Compensation Claims in Danish Emergency Care: Identifying Hot Spots and Blind Spots in the Quality of Care.

BACKGROUND: The Healthcare Complaints Analysis Tool (HCAT) offers a validated way of systematically extracting content from patient complaints for further analysis of complaint hot spots with harm or near misses, and blind spots with, for example, systemic problems or quality problems arising during discharge. This study analyzed a Danish national sample of compensations claims about emergency care using the HCAT. METHODS: Through use of the HCAT, compensation claims about Danish emergency care from 2013 to 2017 (N = 712) were coded and then grouped to identify and highlight hot spot problem areas (harm and near misses) and blind spot problem areas (admission/discharge, systemic problems, errors of omission). Two assessors coded the compensation claims by entering data into a database. RESULTS: The HCAT analyses of the sample resulted in coding of 1,305 problems. Most problems concerned quality and safety issues at the examination/diagnosis stage of care (63.9%). In 91.2% of the cases, the level of harm was moderate or major. Harm hot spots most often involved diagnostic errors (189 problems). Eighty-nine problems related to errors of omission, all causing moderate or major harm. For systemic blind spots, patient harm significantly increased in cases of multiple problem types in the compensation claim (odds ratio = 1.6, 95% confidence interval = 1.3-2.0). CONCLUSION: Systematic coding and analytic approach to the HCAT can highlight potential quality problems in emergency care and point to areas for further consideration. From the perspective of future health care harm prevention, there seems to be a strong incentive for further analysis of the amount, nature, and prevention of diagnostic errors in emergency care.

Risk Factors for Post-treatment Complex Regional Pain Syndrome (CRPS): An Analysis of 647 Cases of CRPS from the Danish Patient Compensation Association.

OBJECTIVES: Complex regional pain syndrome is a challenging condition that includes a broad spectrum of sensory, autonomic, and motor features predominantly in extremities recovering from a trauma. Few large-scale studies have addressed occurrence of and factors associated with complex regional pain syndrome (CRPS) following orthopedic treatment. The present study aimed to identify factors associated with post-treatment development of CRPS. METHODS: Using the Danish Patient Compensation Association's database, we identified 647 patients claiming post-treatment CRPS between 1992 and 2015. Age, gender, initial diagnosis, treatment, and amount of compensation were extracted. Multivariate logistic regressions were performed to identify variables associated with approval of the claim. For carpal tunnel syndrome (CTS) patients, we registered whether symptoms were bilateral or unilateral and if neurophysiology prior to treatment was pathologic. RESULTS: The following ratios were found: women:men was 4:1, primary diagnosis to the upper limb:lower limb was 2.5:1, and surgical:nonsurgical treatment was 3:1. Mean age was 47.5 ± 13.7 years, and no intergender difference was detected. Antebrachial fracture (23%) and CTS (9%) were the most common primary conditions. Surgical treatment was associated with approval of the claim (odds ratio 3.5, 95% confidence interval 2.3 to 5.3; P < 0.001). Half of CTS patients had normal neurophysiology prior to surgery; among patients with unilateral symptoms, 71.4% had normal neurophysiology. CONCLUSIONS: Female gender, surgical treatment, and treatment to the upper limb were risk factors. Elective surgery accounted for a large number of post-treatment CRPS patients. In CTS patients developing CRPS, normal neurophysiological examination findings were common, and it could be suspected that these patients were suffering from an pre-clinical stage of CRPS, not CTS.

Severe and fatal obstetric injury claims in relation to labor unit volume.

