Biomedical subjects

Richard M J Bohmer

Publications and source records attributed to Richard M J Bohmer.

6 recordsLinked to original sources

PubMed2006

Prospective assessment of intraoperative precursor events during cardiac surgery.

OBJECTIVE: Increasing attention has been afforded to the ubiquity of medical error and associated adverse events in medicine. There remains little data on the frequency and nature of precursor events in cardiac surgery, and we sought to characterize this. METHODS: Detailed, anonymous information regarding intraoperative precursor events (which may result in adverse events) was collected prospectively from six key members of the operating team during 464 major adult cardiac surgical cases at three hospitals and were analyzed with univariable statistical methods. RESULTS: During 464 cardiac surgical procedures, 1627 reports of problematic precursor events were collected for an average of 3.5 and maximum of 26 per procedure. 73.3% of cases had at least one recorded event. One-third (33.3%) of events occurred prior to the first incision, and 31.2% of events occurred while on bypass. While 68.0% of events were regarded as minor in severity (e.g., delays and missing equipment), a substantial proportion (32.0%) was considered major and included anastomotic problems, pump failure, and drug errors. Most problems (90.4%) were reported as being compensated for, although many (30.9%) were never discussed among the team. Major events were more likely to be discussed (p<0.0001) and less likely to have been previously encountered (p=0.0005). Perceptions of the severity and compensation of events varied across the team, as did temporal patterns of reporting (p<0.0001). CONCLUSIONS: A wide range of problematic precursor events occurs during the majority of cardiac surgery procedures. Attention to causes and ways of preventing these precursor events could have an impact on the rate of significant errors and improve the safety of cardiac surgery.

Adult↗

PubMed2006

Facing ambiguous threats.

On February 1, 2003, the world watched in horror as the Columbia space shuttle broke apart while reentering the earth's atmosphere, killing all seven astronauts. Some have argued that NASA's failure to respond with appropriate intensity to the so-called foam strike that led to the accident was evidence of irresponsible or incompetent management. The authors' research, however, suggests that NASA was exhibiting a natural, albeit unfortunate, pattern of behavior common in many organizations. The foam strike is a prime example of what the authors call an ambiguous threat-a signal that may or may not portend future harm. Ambiguous threats differ from threats with obvious causes-say, a fire in the building-for which the response is clear. They also differ from unmistakable threats that may lack straightforward response paths (such as the frightening oxygen-tank explosion aboard Apollo 13). However, when the warning sign is ambiguous and the threat's potential effect is unclear, managers may choose to ignore or discount the risk. Such an approach can be catastrophic. Firms that do a good job of dealing with ambiguous threats do not improvise during a crisis; rather, they apply a rigorous set of detection and response capabilities that they have developed and practiced beforehand. In this article, the authors outline how to put such capabilities in place long before a crisis strikes. First, companies need to hone their teamwork and rapid problem-solving skills through practice. Second, they must learn to recognize weak signals, amplify the threat, and encourage employees to ask disconcerting "what if" questions in a safe environment. Finally, they should explore possible responses to threats through quick, low-cost experimentation.

Commerce↗

PubMed2005

National assessment of business-of-medicine training and its implications for the development of a business-of-medicine curriculum.

OBJECTIVES/HYPOTHESIS: The objectives were, first, to determine the current state of business training in otolaryngology residency programs in the United States and, second, to lay the groundwork for development of a business-of-medicine (BOM) curriculum. STUDY DESIGN: Cross-sectional survey. METHODS: A survey concerning methodology and topics for management training of residents was mailed to the chairpersons or program directors of the 102 otolaryngology residency programs. A similar survey was sent to 576 otolaryngology graduates (classes of 2000, 2001, and 2002). An interactive BOM curriculum on CD-ROM was developed based on the results. RESULTS: The response rate among program directors was 74.5% (76 of 102), and among the otolaryngology graduates, 38.2% (220 of 575). Seventy-five percent of graduates rated their BOM training as poor or fair. Only 8% rated their BOM training as excellent. Twenty percent of the graduates responded to having a BOM course during residency. Recent graduates reported that a BOM course can best be taught through lectures and apprenticeship/mentoring, whereas program directors reported that a BOM course can best be taught through lectures and outside consultants. Graduates reported that coding compliance was the topic most neglected in residency, whereas program directors reported that coding compliance was the main topic covered in the business training. Both groups agreed that department attending physicians have the most impact on a resident's business training. Program directors reported that correct coding, planning one's entry into medical practice, risk management, and reimbursement issues are the most important topics for residents to learn, whereas recent graduates stated that the most important topics should be correct coding, office management, risk management, and reimbursement. CONCLUSION: The present study reflects a perceived necessity for improvement of BOM training in otolaryngology residency programs. Based on this finding, the outcome measures from the survey, and the authors' own experience from business courses given in the first author's department, a BOM curriculum was developed that is general enough to target all otolaryngology residents and intended to provide business skills which result in improved use of resources and, ultimately, higher quality of care.

Curriculum↗

PubMed2002

The effect of decreasing length of stay on discharge destination and readmission after coronary bypass operation.

BACKGROUND: Over the decade of the 1990s, hospital stay after operation declined in response to prospective payment and managed care. As a result, complications previously detected and treated in the hospital may have begun to occur after discharge. In addition, discharge to nursing homes and rehabilitation hospitals may have increased. To address these questions, we used a statewide database to look at the use of postacute care and the 30-day readmission and mortality after coronary bypass operation. METHODS: A modification of the Commonwealth of Massachusetts Division of Health Care Finance and Policy discharge data to include a unique patient identifier allowed us to retrospectively track patient destination at discharge and study 30-day readmission to all hospitals in the state. RESULTS: Over the 3-year period after the institution of the unique patient identifier (1993 to 1996), postoperative length of stay after coronary bypass operation decreased from 7.4 to 6 days (19%, P <.0005), but the 30-day readmission rate (17.7%) did not increase. Discharge to rehabilitation hospitals and skilled nursing facilities rose significantly (11.7% to 23.8%), especially in the Medicare population (17.2% to 38.5%). Mortality in the 30 days after discharge remained constant at 0.3%. CONCLUSIONS: A shorter postoperative length of stay did not appear to disadvantage coronary artery bypass patients by increasing their likelihood of readmission or death. Cost savings from reduced length of stay were offset by increased use of postacute services.

Aged↗

PubMedDate not supplied

Medicine's service challenge: blending custom and standard care.

Health care, once resolutely customized, is now a process comprising an uncomfortable mix of custom and standard elements. Although the operations management literature often advocates the separation of custom and standard processes, health care managers must usually provide both simultaneously, attempting to combine the two types of service process within a single organization dynamically. If this is not done effectively, quality of care can suffer. Using examples drawn from health care delivery, this paper introduces three operational strategies for effectively combining custom and standard clinical processes. The choice of operating strategy depends on the nature of the patient's needs and the state of medical knowledge.

Humans↗

PubMedDate not supplied

Hospital disclosure practices: results of a national survey.

New patient safety standards from JCAHO that require hospitals to disclose to patients all unexpected outcomes of care took effect 1 July 2001. In an early 2002 survey of risk managers at a nationally representative sample of hospitals, the vast majority reported that their hospital's practice was to disclose harm at least some of the time, although only one-third of hospitals actually had board-approved policies in place. More than half of respondents reported that they would always disclose a death or serious injury, but when presented with actual clinical scenarios, respondents were much less likely to disclose preventable harms than to disclose nonpreventable harms of comparable severity. Reluctance to disclose preventable harms was twice as likely to occur at hospitals having major concerns about the malpractice implications of disclosure.

Health Care Surveys↗