the day. Participants rated their practice individually on each of the nine MaPSaF dimensions of safety culture, then discussed the dimensions and their scores and chose a practice-wide consensus score for each dimension in turn. These discussions were recorded, transcribed and analysed to determine acceptability and utility of the modified framework in NZ practicesFINDINGS: The framework process took about one hour. Most participants found the process acceptable and useful. The framework directed team discussion about patient safety issues and facilitated communication and prompted some practices to make changes. Some participants from smaller practices deemed the systems advocated in the framework superfluousCONCLUSION: The framework can be adapted and used in NZ practices to stimulate learning about safety culture and to facilitate team communicatio