[Methods and tools for risk management in healthcare organisations]. / Méthodes et outils de la gestion des risques dans les organisations de santé.

Risk management is a major stake for healthcare organisations. In a systemic approach, the process is based on methods and tools, of which the main ones are mentioned, for general application by clinical or technical teams, for some of them with quality and risk management support.

Use of the label "litigation neurosis" in patients with somatoform pain disorder.

The use of the term "litigation neurosis"--a condition with controversial clinical significance--might correspond to the expression for a difficult physician-patient relationship. The characteristics of patients with a DSM-III-R diagnosis of somatoform pain disorder who had been labeled "litigation neurosis" by their physicians were explored. Among 74 patients referred to a pain clinic, 30% had been labeled litigation neurosis, and among 81 patients referred while claiming disability benefits, 19% had been thus categorized. The attribution of this label was neither correlated to actually being involved in a claim for disability benefits nor to involvement in legal action. Patients who had been designated with litigation neurosis were characterized by a lower educational level, a higher rate of DSM-III-R major depression, and a much higher frequency of personality disorders than patients who were not thus labeled. We postulate that the communication style of patients with this constellation of characteristics, in particular the presence of psychiatric comorbidity, may have engendered a difficult doctor-patient relationship, leading physicians to use the label in the absence of objective evidence of litigation or involvement in legal action. We agree that the inappropriate use of labels such as "litigation neurosis" should be questioned.

[Improvement of transfusion safety in a health care service through the implementation of a quality program]. / Amélioration de la sécurité transfusionnelle dans un établissement de santé par le développement d'une démarche qualité.

The quality policy brings with it an efficient method as well as relevant tools to improve transfusion safety in health care services. This article illustrates the details of the approach through the presentation of a project developed in the East Picardie region throughout several hospitals. It underlines the importance of the choice of a good reference system, of a pertinent method and the necessity of a real project management. Furthermore, the follow-up of the project has enabled us to identify a certain number of success criteria in the steering of the changing process.

Clinical situations and results of cardiopulmonary support by peripheral access for resuscitation and recovery.

Use of cardiopulmonary support (CPS) by peripheral access with a membrane oxygenator has made considerable progress as a result of the development of centrifugal pumps, percutaneous cannulation, and preheparinized circuits. We have used CPS for resuscitation in 3 cases, for recovery after cardiotomy in 6 cases (myocardial insufficiency, 4; pulmonary arterial hypertension, 1; respiratory insufficiency, 1), and after heart transplantation in 1 case. Of these 10 patients, 3 died during CPS, 5 were successfully weaned, and 2 underwent heart transplantation. Use of CPS is expanding for emergency cardiac assistance. Installation is simple and rapid. It allows recovery of organs pending more invasive and costly techniques.

[Repeated heart valve replacements: prognosis and results]. / Remplacements valvulaires itératifs; pronostic et résultats.

In order to determine the prognosis of reoperation for valvular replacement, we reviewed the results of a consecutive series of 124 patients operated in the department between 1974 and 1992 (163 multi redo operations). There were 69 women and 55 men, with a mean age 48 years; 77% of the patients were in functional class III or IV. Operations were performed as an emergency in 30% of cases. Endocarditis was found in 24% of cases and was an important risk factor in this content. The main indications for reoperation were periprosthetic leakage in 28.8% of cases and failure of bioprostheses in 23.7%. The valvular replacement was simple in 61%, double in 32% and triple in 7% of cases. An associated procedure was necessary in 27% of cases. Mechanical devices were implanted in 62.3% of cases. Peroperative mortality was 3% and hospital mortality, mainly from cardiac causes, was 21.7% for the second, 20% for the third and 55.6% for the fourth reoperations. Operative mortality was dependent on the number or reoperations, functional class, emergency surgery, duration of bypass and cross-clamping time. Four per cent of patients were lost to follow-up and 30 patients died secondarily. The actuarial survival rate was 52% at 5 years and 33% at 10 years, actuarial survival rate without valvular complication was 41% at 5 years and 19% at 10 years but the functional results remained good with over 90% of patients in functional class I or II at the end of follow-up.