Risk management and Healthcare responsibility. How to guarantee legal protection in Medicine.

Having regard to the increasing attention to the issue of safety and health of patients and workers by low, the hypothesis that this topic will be the growing trend in the next years does not seem to be manifestly unfounded. For this reason, it is wise for healthcare professionals to already be aware that any violation of the interests underlying the legislation in question entails a ruling on civil and/or criminal liability. It is therefore necessary to identify the most suitable means to prevent undue harm occurring, partly to exempt healthcare professionals and hospitals from compensation costs, thereby providing them with recourse to insurance coverage. Healthcare facility organisations must adopt Risk Management techniques as a tool to simultaneously guarantee the effectiveness of health services (in this case), the efficiency of the management economy, and finally compliance with all legally required precautions. This will relegate the occurrence of an adverse event to remote and unpredictable hypotheses, thus guaranteeing useful recourse to insurance coverage to compensate any harm that does occur.

The case of Patient Safety Indicator 12 (PSI12): use of administrative data to estimate the incidence of "Postoperative Pulmonary Embolism or Deep Vein Thrombosis". A pilot study in a General Hospital.

INTRODUCTION: The AHRQ Quality Indicators (QIs) were created in order to both identify the performance and to track the improvement of patient safety. Patient Safety Indicator 12 (PSI12) is relative to the risk of Post Operatory Pulmonary Embolism or Deep Venous Thrombosis (PO DVT/PE). This pilot study has three main objectives. Firstly, to perform an analysis of the performance of different hospital wards by using administrative data; secondly, to analyze defects in the process that led to the occurrence of the adverse event; thirdly, reviewing the single PO DVT/PE. METHODS: Data were extracted from a Hospital Information data flow (SIO) and compared to Clinical Discharge Record. PSI12 estimates were computed before and after the screening. Control Charts allowed the static analysis of performance between different hospital wards in 2014. The Ishikawa diagram was drawn for the analysis of the underlying causal process. RESULTS: The number of PSI12 cases provided by DRGs through SIO data flow decreased from 45 to six after the comparison with the correspondent clinical records. Four clinical records provided full information allowing the analysis of process. The Ishikawa Diagram identified the defects in the process of prophylaxis that resulted into a PO DVT/PE. DISCUSSIONS: The clinical records screening revealed a lower incidence of PO DVT/PE with respect to the DRGs statistics. Overall the PO DVT/PE occurrence in 2014 fell into the control limits, although the result could be undermined by the low quality of clinical records compilation. The failure in the prophylaxis procedure was imputable to pitfalls in the health care management and to the individual attitude towards patient safety procedures. In conclusion, the reliability and validity of administrative data in monitoring quality and safety are worthy to be explored in the context of further validation studies.

Infections in hospital departments. What is Hospital Responsibility?

Infections in hospitals still have a high incidence and many of them could be avoided through better welfare standards. To try to overcome them, a strategy based on prevention is needed, but cleaning, disinfection and sterilization procedures are also a key tool. It is important to provide for all healthcare professionals a constant update and the creation of protocols that take into account the technical, scientific and economic aspects, but also specific operational needs, so that the proposed solutions can be applied in daily routines. The authors outline the mandatory duties to the doctors and hospital and underline the need to document in the clinical record the treatments performed. In case of infections occurred in hospital environment, the patient must demonstrate the guilty nature of the hospital's conduct, the existence of a harm and the causal connection. The hospital must demonstrate that asepsis measures were adopted according to the actual scientific knowledge and they must cover not only the treatment but also the diagnosis, all the activities prior to surgery and the postoperative phase. The sentences examined show that hospitals can avoid being accused of negligence and imprudence only if they can prove that they have implemented all prophylaxis measures contained in the guidelines and protocols. They must demonstrate that the infection was caused by an unforeseeable event. While some initiatives to improve the quality of hospital care have already allowed a decrease in the incidence and cost of these infections, much remains to be done.

