[Disclosing harmful adverse event: Assessment of medical practices from clinical vignettes]. / Annonce d'un événement indésirable grave associé aux soins au patient : évaluation des pratiques médicales à partir de vignettes cliniques.

The French National Authority for Health has made serious adverse event disclosure one of its priority areas of work. The objective of the study was to explore clinicians' perceived practices of disclosing such events. Between June and July 2012, a structured questionnaire was emailed to all clinicians and residents working at the Nantes Teaching Hospital. The questionnaire consisted of 3 parts first, clinical vignettes-with medical and surgical cases exploring five areas of practices (initial disclosure, disclosure of details, disclosure of the cause, apologies, and patient information about preventive actions); second, questions about the reasons for disclosure or non-disclosure; third, an evaluation of the training needs. The overall response rate was 18.8% (n=322/1709). Clinicians did not realize initial disclosure in 13.4%, disclosure of details in 24.5%, disclosure of the cause in 44.1%. Of the respondants, 4% of them would not apologize and 11.2% of them would not discuss detailed plans for preventing recurrences. Results were significantly different between medical and surgical specialities concerning disclosure of details and the cause of adverse events: surgeons were significantly less inclined than physicians to volunteer any details unless asked by the patient (72.9% vs 16.1%; P<0.001); to disclose the cause of the events (54.2% vs 42.3%, P<0.001); and to apologize or to offer an expression of regret (16.7% vs 1.8%; P<0.001). The main reason that led respondents to disclose as well as not disclose was to maintain trust in their relationship with the patient. Younger clinicians expressed more difficulties with adverse event disclosure and had more important training needs. Based on these results, an improvement program for the disclosure of serious adverse events is currently being implemented in the hospital, consisting of training sessions, documentation and support for the clinicians.

Causes of inappropriate hospital days: development and validation of a French assessment tool for rehabilitation centres.

OBJECTIVE: To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units. DESIGN: The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings. SETTING: The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France. MAIN OUTCOME MEASURES: Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK). RESULTS: For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66-0.92) and a PABAK of 0.80 (95% CI 0.63-0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72. CONCLUSIONS: The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement.

[Assessment of inappropriate prescribing in the elderly subject during acute care hospitalisation]. / Évaluation du risque iatrogénique médicamenteux des patients âgés hospitalisés en court séjour.

OBJECTIVE: Inappropriate prescribing in elderly is considered as common (40% of subjects from community from the 3CStudy in France had a inappropriate prescription, using Beer's criteria), and can lead to severe issues. Few studies have assessed inappropriate prescribing for elderly inpatients in acute care, with multiple tools. Our study was designed to assess outcome prescriptions concordance of elderly inpatients, for potentially inappropriate medication use. METHODS: A retrospective study based on a random sample of 170 inpatients in 2009 was performed at Nantes University Hospital. We used standardized tools, especially general prescriptions rules of the "Collège professionnel des gériatres français", Beers's criteria, the Anticholinergic Risk Scale, concordance for renal function, and search for medication with tight therapeutic edge. RESULTS: Mean age of inpatients was 85.2 ±â€Š4.1 years. Median numbers of prescribing drugs was eight. General prescriptions rules were followed up to 90% of inpatients: no forbidden drug-drug interaction was found. However, more than two psychotropic medications were prescribed for 3.9% of inpatients. At least one drug listed in Beers's criteria were found for 41 (27.0%) inpatients: amiodarone (18 inpatients) and long-term benzodiazepines (seven inpatients). A medication from the anticholinergic risk scale was found for 28 subjects (18.6%): however, for only seven of them, the score was higher than 3. Concordance for renal function was required for 126 inpatients (82.9%) for at least one prescription, 9 (7.1%) patients have a medication overdose according to their renal impairment. Medications with tight therapeutic edge were prescribed for 52 subjects (34.2%): mostly oral anticoagulants (27 subjects). In 15 cases, the dose was underneath the recommended level. CONCLUSION: Some potentially inappropriate medication uses were revealed by our study. It is essential to spread out results for clinicians, for a better knowledge of these risks.

[Appropriateness of medical prescriptions, French experience]. / Pertinence des prescriptions médicamenteuses, expérience française.

Appropriateness of care, applied to medical prescription, is a fast-growing professional practice evaluation method, within a context of control spending and quality improvement. A literature review related to the last ten years found 38 publications, including 19 original studies. Results showed that only few studies were published, and that methodologies were not standardized. Development of pedagogical data tools is essential to increase doctor's awareness. Analysis of causes of inappropriateness has to be conducted, in order to plan improvement actions. A second evaluation is necessary to assess the impact of appropriateness review on professional practices.