Biomedical subjects
Publications and source records attributed to S E Feldman.
The authors argue that accidental patient deaths are a significant public health concern and that public health professionals are well positioned to contribute to ongoing efforts to protect the public from unintended injuries in the hospital.
BACKGROUND: Medical accidents can be understood as patient injuries that result from interaction of physician or nurse error during the provision of care with faults latent in the hospital system. Medical accidents are not random events but are events with discoverable associations between human error and system faults through application of methods of failure analysis in the evaluation of patient injuries. CASE ANALYSIS: The goal of a failure analysis is to make apparent system faults that are otherwise obscured. Analyses seek to answer several questions. What characteristics of the system failed to prevent a slip, mistake, or rule violation from evolving into an accident? What system changes might have offset, or prevented, the active error from contributing to the sequence of events culminating in injury? Brief descriptions of eight cases of apparent medical accidents are provided in this article. For three of these cases, the failure analysis approach is used to identify the sequence of events contributing to the patient injury; identify events within this sequence that represent active errors; and identify points within this sequence that represent system faults which failed to prevent the occurrence of subsequent events. CONCLUSIONS: Within the framework of current methods of hospital quality appraisal, attribution of patient injury historically has focused on clinician error. Yet unless detected and corrected, system faults persist and create circumstances of "accidents waiting to happen." Understanding of casual factors in the evolution of medical accidents can be usefully applied toward improvement in the quality of hospital appraisal of iatrogenic injuries and, through that application, toward reduction in the rates of adverse outcomes.
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Required recertification of physicians has been proposed as a way to improve quality of care. Hospital medical staff quality assurance committees may be more meaningful targets for reform than individual physicians. Review standards are needed to make these committees effective monitors. Increasing regulatory attention to medical staff peer review can be expected.
Several major, national forces have created the mandate of the Peer Review Organizations (PROs) for the evaluation of the quality of care received by Medicare patients. The shift of the Medicare Program to prospective payment to hospitals has caused concern that this change in financial incentives may have adverse effects on quality. An analysis and review of the experience of the California PRO (California Medical Review, Inc.)--including the application of sanctions--suggests that corrective actions have been successful in addressing quality deficiencies. However, the relationship between those deficiencies and the prospective payment mechanism remains unclear.
The role of the upper intestine in the regulation of food intake and gastric emptying has been studied in normal, gastrectomized, and "crossover" rats, parabiotic rats with a common visceral cavity in which the proximal duodenum of each parabiont is anastomosed to the pylorus of the stomach of the partner. One rat of "crossover" pairs eats and the partner eats little or nothing. Normal rats fed a raw soybean (RS) diet ate less and gastric evacuation proceeded more slowly than in normal rats fed a heated soybean (HS) diet. It is postulated that RS contains a heat-labile intestinal irritant. The upper intestine of gastrectomized rats regulates food intake and prevents overloading of the intestine. Force feeding of excessive amounts of the RS diet elicited the secretion of much more solids and nitrogen into the upper intestine than did similar amounts of the HS diet. The upper intestines of "crossover" rats lose all control over entry of gastric contents into their duodena. Fed ad libitum, the parabiont whose stomach emptied first, ate continuously, while the recipient partner showed diarrhea. It is postulated that the control of food intake traditionally assigned to the stomach resides, rather, in the upper intestine.
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