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Biomedical subjects

T W Nolan

Publications and source records attributed to T W Nolan.

10 recordsLinked to original sources
PubMed2000

Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study.

OBJECTIVES: To reduce errors made in the interpretation of radiographs in an emergency department. DESIGN: Longitudinal study. SETTING: Hospital emergency department. INTERVENTIONS: All staff reviewed all clinically significant discrepancies at monthly meetings. A file of clinically significant errors was created; the file was used for teaching. Later a team redesigned the process. A system was developed for interpreting radiographs that would be followed regardless of the day of the week or time of day. All standard radiographs were brought directly to the emergency physician for immediate interpretation. Radiologists reviewed the films within 12 hours as a quality control measure, and if a significant misinterpretation was found patients were asked to return. MAIN OUTCOME MEASURES: Reduction in number of clinically significant errors (such as missed fractures or foreign bodies) on radiographs read in the emergency department. Data on the error rate for radiologists and the effect of the recall procedure were not available so reliability modelling was used to assess the effect of these on overall safety. RESULTS: After the initial improvements the rate of false negative errors fell from 3% (95% confidence interval 2.8% to 3.2%) to 1.2% (1.03% to 1.37%). After the processes were redesigned it fell further to 0.3% (0.26% to 0.34%). Reliability modelling showed that the number of potential adverse effects per 1000 cases fell from 19 before the improvements to 3 afterwards and unmitigated adverse effects fell from 2.2/1000 before to 0.16/1000 afterwards, assuming 95% success in calling patients back. CONCLUSION: Systems of radiograph interpretation that optimise the skills of all clinicians involved and contain reliable processes for mitigating errors can reduce error rates substantially.

Diagnostic Errors↗
PubMed2000

Reducing adverse drug events: lessons from a breakthrough series collaborative.

BACKGROUND: In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications. METHODS: The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed. RESULTS: During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols. DISCUSSION: Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.

Adverse Drug Reaction Reporting Systems↗
PubMed1998

Cooperation: the foundation of improvement.

Cooperation--working together to produce mutual benefit or attain a common purpose--is almost inseparable from the quest for improvement. Although the case for cooperation can be made on ethical grounds, neither the motivation for nor the effects of cooperation need to be interpreted solely in terms of altruism. Cooperation can be a shrewd and pragmatic strategy for accomplishing personal goals in an interdependent system. Earlier papers in this series have explored the conceptual roots of modern approaches to improvement, which lie in systems theory. To improve systems, we must usually attend first and foremost to interactions. Among humans, "better interaction" is almost synonymous with "better cooperation." Physicians have ample opportunities and, indeed, an obligation to cooperate with other physicians in the same or different specialties, with nurses and other clinical workers, with administrators, and with patients and families. Many intellectual disciplines have made cooperation an object of study. These include anthropology; social psychology; genetics; biology; mathematics; game theory; linguistics; operations research; economics; and, of course, moral and rational philosophy. Scientifically grounded methods to enhance cooperation include developing a shared purpose; creating an open, safe environment; including all who share a common purpose and encouraging diverse viewpoints; negotiating agreement; and insisting on fairness and equity in the application of rules. These methods apply at the organizational level and at the level of the individual physician. This paper describes the application of these methods at the organizational level and focuses on one especially successful example of system-level cooperation in a care delivery site where interactions matter a great deal: the modern intensive care unit.

Cooperative Behavior↗
PubMed1998

Physicians as leaders in improving health care: a new series in Annals of Internal Medicine.

Searching for one word to describe the state of mind of the physician in the United States today, we might choose beleaguered. Threats appear from all sides--from payers, would-be managers of care, the growth of technology, and even patients. The rhetoric is one of siege and battle, and the dynamic seems to be a clash of values from which only one winner can emerge. But scientific and health services research suggest otherwise. Science suggests that health care could, indeed, perform a great deal better than it does today and that a shared aim of improving health outcomes for patients at a cost that society can afford is sensible and within reach. However, achievement of these improvements will require of physicians not handwringing and resistance to change but concerted, positive, capable leadership. The goal of this series in Annals is to describe a new knowledge base that will help physicians participate effectively in the redesign of the health care system. The series is intended to raise the curiosity of physicians about the skills they will need to become more active and influential citizens of the health care community in accomplishing improvements. These skills will help physicians better deploy their clinical expertise and professional purpose in a debate that has heretofore been informed primarily by economics.

Humans↗
PubMed1998

Understanding medical systems.

The prominence of physicians in highly interdependent medical systems confers tremendous power on them, individually and as a profession. With this power comes an ethical responsibility to be deeply concerned about medical systems. Examples of medical systems include the process of treating patients with diabetes; a hospital; the development and testing of new medical procedures; and a medical practice, including locations of care, billing, and collection of fees for medical care. The physician who is willing to learn about the nature of systems, how to control them, and how to improve them can significantly influence medical systems. Many persons in health care organizations identify strongly with their individual profession or department. Management structures, professional organizations, and methods of billing for services reinforce these divisions. This fragmented environment allows the structure of medical systems to evolve piecemeal from the various actions and points of view of physicians, nurses, administrators, patients, and payers. Improvement results from new structures that are purposefully designed. To achieve improvement, people must look beyond their own professional or organizational identities and see themselves as part of the larger system. Even a rudimentary understanding of the structures and dynamics of systems combined with clinical knowledge can equip a physician to collaborate with colleagues to diagnose faults of a system and design remedies. This paper explores the nature of medical systems and develops ideas their proper application to medicine and the activities of physicians.

Clinical Laboratory Techniques↗