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英语翻译
Insurers contributed claims to the study sample in proportion to their annual volume of claims.The number of claims by site varied from 84 to 662 (median,294).One site contributed obstetrics claims only; another site had claims in all categories except obstetrics; and the remaining three contributed claims from all four categories.
Review of Claim Files
Reviews were conducted at insurers' offices or insured facilities by board-certified physicians,fellows,or final-year residents in surgery (for surgery claims),obstetrics (for obstetrics claims),and internal medicine (for diagnosis and medication claims).Physician investigators from the relevant specialties trained the reviewers,in one-day sessions at each site,with regard to the content of claims files,use of the study instruments,and confidentiality procedures.Reviewers were also given a detailed manual.Reviews lasted 1.6 hours per file on average and were conducted by one reviewer.To test the reliability of the process,10 percent of the files were reviewed again by a second reviewer who was unaware of the first review.
Staff members at the insurance companies recorded administrative details of each claim,and clinical reviewers recorded details of the patient's adverse outcome,if any.Physician reviewers then scored adverse outcomes on a severity scale that ranged from emotional injury to death.20 If there was no identifiable adverse outcome,the review was terminated.For all other claims,reviewers considered the potential contributory role of 17 "human factors" in causing the adverse outcome.
Next,in the light of all available information and their decisions about contributing factors,reviewers judged whether the adverse outcome was due to medical error.We used the definition of error of the Institute of Medicine:"the failure of a planned action to be completed as intended (i.e.,error of execution) or the use of a wrong plan to achieve an aim (i.e.,error of planning)."21 Reviewers recorded their judgments using a 6-point confidence scale in which a score of 1 indicated little or no evidence that an adverse outcome resulted from one or more errors and a score of 6 indicated virtually certain evidence that an adverse outcome resulted from one or more errors.Claims that received a score of 4 ("more likely than not that adverse outcome resulted from error or errors; more than 5050 but a close call") or higher were classified as involving an error.
Reviewers were not blinded to the outcome of litigation because it was logistically impossible to censor this information in the files.However,they were instructed to ignore this outcome and exercise independent clinical judgment in rendering determinations with regard to injury and error.Training sessions stressed both that the study definition of error is not synonymous with the legal definition of negligence and that a mix of factors extrinsic to merit influences whether claims are paid during litigation.
Insurers contributed claims to the study sample in proportion to their annual volume of claims.The number of claims by site varied from 84 to 662 (median,294).One site contributed obstetrics claims only; another site had claims in all categories except obstetrics; and the remaining three contributed claims from all four categories.
Review of Claim Files
Reviews were conducted at insurers' offices or insured facilities by board-certified physicians,fellows,or final-year residents in surgery (for surgery claims),obstetrics (for obstetrics claims),and internal medicine (for diagnosis and medication claims).Physician investigators from the relevant specialties trained the reviewers,in one-day sessions at each site,with regard to the content of claims files,use of the study instruments,and confidentiality procedures.Reviewers were also given a detailed manual.Reviews lasted 1.6 hours per file on average and were conducted by one reviewer.To test the reliability of the process,10 percent of the files were reviewed again by a second reviewer who was unaware of the first review.
Staff members at the insurance companies recorded administrative details of each claim,and clinical reviewers recorded details of the patient's adverse outcome,if any.Physician reviewers then scored adverse outcomes on a severity scale that ranged from emotional injury to death.20 If there was no identifiable adverse outcome,the review was terminated.For all other claims,reviewers considered the potential contributory role of 17 "human factors" in causing the adverse outcome.
Next,in the light of all available information and their decisions about contributing factors,reviewers judged whether the adverse outcome was due to medical error.We used the definition of error of the Institute of Medicine:"the failure of a planned action to be completed as intended (i.e.,error of execution) or the use of a wrong plan to achieve an aim (i.e.,error of planning)."21 Reviewers recorded their judgments using a 6-point confidence scale in which a score of 1 indicated little or no evidence that an adverse outcome resulted from one or more errors and a score of 6 indicated virtually certain evidence that an adverse outcome resulted from one or more errors.Claims that received a score of 4 ("more likely than not that adverse outcome resulted from error or errors; more than 5050 but a close call") or higher were classified as involving an error.
Reviewers were not blinded to the outcome of litigation because it was logistically impossible to censor this information in the files.However,they were instructed to ignore this outcome and exercise independent clinical judgment in rendering determinations with regard to injury and error.Training sessions stressed both that the study definition of error is not synonymous with the legal definition of negligence and that a mix of factors extrinsic to merit influences whether claims are paid during litigation.
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