Marilynn M. Rosenthal

Communication failures: an insidious contributor to medical mishaps.

Purpose To describe how communication failures contribute to many medical mishaps. Method In late 1999, a sample of 26 residents stratified by medical specialty, year of residency, and gender was randomly selected from a population of 85 residents at a 600-bed U.S. teaching hospital. The study design involved semistructured face-to-face interviews with the residents about their routine work environments and activities, the medical mishaps in which they recently had been involved, and a description of both the individual and organizational contributory factors. The themes reported here emerged from inductive analyses of the data. Results Residents reported a total of 70 mishap incidents. Aspects of “communication” and “patient management” were the two most commonly cited contributing factors. Residents described themselves as embedded in a complex network of relationships, playing a pivotal role in patient management vis-à-vis other medical staff and health care providers from within the hospital and from the community. Recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of medical mishaps. Conclusion The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

Residents' responses to medical error: coping, learning, and change.

Purpose To explore the significant emotional challenges facing resident physicians in the setting of medical mishaps, as well as their approaches to coping with these difficult experiences. Method Twenty-six resident physicians were randomly selected from a single teaching hospital and participated in in-depth qualitative interviews. Transcripts were analyzed iteratively and themes identified. Results Residents expressed intense emotional responses to error events. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish. For the great majority of residents, their ability to cope with these events was dependent on a combination of reassurance and opportunities for learning. Interactions with medical colleagues and supervisory physicians were critical to this coping process. Conclusions Medical mishaps have a profound impact on resident physicians by eliciting intense emotional responses. It is critical that resident training programs recognize the personal and professional significance of these experiences for young physicians. Moreover, resident education must support the development of constructive coping skills by facilitating candid discussion and learning subsequent to these events.

Resident Perceptions of Medical Errors in the Emergency Department

OBJECTIVES To evaluate resident experience and perceptions of medical error associated with emergency department (ED) care. METHODS Using a semistructured interview protocol, three researchers interviewed 26 randomly selected medical, surgical, and obstetrics residents regarding medical error. The authors chose a 16-case subset of incidents involving ED care for initial review. Interview transcripts were reviewed iteratively to draw out recurrent categories and themes. Two investigators separately analyzed all cases to ensure common understanding and agreement. RESULTS Most cases involved misdiagnosis, misread radiographs, or inappropriate disposition. Two thirds of the case patients died or experienced delays in care. Residents felt that the complexity of the patients, as well as the complexity of their own jobs, contributed to error. Attending supervision, nurse evaluation, and additional physician involvement all were noted to be important checks within the hospital system. Residents most often held the ED responsible for error. In addition, they deemed themselves, their teams, and their lack of training responsible. Though residents often discussed events with their admitting teams, follow-up with the ED or other associated individuals was uncommon. The findings revealed seven common themes that include factors contributing to errors, checks and adaptations, and follow-up of the event. CONCLUSIONS Residents are aware of medical error and able to recall events in detail. Whereas events are discussed among inpatient teams, little information finds its way back to the ED, potentially resulting in misunderstandings between departments and hindering learning from events. In-depth interviewing allows a nuanced and detailed approach to error analysis.

Setting the context

The last two decades have seen significant improvements in planning methodologies, in refining definitions of medical manpower needs, and in the sophistication of manpower analyses, both national and international. It has become the conventional wisdom that manpower planning is a quasi-scientific endeavor and that continued progress in concepts, tools and methodologies will enable planners, in a rational and intelligent manner, to assure systematically that the right number of physicians will be found in the desired specialities and locations. An examination of the situation in most if not all countries, as seen later in this volume, suggests that this Brave New Medical World is more fantasy than reality. There are no nations in which problems of shortage, surpluses and maldistribution have been prevented or promptly and adequately remedied. One possible explanation is the neglect of the political context in which planning, policy determination and implementation take place in a systematic and effective manner. In an attempt to address the neglect of political, economic and socio-cultural factors, a group of interdisciplinary and international experts from industrial countries were invited to prepare individual country case studies analysing the political context and the non-health systems variables which, in the final analysis, shape and constrain physician manpower and plans. In a perfect world and in the perfect health care system, the number of physicians matches the demand or need which the society has for them. As the health system evolves from year to year, as new demands appear on the part of the population, as demographics change, as new knowledge and technologies emerge, specially trained physicians come on line, and those whose specialty has become obsolescent or redundant are recycled into new medical areas. At the same time, the number of primary care physicians or generalists is adequate to meet the needs of the public, and they are distributed geographically and socially on an equitable basis so that no one is deprived of the opportunity of seeing a physician when the need arises. Likewise, the health care system is so structured and managed that its costs are kept within reasonable limits, and other social needs are met without encroaching on those of the health care system. Physicians are assisted by an array of other health personnel and technicians who support, extend and complement the work of doctors so they can concentrate on what they are uniquely qualified to do. In such

Beyond the medical record

BACKGROUND: Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported.DESIGN: The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged.OBJECTIVE: This paper reports the ways in which medical error is or is not reported and residents’ responses to a perceived medical error.PARTICIPANTS: Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital.MEASUREMENTS: Outcome measures were based on analysis of casers residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented, Discussed, and Uncertain.RESULTS: Of 73 cases, 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases involved medication errors, which were acknowledged in different categories.CONCLUSIONS: The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents’ education to prepare them to recognize and address medical errors.

Medical malpractice reform: the current proposals.

