tetano
Editor, Senior Moderator
J Forensic Leg Med. 2013 Nov;20(8):1131-4. doi: 10.1016/j.jflm.2013.09.012. Epub 2013 Oct 4.
Adverse event analysis in fatal cases of influenza A (H1N1) - A lesson from Poland.
Jurek T, Rorat M.
Source
Department of Forensic Medicine, Wroclaw Medical University, Poland.
Abstract
During pandemic of influenza A (H1N1) in 2009 the relationship between mortality and medical errors, especially delayed antiviral treatment initiation, was highlighted in many studies. Our study was based on 5 fatal cases of pandemic influenza A (H1N1) hospitalized in Poland between November 2009 and February 2011. The material included data from medical documentation as well as testimonies from medical personnel and patients' families recorded during on-going lawsuits alleging medical malpractice. The risk factors of adverse events were: lack of typical symptoms, lack of detailed medical history, clinical masking of a "trivial" illness, doctors' ignorance and insufficient knowledge, several physicians treating the same patient during hospitalization. Recommendations for improving management of pandemic infectious disease include: an effective, quick and detailed system of information about the epidemiological threat, clear indication of units with diagnostic and medical possibilities, rational health policy and national system of closed claims and adverse event analysis.
Copyright ? 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
KEYWORDS:
Medical error, Pandemic, Risk factor, Strategy
PMID:
24237836
[PubMed - in process]
http://www.ncbi.nlm.nih.gov/pubmed/24237836
Adverse event analysis in fatal cases of influenza A (H1N1) - A lesson from Poland.
Jurek T, Rorat M.
Source
Department of Forensic Medicine, Wroclaw Medical University, Poland.
Abstract
During pandemic of influenza A (H1N1) in 2009 the relationship between mortality and medical errors, especially delayed antiviral treatment initiation, was highlighted in many studies. Our study was based on 5 fatal cases of pandemic influenza A (H1N1) hospitalized in Poland between November 2009 and February 2011. The material included data from medical documentation as well as testimonies from medical personnel and patients' families recorded during on-going lawsuits alleging medical malpractice. The risk factors of adverse events were: lack of typical symptoms, lack of detailed medical history, clinical masking of a "trivial" illness, doctors' ignorance and insufficient knowledge, several physicians treating the same patient during hospitalization. Recommendations for improving management of pandemic infectious disease include: an effective, quick and detailed system of information about the epidemiological threat, clear indication of units with diagnostic and medical possibilities, rational health policy and national system of closed claims and adverse event analysis.
Copyright ? 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
KEYWORDS:
Medical error, Pandemic, Risk factor, Strategy
PMID:
24237836
[PubMed - in process]
http://www.ncbi.nlm.nih.gov/pubmed/24237836