[Failure prevention in clinical practice through identification of failure examples]. / Fehlervermeidung in der klinischen Praxis durch Erkennung von Fehlermustern.

"Learning from ones mistakes" is an essential part of clinical quality improvement. But focusing on a retrospective analysis of mishaps from the past is not sufficient for quality enhancements, nor is the restriction to mistakes in the solely legal sense. Analysis has to include anonymous data aggregated over dissatisfying results from multiple sources. Recognizing patterns of underlying causes for errors is the key to effective error prevention. In many cases the true cause might be predominantly organizational.

[Accusations of malpractice in chirotherapeutic treatment]. / Vorgeworfene Behandlungsfehler im Zusammenhang mit chirotherapeutischen Behandlungen.

BACKGROUND: Little is known about the incidence of adverse effects after chiropractic manipulation. Over representation of severe and under representation of less severe complications has to be assumed. MATERIAL AND METHODS: A total of 57 expert opinions from the malpractice advisory board of the North Rhine General Medical Council (Nordrheinische Arztekammer), as well as judgments from German courts since 1949, were analyzed. RESULTS AND CONCLUSIONS: A total of 16 of 57 cases of chiropractic manipulation (since 1975) were attested as malpractice by expert opinion, seven of which had significant negative consequences. In nine cases, the judgments of German courts refer to manual therapy. Of these, five deal with informed consent. Observance of the "Bingen Declaration" would have avoided all cases of malpractice found by the advisory board over 29 years.

[Hygiene between tradition and implementation]. / Hygiene zwischenTradition und Erkenntnis.

The basis of evidence for hygiene rules implemented in hospitals is traditionally small. This is not only because there is little theoretical knowledge on the reciprocal influence between a single hygienic mistake/a single microbial input and the manifestation of a nosocomial infection. There are also not enough clinical studies, especially on complex hygiene questions, to determine whether special measures (e.g., septic rooms)can compensate for deficits in hygiene practice. Furthermore, it would be necessary to designate security buffers distinctly. In-house traditions are able to stabilize hygienic behavior in an excellent manner. They should be fostered and not disparaged as myths. Discussions of experts should not be conducted in public; that is disastrous for the everyday work of physicians in hospitals.

[Quality assurance in ambulatory surgery]. / Qualitätssicherung beim ambulanten Operieren.

Surgery in outpatients and surgery under hospital conditions should provide the patient with the same high level of quality and the same low risk level. The one-person surgery practice is able to offer the patient a classic "one client-one customer" relation. Thus, the continuity of treatment is optimal. On the other hand, intervening systemic complications are more easily managed by the multidisciplinary staff of a hospital with its equipment. The weaknesses of both principles can be counteracted by employing special precautions in organization. The future of surgery is to be seen in combined forms, for example, in-sourcing of a surgeon from private practice into a hospital.

[Medical malpractice in surgery I: Suspected malpractice and patterns of risks]. / Der ärztliche Behandlungsfehler in der Chirurgie I: Typische Fehlervorwürfe und Fehlerkonstellationen.

Medical malpractice is assumed for surgical procedures much more often than for conservative treatment. In a nut shell there can be identified three general problem areas--treatment of patient in inappropriate facilities, inadequate information of patient and lack of documentation. Several examples are given. For the assessment of assumed medical malpractice the expert opinion and consented guidelines are crucial; they both benchmark "good medical practice". Thus these two tools have to be handled and developed carefully.

[Medical malpractice in surgery II: Ways of risk management]. / Der ärztliche Behandlungsfehler in der Chirurgie II: Wege der Fehlervermeidung.

The aims of risk management concerning medical malpractice are (1) the quick, correct and fair assessment of assumed medical failures, (2) to prevent the expansion of medical complications after an assumed medical failure and (3) the identification of patterns of risks. The latter has to be done locally and national-wide; it has to be done focussed to the respective medical subject and in a general matter as well.

Malpractice in oncology.