M uch of the d i s cus s ion of hea l t h pol icy reform h a s focused on f inanc ing a n d del ivery m e c h a n i s m s , appropr ia te ly so, given the c r i s i s in access to care. But the major hea l th care bi l ls cons ide red by Congress in 1994 all con t a ined s ign i f i can t s ec t ions on medica l malpractice. 1--3 They s h a r e d a two-pronged s t ra tegy. The first p rong is federal p r e e m p t i o n of s t a t e law in a var ie ty of doct r ina l areas . These changes in doc t r i ne s a re des igned to l imi t c l a ims by pa t i en t s . S i m i l a r re forms have been passed by s t a t e leg is la tures , b u t never by the federal government . The s econd p r o n g is e x p e r i m e n t a t i o n wi th a l ternat ives to tor t l i t iga t ion , w h i c h could lay the founda t ion for more sweep ing changes in the way we preven t and c o m p e n s a t e medica l in jur ies . If the Repub l i can -controlled Congress p u r s u e s hea l th care reform in 1995, it is likely ma lp rac t i ce reform will be a cen t ra l p a r t of any package. The e m p h a s i s on e x p e r i m e n t s w i t h a l t e r n a t i v e m e c h a n i s m s at the federal level will l ikely give fu r the r impe tus to efforts a l ready u n d e r way a t the s t a t e level. Two s ta tes have growing exper ience w i th no-faul t mecha n i s m s for neona t a l neuro logie in jur ies . A n o t h e r s ta te has had a sys tem in place for i n t e g r a t i n g medica l practice gu ide l ines in to ma lp rac t i ce l i t iga t ion , a n d o the r s a re now following sui t . Two o the r s t a t e s are c o n s i d e r i n g provider p roposa l s to expe r imen t wi th no-faul t c o m p e n s a t ion for all medica l in jur ies . The a m o u n t of in te res t in ma lp rac t i ce reform is no t surpr i s ing . Medical ma lp rac t i ce p r e m i u m s r e p r e s e n t 1% of the total hea l th care costs , 4 b u t p rov ide r conce rns abou t l awsui t s have often t ended to p u s h tor t re form to the front of legislat ive agendas , a n d likely ma lp rac t i ce modi f ica t ions will con t inue to d r aw more a n d more atten t ion bo th in Wash ing ton , DC, a n d in s t a t e capi ta l s .

Political process and the integration of traditional and western medicine in the people's Republic of China

Abstract One of the major health policies in the Peoples Republic of China since the Communist Revolution in 1949 has been an unique effort to integrate Chinese Traditional and Western-style medicine. Mao Tse-tung called for a ‘United Front’ of the two medical approaches for reasons of cultural pride, economic necessity and political obligation. An analyses of this policy is presented combining previous discussions of the issue with material collected in the PRC in 1979. Four possible modes of response to the policy are hypothesized and data analyzed to suggest which mode they fit. It is suggested that four modes of response could have been, and continue to be, Total Integration, Selective Integration. Assimilation or Rejection. Data collected include (1) personal statements on preference for Traditional or Western medicine, (2) examples of institutional approaches to integration, (3) lists of conditions being treated with one or combined approaches and (4) examples of the teaching of Traditional medicine. The current status of the original policy is described based on a briefing at the China Medical Association. With reference to the implementation of the Integration policy, the tentative conclusion is that throughout the PRC health care system. Traditional medicine is subordinate to a Western medical frame of reference and Western-style practitioners. Selective integration is the typical mode of response.

Growth of private medicine in Sweden: The new diversity and the new challenge

The growth of private medical care in Sweden has occurred despite the lack of overt encouragement by the long-term Social Democrat government. This can be documented from official government statistics, private insurance sales, media sources, membership growth in the private doctors association, purchase of private risk insurance, growth of private health care organizations and services, and particularly an increase in public sector private contracting. While the percent of the population with private insurance is close to 1%, it is probable that over 20% of physicians engage in some form of private practice. Explanations range from increasing criticism of poor service orientation in the public system, long waiting lists and the reduced rate of public spending, to a general atmosphere that asserts more individual choice. With the Social Democrats now out of power, it is likely that the Moderate coalition will officially promote some forms of privatization. What will be the impact on the long-cherished Swedish principle of equity?

The Swedish medical care programs: an interim assessment.

The medical care program (MCP) concept emerged from a conviction that it would be possible to combine biomedical knowledge about a certain disease, principles of care and an efficient organization into a holistic approach to care. The purpose of the present review of nine MCPs was to: (1)provide and overview of MCP development and and evaluation in the Stockholm County; (2) present different perspectives regarding the current status of the MCP policy and future developments; and (3) contribute to a discussion of factors which enhance or block the effectiveness of MCPs. Information was gathered during interviews with 32 representatives of professionals and interest groups. The majority of MCPs were initiated by medical professionals while two, the program for alcohol disorders and that for rheumatoid diseases, were initiated by politicians or the rheumatoid patients. Three central problems were identified: (1) the original desire for standardization and the emergent demand for local variation; (2) ambiguities about specific roles of the newly developing general practitioners; and (3) lack of resources to develop, implement and evaluate MCPs to the standards of the original concept. The experience of the MCPs certainly has increased understanding of the policy-program-implementation-outcome process and inevitable gaps that materialize as policy struggles towards implementation.

Synthesis and prospects

The papers in this volume have introduced the physician manpower policy histories of eight different countries, each with different political structures, different economic systems, different historical cultures, and different approaches to physician manpower policy. Yet, it is possible to discern several kinds of patterns in the country case studies. These include what may be called ‘overarching patterns’: categories of political structure and styles; categories of planning mechanisms; common actors in the policy arenas; non-health systems factors; and a common current pattern of economic constraint.