home Work and education Classification of risks in healthcare. Risk management in clinical and expert work on the example of dental care in clinics of the Samara State Medical University

Classification of risks in healthcare. Risk management in clinical and expert work on the example of dental care in clinics of the Samara State Medical University

Sonis BUT. G. 1 , Gilmiyarov E. M. 2 , Dodonov BUT. G. 3 , Alekseev D. G. 4 , Gryzunova T. E. 5

3 Candidate of Medical Sciences,

4 Candidate of Medical Sciences, Associate Professor,

5 Applicant,

1,2,3,4,5 Samara State Medical University

RISK MANAGEMENT IN CLINICAL EXPERT WORK ON THE EXAMPLE OF DENTAL CARE IN CLINICS OF SAMARA STATE MEDICAL UNIVERSITY

annotation

The article presents the experience of introducing the standard "Quality Management Systems" ISO 9001-2015 into the clinical and expert work on the example of dental care provided at the Clinics of the Samara State Medical University. The contents of the concepts of risk, risk-oriented thinking and risk management in a medical organization are disclosed. By analyzing the execution of 400 medical records of dental patients, the risks arising from the provision of dental care were identified, and an analysis of their possible consequences was carried out. Methods for managing identified risks have been selected that help reduce the likelihood of adverse consequences and corresponding losses.

Keywords: quality management system, ISO standard, dental care, risk, risk management, consequences.

Sonis A. G. 1 , Guilmiyarov E. M. 2 , Dodonov A. G. 3 , Alekseev D. G. 4 , Gryzunova THOSE. 5

1 MD, Professor,

2 MD, Professor,

4 MD, Associate Professor,

5 Postgraduate student,

RISK MANAGEMENT IN CLINICAL AND EXPERT WORK ON EXAMPLE OF DENTAL CARE IN CLINICS OF SAMARA STATE MEDICAL UNIVERSITY

Abstract

The article presents the experience of introduction of ISO quality management system 9001-2015 in the clinical and expert work on the example of dental care provided by the Clinics of the Samara State Medical University. The contents of the concepts of a risk, a risk-oriented thinking and a risk management in a medical organization are disclosed. By analyzing the registration of 400 medical records of dental patients, the risks associated with the provision of dental care were identified, and the analysis of their possible consequences was carried out. The managing methods for the identified risks were chosen, which contribute to reducing the likelihood of adverse consequences and corresponding losses.

keywords: quality management system, ISO standard, dental care, risk, risk management, consequences.

In a medical organization, to meet the needs of patients, it is necessary to follow the developed standards of the "Quality Management System". The most latest version ISO 9001, the optimal sample of the Quality Management System standard, was approved on September 28, 2015 by the Order of Rosstandart No. 1391-st “On approval of the national standard” (hereinafter referred to as the ISO 9001-2015 standard). ISO 9001-2015 “Quality management systems. Requirements” introduced the concept of risk-based thinking, which allows the organization to identify factors that can lead to a deviation from the planned results of the quality management system, as well as use preventive controls to minimize negative consequences, that is, manage risks.

Risk management is the process of making and implementing management decisions aimed at reducing the likelihood of an adverse outcome and minimizing possible losses.

Currently, there is no single, standardized definition of the concept of "risk" in relation to medical and clinical expert work. As a result, risk management is difficult. Therefore, before considering the features of risk management procedures, it is necessary to define exactly what we mean by “risk” in a medical organization. In accordance with the modern approach to the category of risk in the economy, the risk in the work of a medical organization can be considered the likelihood of negative consequences as a result of the implementation medical activities.

Applicable to medicine, there are two types of risk: systematic and non-systematic. Systematic risks are related to external factors and are outside general control medical organization, for example, the state of health care financing in the country. These factors should be considered and taken into account, because the medical organization is not able to influence their change. Unsystematic risks are something that directly concerns the medical organization. These risks may be associated with the process of providing medical care: diagnostic, therapeutic, rehabilitation; or associated with auxiliary processes: feeding patients, cleaning the institution, etc. . These risks can be controlled or influenced within the organization.

According to the degree of impact on the patient's health, risks can be divided into: permissible (without causing harm to health), critical (deterioration of health) and catastrophic (disability or fatal outcome). If possible, risks are divided into non-diversified (not subject to elimination) and diversified (for which there are possible ways to overcome).

