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医疗保健服务是一个高度混乱和复杂的过程，人们对这一点知之甚少。家庭医生平均每次就诊处理3.05个问题；问题的具体数量变化很大，与患者的年龄和是否存在潜在的医疗条件有关。此外，平均相遇时间为17分钟。在注意力不集中、相互竞争的需求和时间紧张的环境中，医疗事故可能会频繁发生。假设：假设多个患者问题的竞争需求和有限的时间对临床医生的精神工作量有显著影响，这反过来又影响护理质量和医疗差错倾向。目标和目的：我们将进行一项试点研究，以更好地定义遇到问题密度（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）、感知医疗差错和质量指标之间的关系。将探讨在繁忙的WREN实践中使用医师-医疗助理团队收集这些数据的可行性。方法：招募的30名WREN医生将收集20名常规成人患者在四周内就诊的数据，从而产生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、患者在就诊期间将要讨论的医疗问题的预期数量、就诊后NASA TLX测量的临床医生心理工作量、医生报告的问题数量和解决的类型、就诊期间面对面花费的时间、医生估计的错误可能性、患者报告的问题得到解决的程度。以及一份评估血压和烟草使用质量指标的临床记录副本。将评估遇到问题密度、临床医生精神工作量和感知到的医疗错误之间的相关性。对医生进行结构化访谈，选取一组（n~30）偏远地区（即高问题密度和低精神负荷）的医生进行访谈。意义：本初步研究的结果将用于完善由工业工程师开发的系统模型，以更好地定义初级卫生保健提供的过程。这将为进一步研究家庭实践和初级保健中的复杂性和错误之间的关系奠定基础。随着这一模式得到更好的发展，在关键点上的改进可能会导致更有效地提供医疗服务，减少错误，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.