RESUMEN
OBJECTIVE: To evaluate whether implementation of the Michigan Keystone ICU project, a comprehensive statewide quality improvement initiative focused on reduction of infections, was associated with reductions in hospital mortality and length of stay for adults aged 65 or more admitted to intensive care units. DESIGN: Retrospective comparative study, using data from Medicare claims. SETTING: Michigan and Midwest region, United States. Population The study period (October 2001 to December 2006) spanned two years before the project was initiated to 22 months after its implementation. The study sample included hospital admissions for patients treated in 95 study hospitals in Michigan (238,937 total admissions) compared with 364 hospitals in the surrounding Midwest region (1,091,547 total admissions). MAIN OUTCOME MEASURES: Hospital mortality and length of hospital stay. RESULTS: The overall trajectory of mortality outcomes differed significantly between the two groups upon implementation of the project (Wald test χ(2) = 8.73, P = 0.033). Reductions in mortality were significantly greater for the study group than for the comparison group 1-12 months (odds ratio 0.83, 95% confidence interval 0.79 to 0.87 v 0.88, 0.85 to 0.90, P = 0.041) and 13-22 months (0.76, 0.72 to 0.81 v 0.84, 0.81 to 0.86, P = 0.007) after implementation of the project. The overall trajectory of length of stay did not differ significantly between the groups upon implementation of the project (Wald test χ(2) = 2.05, P = 0.560). Group differences in adjusted length of stay compared with baseline did not reach significance during implementation of the project (-0.45 days, 95% confidence interval -0.62 to -0.28 v -0.35, -0.52 to -0.19) or during post-implementation months 1-12 (-0.59, -0.80 to -0.37 v -0.42, -0.59 to -0.25) and 13-22 (-0.67, -0.91 to -0.43 v -0.54, -0.72 to -0.37). CONCLUSIONS: Implementation of the Keystone ICU project was associated with a significant decrease in hospital mortality in Michigan compared with the surrounding area. The project was not, however, sufficiently powered to show a significant difference in length of stay.
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Cuidados Críticos/normas , Tiempo de Internación/estadística & datos numéricos , Mejoramiento de la Calidad , Anciano , Anciano de 80 o más Años , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Michigan , Estudios RetrospectivosRESUMEN
BACKGROUND: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Errores de Medicación/estadística & datos numéricos , Distribución de Chi-Cuadrado , Estudios Transversales , Humanos , Enfermeras y Enfermeros/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud , Médicos/estadística & datos numéricos , Sistema de Registros , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To describe inpatient and outpatient pediatric antidepressant medication errors. METHODS: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. RESULTS: Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p < .001) and more errors due to inaccurate or omitted transcription (p < .001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors. CONCLUSIONS: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.
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Antidepresivos/uso terapéutico , Bases de Datos como Asunto , Errores de Medicación , Adolescente , Atención Ambulatoria , Antidepresivos/administración & dosificación , Niño , Preescolar , Femenino , Hospitalización , Humanos , Masculino , Pediatría , Estados UnidosRESUMEN
OBJECTIVE: To determine whether high patient inflow volumes to an intensive care unit are associated with unplanned readmissions to the unit. DESIGN: Retrospective comparative analysis. SETTING: The setting is a large urban tertiary care academic medical center. PATIENTS: Patients (n = 3233) discharged from an adult neurosciences critical care unit to a lower level of care from January 1, 2006 through November 30, 2007. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome variable is unplanned patient readmission to the neurosciences critical care unit within 72 hrs of discharge to a lower level of care. The odds of one or more discharges becoming an unplanned readmission within 72 hrs were nearly two and a half times higher on days when > or =9 patients were admitted to the neurosciences critical care unit (odds ratio, 2.43; 95% confidence interval, 1.39-4.26) compared with days with < or =8 admissions. The odds of readmission were nearly five times higher on days when > or =10 patients were admitted (odds ratio, 4.99; 95% confidence interval, 2.45-10.17) compared with days with < or =9 admissions. Adjusting for patient complexity, the odds of an unplanned readmission were 2.34 times higher for patients discharged to a lower level of care on days with > or =10 admissions to the neurosciences critical care unit (odds ratio, 2.34; 95% confidence interval, 1.27-4.34) compared with similar patients discharged on days of < or =9 admissions. CONCLUSIONS: Days of high patient inflow volumes to the unit were associated significantly with subsequent unplanned readmissions to the unit. Furthermore, the data indicate a possible dose-response relationship between intensive care unit inflow and patient outcomes. Further research is needed to understand how to defend against this risk for readmission.