As part of risk management, the following options for responding to risks should be distinguished:

Risk avoidance;
Elimination of the source of risk;
Change in likelihood or consequences;
Risk sharing;
Risk containment.

In the Clinics of the Samara State Medical University (hereinafter referred to as the Clinics of Samara State Medical University), in order to improve the quality of dental care and comply with European standards, the goal was to introduce risk-based thinking into clinical expert work.

Achieving this goal would be impossible without a preliminary, search and analytical stage. For its implementation, we have formulated and assigned to solve the following tasks:

Identify risks;
Conduct an analysis of their consequences;
Select risk management methods.

To identify risks in dental care, an assessment was made of the execution of a medical card for a dental patient, since it is this that is the main legal and financial document, reflecting the patient's condition, serves as reliable evidence of the carried out diagnostic and treatment process, reflects the dynamics and outcome of the disease, as well as the interaction of the attending physician with other specialists and services.

To process the obtained results, we used the analytical and statistical methods research.

At the 1st stage, 400 medical records of a dental patient were studied, which made it possible to identify the following risks:

I Mistakes in issuing a medical card:

For a patient who has already applied for dental care at the Clinic this year, a medical card is re-started.
Informed voluntary consent to medical intervention, the approved form (refusal of medical intervention) is not filled in full, with a detailed description of all manipulations.
Information about concomitant and past diseases is not filled out.
There is no information on the section of the allergic anamnesis.
Insufficient objective examination.
There are no indices (intensity of caries - CPU, complex periodontal index - CPI, hygiene index - IG).
There is no description of the patient's x-rays, there is no x-ray control after endodontic treatment.
The diagnosis is not formulated in accordance with the clinical data and the results of diagnostic studies, and also not in full (the nature of the course of the disease, coding according to the International Classification of Diseases - ICD-10, class according to Black, etc.)
The treatment does not indicate the names of antiseptics that are used for drug treatment and their dosage.
The type of local anesthesia performed is not indicated.
In the recommendations, the patient is prescribed branded drugs.
Oncological examination registration card is not filled out.
The date of the next visit to the patient is not indicated (the date of application of the devitalizing paste, medical pads, sutures, etc.)
There is no doctor's signature in the diaries.
In endodontic treatment, the number of root canals of teeth that have been mechanically processed and sealed is not indicated.

II Violations in the storage of medical records of dental patients and the lack of their general availability for all doctors of the Clinic, which was established in connection with the revealed facts of duplication of medical records for the same patient by different dentists.

III Personnel risks associated with the work of doctors with little professional experience.

IV Risks of management and organization of medical activities, in which it is necessary to take into account the human factor, which plays an important role in the occurrence of defects, no matter how the work of a medical institution is organized.

Identified risks can lead to the following negative consequences:

Legal (legal): appeals (complaints, claims) of citizens; lawsuits; punishments imposed by a court verdict (deprivation of the right to occupy certain positions or engage in certain activities, compulsory, corrective or forced labor, restriction of liberty, arrest, imprisonment for certain period, life imprisonment) ; unscheduled examinations by insurance companies, the territorial compulsory medical insurance fund and inspections of regulatory authorities (Roszdravnadzor, Rospotrebnadzor, the Ministry of Health, the prosecutor's office); suspension, termination of a license or revocation of a license.
Financial (economic): court costs, in the form of a state fee and costs associated with the consideration of a court case (amounts payable to witnesses, experts, specialists; travel and accommodation costs incurred in connection with appearing in court; costs for paying for the services of representatives ; compensation for the actual loss of time; postage and other expenses recognized by the court) ; fines, sanctions, penalties; compensation for losses, damage and harm; decrease in off-budget revenues; occurrence of additional expenses; increase in the cost of services and loss of business reputation.
Medico-social: prolongation of treatment time; progression of the patient's disease; the emergence of a new disease; deterioration in the health of the patient; lack of effect from treatment; development of complications and side effects; lengthening the period of incapacity for work; disability; fatal outcome; occupational infection of medical workers and accidents at work.

In accordance with the ISO 9001-2015 standard, a medical organization must develop, update and apply documented information to the extent necessary, register it and save it. That is, the documentation must be controlled to ensure that the controlled processes are carried out as planned. In this regard, as part of risk management at the Clinics of Samara State Medical University, the following have been developed:

"Form of control of registration of a medical card of a dental patient";
"The procedure for maintaining and issuing a medical record of a dental patient in the Clinics of the Samara State Medical University", which contains detailed information on the most frequently arising registration issues;
Inserts (templates, samples of diaries) in the medical record of a dental patient;
A new expanded form of "informed voluntary consent for dental intervention", indicating the need for certain manipulations, possible complications during and after treatment, as well as the consequences if the patient refuses medical intervention.