OBJECTIVE: To assess possible association between the incidence of approved claims for severe and fatal obstetric injuries and delivery volume in Denmark. DESIGN AND SETTING: A nationwide panel study of labor units. POPULATION: Claimants seeking financial compensation due to injuries occurring in labor units in 1995-2012. METHODS: Exposure information regarding the annual number of deliveries per labor unit was retrieved from the Danish National Birth Register. Outcome information was retrieved from the Danish Patient Compensation Association. Exposure was categorized in delivery volume quintiles as annual volume per labor unit: (10-1377), (1378-2016), (2017-2801), (2802-3861), (3862-6659). MAIN OUTCOME MEASURES: Five primary measures of outcome were used. Incidence rate ratios of (A) Submitted claims, (B) Approved claims, (C) Approved severe injury claims (120% degree of disability), (D) Approved fatal injury claims, and (C+D) Combined. RESULTS: 1 151 734 deliveries in 51 labor units and 1872 submitted claims were included. The incidence rate ratios of approved claims overall, of approved fatal injury claims, and of approved severe and fatal injuries combined increased significantly with decreasing annual delivery volume. Face value incidence rate ratios of approved severe injuries increased with decreasing labor unit volume, but the association did not reach statistical significance. CONCLUSION: High volume labor units appear associated with fewer approved and fewer fatal injury claims compared with units with less volume. The findings support the development towards consolidation of units in Denmark. A suggested option would be to tailor obstetric patient safety initiatives according to the delivery volume of individual labor units.

Outsourced cataract surgery and postoperative endophthalmitis.

PURPOSE: To compare the risk of postoperative endophthalmitis (PE) after cataract surgery at eye departments in public hospitals and private hospitals/eye clinics and to evaluate if the Danish National Patient Registry (NPR) is a reliable database to monitor the PE risk. METHODS: Postoperative endophthalmitis cases were retrospectively identified via the NPR and chart review in order to confirm PE cases that had cataract surgery in the calendar period 2002-2010. RESULTS: We identified 39 cases of PE after 107 701 registered public cataract operations; PE risk = 0.36 [corrected] per 1000 operations and 27 cases of PE after 36 760 registered private operations; PE risk = 0.73 [corrected] per 1000 operations. There was homogeneity in the PE risk among the eye departments in public hospitals (p = 0.6), but heterogeneity in the PE risk among the private hospitals/eye clinics (p = 0.0001). Six private hospitals/eye clinics had a statistically significantly higher PE risk compared with the eye departments in public hospitals. In all, 98% of public cataract surgery was registered in the NPR compared with 38% of private cataract surgery. The private hospitals/eye clinics with the highest PE risk after registered cataract surgery had many cases of PE where the causative cataract operation was not registered with the NPR. CONCLUSION: A few private hospitals/eye clinics had a statistically significantly higher PE risk than the PE risk at the eye departments in public hospitals. The lack of registration with the NPR by the private hospitals/eye clinics suggests that better monitoring of cataract surgery is needed in Denmark to reduce risk and to improve quality.

Risk of pseudophakic retinal detachment in 202,226 patients using the fellow nonoperated eye as reference.

PURPOSE: To study the risk of pseudophakic retinal detachment (PRD) after first-eye phacoemulsification cataract surgery in Denmark relative to the risk of retinal detachment (RD) in the patients' fellow nonoperated eyes. DESIGN: Register-based cohort study. PARTICIPANTS: Danish patients (n = 202 226). METHODS: All patients underwent uncomplicated first-eye phacoemulsification cataract surgery from 2000 through 2010. Surgeries were identified via the National Patient Registry in Denmark and the Civil Registration Number. The fellow nonoperated eye was used as a reference. MAIN OUTCOME MEASURES: Rhegmatogenous RD. RESULTS: We identified 110 RDs in the fellow nonoperated reference eyes. In these eyes, male sex and younger age were associated significantly with greater risk of RD. We identified 465 PRDs on the cataract-operated eyes. The relative risk of PRD was 4.23. This effect of cataract surgery on the relative risk of RD (the PRD risk ratio) was not statistically significantly modified by sex and age. The PRD risk ratio was not significantly higher in men compared with women (hazard ratio, 1.26); was highest for the 40-year-old cohort and lowest for the 80-year-old cohort; and was highly increased during the first 6 months after surgery and leveled off but remained significantly elevated up to 10 years after cataract surgery. CONCLUSIONS: Using the fellow nonoperated eye as a reference, this comprehensive matched-design cohort study clearly separates the epidemiologic factors of occurrence of RD from the relative risk of PRD. The epidemiologic factors of RD in the fellow eyes was predicted strongly by age and sex. The 4-fold increase in risk associated with cataract surgery, the PRD risk ratio, was not statistically significantly modified by gender and age. The long follow-up demonstrated a persistently significantly elevated relative risk of PRD up to 10 years after cataract surgery. Because the fellow eye was used as reference, the PRD risk ratio can be considered a true etiologic effect of cataract surgery.

