[Patient safety in hospitals]. / Veiligheid van patiënten in ziekenhuizen.

In various studies outside the Netherlands, it has been shown that a substantial number of patients suffer some kind of damage during their treatment in a hospital. The incidence of these so-called adverse events varies between 2.9% and 16.6%; of these, estimates between more than a quarter and up to half are considered to have been avoidable. Preventable adverse events can offer a starting point for interventions to increase patient safety. Therefore, a study has been initiated in Dutch hospitals investigating the nature and extent of adverse events and their causes. Important goals of the study are to reach a consensus on basic concepts and to improve the research methodology.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses.

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60-71%). Of the respondents, 11-30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

The disciplinary code for nurses and its contribution to the quality of nursing care in the Netherlands.

AIM: To obtain insight into the contribution of the disciplinary code for nurses to monitoring the quality of nursing care in the Netherlands. METHODS: Complaints dealt with in the period 1998-2001 were studied. Questionnaires were sent to 3200 nurses (71%), all 388 members of the disciplinary boards (89%) and 43 lawyers (65%). RESULTS: There was an increase in the number of nurses who were accused (20 in 1998, 12 in 1999, 54 in 2000, and 56 in 2001) and also in the annual percentages of sanctions imposed (0% in 1998, 8% in 1999, 13% in 2000 and 16% in 2001). The disciplinary code appears to be an important corrective instrument for serious professional misconduct.

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey.

Occurrence of problems with, refusals of orders and contemplated refusals of orders for risky procedures by nurses in Dutch hospitals and views on the safety of performance was studied using postal questionnaires (600 physicians and 3200 nurses, response 60--71%). Of the respondents, 11--30% experienced problems with and (contemplated) refusals of orders for risky procedures in the previous 12 months. Gynaecologists and internists most frequently mentioned problems concerning the practical performance of the procedure (44% and 30%, respectively). The reason for a problem or a contemplated refusal most frequently given by nurses was that they disagreed with the medication policy (34% and 35%, respectively). The reason for a refusal most frequently given by the gynaecologists, internists, and nurses was that the nurses themselves were of the opinion that they did not have the necessary authorisation (95%, 67%, and 62%, respectively). With regard to certain procedures, the views of professionals are more strict than the current legal regulations.

[Publication practice and policy for disciplinary proceedings regarding health care in the Netherlands]. / Publicatiepraktijk en -beleid van de tuchtrechtspraak voor de gezondheidszorg.

OBJECTIVE: To provide insight into practice and policy regarding the publication of disciplinary verdicts in Dutch health care. DESIGN: Descriptive. METHOD: The study covered all of the verdicts issued by disciplinary boards and courts of justice that were published in the Dutch the Staats-courant (Government Gazette) during the period 1995-2002. The following attributes were recorded for each verdict: year of publication and verdict, the disciplinary board concerned, the accused professional, the type of complainant, the nature of the complaint and verdict, and the journals that were offered the decision. The published verdicts were related to the total number of verdicts and cases during the study period. Questionnaires were used to investigate the publication policy of the disciplinary boards. RESULTS: A total of 4% of all verdicts were published in the Dutch Government Gazette (323/8902). The central disciplinary board decided to publish more often than the regional disciplinary boards (8% and 2%, respectively). There were considerable differences between the various regional disciplinary boards (range: 1-5%). Per professional group the percentage of verdicts in cases that were published ranged from 2% to 23%. The decisions were offered to over 20 journals, but mainly to the Tijdschrift voor Gezondheidsrecht [Dutch Journal of Health Law] (TvGR; 92%) and Medisch Contact [Medical Contact] (MC; 88%). The TvGR published almost two-thirds of the verdicts offered (63%), and the MC published almost three-quarters (74%). In the decision to publish, the disciplinary boards differed in their interpretation of the concept of 'general importance'. CONCLUSION: If disciplinary proceedings are to achieve the desired quality-promoting effect on professional practice, then more attention will need to be paid to the publication policy, and the disciplinary boards will have to develop a joint code of practice. More verdicts could be published, also in professional journals.

Reserved procedures in Dutch hospitals: knowledge, experiences and views of physicians and nurses.

The Individual Health Care Professions Act came into force in The Netherlands in 1997, introducing a mixed system for the regulation of the practice of medicine. One of its components, the reserved procedures regulations, was studied in hospitals to gain insight into the knowledge, experiences and views of physicians and nurses with regard to these regulations. Questionnaires were sent to representative samples of 250 gynaecologists, 350 internists, and 3200 nurses, response rates were 65, 60 and 71%, respectively. Almost all respondents were aware that physicians are authorised to perform reserved procedures on their own initiative (93-99%), and 48-63% knew that nurses are not authorised to do this. A substantial percentage of the nurses performed reserved procedures on their own initiative (17-53%). A majority of gynaecologists and internists presumed that the hospital had ensured the proficiency of the nurses to perform reserved procedures (58% resp. 65%), while 82% of the nurses determined their own proficiency for each procedure. Most respondents felt that the reserved procedures regulations offer adequate protection for patients (58-72%). Although recommendations are made for improvement, the functioning of the reserved procedures regulations in hospitals is considered to be moderately positive.

