Hospital risk management: the second decade.

Risk management is defined as the systematic process of identifying, evaluating and addressing potential and actual risk. Although introduced to the hospital industry nearly a decade ago, it status in Canadian hospitals remains uncertain, a position that is in sharp contrast to the American situation. Chiefly as a result of the medical malpractice crisis and associated circumstances in the mid-1970s, risk management has emerged as an integral element in the operational activities of American hospitals. The process is a mechanism for self-protection in co-operative, self-insurance arrangements and to secure commercial premium adjustments. Many trends have been recognized in canada that would suggest a predisposition toward the proliferation of risk management programs. These indicators include an increase in the number and size of claims against hospitals and physicians, a reduction in the availability of commercial health care insurance, and an increase in alternative insurance arrangements. Despite these indicators, movement toward risk management by Canadian hospitals has been minimal. A prime reason appears to be lack of financial incentives to stimulate the development of risk management programs. There is also an absence of specific accreditation standards pertaining to such programs. The case in support of risk management for Canadian hospitals continues to grow. The basic assumptions associated with a program are board, medical and staff support; a concerted effort to recognize and reduce potentially litigious situations and occurrences; and an ability to adapt. The initial steps to develop a risk management program include assessing current risk control activities and implementing structural elements. As well, a program must address its relationship to Quality Assurance activities in the hospital.

A study to identify who is the responsible physician for each patient in a teaching hospital.

A one-day study was conducted to confirm evidence of disagreement about which physician was responsible for the care of patients in a teaching hospital. Sixteen percent of the patients reported the responsible physician as someone different from the physician listed on their medical record, and 13% could not provide any physician's name. Significant disagreement was also discovered between the name given by the charge nurse, the patient's identification band, and the face sheet on the patient's chart. Twenty-nine percent of the charts reviewed revealed no documented involvement by the responsible physician within the previous ten days. As a result of the study, the hospital changed its documentation procedures and the hospital and the medical school became aware of the need to improve monitoring of supervision of student physicians.

'No resuscitation' orders: perspectives, policies, problems and procedures.

Chedoke-McMaster Hospitals in Hamilton have evolved a 'No CPR' Policy for over seven years. This article describes some of the important ethical, administrative and practical clinical factors in successful application of a 'No CPR' order to the management of terminally ill patients. The role of the attending physician is critical in negotiating 'No CPR' decisions with patients and families. Physicians' attitudes toward death and their perceptions of their professional responsibilities for patients determine if and how an order will be written. Several clinical strategies are suggested to help negotiate a 'no CPR' decision.