Work-related stressors and occurrence of adverse events in an ED.

OBJECTIVE: The purpose of this study was to investigate the relationship between 12 work-related stressors and the occurrence of adverse events in an emergency department (ED). METHODS: Nurses and physicians, working in an ED at a Danish regional hospital, filled out a questionnaire on occurrence and emotional impact of 12 work-related stressors after each shift during a 4-week period. The questionnaire also instructed the participants to describe any adverse events that they were involved in during the shift. RESULTS: Two hundred fourteen adverse events were reported during the 979 studied shifts. During the same period, only 27 adverse events were reported to the mandatory national reporting system, and only 10 of these were duplicates. A high variability of stressors and emotional impact among the different groups of participants was found. Linear regression analysis showed an association between involvement in adverse events and the occurrence and emotional impact of stressors across groups, whereas no significant association was found for age, seniority, shift type, or length. CONCLUSION: The study showed an association between the occurrence and impact of 12 work-related stressors and involvement in adverse events across the groups of participants. Furthermore, the study showed that most adverse events were not reported to the mandatory national reporting system.

Improving construction site safety through leader-based verbal safety communication.

BACKGROUND: The construction industry is one of the most injury-prone industries, in which production is usually prioritized over safety in daily on-site communication. Workers have an informal and oral culture of risk, in which safety is rarely openly expressed. This paper tests the effect of increasing leader-based on-site verbal safety communication on the level of safety and safety climate at construction sites. METHOD: A pre-post intervention-control design with five construction work gangs is carried out. Foremen in two intervention groups are coached and given bi-weekly feedback about their daily verbal safety communications with their workers. Foremen-worker verbal safety exchanges (experience sampling method, n=1,693 interviews), construction site safety level (correct vs. incorrect, n=22,077 single observations), and safety climate (seven dimensions, n=105 questionnaires) are measured over a period of up to 42 weeks. RESULTS: Baseline measurements in the two intervention and three control groups reveal that foremen speak with their workers several times a day. Workers perceive safety as part of their verbal communication with their foremen in only 6-16% of exchanges, and the levels of safety at the sites range from 70-87% (correct observations). Measurements from baseline to follow-up in the two intervention groups reveal that safety communication between foremen and workers increases significantly in one of the groups (factor 7.1 increase), and a significant yet smaller increase is found when the two intervention groups are combined (factor 4.6). Significant increases in the level of safety are seen in both intervention groups (7% and 12% increases, respectively), particularly in regards to 'access ways' and 'railings and coverings' (39% and 84% increases, respectively). Increases in safety climate are seen in only one of the intervention groups with respect to their 'attention to safety.' No significant trend changes are seen in the three control groups on any of the three measures. CONCLUSIONS: Coaching construction site foremen to include safety in their daily verbal exchanges with workers has a significantly positive and lasting effect on the level of safety, which is a proximal estimate for work-related accidents. It is recommended that future studies include coaching and feedback at all organizational levels and for all involved parties in the construction process. Building client regulations could assign the task of coaching to the client appointed safety coordinators or a manager/supervisor, and studies should measure longitudinal effects of coaching by following foremen and their work gangs from site to site.

A nationwide population study of severe head injury and Parkinson's disease.

The aim was to analyze prospectively the association between severe head injury and Parkinson's disease. All people in Denmark who were at least 20 years old as on 1 January 1981 were followed for hospitalisation due to previous head trauma during 1981-1993 and for hospital contacts due to PD during 1995-2004. We observed 107 cases of PD among people at hypothetical risk due to previous head injury. The expected number was 112.1, which yielded a standardised morbidity ratio of 0.954 (95% CI: 0.782-1.15). The study provides no support for severe head injury among adults being a risk factor for Parkinson's disease.

Social inequalities in injury occurrence and in disability retirement attributable to injuries: a 5 year follow-up study of a 2.1 million gainfully employed people.