[No improvement of disciplinary jurisprudence since the implementation of the Individual Health Care Professions Act (IHCP Act)]. / Tuchtrechtspraak niet verbeterd sinds de invoering van de Wet op de Beroepen in de Individuele Gezondheidszorg (Wet BIG).

OBJECTIVE: To compare the number and nature of the complaints, the complainants, the accused health professionals and the sanctions imposed by the disciplinary boards before and after the Individual Health Care Professions Act (IHCP Act) came into effect at the end of 1997. DESIGN: Descriptive, retrospective. METHOD: The authors examined all 4980 verdicts pronounced by the disciplinary boards in the first instance during the period 1995-1997 (before the IHCP Act) and then during the period 1999-2001 (after the IHCP Act), together with the resulting appeal procedures involving physicians, dentists, pharmacists and midwives. The following were noted: the year of the verdict, the number and nature of the complaints, the types of complainants, the categories of professionals accused, the nature of the verdicts, and the number of appeal procedures. RESULTS: During the first period, 2453 complaints were brought before the disciplinary board, compared to 2527 during the second period. Most of the complaints were made against physicians (92% in both periods). The number of complaints that were declared to be justified fell from 19% to 15% (p < 0.001). In both periods, approximately half of the complaints concerned 'lack of care or inadequate care' or 'incorrect treatment', the most frequent verdict was a warning (67% and 72%, respectively), and appeals were lodged against almost one-third of the verdicts. The number of complaints submitted by the Inspectorate for Health Care decreased from 47 to 19. CONCLUSION: In any important aspects, the IHCP Act did not lead to improvement in the disciplinary jurisprudence. The decrease in the number of complaints that were declared to be justified could be explained by the change in composition of the disciplinary boards prescribed by the IHCP Act (more lawyers and less fellow professionals). Informing citizens about disciplinary jurisprudence and other procedures for lodging complaints may increase the number of justified complaints and hence the number of 'justified' verdicts. There is a need for further clarification of the tasks and responsibility of the Inspectorate for Health Care in case of complaints to the disciplinary boards.

The role of the medical examiner in the euthanasia notification procedure in The Netherlands.

The objective of the study was to provide an insight into the role of the medical examiner in the euthanasia notification procedure in The Netherlands. At the beginning of 1996 a representative group of 116 medical examiners was interviewed. The study found that there was a considerable variation in the way in which the medical examiners fulfilled their tasks. In all cases, after the physician-assisted death had taken place, the medical examiner investigated whether the attending physician had met the requirements for prudent practice, and in approximately 75% of the cases he reported his findings to the Public Prosecutor. In 78% of cases the attending physician was well known to the medical examiners, who were general practitioners, and in a third of the cases this influenced their assessment. Seventy-six per cent of the medical examiners, 61% of the members of the public prosecution and 47% of the physicians thought that it is the task to the medical examiner to review whether the requirements for prudent practice have been met by the attending physician. In conclusion further specification of the task of the medical examiner would appear to be beneficial to increase uniformity in the procedure. In particular, it should be determined whether it is the medical examiner's responsibility to review whether the requirements for prudent practice have been met. It should also be taken into consideration whether the position of the general practitioner medical examiner is sufficiently independent to make an objective report.

Assessment of physician-assisted death by members of the public prosecution in The Netherlands.

OBJECTIVES: To identify the factors that influence the assessment of reported cases of physician-assisted death by members of the public prosecution. DESIGN/SETTING: At the beginning of 1996, during verbal interviews, 12 short case-descriptions were presented to a representative group of 47 members of the public prosecution in the Netherlands. RESULTS: Assessment varied considerably between respondents. Some respondents made more "lenient" assessments than others. Characteristics of the respondents, such as function, personal-life philosophy and age, were not related to the assessment. Case characteristics, i.e. the presence of an explicit request, life expectancy and the type of suffering, strongly influenced the assessment. Of these characteristics, the presence or absence of an explicit request was the most important determinant of the decision whether or not to hold an inquest. CONCLUSIONS: Although the presence of an explicit request, life expectancy and the type of suffering each influenced the assessment, each individual assessment was dependent on the assessor. The resulting danger of legal inequality and legal uncertainty, particularly in complicated cases, should be kept to a minimum by the introduction of some form of protocol and consultation in doubtful or boundary cases. The notification procedure already promotes a certain degree of uniformity in the prosecution policy.