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Current Pharmaceutical Biotechnology

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ISSN (Print): 1389-2010
ISSN (Online): 1873-4316

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Research Article

Medical Records Quality as Prevention Tool for Healthcare-Associated Infections (HAIs) Related Litigation: a Case Series

Author(s): Giuseppe D. Albano, Giuseppe Bertozzi, Francesca Maglietta, Angelo Montana, Giulio Di Mizio, Massimiliano Esposito, Pietro Mazzeo, Stefano D'Errico and Monica Salerno*

Volume 20, Issue 8, 2019

Page: [653 - 657] Pages: 5

DOI: 10.2174/1389201020666190408102221

Price: $65

Abstract

Background: Healthcare-associated infections are one of the most serious Public Health concern, as they prolong the length of hospitalization, reduce the quality of life, and increase morbidity and mortality. Despite they are not completely avoidable, the number of healthcare-associated infections related to negligence claims has risen over the last years, contributing to remarkable economic and reputation losses of Healthcare System.

Methods: In this regard, several studies suggested a key role of medical records quality in determining medical care process, risk management and preventing liability. Clinical documentation should be able to demonstrate that clinicians met their duty of care and did not compromise patient’s safety.

Results: Therefore, it has a key role in assessing healthcare workers’ liability in malpractice litigation. Our risk management experience has confirmed the role of medical records accuracy in preventing hospital liability and improving the quality of medical care.

Conclusion: In the presented healthcare-associated infections cases, evidence-based and guidelinesbased practice, as well as a complete/incomplete medical record, have shown to significantly affect the verdict of the judicial court and inclusion/exclusion of hospital liability in healthcare-associated infections related claims.

Keywords: Healthcare-associated infections (HAIs), litigation, malpractice, claims, medical records, quality, prevention, clinical documentation.

