Ethical and malpractice issues in hospital practice.

Ethical and malpractice issues arising in hospital practice are reviewed. Topics include (a) preparation and authorization to carry out clinical responsibilities, (b) personnel procedures, (c) financial and political forces influencing hospital policies, (d) billing procedures, (e) clinical procedures for responding to patients' needs, (f) confidentiality, (g) discrimination, (h) internship and training issues, (i) sexual abuse of patients, and (j) staff conflicts influencing patient care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Questions of liability in unsuccessful voluntary sterilization (author's transl)

Since the June 29, 1976, decision of the Federal High Court of the Federal Republic of Germany, voluntary sterilization is permitted under certain, limited, circumstances. After the physician has thoroughly instructed the patient, the patient must give written consent in agreement with S 226 of the penal code. The physician cannot then later be charged with commiting bodily injury according to S 224 of the penal code. Recently, the German courts have tended more and more to consider the unplanned birth of a child following unsuccessful sterilization as a damage case for which the attending physician is held responsible under civil law. For most physicians, this means that the financial compensation set by the court is not, or at least not fully, covered by their medical indemnity insurance. A corresponding increase in the medical indemnity coverage or a release from all damage claims overagainst the attending physician signed by the patient is urgently indicated.     

Withholding medical care as a physical injury--manslaughter and withdrawal of treatment]

Withholding therapy may cause a charge of manslaughter and the intended withdrawal of therapy may result in proceedings because of second-degree murder, requested homicide and omission of help, respectively. According to the criminal law, negligence of the duty to help does not require a guarantor position of the physician but the intent for punishableness. Otherwise, the physician is liable for negligence only if he holds a guarantor position for the protection of the patient's life and health. The facts of manslaughter require the violation of medical care which is not equal to the violation of common or mostly acknowledged rules of medical science. Another requirement for liability is causality. Thus, is has to be proven without doubt that the patient's death would have been avoided if the omitted therapy had been applied. The legal requirements on the principle of causality are high. Therefore, negligence can be proven in many cases but the proof of causality does not succeed and the charges have to be dropped. In such a case, it is totally wrong to attempt a charge of omission of help since the criminal law requires intent and is not a collector for neglected medical procedures.     

Malpractice liability of physicians to nonpatients

Sometimes physicians assume responsibilities to third parties when undertaking the care of patients. Physicians have been held liable to third parties, though strangers to the patients, for failing to warn regarding the communicability of contagious diseases. Two suits have been allowed against physicians by third parties who were injured by drivers of vehicles who had not been warned by the physician of the danger of driving caused by their medical problem. Hospitals and psychiatrists have been held liable to injured third parties for failing to warn of the dangerous propensities of their patients under psychotherapy. Courts have held that such disclosures do not violate the patient's right to privacy and confidentiality. However, physicians may exercise professional discretion and need not warn if, in their judgment, that would be unreasonable, unnecessary, or harmful. Nevertheless, rights of patients must yield to the public interest when it collides with public safety and welfare.     

Malpractice: Professional liability and the law.

Contends that psychologists typically possess only the most rudimentary understanding of the medical–legal concept surrounding today's professional malpractice suits. This article explores the elements making up the underlying concept of negligence and the related notion that it should ultimately be the profession itself, and not the jury, that determines the standard of care with which the accused provider must be compared. Although the proof of provider negligence, or "fault," is the present basis of malpractice, the inherent inappropriateness of such a conceptual model for most medical and especially therapeutic "injuries" is stressed. A recently enacted Hawaii statute establishing medical–legal "claim conciliation panels" is prefered as a logical step in the eventual evolution of a pure "no-fault" approach to the rising incidence of health care suits. (12 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Committee on Professional Liability Insurance. Professional liability insurance for psychologists.

