Zvi Stern

Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety.

Background:Medical error reporting is an essential component of patient safety enhancement. However, increasingly, the literature points to a problem of underreporting of treatment errors, mainly as a result of the fear of malpractice lawsuits and limited formal data collection systems. Few studies, if any, have examined the influence of informal aspects of the organization, such as safety climate, on employees’ willingness to report errors. Objectives:This study investigated the relationship between safety climate aspects and personnel readiness to report treatment errors in different hospital departments. Method:The model was tested in 3 hospitals (n = 632 in 44 medical departments of 3 types; internal medicine, surgery, and intensive care). Three safety climate aspects were measured using questionnaires: the way employees perceive the safety procedures, the safety information flow within their department, and the relative priorities given to safety in the department. Readiness to report was measured by tallying each departments annual number of treatment errors reported to the hospitals’ risk management systems. Results:Negative binomial regression analysis indicated that the more personnel perceive procedures as suitable and safety information as available, the higher was their willingness to report treatment errors. These relationships significantly differed depending on the department type. Conclusions:Hospitals should take into account the perceptions of personnel regarding safety procedures and information and understand that these perceptions operate differently in different department types in their effect on the staffs willingness to report treatment errors.

How quality improvement programs can affect general hospital performance

PURPOSE Given the enormous size of the health care industry, the problem of developing high-quality, cost-effective health care delivery systems is growing in importance. There is general consensus that health care systems require a continuous process of quality improvement (QI). Less agreement, however, surrounds the mechanisms to be implemented so that such a process is effective. This study aims to bring empirical evidence to support the hypothesis that a QI program in a general hospital - a special context of the health care delivery system - does not necessarily lead to better overall organizational performance results. DESIGN/METHODOLOGY/APPROACH The study was done at the hospital level, and included all acute care hospitals in Israel. Data was collected in 16 of the countrys 23 hospitals, a 70 percent response rate. The study compared hospital performance before and after the QI program implementation. FINDINGS The study shows that QI creates meaningful improvement events. In addition, the research supports the hypothesis that increasing the number of QI activities (items) included in the QI program brings about more improvement events. The results do not support the hypothesis that high, rather than low, intensive implementation of QI activities leads to more improvement events. ORIGINALITY/VALUE The special context of general hospitals decreases the effects of a QI program on overall hospital performance, whereas QI activities function as triggers in initiating improvement events.

Active Learning: When Is More Better? The Case of Resident Physicians' Medical Errors

An active learning climate facilitates new knowledge acquisition by encouraging employees to ask questions, seek feedback, reflect on potential results, explore, and experiment. These activities, however, also increase a learners chances of erring. In high-reliability organizations, any error is unacceptable and may well be life threatening. The authors use the example of resident physicians to suggest that by adjusting the conditions of priority of safety and managerial safety practices, organizations can balance these potentially conflicting activities. Participants in the study were 123 residents from 25 medical wards. Results demonstrated that the positive linear relationship between priority of safety and safety performance, demonstrated in earlier studies, existed only when the active learning climate was low. When the active learning climate was high, results demonstrated a U-shaped curvilinear relationship between priority of safety and number of errors. In addition, high managerial safety practices mitigated the number of errors as a result of the active learning climate.

Emergency room visit: a red-flag indicator for poor diabetes care

Aim  To determine the association between emergency room (ER) admission and quality of diabetes care in the community.

Differences in quality of diabetes care between Jews and Arabs in Jerusalem.

Aims. To evaluate whether differences exist in the quality of diabetes care delivered to the Arab and Jewish populations in Jerusalem. Methods. A cross-sectional study was conducted in West Jerusalems 4 major hospitals. Participants were patients with type 2 diabetes mellitus, 45 to 75 years of age, who were insured by Israels largest health maintenance organization (HMO) and admitted to an emergency room (ER) between May and June 2004 for any medical cause. Hospital files were reviewed, patients were interviewed, and computerized data were retrieved from the HMOs database. Results. Arab patients received less nutritional counseling (odds ratio [OR] = 0.46; 95% CI = 0.24-0.85; P = .013), fewer recommendations about and less support in performing physical activities (OR = 0.42; 95% CI = 0.24-0.74; P = .003), and less guidance in performing self foot examinations (OR = 0.55; 95% CI = 0.32-0.96; P = .035). Conclusions. Arab patients in Jerusalem receive lower quality diabetes care compared with Jewish residents. (Am J Med Qual 2008;23:60-65)

Resident physicians’ clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature

Resident physicians’ clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores the relationships between residents’ error rates and three clinical training methods (1) progressive independence or level of autonomy, (2) consulting the physician on call, and (3) familiarity with up-to-date medical literature, and whether these relationships vary among the specialties of surgery and internal medicine and between novice and experienced residents. 142 Residents in 22 medical departments from two hospitals participated in the study. Results of hierarchical linear model analysis indicated that lower levels of autonomy, higher levels of consultation with the physician on call, and higher levels of familiarity with up-to-date medical literature were associated with lower levels of resident’s error rates. The associations varied between internal and surgery specializations and novice and experienced residents. In conclusion, the study results suggested that the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience. In addition, it is necessary to create a supportive and judgment free climate within the department that may reduce a resident’s hesitation to consult the attending physician.

Formal and Informal Authority of Hospital Directors

Describes and contrasts the perceptions of formal and informal authority of hospital directors of two different kinds of organizations: hospitals that are part of public multi-hospital organizations (PMOs) and independent hospitals. Indicates that all the directors perceive their formal authority to be greater than their formal authority. However, there is a gap in the perception of formal and informal authority by directors of the two types of hospital. Directors of independent hospitals perceive themselves to have more formal and informal authority than do their colleagues at hospitals that are part of PMOs. Both structural and personal explanations for these findings are given. In addition, discusses the implications for policy making of the source of authority, informal, and formal authority in the transition to autonomous semi-independent hospitals in a changing environment.