Problem Density, Mental Workload and Medical Error in Primary Care Practice

描述(由申请人提供)：在初级保健实践中向患者提供保健服务是一个高度混乱和复杂的过程，人们对此知之甚少。平均而言，家庭医生在每次就诊期间处理3.05个问题；问题的具体数量高度可变，与患者的年龄和潜在医疗条件有关。此外，平均相遇时间为17分钟。医疗差错可能会在注意力不集中、相互竞争的要求和时间压力的环境中蓬勃发展。假设：假设多个患者问题和有限的时间的相互竞争的需求对临床医生的精神工作量有显著影响，而这反过来又影响护理质量和医疗差错倾向。目的和目的：我们将进行一项试点研究，以更好地确定遭遇问题密度(单位时间内的问题数量)、临床医生的精神工作量(由NASA任务负荷指数确定)、感知的医疗差错和质量指标之间的关系。将探索在繁忙的Wren诊所中使用医生-医疗助理团队收集这些数据的可行性。方法：招募的30名瑞恩医生每人将收集为期四周的20次常规成人患者就诊的数据，从而获得600次就诊的样本。收集的具体数据将包括患者的年龄和性别、患者在访问期间要讨论的医疗问题的预期数量、访问后NASA TLX衡量的临床医生的精神工作量、医生报告的问题数量和类型、访问期间花费的面对面时间、医生估计的出错可能性、患者报告的疑虑得到解决的程度，以及用于评估有关血压和烟草使用的质量指标的最终临床笔记的副本。将评估遭遇问题密度、临床医生的精神工作量和感知的医疗差错之间的相关性。将对医生进行结构化访谈，内容涉及离奇接触的子集(n~30)(即，高问题密度和低脑力劳动)。意义：这项初步研究的结果将被用来改进由工业工程师开发的系统模型，以更好地定义初级保健提供的过程。这将作为进一步研究家庭实践和初级保健中复杂性与错误之间关系的基础。随着这一模式得到更好的发展，在关键点所做的改进可能会导致更有效地提供护理，同时减少错误和提高质量。

DESCRIPTION (Provided by the Applicant): The provision of healthcare services to patients in primary care practices is a highly chaotic and complex process, which is poorly understood. On average, family physicians deal with 3.05 problems during each encounter; the specific number of problems is highly variable and related to patient age and the presence of underlying medical conditions. Furthermore, the average encounter lasts 17 minutes. Medical errors can thrive in an environment of inattention, competing demands and time stress. Hypothesis: It is hypothesized that the competing demands of multiple patient problems and limited time have a significant effect on clinician mental workload, which, in turn, affects quality of care and propensity for medical error. Goals and Objectives: We will conduct a pilot study to better define the relationships between encounter problem density (number of problems per unit time), clinician mental workload (as ascertained by the NASA Task Load Index), perceived medical error, and quality indicators. The feasibility of collecting this data using physician-medical assistant teams within busy WREN practices will be explored. Methods: Each of 30 recruited WREN physicians will collect data on 20 routine adult patient visits over a four-week period, thus resulting in a sample of 600 visits. Specific data collected will include patient age and gender, the patient's anticipated number of medical issues to be discussed during the visit, clinician mental workload as measured by the post-visit NASA TLX, physician reported number and types of problems addressed, face-to-face time spent during the visit, physician estimated likelihood of error, patient reported extent to which concerns were addressed, and a copy of the resulting clinical note for assessment of quality indicators around blood pressure and tobacco use. Correlations between encounter problem density, clinician mental workload, and perceived medical error will be evaluated. Structured interviews will be conducted with physicians on a subset (n~30) of outlying encounters (i.e., high problem density and low mental workload). Significance: Results of this pilot study will be used to refine a systems model developed by industrial engineers to better define the process of primary healthcare delivery. This will serve as a basis for additional studies of the relationship between complexity and error in family practice and primary care. As this model is better developed, enhancements made at critical points may result is more efficient delivery of care with a reduction in error and improvement in quality.