BACKGROUND: Inequalities in injury related disability retirement may be due to differences in injury risk and or differences in retirement given injury. The aim of the present study was to measure social inequalities in injury occurrence and injury related disability retirement. METHODS: All people in the Danish labour force aged 20-59 years 1 January 1997 were followed for injury related hospital contacts during 1997 and all people in the Danish labour force aged 21-54 years 1 January 1998 were followed for injury related hospital contacts during 1997 and for disability retirements during 1998-2002. As inequality indices we used excess fractions (EF) i.e. the proportions of the cases that would not have occurred if the risks in each social group had been as low as they were in the occupational group with the highest skill requirements. RESULTS: With regard to the risk that an injury will occur, the EF was 36% among men and 10% among women. With regard to the risk that an injury will lead to disability retirement, the EF was 43% among men and 47% among women. The combined effect of the two types of inequalities rendered an EF for injury related disability retirement of 64% among men and 53% among women. The correlation between the case disability rate ratios among men and those among women was low (r = -0.110, P = 0.795). CONCLUSION: The social inequality in injury related disability retirement lies only to some degree in the differences in the injury risk. More important are differences in the consequences of an injury. This was especially pronounced among the women.

Efficiency in reducing lost-time injuries of a nurse-based and a first-aid-based on-site medical facility.

OBJECTIVES: The purpose of the study was to evaluate the efficiency of two standards for on-site medical facilities in reducing lost-time injuries during the construction of the link across the Oresund sound between Sweden and Denmark. One medical facility employed licensed nurses, who had advanced medical assistance at their disposal. The other medical facility utilized first-aid-trained watchmen. The on-site medical facilities aimed both at providing immediate medical assistance to workers subjected to occupational injuries and at reducing lost worktime. METHODS: The distributions of injuries treated on-site (the worker resumed work after treatment) and injuries sent to hospitals or to specialists were compared for each type of injury and for each category of injured body part. RESULTS: The on-site medical facilities dealt, in particular, with the treatment of ocular injuries (21%), wounds (21%), and sprains or strains (15%). The study showed a statistically significant on-site treatment (and resume work) rate ratio of 3.3 between the nurse-based (76%) and the first-aid-based (23%) medical facility. CONCLUSIONS: The construction of the Oresund Link shows a need for on-site medical facilities, particularly at remote construction sites, and that it is essential that the medical personnel have both the qualifications and authorization to treat site-specific workplace injuries effectively in order to obtain high on-site treatment rates.

Large heterogeneity of the obesity epidemic in Danish adults.

OBJECTIVE: To examine to what extent the obesity epidemic is a general phenomenon in adults by assessing the secular change, by birth cohort and age, in the prevalence of obesity and median body mass index (BMI) in Danish men and women measured between 1964 and 1994. DESIGN: Multiple cross-sectional population surveys. SETTING: The greater Copenhagen area of Denmark. SUBJECTS: The study included 17,065 men (30 336 observations) and 13,417 women (24,065 observations), aged 20-84 years. MAIN OUTCOME MEASURES: Trends in median BMI and prevalence of obesity estimated from measured height and weight in 10-year age groups. RESULTS: In general the prevalence of obesity was increasing, although in an irregular way: among men in two phases, during the 1970s and 1990s and among women only during the 1990s. Great heterogeneity was observed between birth cohorts and age groups. There was only little indication of an increasing trend in obesity prevalence for women, except for the 55-64-year-olds. In men, the prevalence of obesity was increasing in all age groups except in the youngest ones, and it was statistically significant only for men aged 35-74 years. There was no significant linear change in median BMI in any group, except for an increasing trend among men aged 50 years and above. CONCLUSION: Although the overall Danish trend for obesity prevalence, similar to trends world-wide, showed a marked increase, the trend was very heterogeneous and generally neither uniform nor significantly positive; the changes were irregular, different among men and women, and different in the different age and birth cohorts. The obesity problem in middle-aged and older men of certain birth cohorts poses a specific public health challenge. Future studies of determinants behind the heterogeneity in the development of the obesity epidemic may provide clues to its causes.