Patient Safety Monitoring in Acute Care in a Decentralized National Health Care System: Conceptual Framework and Initial Set of Actionable Indicators.

OBJECTIVES: Monitoring patient safety is critical for continuous quality improvement in acute care. We carried out a national project to identify a conceptual framework with core indicators that could be uniformly applied in the decentralized health system of Italy. METHODS: We used key international references to identify a framework with a core list of indicators and data sources for calculation in 4 hospitals in the Lombardy region. Two different data processing methods were applied: (a) centralized analysis of national databases and (b) decentralized data extraction and calculation using different hospital data available in Lombardy. RESULTS: Agreement was reached on a conceptual framework for patient safety monitoring in acute care, including structures, processes, and outcomes as vertical dimensions and health care needs as horizontal axes. We were able to compute 15 of 32 indicators through the application of a range of methods. The calculation of indicators using national databases was based on international standards. The consistency of the estimates obtained through the use of different methods and data sources seemed limited. CONCLUSIONS: We successfully identified a conceptual framework for patient safety in acute care including actionable indicators that can be calculated routinely using different data sources at national, regional, and hospital levels. Further work is required to compare methods and understand whether a combination of strategies at national and local levels could be proven effective.

Development of Guidelines for Health Impact Assessment in Southern Italy.

Health impact assessment (HIA) is a multidisciplinary method aimed at assessing the health effects of policies, plans, and projects using quantitative, qualitative, and participatory techniques. In many European countries, such as in Italy, there is a lack of implementation of HIA procedures and it would be necessary to develop instruments and protocols in order to improve the specific skills of professionals involved in the assessment process. This article aims to describe the development and implementation of HIA guidelines, promoted by the Italian National Agency for Regional Health Services (AGENAS), in 4 Southern Italian regions. Public health search engine and institutional Web sites were consulted to collect international data existing in this field. Monthly workshops were then organized with regional representatives to discuss the scientific literature and to identify the guidelines' contents: source of data, stakeholders, screening- and scoping-phase checklist tools, priority areas, monitoring, and reporting plans. Four regions (Calabria, Campania, Puglia, and Sicilia) took part in the project. This article describes the methodology of development and implementation of HIA guidelines in the Italian context. The tools created to collect data and assess health consequences (such as screening and scoping grids) are reported. This project represents the first structured initiative proposed and supported by the Ministry of Health aiming to introduce HIA in Italy. HIA should be considered a priority in the public health agenda, as a fundamental instrument in helping decision makers to make choices about alternatives to prevent disease/injury and to actively promote health.

[Defensive Medicine: Defensive Medicine: Overview of the literature]. / Overview della letteratura scientifica sul tema medicina difensiva.

A literature review was performed on the subject of defensive medicine, in order to gather information and evidence for identifying a shared definition of this phenomenon, identify its causes, quantify its frequency and its economic impact.Results show that defensive medicine is primarily the result of medical professionals adapting to the pressure of litigation risks, and whose behaviour is motivated by fear of malpractice claims rather than by the patient's health. Defensive medicine seems to have become a diffuse phenomenon, afflicting all diagnostic-therapeutic areas and some disciplines to a greater degree, and leading to a large waste of human, organizational and economic resources.

[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]. / "Fare di più non significa fare meglio". Le proposte dell'ANMCO.

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.

[Second victims of medical errors: a systematic review of the literature]. / Le seconde vittime in Sanità: una revisione sistematica di letteratura.

"Second victims" are health care providers who remain traumatized and suffer at the psycho-physical level after being involved in a patient adverse event. A systematic review of the literature was conducted to: a) estimate the prevalence of second victims among healthcare workers, b) describe personal and work outcomes of second victims, c) identify coping strategies used by second victims to face their problems, and d) describe current support strategies. Findings reveal that the prevalence of "second victims" of medical errors is high, ranging in four studies from 10.4% to 43.3%. Medical errors have a negative impact on healthcare providers involved, leading to physical, cognitive and behavioural symptoms including the practice of defensive medicine. Managers of health organizations need to be aware of the "second victim" phenomenon and ensure adequate support is given to healthcare providers involved. The best strategy seems to be the creation of networks of support at both the individual and organizational levels. More research is needed to evaluate the efficacy of support structures for second victims and to quantify the extent of the practice of defensive medicine following medical error.

[Secondary cardiovascular prevention after acute coronary syndrome in clinical practice]. / Prevenzione cardiovascolare secondaria dopo sindrome coronarica acuta nella pratica clinica.

Secondary prevention after acute coronary syndromes should be aimed at reducing the risk of further adverse cardiovascular events, thereby improving quality of life, and lengthening survival. Despite compelling evidence from large randomized controlled trials, secondary prevention is not fully implemented in most cases after hospitalization for acute coronary syndrome. The Lazio Region (Italy) has about 5.3 million inhabitants (9% of the entire Italian population). Every year about 11 000 patients are admitted for acute coronary syndrome in hospitals of the Lazio Region. Most of these patients receive state-of-the art acute medical and interventional care during hospitalization. However, observational data suggest that after discharge acute coronary syndrome patients are neither properly followed nor receive all evidence-based treatments. This consensus document has been developed by 11 Scientific Societies of Cardiovascular and Internal Medicine in order develop a sustainable and effective clinical approach for secondary cardiovascular prevention after acute coronary syndrome in the local scenario of the Lazio Region. An evidence-based simplified decalogue for secondary cardiovascular prevention is proposed as the cornerstone of clinical intervention, taking into account regional laws and relative shortage of resources. The following appropriate interventions should be consistently applied: smoking cessation, blood pressure control (blood pressure < 130/80 mmHg), optimal lipid management (LDL cholesterol < 80 mmHg), weight and diabetes management, promotion of physical activity and rehabilitation, correct use of antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone system blockers.