In oncology, as in all other medical disciplines, medical malpractice is assumed when the physician has not taken sufficient care in his treatment, and when he has not met the required standards of medical care. The physician is liable for damages when distinct harm has arisen from this. In oncology, accusations of malpractice arise especially when suspicion of a malignancy is not based on unequivocal substantive diagnostic criteria (for example, the appropriate appraisal of routine x-rays or screening scans), or in terms of organizational mistakes. Stringent safeguards in oncological diagnostics and therapy are usually based on approved and generally recognized guidelines. From the time that the malignancy is suspected, there is therefore little concrete danger that malpractice will be attested provided these guidelines are complied with. The tolerance accorded by experts in respect of intraoperative complications in oncological operations appears to be great amongst medical expert witnesses. If a malpractice is attested, the distinct damage resulting from this can only be appraised approximately, e.g. by comparing the statistical probability of survival in various tumor stages.

[The medical advisory services of social health insurance]. / Aufgaben des Medizinischen Dienstes der Krankenversicherung.

A social health insurance needs opinions on diagnostic and therapeutic procedures - for the single question regarding the individual patient and as general assessments (health technology assessments) as well. The Medical advisory services of social health insurance (their federal branches and their central board) have to do more than 9 Mio individual expert opinions and more than 100 general assessments or HTA-reports a year. Several examples are to be shown.

[Innovations in medicine--the structured way from an idea to recognized treatment]. / Innovationen in der Medizin--der strukturierte Weg von der Idee zur anerkannten Leistung.

New techniques in medicine in an enormous variety and limited financial resources make it necessary to define step by step the "national medical how to do". This is to be done by the four boards of health care self-government--especially by the "Koordinierungsausschuss". Thus the clinically active physicians are enabled to implement their own new ideas and their own innovations--especially via high quality guidelines, consented within the scientific societies. This new closed circle, a kind of "government free zone" should be used intensively by all active colleagues.

[Evidence-based scientific analysis of fundamental Medical Services of Statutory Health Insurance internal principle assessment]. / Die evidenzbasierte wissenschaftliche Analyse als Grundlage MDK-interner Grundsatzgutachten.

In Germany, the increasing relevance of Evidence-based medicine (EbM) is not only a consequence of growing economic limitations in the health care system but of a changed jurisdiction, too: liability of the statutory health insurances (SHI) to pay for medical care depends on the proof of its effectiveness. This is of special importance for the Medical Services in their role as an advisor of the SHI. The article depicts the basic assignments of the Medical Services of the Statutory Health Insurance, their legal frame and the role of EbM in sociomedical expertising. The way of fundamental sociomedical expertising, its internal and external effects, the personnel and technical/logistic requirements are described as well as potential of improvement.

[The importance of guidelines in the area of malpractice procedure]. / Die Bedeutung von Leitlinien im Rahmen der Behandlungsfehler-Begutachtung.

Generally available national guidelines are the only way to guarantee that the clinically active doctor will consider the same rules as the doctor as an expert within a malpractice procedure. Especially the following question has to be ruled out by national guidelines: From what time on is an innovation to be considered as "normal"--as "standard"? The same is true for continued expert discussions and for the "medical-economic balance". Without national guidelines recognized as well-known rules, the doctor accused in a malpractice procedure will find himself in an unacceptable position of legal uncertainity.

[Managing risks in clinical routine practice and effect of guidelines]. / Der Umgang mit Risiken im klinischen Alltag und seine Beeinflussung durch Leitlinien.

Four steps of risk management are known at present in the clinical practice. For all forms guidelines are important--these could be national guidelines or in-house guidelines. All guidelines are respected to perform reliable and steady quality and to reduce risks.

[Quality management in hospital departments. References for implementation and basic requirements]. / Qualitätsmanagement an Krankenhausabteilungen. Hinweise zum Einstieg und grundlegende Anforderungen.

Every hospital department has to install a basic quality management system within the next years. This is necessary for two reasons: The legal regulations and the introduction of a payment system based on diagnosis related groups. The very first beginning often is the hardest part of quality assessment work. This paper shows how to start with TQM everywhere--without inadequate expense and by own means. Basis for this is the identification of a couple of important targets, procedures and risks at the pit face. Further developments and the political background is outlined.