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Patient Safety and Quality

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Organizational style influences clinical departmental differences in dealing with patient safety

How physicians deal with patient safety and medical errors depends, in large part, on how their clinical department is organized and the flow of work in it. For example, the hierarchical structure of the surgery department and its emphasis on individual blame for mistakes contrasts with the more collegial environment, available physician downtime, and work predictability of the medical intensive care unit (ICU). The emergency department, though the most egalitarian, suffers from intense workload, excessive disruptions, and high unpredictability of its clinical work. Each of these factors influences the ability of the clinical unit to respond to medical errors effectively.

To determine the differences between the work environments in these clinical units, Timothy J. Hoff, Ph.D., of the University of Albany (State University of New York), observed and interviewed (over three 3-week periods) the attending and resident physicians in the surgery, medical ICU, and emergency departments at an academic medical center. He looked at permeability (the speed and ease with which both physicians and patients moved in and out of a clinical setting), the complexity and predictability of the clinical work, the extent and quality of time available for physicians to do and reflect on the clinical work, social relations between physicians in each setting, and specifics of the clinical workload.

On the basis of Dr. Hoff's observations, the medical ICU appeared to have the highest potential capacity for dealing with patient safety and quality of care. This was due, in part, to much "downtime" for the ICU physicians to discuss medical errors that happened or were caught before any injury to the patient occurred. In contrast, the physicians on the surgical unit had little time for group learning or reflection on errors, and its hierarchical structure tended to place the blame for errors on individuals. Although the physicians in the emergency department also had little time for reflection, the department had a nonhierarchical style and accepted that errors sometimes were due to factors beyond the physician's control.

For change in patient safety behavior to occur, there must be an understanding of the context of the work environment in a particular clinical setting, and of the interventions most likely to improve patient safety in each setting, suggests Dr. Hoff. His study was funded by the Agency for Healthcare Research and Quality (HS11697).

More details are in "How work context shapes physician approach to safety and error," by Dr. Hoff, in the April-June 2007 Quality Management in Health Care 17(2), pp. 140-153.

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