Knowledge of Emergency Department Triage nurses in management of patients with mental health needs: comparisons with the Triage Model of Lazio (TLM).

OBJECTIVES: To refer the current competences of Triage Nurses (TRNs) assessing the person with metal health problems in Emergency Departments (ED), and the impact of the Triage Lazio Model (TLM) upon it. MATERIALS AND METHODS: An anonymous questionnaire was administered to ED TRNs of the Lazio Region. Standardized Cronbach's alpha was used for reliability estimation. RESULTS: The Cronbach's alpha was 0.4. Two hundred ninety-nine TRNs were interviewed: 66% women, 47% aged 31-40 years, 60% followed TLM. The consideration of the patient as 'one who comes out of the normal', 'a person with altered functions of mind or mental function' and as 'hostile, aggressive and unpredictable' was reported more by females in comparison to the males (OR=1.76; OR=3.50; OR=1.79); TRNs who have not followed the course on TLM had higher probability to consider 'hostile, aggressive and unpredictable' the psychiatric patients (OR=1.87) in comparison with other Triage courses; those who have taken a course on Triage but at least 3 years ago, had a lower probability to consider as 'one who comes out of the normal' (OR=0.55). CONCLUSIONS: having followed the course TLM, having participated in a recent triage course, male gender, and the seniority in this job appear to be contributing factors for a proper management of psychiatric patients. Continuous improvement of specific knowledge and skills for the management of patients with mental health needs are mandatory.

Conley Scale: assessment of a fall risk prevention tool in a General Hospital.

INTRODUCTION: "Umberto I" Teaching Hospital adopted 'Conley scale' as internal procedure for fall risk assessment, with the aim of strengthening surveillance and improving prevention and management of impatient falls. MATERIALS AND METHODS: Case-control study was performed. Fall events from 1st March 2012 to 30th September 2013 were considered. Cases have been matched for gender, department and period of hospitalization with two or three controls when it is possible. A table including intrinsic and extrinsic 'fall risk' factors, not foreseen by Conley Scale, and setted up after a literature overview was built. Univariate analysis and conditional logistic regression model have been performed. RESULTS: 50 cases and 102 controls were included. Adverse event 'fall' were associated with filled Conley scale at the admission to care unit (OR = 4.92, 95%CI = 2.34-10.37). Univariate analysis identified intrinsic factors increasing risk of falls: dizziness (OR = 3.22; 95%CI = 1.34-7.75), psychomotor agitation (OR = 2.61; 95%CI = 1.06-6.43); and use of means of restraint (OR = 5.05 95%CI = 1.77-14.43). Conditional logistic regression model revealed a significant association with the following variables: use of instruments of restraint (HR = 5.54, 95%CI = 1.2- 23.80), dizziness (OR = 3.97, 95%CI = 1.22-12.89). DISCUSSION: Conley Scale must be filled at the access of patient to care unit. There were no significant differences between cases and controls with regard to risk factors provided by Conley, except for the use of means of restraint. Empowerment strategies for Conley compilation are needed.

[Professional accreditation of emergency care services. Experience of the polyclinic "Umberto I" of Rome]. / L'accreditamento professionale dei servizi di Pronto Soccorso. Il percorso del Policlinico "Umberto 1o" di Roma.

Professional Accreditation can be seen as a Quality Improvement/Assurance Program for the delivery of Medical and Nursing Care, through organizational analysis to determine the level of compliance to specific criteria, correlated with satisfactory assistance processes. We report the experience of a professional accreditation process of an Emergency Department within a University Hospital in Rome, with high level assistance facilities. Voluntary interdisciplinary working groups were formed and working process was decomposed, as Quality Assurance Programs propose, so that critical points in each phase could be pointed out and hypothesis for improvements could be advanced for subsequent operative planning of changes. This method was used and applied to analyze the Emergency Department's "mission", clearing the goals of department, accordingly with the hospital's management mandate, and therefore permit the assessment of the level of compliance to quality indicators. Results of the different phases and critical analysis of all the steps are described.