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[1]
Arias, C.A.; Murray, B.E. Antibiotic-resistant bugs in the 21st century-a clinical super-challenge. N. Engl. J. Med., 2009, 360(5), 439-443.
[2]
Donaldson, L.J.; Appleby, L.; Boyce, J. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. Norwich, United Kingdom Stationery Office, 2000.
[3]
Goldenberg, S.D.; Volpé, H.; French, G.L. Clinical negligence, litigation and healthcare-associated infections. J. Hosp. Infect., 2012, 81(3), 156-162.
[4]
Mulcahy, L.; Tritter, J. Pyramids, pathways, and icebergs-understanding the relationship between dissatisfaction, complaints and disputes. Social. Health Illn., 1998, 20(6), 825-847.
[5]
Dancer, S.J. Pants, Policies and paranoia. J. Hosp. Infect., 2010, 74(1), 10-15.
[6]
Pittet, D. Infection control and quality healthcare in the new millennium. Am. J. Infect. Control, 2005, 33(5), 258-267.
[7]
Steffen, G.E. Quality medical care: a definition. JAMA, 1988, 260(1), 56-61.
[8]
Gutheil, T.G. Fundamentals of medical record documentation. Psychiatry (Edgmont), 2004, 1(3), 26.
[9]
Dunlay, S.M.; Alexander, K.P.; Melloni, C.; Kraschnewski, J.L.; Liang, L.; Gibler, W.B.; Peterson, E.D. Medical records and quality of care in acute coronary syndromes: results from CRUSADE. Arch. Intern. Med., 2008, 168(15), 1692-1698.
[10]
Garcia, A.; Revere, L.; Sharath, S.; Kougias, P. Implications of Clinical Documentation (In) Accuracy: A Pilot Study Among General Surgery Residents. Hosp. Top., 2017, 95(2), 27-31.
[11]
Dang, V.M.; Francois, P.; Batailler, P.; Seigneurin, A.; Vittoz, J.P.; Sellier, E.; Labarère, J. Medical record-keeping and patient perception of hospital care quality. Int. J. Health Care Qual. Assur., 2014, 27(6), 531-543.
[12]
Anderson, D.J.; Podgorny, K.; Berrios-Torres, S.I.; Bratzler, D.W.; Dellinger, E.P.; Greene, L.; Kaye, K.S. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect. Control Hosp. Epidemiol., 2014, 35(S2), S66-S88.
[13]
Hawn, M.T.; Vick, C.C.; Richman, J.; Holman, W.; Deierhoi, R.J.; Graham, L.A.; Itani, K.M. Surgical site infection prevention: Time to move beyond the surgical care improvement program. Ann. Surg., 2011, 254(3), 494-501.
[14]
Park, B.Y.; Kwon, J.W.; Kang, S.R.; Hong, S.E. Analysis of malpractice claims associated with surgical site infection in the field of plastic surgery. J. Korean Med. Sci., 2016, 31(12), 1963-1968.
[15]
Defres, S.; Marwick, C.; Nathwani, D. MRSA as a cause of lung infection including airway infection, community-acquired pneumonia and hospital-acquired pneumonia. Eur. Respir. J., 2009, 34(6), 1470-1476.
[16]
Zetola, N.; Francis, J.S.; Nuermberger, E.L.; Bishai, W.R. Community-acquired meticillin-resistant Staphylococcus aureus: An emerging threat. Lancet Infect. Dis., 2005, 5(5), 275-286.
[17]
Guinan, J.L.; McGuckin, M.; Shubin, A.; Tighe, J. A descriptive review of malpractice claims for healthcare-acquired infections in Philadelphia. Am. J. Infect. Control, 2005, 33(5), 310-312.
[18]
Bailey, T.M.; Ries, N.M. Legal issues in patient safety: the example of nosocomial infection. Healthc. Q., 2005, 8, 140-145.
[19]
Plowman, R.; Graves, N.; Griffin, M.; Roberts, J.A.; Swan, A.V.; Cookson, B.; Taylor, L. Socio-economic burden of hospital acquired infection; Health Protection Agency, 1999.
[20]
Wilcox, M.H.; Dave, J. The cost of hospital-acquired infection and the value of infection control. J. Hosp. Infect., 2000, 45(2), 81-84.
[21]
Gould, I.M.; Reilly, J.; Bunyan, D.; Walker, A. Costs of healthcare-associated methicillin-resistant Staphylococcus aureus and its control. Clin. Microbiol. Infect., 2010, 16(12), 1721-1728.
[22]
Ghantoji, S.S.; Sail, K.; Lairson, D.R.; DuPont, H.L.; Garey, K.W. Economic healthcare costs of Clostridium difficile infection: A systematic review. J. Hosp. Infect., 2010, 74(4), 309-318.
[23]
Eber, M.R.; Laxminarayan, R.; Perencevich, E.N.; Malani, A. Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia. Arch. Intern. Med., 2010, 170(4), 347-353.
[24]
Authority, N.L. Factsheet 3: Information on claims; National Health Service Litigation Authority, 2011.
[25]
Schaffer, A.C.; Puopolo, A.L.; Raman, S.; Kachalia, A. Liability impact of the hospitalist model of care. J. Hosp. Med., 2014, 9(12), 750-755.
[26]
Cox, J.L.; Zitner, D.; Courtney, K.D.; MacDonald, D.L.; Paterson, G.; Cochrane, B.; Johnstone, D.E. Undocumented patient information: an impediment to quality of care. Am. J. Med., 2003, 114(3), 211-216.
[27]
Mears, A.; White, A.; Cookson, B.; Devine, M.; Sedgwick, J.; Phillips, E.; Bardsley, M. Healthcare-associated infection in acute hospitals: Which interventions are effective? J. Hosp. Infect., 2009, 71(4), 307-313.
[28]
Wilbanks, B.A.; Geisz-Everson, M.; Boust, R.R. The role of documentation quality in anesthesia-related closed claims: A descriptive qualitative study. CIN. Comput. Inform. Nurs., 2016, 34(9), 406-412.
[29]
Turillazzi, E.; Neri, M. Informed consent and Italian physicians: change course or abandonship - From formal authorization to a culture of sharing. Med. Health Care Philos., 2015, 18(3), 449-453.
[30]
Paik, A.M.; Mady, L.J.; Sood, A.; Lee, E.S. Beyond the operating room: A look at legal liability in body contouring procedures. Aesthet. Surg. J., 2014, 34(1), 106-113.
[31]
Hickson, G.B.; Federspiel, C.F.; Pichert, J.W.; Miller, C.S.; Gauld-Jaeger, J.; Bost, P. Patient complaints and malpractice risk. JAMA, 2002, 287(22), 2951-2957.
[32]
Levinson, W.; Roter, D.L.; Mullooly, J.P.; Dull, V.T.; Frankel, R.M. Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 1997, 277(7), 553-559.
[33]
Bhattacharyya, T.; Yeon, H.; Harris, M.B. The medical-legal aspects of informed consent in orthopaedic surgery. JBJS, 2005, 87(11), 2395-2400.
[34]
Gogos, A.J.; Clark, R.B.; Bismark, M.M.; Gruen, R.L.; Studdert, D.M. When informed consent goes poorly: A descriptive study of medical negligence claims and patient complaints. Med. J. Aust., 2011, 195(6), 340-344.
[35]
Merle, V.; Tavolacci, M.P.; Moreau, A.; Dubreuil, N.; Dollois, B.; Gray, C.; Czernichow, P. What factors influence healthcare professionals’ opinion and attitude regarding information for patients about hospital infection? J. Hosp. Infect., 2007, 66(3), 269-274.
[36]
World Health Organization.Guidelines for medical record and clinical documentation; In: WHO-SEARO coding workshop,. , 2007.
[37]
Di Sanzo, M.; Cipolloni, L.; Borro, M.; La Russa, R.; Santurro, A.; Scopetti, M.; Simmaco, M.; Frati, P. Clinical applications of personalized medicine: A new paradigm and challenge. Curr. Pharm. Biotechnol., 2017, 18(3), 194-203.
[38]
La Russa, R.; Fineschi, V.; Di Sanzo, M.; Gatto, V.; Santurro, A.; Martini, G.; Scopetti, M.; Frati, P. Personalized Medicine and Adverse Drug Reactions: The experience of an Italian Teaching Hospital. Curr. Pharm. Biotechnol., 2017, 18(3), 274-281.
[39]
Borro, M.; Gentile, G.; Cipolloni, L.; Foldes-Papp, Z.; Frati, P.; Santurro, A.; Lionetto, L.; Simmaco, M. Personalised healthcare: The DiMA Clinical Model. Curr. Pharm. Biotechnol., 2017, 18(3), 242-252.
[40]
Panting, G. How to avoid being sued in clinical practice. Postgrad. Med. J., 2004, 80(941), 165-168.
[41]
Pomara, C.; D’Errico, S.; Neri, M.; Riezzo, I.; Telesforo, F.; Martelloni, M. Quality of the medical record as a medical - legal indicator of appropriateness and instrument for clinical risk management. First Pugliese experience in private healthcare - verification and analysis of the results of a study on 2000 medical records. Profession - Culture Prac. Doctor D’Oggi, 2009, 8, 24-30.
[42]
Ducel, G.; Fabry, J.; Nicolle, L. World Health Organization. Prevention of hospital-acquired infections: A practical guide, 2002.
[43]
Umscheid, C.A.; Mitchell, M.D.; Doshi, J.A.; Agarwal, R.; Williams, K.; Brennan, P.J. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect. Control Hosp. Epidemiol., 2011, 32(2), 101-114.

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