Root cause analysis
medical errorの原因特定するためのツール
| 分類 | 要素 | |
| 患者 | 臨床的状態 言語 文化、宗教、 ソーシャル・サポート | |
| スタッフ | 疲労・ストレス、言語 | |
| 設備 | Availability | |
| 労働環境 | 業務量、エラーの報告システム、職場の物理的デザイン | |
| 教育・トレーニング | シニアスタッフ、訓練を受けていたか | |
| タスク | ガイドライン・アルゴリズムの有無 検査結果が得られたかどうか |
1 情報収集
2 Causal Factor Flow Chartを作る
3 Root Causeを特定する。
4 改善を提案し、実行する。
5 変化がよい方向に向かっているか確かめる。
よく起こる入院中のAdverse Event
外科入院：感染、出血、静脈血栓症
内科入院：薬剤副作用（糖尿病薬、抗凝固薬、抗生剤、鎮痛薬等で）５−７％で生じる。
高齢者における薬剤副作用のリスクの主要因は、すでに多剤を用いている事である。
引き継ぎに含めるべき項目
患者の基本情報、臨床的な状態（現在の医学的問題点、バイタル等）、治療計画、予想される問題点、現在待機中のアクション（待っている検査結果、等）
ETHICS
Beneficence：患者の利益となるように務める医師の義務
Brain Death; legally accepted condition of death and can discontinue the life support, without any consent or court order.
Organ donation;minor can be compelled to donate tissue to a close relative.
Euthanasia; criminal act for physicians.
Withholding of intake or care or Withdrawal of artificial life support; legal upon competent adult request.
Advance directive
Durable power of attorney / Healthcare proxy;only effective when pt is incapable to have decision.
Advance directives/Living will
患者が意識ある間は、まずは患者本人に確認を行う。意思決定能力がなくなった際にこれらを元に判断する。written or oral document.
Persistent vegetative state;maintain or withdrawal is dependent on advance directives or surrogates
DNRは常にすべての治療を中止というわけではなく、抗生剤、昇圧剤などのサポーティブケアも拒否するのかどうか、確認をする必要がある。
本人が意思決定できない＞Surrogate代理の意思決定者＝Next of kin
患者が意識があればどのようにされたいと思うかも代弁する。
priority order=1 spouse, 2 adult children, 3 parents, 4 siblings, 5 other relatives.
同じレベルの代理人間で意見の相違があれば、ethic committee or legal intervention.
*If patient is incapaciated, basic information can be shared with the family member if dr judge that doing so is the patient’s best interest.
Hospice; require <6 months prognosis
SPIKES for bad news; set the stage, perception, invitation, knowledge, empathy, summary
*Most American spend most of the last 5 years on her own.
Pregnant women can decide whether abort or not, not depending on husband opinion.
Accidental finding of fetus genetic test outside the purpose should not be told to parents nor written in chart.
Denial of Treatment
Autonomy is respected but the public health interest is more respected.
Discharge Against medical advice AMA
治療のリスクベネフィットの説明、治療拒否のリスク説明、意思決定能力の判定、退院後フォローアップの説明、外来主治医に連絡、記録に文章を残す。
Blood transfusion:Do when there are no directive cards, but Don’t if requested by competent adult
Legal competent adult(including pregnant women); can reject own treatment, but not their minors’ treatment.
未成年の治療
親もしくは法的後見人のみが同意をサインできる。
if they are not available, do the treatment without consent even if other relatives are available. If parents object to treatment, court order or child protection agency will be involved.
Custody後見for minors;one custody agreement is enough for the Tx
未成年が自分で意思決定できる状況
MEDICAL: Emergency, STD, treatment for Mental health or Substance abuse, pregnancy care, contraception,
LEGAL: 経済的に独立、子供がいる、結婚している、軍隊所属、高校卒業している
治療の同意
理解はしたがサインは拒否する場合：十分に理解して同意しているならば、口頭だけでOKで、その旨をカルテに書く。
Emergency situationで、患者が意思決定能力がない場合は、同意なし治療を行って良い。この場合はImplied consent（一般的な人であれば同意するであろう治療）に基づいて治療を行う。
Genetic disorder testing; if the onset is childhood, parents can decide. if adult onset, patients can decide
Confidentiality;in case of child/elderly abuse, suicide risk, threat to another person, public safety risk, confidentiality is not required
家族の治療
他の医師が手配できない緊急事態のみに限る。
虐待Child/Elderly
after full evaluation including separate interview, Dr needs to contact protective servises=つまり入院を手配する。
Reportable diseases;Dr to State health department. “B A SSSMMART Clam or Chicken or you’re Gone”. HBV, HAV, Salmonella, Shigella, Syphilis, Measles, Mumps, AIDS (but not HIV-positive), Rubella, TB, Chlamydia, Chicken Pox, Gonorrhea.