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Unidades de Cuidados Intensivos , Admisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Centros Médicos Académicos , Adulto , Anciano , Femenino , Precios de Hospital/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/epidemiología , Estudios RetrospectivosRESUMEN
Little is known about vaccination errors. We analyzed 607 outpatient pediatric vaccination error reports from MEDMARX, a nationwide, voluntary medication error reporting system, occurring from 2003 to 2006. We used the "5 Rights" framework (right vaccine, time, dose, route, and patient) to determine whether vaccination error types were predictable. We found that "wrong vaccine" errors were more common among look-alike/sound-alike groups than among vaccines with no look-alike/sound-alike group. Scheduled vaccines were more often involved in "wrong time" errors than seasonal and intermittent vaccines. "Wrong dose" errors were more common for vaccines whose dose is weight-based and age-based than for vaccines whose dose is uniform. "Wrong route" and "wrong patient" errors were rare. In this largest-ever analysis of pediatric vaccination errors, error types were associated with predictable vaccine-related human factors challenges. Efforts to reduce pediatric vaccination errors should focus on these human factors.
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Errores de Medicación/estadística & datos numéricos , Medición de Riesgo , Vacunación , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , MasculinoRESUMEN
The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.
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Accidentes de Aviación/prevención & control , Comités de Monitoreo de Datos de Ensayos Clínicos/tendencias , Política de Salud/tendencias , Errores Médicos/prevención & control , Calidad de la Atención de Salud/tendencias , Administración de la Seguridad/tendencias , Conducta Cooperativa , Bases de Datos Factuales/tendencias , Predicción , Reforma de la Atención de Salud , Humanos , Comunicación Interdisciplinaria , Gestión de Riesgos/tendencias , Estados UnidosRESUMEN
Of 361 reports of errors involving pediatric attention deficit hyperactivity disorder from 2003 to 2005, 82% reached the patient but were not harmful; more serious errors were rare.
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Atención Ambulatoria/normas , Trastorno por Déficit de Atención con Hiperactividad/tratamiento farmacológico , Errores de Medicación/estadística & datos numéricos , Adolescente , Inhibidores de Captación Adrenérgica/uso terapéutico , Atención Ambulatoria/estadística & datos numéricos , Estimulantes del Sistema Nervioso Central/uso terapéutico , Niño , Preescolar , Bases de Datos Factuales , Inhibidores de Captación de Dopamina/uso terapéutico , Humanos , Estados Unidos/epidemiologíaRESUMEN
Health insurance systems in Central and Eastern Europe have evolved in different ways from the centralized health systems inherited from the Soviet era, but there remain common trends and challenges in the region. Health spending is low in comparison to the spending of pre-2004 European Union members, but population aging, medical technology, economic growth, and heightened expectations will generate major spending pressures. Social health insurance is the dominant model in the region, but coverage is uneven. Key3reform issues include identifying ways to encourage additional investment in the health sector; and defining formal benefit packages, copayments, and the role of private insurance.
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Reforma de la Atención de Salud/tendencias , Gastos en Salud/tendencias , Cobertura del Seguro/tendencias , Seguro de Salud/tendencias , Europa (Continente) , Reforma de la Atención de Salud/organización & administración , Sector de Atención de Salud , Humanos , Cobertura del Seguro/economía , Seguro de Salud/economía , Sector PrivadoRESUMEN
BACKGROUND: Errors may be more common and more likely to be harmful with opioids than with other medications, but little research has been conducted on these errors. METHODS: The authors retrospectively analyzed MEDMARX, an anonymous national medication error reporting database, and quantitatively described harmful opioid errors on inpatient units that did not involve devices such as patient-controlled analgesia. The authors compared patterns among opioids and qualitatively analyzed error descriptions to help explain the quantitative results. RESULTS: The authors included 644 harmful errors from 222 facilities. Eighty-three percent caused only temporary harm; 60 percent were administration errors and 21 percent prescribing errors; and 23 percent caused underdosing and 52 percent overdosing. Morphine and hydromorphone had a significantly higher proportion of improper dose errors than other opioids (40 percent and 41 percent compared with 22 percent with meperidine). Hydromorp hone errors were significantly more likely to be overdoses (78 percent vs 47 percent with other opioids). Omission errors were significantly more common with fentanyl patches (36 percent compared with 12 percent for other opioids). Wrong route errors were significantly more common with meperidine (given intravenously when prescribed as intramuscular, 34 percent vs 3 percent for morphine). Oxycodone errors were significantly more likely to be wrong drug errors (24 percent vs. 11 percent for other opioids), often because of confusion between immediate- and sustained-release formulations. CONCLUSIONS: Reported opioid errors are usually associated with administration and prescribing and frequently cause uncontrolled pain as well as overdoses. These patterns of errors should be considered when using opioids and incorporated into pain guidelines, education, and quality improvement programs.
