Efforts to improve patient safety in large,capitated medical groups: description and conceptual model

Medical care should be safer. Inpatient problems and solutions have received the most attention; this outpatient qualitative case study addresses a gap in knowledge. We describe safety improvements among large physician groups, model the key influences on their behavior, and identify beneficial public and private policies. All groups were trying to reduce medical injury, which was part of the sample design. The most commonly targeted problems are those that are similar across groups: shortcomings in diagnosis, abnormal tests follow-up, scope of practice and referral patterns, and continuity of care. Medical group innovators vary greatly, however, in implementation of improvements, that is, in the extent to which they implement process changes that identify events/problems, analyze and track incidents, decide how to change clinical and administrative practices, and monitor impacts of the changes. Our conceptual model identifies key determinants: (1) demand for safety comes from external factors: legal, market, and professional; (2) organizational responses depend on internal factors: group size, scope, and integration; leadership and governance; professional culture; information-system assets; and financial and intellectual capital. Further, safety is an aspect of quality (the same tools, decision making, interventions, and monitoring apply), and safety management benefits from prior efficiency management (similar skills and culture of innovation). Observed variation in even simple safeguards shows that existing safety incentives are too weak. Our model suggests that the biggest improvement would come from boosting the demand for quality and safety from both private and public larger group purchasers. Current policy relies too much on litigation and discipline, which have sometimes helped, but not solved, problems because they are inefficient, tend to drive needed information underground, and complicate needed cultural change. Patients' safety demand is also weak for want of information and market power. Big purchasers' demands, however, quickly influence the internal environment of medical groups, helping managers advance quality safety toward the top of groups' congested decision-making "queues."     

A method for estimating the GNP loss from a future oil embargo

This article develops a theoretical model to estimate the loss in GNP to the U.S. economy that would result from a future oil embargo. The model is based on an input-output matrix of the economy, but modifies the traditional input-output analysis in order to take account of conservation and substitution possibilities. Data generated from the 1973–74 embargo is used as a bench mark for this study in order to assure that the model produces reasonable estimates. Based upon estimates of future economic and energy growth, this study concludes that the United States will become increasingly vulnerable to economic damage as a result of a future embargo.This work was begun while the author was employed at the Center of Naval Analyses during the summer of 1974. Financial support for the continuation of this project was received from the Federal Energy Administration, and this paper is a condensed version of a report sent to the FEA. Views expressed in this paper are those of the author, and do not necessarily reflect the position of either of the above organizations.     

THE PRIVATE SECTOR IN PUBLIC EMPLOYMENT AND TRAINING PROGRAMS

Assimilating disadvantaged workers in labor markets has been the focus of national policy initiatives for at least two decades. In recent years, public policies have been formulated which will not only provide incentives for the private sector to employ the disadvantaged, but also afford the private sector a larger responsibility in formulating and implementing targeted employment programs. The Job Training Partnership Act (JTPA) and Target Jobs Tax Credit (TJTC) are two major examples. This paper initially reviews the public and private employment and training efforts between 1962 and 1982. Considerable attention is given to summarizing and evaluating the performance of these efforts, especially in light of recent program initiatives by the Reagan Administration.     

Dilute solution viscometry of single polyester fibers

Efflux times were measured for dilute solutions of short lengths of ten single polyester fibers by micro capillary viscometry using a 50-μl charge. Limiting viscosity numbers (intrinsic viscosities) and molecular weights were calculated for each fiber by a single-point method. Efflux times were measured for three of the fibers after they were subjected to two different laundering procedures and outdoor exposure. The viscometric method was unsuitable for fiber identification but was shown to be highly discriminating for the comparison of fibers of similar commercial origins.     

Dicyclomine in the sudden infant death syndrome (SIDS)--a cause of death or an incidental finding?

We report a case of a small infant apparently dying of the Sudden Infant Death Syndrome (SIDS) with a postmortem blood dicyclomine level of 200 ng/mL. Review of the literature and the comparison with blood dicyclomine values from four rabbits given equivalent doses suggests that a blood dicyclomine value of 200 ng/mL probably is in the therapeutic range for infants. Although safely used for years for infantile colic, recently, the administration of dicyclomine has been related to acute episodes of apnea, seizures, and coma. In the absence of those acute reactions, we feel that a 200-ng/mL blood dicyclomine level in a child dying of apparent SIDS should not prevent categorization of the death as SIDS.     

Fatal intravenous drug abuse secondary to streptomycin overdose

A fatal case of chronic intravenous drug abuse involving the injection of a nonpsychoactive veterinary combination of penicillin G and streptomycin is reported. The circumstances surrounding the death indicate that the decedent died as a result of streptomycin induced paralytic neuromuscular blockade.     

The Violent Female Juvenile Offender: An Ignored Minority Within the Juvenile Justice System

Little attention is given to the violent female adolescent. While there is no argument that males commit most of the violent crimes (both juveniles and adults), violent females may demand the attention of policy-makers and administrators. Historically there has been a lack of program offerings for these offenders. This article examines violent female adolescent offenders referred to the Clark County (Las Vegas, Nevada) Juvenile Court Services in two different years (1985 and 1988). This examination includes a review of programs and alternatives for these offenders and a review of what is currently being done by the juvenile justice system to accommodate this population. Dispositions and programmatic treatment offerings for violent adolescent males and females are compared. Recommendations are offered for the juvenile justice system for consideration.