Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.

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To Err Is Human Building a Safer Health System

ContextEvaluation of trends in organ dysfunction in critically ill patients
may help predict outcome.ObjectiveTo determine the usefulness of repeated measurement the Sequential Organ
Failure Assessment (SOFA) score for prediction of mortality in intensive care
unit (ICU) patients.DesignProspective, observational cohort study conducted from April 1 to July
31, 1999.SettingA 31-bed medicosurgical ICU at a university hospital in Belgium.PatientsThree hundred fifty-two consecutive patients (mean age, 59 years) admitted
to the ICU for more than 24 hours for whom the SOFA score was calculated on
admission and every 48 hours until discharge.Main Outcome MeasuresInitial SOFA score (0-24), Δ-SOFA scores (differences between
subsequent scores), and the highest and mean SOFA scores obtained during the
ICU stay and their correlations with mortality.ResultsThe initial, highest, and mean SOFA scores correlated well with mortality.
Initial and highest scores of more than 11 or mean scores of more than 5 corresponded
to mortality of more than 80%. The predictive value of the mean score was
independent of the length of ICU stay. In univariate analysis, mean and highest
SOFA scores had the strongest correlation with mortality, followed by Δ-SOFA
and initial SOFA scores. The area under the receiver operating characteristic
curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score
during the first 96 hours, regardless of the initial score, the mortality
rate was at least 50% when the score increased, 27% to 35% when it remained
unchanged, and less than 27% when it decreased. Differences in mortality were
better predicted in the first 48 hours than in the subsequent 48 hours. There
was no significant difference in the length of stay among these groups. Except
for initial scores of more than 11 (mortality rate >90%), a decreasing score
during the first 48 hours was associated with a mortality rate of less than
6%, while an unchanged or increasing score was associated with a mortality
rate of 37% when the initial score was 2 to 7 and 60% when the initial score
was 8 to 11.ConclusionsSequential assessment of organ dysfunction during the first few days
of ICU admission is a good indicator of prognosis. Both the mean and highest
SOFA scores are particularly useful predictors of outcome. Independent of
the initial score, an increase in SOFA score during the first 48 hours in
the ICU predicts a mortality rate of at least 50%.

https://jamanetwork.com/journals/jama/articlepdf/194262/JCE00056.pdf

Serial evaluation of the SOFA score to predict outcome in critically ill patients.

Background It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die. Methods We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables. Results The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nur...

Nurse-Staffing Levels and the Quality of Care in Hospitals

The Institute of Medicine study Crossing the Quality Chasm (2001) recommended that an interdisciplinary summit be held to further reform of health professions education in order to enhance quality and patient safety. Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education. These core competencies include patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. This book recommends a mix of approaches to health education improvement, including those related to oversight processes, the training environment, research, public reporting, and leadership. Educators, administrators, and health professionals can use this book to help achieve an approach to education that better prepares clinicians to meet both the needs of patients and the requirements of a changing health care system.

/pdf/health-professions-education-a-bridge-to-quality-2z1kahnjph.pdf

Health Professions Education: A Bridge to Quality

Objective:To evaluate the relationship between burnout and perceived major medical errors among American surgeons.Background:Despite efforts to improve patient safety, medical errors by physicians remain a common cause of morbidity and mortality.Methods:Members of the American College of Surgeons we

Burnout and medical errors among American surgeons.

A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

The performance of intensive care units: does good management make a difference?

Objective:To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance.Design:Prospective multicenter study. On-site organizational analysis; prospective inception cohort.Setting:Nine ICUs (one medical, two surgical, six medical-surgical) at five

Improving intensive care: Observations based on organizational case studies in nine intensive care units A prospective, multicenter study

OBJECTIVE To examine variations in case-mix, structure, resource use, and outcome performance among teaching and nonteaching intensive care units (ICU). DESIGN Prospective inception cohort study. PATIENTS A consecutive sample of 15,297 patients at 35 hospitals, which compared 8,269 patients admitted to 20 teaching ICUs at 18 hospitals vs. 7,028 patients admitted to 17 non-teaching ICUs at 17 hospitals. INTERVENTIONS None. MEASUREMENTS We selected demographic, physiologic, and treatment information for an average of 415 patients at each ICU, and collected data on hospital and ICU structure. Outcomes were compared using ratios of observed to risk-adjusted predicted hospital death rates, ICU length of stay, and resource use. MAIN RESULTS When compared to nonteaching ICUs, teaching ICUs had twice the number of physicians who regularly provided services and cared for significantly younger and more severely ill (p < .001) patients. Risk-adjusted ICU length of stay was similar, but resource use was significantly (p < .001) greater in teaching ICUs, with $3,000 (10.5%) of estimated total costs for an average ICU admission related to increased use of diagnostic testing and invasive procedures in teaching ICUs. Risk-adjusted hospital death rates were not significantly different (p = .1) between all teaching and nonteaching ICUs, but were significantly (p < .05) better in four teaching ICUs, but in only one nonteaching ICU. The 14 hospitals that were members of the Council of Teaching Hospitals had significantly better risk-adjusted outcome in their 16 ICUs than all others (odds ratio = 1.21, confidence interval 1.06 to 1.38, p = .004). CONCLUSIONS Teaching ICUs care for more complex patients in a substantially more complicated organizational setting. The best risk-adjusted survival rates occur at teaching ICUs, but production cost is higher in teaching units, secondary to increased testing and therapy. Teaching ICUs are also successfully transferring knowledge to trainees who, after their training, are achieving equivalent results at slightly lower cost in nonteaching ICUs.

Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study.

OBJECTIVE To examine structural and organizational characteristics at two ICUs with marked differences in risk-adjusted survival. METHODS We performed on-site organizational analysis in two ICUs at two major teaching hospitals. Our main outcome measures were interviews and direct observations by a team of clinical and organizational researchers; demographic, clinical, and survival data for 888 ICU admissions; and questionnaire responses from 70 nurses and 42 physicians on ICU structure and organization. ICU performance was measured using risk-adjusted survival and the ratios of actual to predicted ICU length of stay and resource use. RESULTS Structural and organizational questionnaires, self-evaluation by staff members, and the research team's implicit judgments following detailed on-site analysis failed to distinguish units with higher and lower risk-adjusted survival. Both units exhibited practices to emulate and practices to avoid. CONCLUSIONS The methods used in this study can identify organizational problems and potential means for improvement. The best practices and suggestions for improvement at these units provide examples of methods for improving ICU management.

Robin R. Gillies

Papers

The performance of intensive care units: does good management make a difference?

Improving intensive care: Observations based on organizational case studies in nine intensive care units A prospective, multicenter study

Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study.

Intensive care at two teaching hospitals: an organizational case study

Value and Cost of Teaching Hospitals: A Prospective, Multicenter, Inception Cohort Study