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Sistemas de Registro de Reacción Adversa a Medicamentos , Analgésicos Opioides , Errores de Medicación/tendencias , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Prescripciones de Medicamentos/normas , Prescripciones de Medicamentos/estadística & datos numéricos , Estudios Retrospectivos , Estados UnidosRESUMEN
PURPOSE: The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units. MATERIALS AND METHODS: We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients. RESULTS: The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups. CONCLUSIONS: Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.
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Unidades de Cuidados Intensivos , Errores Médicos/prevención & control , Errores Médicos/estadística & datos numéricos , Gestión de Riesgos/estadística & datos numéricos , Adulto , Anciano , Falla de Equipo/estadística & datos numéricos , Femenino , Humanos , Enfermedad Iatrogénica/epidemiología , Enfermedad Iatrogénica/prevención & control , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Cuidados Posoperatorios , Estudios Prospectivos , Vigilancia de Guardia , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To describe the organization of physician services in intensivist-staffed intensive care units (ICU) reporting that they meet vs. do not meet the Leapfrog Physician Staffing standard, and to describe ICU directors' perceptions of the quality of care in their unit. DESIGN: Hospitals that were asked to participate in the 2001 and 2002 Leapfrog surveys regarding implementation of the ICU Physician Staffing standard were sampled. Survey instruments were developed and used to determine organizational characteristics, status regarding implementing and meeting the standard, financing of physician staffing, and perceptions of clinical performance. SUBJECTS: ICU directors. MEASUREMENTS AND MAIN RESULTS: Intensivists staffed ICUs in 100% of hospitals meeting the standard, and in 59% not meeting the standard. Mean percentage of patients visited on rounds by intensivists in ICUs who met (80 +/- 14.58) vs. did not meet (57.5 +/- 23.20) the standard showed no statistical difference, Wilcoxon rank-sum test = -1.99, p = .065. Only 25% (three of 12) of intensivists in ICUs meeting the standard had authority to write patient orders on all patients, compared to 65% (11 of 17) in ICUs not meeting the standard. Intensivists were present at least 8 hrs/day in 83% (ten of 12) of ICUs meeting and 18% (three of 17) of ICUs not meeting the standard. Provision of medical liability insurance for physicians occurred in 58% (seven of 12) of ICUs meeting and 25% (four of 16) of ICUs not meeting the standard (p = .003). ICU directors rated quality of ICU care as excellent in 70% of ICUs meeting and 35% of ICUs not meeting the standard. CONCLUSIONS: ICUs now classify themselves as meeting or not meeting the ICU Physician Staffing standard. Yet, there is wide variation in organizational characteristics among ICUs meeting the standard, and between those meeting and not meeting the standard. The criteria defined by the Leapfrog Group for meeting the ICU Physician Staffing standard must be clearly defined if hospitals are to meet the standard.
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Cuidados Críticos/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Cuerpo Médico de Hospitales/organización & administración , Estados Unidos , Recursos HumanosRESUMEN
PURPOSE: The aim of this study was to describe hospital efforts to meet the Leapfrog Group's intensive care unit (ICU) physician staffing (IPS) standard; compare adopters and committers with resisters relative to perceived benefits, barriers and motivating factors; and examine implementation strategies. MATERIALS AND METHODS: Chief medical officers (CMO) and ICU directors at hospitals in 6 US regions were surveyed between August 2003 and January 2004. Hospital classifications were based on level of IPS implementation pioneer (met before IPS), adopter (met after IPS by 2002 Leapfrog survey), committer (not met but committed to December 2004 implementation), and resister (refused to adopt IPS). Meeting IPS included intensivist staffing, 8 hours/day 7 days/week; sole patient care in ICU; 95% pager response time
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Implementación de Plan de Salud , Unidades de Cuidados Intensivos , Cuerpo Médico de Hospitales/normas , Admisión y Programación de Personal/normas , Calidad de la Atención de Salud , Actitud del Personal de Salud , Encuestas de Atención de la Salud , Humanos , Innovación Organizacional , Gestión de Riesgos , Estados Unidos , Recursos HumanosRESUMEN
PURPOSE: To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS: Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS: Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS: The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.