Professional liability insurance for psychologists is obtainable through the Smith-Hoggatt-Dawson Insurance Agency of Champaign, Illinois. Coverage is described and premiums specified. Insurance is granted automatically to an APA member if he is an ABEPP diplomate "… or if he is a regular member of the staff of a recognized college, university, school or school system, firm of industrial or clinical practitioners' clinic, hospital, or church" and to others. Non-ABEPP diplomates "… in completely independent private practice… " must be sponsored in writing by two ABEPP diplomates. The "… insurance now available is written in such a way as to cover research workers as well as… " practitioners. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Settlement fraud from the viewpoint of the defendant

When a physician by attempting to gain an illegal financial advantage for himself or another person damages the property of somebody in such a way that he produces or maintains an error under false pretense or distortion or suppression of facts, the physician is guilty of fraud. The attempt is a criminal offense. Following terms are discussed in this paper: illegal financial advantage, damage of property, intent, and status proceedings.     

Reactive oxygen species in human semen: investigations and measurements

OBJECTIVES: The introduction of the Medicare Prospective Payment System and the more recent rise of managed care plans have greatly increased the importance of effective hospital financial management. Because physicians play a central role in directing hospital resource use, policies to influence physician behavior and to align physician and hospital interests more effectively are being advocated increasingly. This article evaluates the effect of nine strategies to facilitate physician involvement and integration into the hospital on hospital financial performance. METHODS: Data came primarily from the Prospective Payment Assessment Commission's hospital-physician relations survey of 1,485 hospitals and the Medicare Cost Reports. Both ordinary least squares and first differencing models were used to evaluate the effect of physician integration on hospital financial performance. RESULTS: Hospitals with lower margins and higher costs were more likely to have implemented strategies to integrate physicians and to modify physician behavior than their counterparts. Analysis using first differencing models indicated that making department heads responsible for the profits and losses had a significant positive effect on margins, whereas including medical staff on the hospital's board and offering physicians management services had a significant negative impact on average Medicare costs. In addition the number of strategies implemented was associated positively with financial performance. The paper also emphasizes the importance of model specification in evaluations of hospital-physician arrangements. CONCLUSIONS: Changes in hospital-physician relations may have been one reason why hospitals have been relatively successful at containing costs and retaining profitability in recent years. More research needs to be done on which specific arrangements affect hospital financial performance, as well as their effect on the quality of patient care.     

Supervisor personal liability for ADA discrimination. Emerging issues for hospital administrators and physicians

This article discusses emerging and conflicting trends in recent Americans with Disabilities Act discrimination legal decisions in which plaintiffs seek compensatory or punitive damages directly from supervisors and their employers, creating potential issues of personal liability for physicians or hospital administrators, for example. Also addressed in the article are potential problems employers face if supervisors are held personally liable for Americans with Disabilities Act discrimination.     

Mode of referral to hospital of patients with heart attacks: relevance to home care and special ambulance services

Out of 1250 consecutive patients brought to hospital with heart attacks 956 (76%) were at home when their symptoms began. Of these, 587 (61%) called their general practitioner, and for the remainder an ambulance was summoned by a member of the public. Of the 294 patients who were away from home when the attack occurred 291 were brought to hospital by ambulance. Of these, only 70 (24%) were attended by a general practitioner. Patients for whom ambulances were called by a general practitioner had had their symptoms significantly longer and had significantly lower prehospital and hospital mortalities than those for whom ambulances were summoned by members of the public. Special "cardiac" ambulances appear to be inappropriate for patients who have been seen by a general practitioner, and for this group home care may well be as effective as hospital admission.     

Tomodensitometry imaging and MRI of primary lung cancers

At present limited data exist describing the hospital use patterns of intravenous drug users (IVDUs) and women with AIDS. Our objective was to determine if frequency of hospitalization, length of stay (LOS), and cost per hospitalization varied by risk status and gender, controlling for a variety of confounders, including severity of illness as measured by the Turner-Kelly-Ball and Justice AIDS severity of illness systems. We performed a population-based cohort study that compared all women (n = 69) and male IVDUs (n = 74) with AIDS diagnosed in Massachusetts in 1987 with a random sample of all male, nonintravenous drug-using patients diagnosed in that year (n = 148). Frequency of hospitalization, LOS, and cost of hospital care were obtained from hospital billing records for 1987 and 1988. Regression analysis showed 42% longer lengths of stay (p < or = 0.001) and 38% higher cost (p < or = 0.001) per hospitalization for IVDUs with AIDS compared with non-IVDU homosexual AIDS patients. No statistically significant differences by gender were observed. Our results suggest that hospital care for IVDUs is likely to be more expensive. Policymakers should incorporate these data when planning for AIDS care. In addition, instruments to assess severity of illness should incorporate information on intravenous drug use.     