HIV positive status of Dr;if taken appropriate procedures, Dr doesn’t have to tell pt.
Patient HIV status;should be told to the partner if pt failed to do so.
HIV検査
患者は拒む権利がある。書面での同意書は不要。
EMTALA;Emergency Medical Treatment and Active Labor Act, anyone can have treatment regardless of payment ability
Medical malpractice
Use of checklist,
Independent verification of surgical site
Root cause analysis; staff interview
use of standardized handoffs
Insurance plan
Capitation;fixed monthly fee. ex in HMO
Point-of-Service plan; primary physician and referral to specialty. can go outside of the network with out-of-pocket fee,
Global payment;single payment to cover whole expense relating to a procedure.
Family Medical Leave Act (FMLA) : Federally mandate
| Benefit | Up to 12 weeks unpaied leave Job is protected during leave |
| Qualifying employee | >half-time employee Employed >1 year Employer with >50 employees |
| Covered conditions | serious health condition childbirth care of spouse, child parent |
雇用主への情報開示
患者が許可した場合行う。
その場合も、疾患情報は業務に関連するもののみを伝え、それ以外は伝えない。雇用主も不必要な疾患情報は望んでいない。
医師患者関係
長期患者のライフイベントに参加することは決して禁止されてない。個別の判断。
ロマンティックな関係は、医師の信頼・知識・影響力に基づいているものは、過去に医師患者関係であったとしても非倫理的とされる。また、アメリカ精神科学会は常に非倫理的と規定している。このような関係を確認した医療者はmedical boardに報告する必要がある。
LIFE CYCLE
Infancy
Birth rate; 4million/per year, 1/3 is cesarean and decreasing
Premature, very premature;<37, <32
Infant death; 6/1000 in total birth, 11/1000 in African American
Adoption; tell the child of birth as soon as they can understand language.
Bonding of parents and infant; enhanced by physical contact, decreased by low weight/ill birth or mother-father relationship
Educated mother; prepared and short labor time
Attachment of infant to caregiver; principal psychological task. at 1y, separation anxiety raises. if mother absent in physically or emotionally, risk of infant depression (poor health, slowed physical growth)
Reactive attachment disorder; withdrawn and unresponsive
Disinhibited social engagement disorder; attach to stranger
Reflex at birth
reflexive smile; social smile, first marker of reaction to other individual. from birth
Palmar grasp; <2m
Rooting and sucking reflexes; <3m
Moro (Startle) reflex; <4m
Babinski reflex; <12m
Trackingreflex; visually tracking, continues (not diminish)
Toddler 15m-2.5y
50-200 words at age 2.
can separate from mother by 3y
Death; consider as abandonment or separation
Preschool 3-6y
Separation anxiety disorder; if can’t stay separated after 3y
Death; consider as a punishment for bad behavior. death is temporary and the dead will come back. 6y consider death is irreversible. 9y understand he/she can die.
Regression; in case of the birth of other child
Strange anxiety; from 7m
Separation anxiety; from 12m
mental image; from 12m. can maintain mental image of mother or object
Risk of suicide; age>45 is the greatest risk. other include alcohol abuse, marital separation, male gender
Genetics
general population; Schizo=1%. Bipolar=1%
one parent or sibling with Dx; Schizo=10%. Bipolar=20%
two parents with Dx; Schizo=40%. Bipolar=60%
monozygotic twin with Dx; Schizo=50%. Bipolar=75%
Gender dysphoria (transsexual, transgender);permanent different gender identity. should allow different gender clothing at school age
*playing with other gender’s toy is normal as an explornation.
Estrogen;Menopause dose not effect to sex drive as E is minimally involved in libido.
Testosterone; define libido. may decrease by physiological or psychological stress.
Homosexuality;normal variant of sexual expression. 5-10%. no ethnic differences. possibly defined by prenatal sex hormone resulting in anatomic changes in some hypothalamic nuclei. sex hormone level in adults is non-specific.
Paraphilia;pedophilic is the most common. almost exclusive in men.
DM;no orgasmic problem. sildenafil is effective, psychological factor may be involved
Spinal cord injury; erectile and orgasmic problem. reduced testosterone level and decreased male fertility (but in females)
Learning Theory
Habituation; repeated stimulation results in a decreased response
Sensitization;repeated stimulation results in a increased response
Classical Conditioning; natural (unconditional) or learned (conditional) response by a stimulus. in stimulus generalization, a new stimulus causes a conditional response. Leaned helplessness is one of classical conditioning
Operant Conditioning; Behavior is determined by its consequences. positive/negative reinforcement (behavior is increased by reward or avoidance/escape), Punishment (aversive feedback) , Extinction (behavior is decreased by elimination of reinforcement)
Schedule of reinforcement;
Continuous, Fixed ratio, Fixed interval, Variable ratio, Variable interval
Shaping;rewarding closer and closer approximation of wanted behavior
Modeling; by role model