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Relaciones Interinstitucionales , Errores Médicos/prevención & control , Errores Médicos/estadística & datos numéricos , Sistemas en Línea , Gestión de Riesgos , Adulto , Niño , Estudios de Cohortes , Humanos , Internet , Estudios Prospectivos , Factores de Riesgo , Estados UnidosRESUMEN
OBJECTIVE: To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU). DESIGN: Voluntary, anonymous Web-based patient safety reporting system. SETTING: Eighteen ICUs in the United States. PATIENTS: Incidents reported by ICU staff members during a 12-month period ending June 2003. INTERVENTIONS: None. MEASUREMENTS: Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported. MAIN RESULTS: Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25-9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12-11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28-5.92), and age of 1-9 yrs (OR, 7.95; 95% CI, 3.29-19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11-0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09-2.97). CONCLUSIONS: Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events.
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Unidades de Cuidados Intensivos/organización & administración , Errores Médicos/prevención & control , Gestión de Riesgos , Análisis de Sistemas , Adolescente , Adulto , Anciano , Estudios de Casos y Controles , Cateterismo/efectos adversos , Catéteres de Permanencia/efectos adversos , Niño , Preescolar , Drenaje/efectos adversos , Femenino , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos/estadística & datos numéricos , Intubación/efectos adversos , Modelos Logísticos , Masculino , Errores Médicos/estadística & datos numéricos , Persona de Mediana Edad , Análisis Multivariante , Factores de Riesgo , Estados UnidosRESUMEN
In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter.
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Unidades de Cuidados Intensivos/organización & administración , Internet , Gestión de Riesgos/métodos , Redes de Comunicación de Computadores , Recolección de Datos/métodos , Sistemas de Información en Hospital , Humanos , Garantía de la Calidad de Atención de Salud , Administración de la Seguridad/métodos , Estados UnidosRESUMEN
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.
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Comunicación , Cuidados Críticos/métodos , Unidades de Cuidados Intensivos , Errores de Medicación/prevención & control , Calidad de la Atención de Salud , Adulto , Cuidados Críticos/organización & administración , Humanos , Masculino , Gestión de Riesgos , SeguridadRESUMEN
OBJECTIVE: To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine. DESIGN: Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS). SETTING: Sixteen adult and two pediatric intensive care units (ICU) across the United States. PATIENTS: Incidents reported during the 12-month period ending June 30, 2003. INTERVENTIONS: None MEASUREMENTS: Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events. MAIN RESULTS: There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32). CONCLUSIONS: Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.
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Unidades de Cuidados Intensivos/organización & administración , Intubación Intratraqueal/efectos adversos , Errores Médicos/estadística & datos numéricos , Gestión de Riesgos/organización & administración , Análisis de Sistemas , Traqueostomía/efectos adversos , Adolescente , Adulto , Actitud Frente a la Salud , Niño , Preescolar , Competencia Clínica/normas , Comorbilidad , Bases de Datos Factuales , Falla de Equipo/estadística & datos numéricos , Familia/psicología , Investigación sobre Servicios de Salud , Humanos , Lactante , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Errores Médicos/efectos adversos , Errores Médicos/métodos , Errores Médicos/prevención & control , Análisis Multivariante , Evaluación de Necesidades/organización & administración , Admisión y Programación de Personal/organización & administración , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Quality-based purchasing is a growing trend that seeks to improve healthcare quality through the purchaser-provider relationship. This article provides a unifying conceptual framework, presents examples of the purchaser-provider relationship in countries at different income levels, and identifies important supporting mechanisms for quality-based purchasing. As countries become wealthier, a higher proportion of healthcare spending is channeled through pooled arrangements, allowing for greater involvement of purchasers in promoting the quality of service provision. Global and line item budgets are the most common type of provider payment system in low and middle-income countries. In these countries, improving public hospital performance through contracting and incentives is a key issue. In middle and high-income countries, there are several documented examples of governments contracting to private or non-governmental health care providers, resulting in higher perceived quality of care and lower delivery costs. Encouraging quality through employer purchasing arrangements has been promoted in several countries, particularly the United States. Community-based financing schemes are an increasingly common form of health financing in parts of sub-Saharan Africa and Asia, but these schemes still cover less than 10% of national populations in countries in which they are active. To date, there is little evidence of their impact on healthcare quality. The availability of information--concerning healthcare service provision and outcomes--determines the options for establishing and monitoring contract provisions and promoting quality. Regardless of the context, quality-based purchasing depends critically on informa-tion--reporting, monitoring, and providing useful information to healthcare consumers. In many low and middle-income countries, the lack of availability of information is the principal constraint on measuring performance, a critical component of quality-based purchasing.