The influence of the concentration of volatile anesthetics on the stapedius reflex determined intraoperatively during cochlear implantation in children

STUDY OBJECTIVE: To evaluate the impact of a protocol on partner abuse (PA) at increasing identification and improving acute management of abused women by emergency department (ED) staff. METHODS: A community intervention trial compared two public hospital EDs at baseline and following implementation of a PA intervention. The intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff documentation of abuse and use of interventions. RESULTS: Approximately equal numbers of records were reviewed at each ED, pre and post implementation (total n = 8,051). Eighty-nine per cent of ED staff were trained. No difference in the overall identification of PA was found (chi 2 = 0.13, p = 0.72), but logistic regression analyses showed other significant changes. At the intervention site, there was an increase in confirmed cases of PA (chi 2 = 7.6, p = 0.006), a trend towards increased documentation (chi 2 = 3.5, p = 0.06) and a significant increase in interventions offered (chi 2 = 13.8, p = 0.002). Changes at the comparison site failed to reach significance. CONCLUSION: Implementation of this protocol resulted in a moderate increase in confirmed cases of abuse and improved the acute management offered to identified victims. The findings reinforce recommendations for widespread implementation of training and protocols to address partner abuse.     

The use of nurse practitioners in the acute care setting

A collaborative practice model was initiated in a university hospital to assist resident physicians to coordinate patient care on specialty services. Nurse practitioner (NP) data were collected on daily work activities and categorized as direct care, indirect care, administration, education, and research. Satisfaction surveys were collected from patients, physicians and nursing staff. Data on clinic evaluation and management service provided by the NPs were reported. The study supported the appropriateness of NPs in the acute care setting.     

Pulmonary complications of methotrexate therapy

About 10% of patients consulting a family practitioner have neurological complaints, and about 2% ultimately receive a neurological diagnosis. As it is not possible to train enough neurologists for these patients, graduating medical students must be competent and confident in assessing neurological problems, particularly those that are common, treatable or require emergency management. An evaluation was made of the neurological problems commonly seen in family practice, the difficulties in managing neurological problems by the family practitioner and the criteria for referral to a neurologist. To evaluate the teaching of medical students and house staff, the types of problems seen in a teaching hospital neurology service were examined. As a result of this study an approach to the training of physicians is outlined to assist them to handle confidently and competently the neurological problems they will see in daily practice.     

Development of an ostomy competency

Staff educators and staff nurses developed an ostomy competency, with the guidance and expertise of the advanced practitioner and enterostomal nurse at a large teaching hospital. The competency improved the quality of care for surgical ostomy patients. Care was standardized and staff nurses' clinical knowledge was enhanced. Following the sessions, staff nurses verbalized increased confidence in working with patients with ostomies and demonstrated increased autonomy and problem-solving abilities. No variances in educational aspects of care were noted on clinical pathways.     

Assessment of Anger and Aggression in Male Offenders With Developmental Disabilities.

Systematic assessment of anger among people with developmental disabilities has been lacking, especially for hospital inpatients. Reliability and validity of anger self-report psychometric scales were investigated with 129 male patients, mostly forensic. Anger prevalence and its relationship to demographic, cognitive, and personality variables and to hospital assaultive behavior were examined. High internal and intermeasure consistency, and some concurrent validity with staff ratings, were found. Retrospective validity regarding physically assaultive behavior in the hospital was obtained. Hierarchical regressions revealed that patient-reported anger was a significant predictor of assaults postadmission, controlling for age, length of stay, IQ, violence offense history, and personality variables. (PsycINFO Database Record (c) 2010 APA, all rights reserved)