When studying medical records, it was noted that in 98.6% of cases there are defects in the writing of medical records, which can serve as a reason for supervisory, control, inspection organizations and courts to make decisions not in favor of the doctor and Clinics.

When analyzing acts on the control of issuing medical records, we found that young professionals do not tend to improve when issuing medical records, unlike doctors with extensive experience. This is due to the underestimation of the importance of the completeness and literacy of medical documentation, as well as the possible onset of liability for improper provision of medical care, which is one of the main reasons underlying the dishonest attitude to the execution of their obligations. professional duties.

Thus, in the course of monitoring the execution of 400 medical records of dental patients, it was possible to identify 18 risks in dental care and group them into 4 groups. After analyzing the identified risks, we came to the conclusion that they can lead to at least 23 consequences, which we grouped into 3 groups. As part of risk management at the Clinics of Samara State Medical University, work began on the development of the “Form for Controlling the Registration of a Medical Record of a Dental Patient”, “The Procedure for Maintaining and Issuing a Medical Record of a Dental Patient in the Clinics of Samara State Medical University”, samples of diaries in the medical record of a dental patient and a new expanded form of “informed voluntary consent for dental intervention.

Thanks to the data obtained and the planned plan for further work on risk management, we plan to reduce violations when issuing new medical records, reduce the number of risks and, as a result, possible negative consequences for the medical organization and patients.

We face risks every day in life. For example, when crossing the road, we evaluate the possible risks (going to a red traffic light) and their negative consequences for our lives (injury). In medicine, the patient trusts the doctor with nothing less than his life, which is why the risk management system is the most important tool for improving the quality of medical care.

References / References

References in English / References in English

At the end of the twentieth century. in developed countries, a new scientific and practical direction has arisen - risk management in various areas human activity. The influence of random events (risks) causing physical, moral and economic damage to the health of patients explores a new direction for the system of protection and restoration of public health - risk management in healthcare.

In general terms risk- this is an event or a group of related random events that cause damage to an object that has a given risk.

Randomness, or unpredictability of the occurrence of an event means the impossibility of accurately determining the time and place of its occurrence.

Risk management (risk management)- this is a system of measures, the purpose of which is to reduce the damaging or destroying impact of a hazard on the health, life, property, financial situation of the person at risk, etc.

The priority of risk management in medicine is to manage the quality of the diagnostic and treatment process and thus ensure the patient's medical safety.

Currently offered the following classification of patient risks:

1. Socio-political risks:

o changes in legislation on the forms and methods of organizing medical care for the population

o changes in the health financing system

o development of new economic relations and methods of healthcare management

o introduction and reorganization of the health insurance system

o privatization or nationalization of healthcare entities

o innovation processes in improving the regulatory framework for health care (new organizational and legal forms of activity medical organizations, entrepreneurship in health care, protection of patients' rights, insurance of professional medical activities, etc.)

o amendments to arbitration law

2. Risks associated with management:

o lack of a system of basic training for specialists in the field of health management and economics, medical law

o incompetence of managers in the field of management, economics and legislation in healthcare

o low professional level of a certain part of the staff

o not scientifically informed choice industry reform strategies

o neglect of occupational health and safety activities

3. Professional (medical) risks associated with civil liability:

o diagnostic

o medical

o medical (pharmacotherapeutic)

o preventive

o infectious

o psychogenic (psycho-emotional)

4. Risks associated with a threat to the health of medical workers from:

o patients with especially dangerous infections

o patients with viral hepatitis B and C, HIV infection, syphilis and other sexually transmitted diseases

o TB patients

o mental patients

o drug addicts

o criminals who infringe on medical personnel in order to obtain drugs

5. Other risks:

o technogenic (technical and operational)

o flammable

o explosive (storage and operation of oxygen)

o terrorist

In accordance with the proposed Classification of risks in healthcare, we will analyze the problems of patient safety in the most vital situations of medical practice.

Medical errors can be made at all stages of the relationship with the patient. The greatest dangers lie in diagnostic errors.