ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00001.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00002.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

Abstract‘Audit’ is now in widespread use in our National Health Service, but there is little documentation of improvement resulting from audit. If it is to be used to identify mistakes in clinical practice, we must be prepared to admit them, or to have our work evaluated by others; such openness is uncommon. Understandably, doctors are concerned about possible litigation, under‐ mining of their authority, and/or interference with their methods of practice. Furthermore, few are willing to comment adversely on the work of others.There is confusion about the best method(s) of audit. Outcome and process audit serve different purposes. Outcome audit measures the effect of care on patients' health, but in individual cases a poor outcome may result after impeccable medical care and a good outcome after poor care. Outcome audit requires a large patient group, is costly, and is of value for a limited number of conditions. Appropriate standards are needed to judge the results; it may be fallacious to compare outcomes in different settings, and with different patient groups. Furthermore, outcome audit is of little value for auditing the care given by individual doctors, and this limits its value in clinical education.Process audit deals with the appropriateness of clinical actions, on the assumption that they affect outcome. It can detect poor performance when outcome audit would be unlikely to identify poor outcome. For common or well‐defined problems, process audit can make use of clear criteria, for example agreed protocols, and this may have immediate benefit for individual patients. When there is no agreed protocol the overall quality of care can still be audited against relatively explicit criteria, if there is agreement on the relevant ‘principles of clinical practice’, i.e. the rules which should guide the clinical management of individual patients. Clearly these should cover the collection, recording and analysis of patient data; planning for diagnosis, monitoring, treatment and patient education, and steps to be taken when there is uncertainty about the best course of action. Performance in these areas can be assessed by reviewing the patients' notes, but most clinical records are inadequate for this purpose.Process audit can be applied to all clinical problems, and is the method of choice for assessing the actions of individuals. Its educational value is self‐ evident. It allows the identification of deficiencies, and the provision of feedback to correct them. Furthermore, it provides for a continuum of audit through the undergraduate and postgraduate years of a doct

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00003.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractAcquisition of adequate patient data for clinical management is hard enough, but higher quality patient data are needed for clinical audit and research. This article discusses some of the problems of using routine clinical data for audit and research, aspects of data quality, sources of audit or research data and their problems, methods for improving data quality, the benefits and problems of computer‐based systems and current trends in the capture and processing of clinical dat

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00004.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractThis article examines the usefulness of meta‐analysis, and articulates many of the criticisms that have been made of its workings. An attempt is made to outline the precautions that have to be taken before a scientifically useful and meaningful meta‐analysis can be carried out. The problems encountered include heterogeneity of samples, conditions, interventions and end‐points; narrow focus; curvilinearity of regression; lack of independence of determinants; synergistic interactions; contradictory experimental results. It is suggested that best‐evidence synthesis, or theorydirected analysis, might be a safer

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00005.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractValid guidelines, when appropriately disseminated and implemented, can lead to changes in clinical practice and improvements in patient outcome. Guidelines are more likely to be valid if they are developed using systematic reviews, national or regional guideline development groups (including representatives of key disciplines) and explicit links between recommenda‐ tions and scientific evidence. This paper discusses the practical implications of adopting this approach for guideline development and the role of peer review of guidelines as another element of the process to ensure validity. Considerable resources are required to develop evidence‐linked guidelines, but this investment can be recouped by relatively small changes in the process or outcome of care. Good leadership and technical support are required for the successful development of clinically valid guidelines, which is dependent upon the small‐group processes of guideline development panels and the translation of evidence into recommendations. Future guideline developers need to gain expertise in these areas. Research priorities are ident

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00006.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

AbstractProliferation of clinical guidelines has given rise to a number of concerns about the status of clinical advisory statements. Are guidelines advisory or mandatory? What regulatory functions do guidelines serve; do they allow clinical discretion a large enough role?Relationships between legislation and guidelines, and the way courts go about determining the legal status of guidelines, are explained. The following questions in the context of the law of negligence are addressed. Do doctors who deviate from guidelines place themselves at increased risk of being found liable in negligence if patients suffer injury as a result? Could compliance with guidelines protect health care workers from liability in such circumstances? What legal responsibility do the developers and issuers of guidelines have if their guidance is found to be faulty?Common law cases featuring clinical guidelines or protocols have been identified from the databaseLexis, which searches the full text of the transcripts and reports of court cases in UK, Commonwealth and United States jurisdictions. Secondary literature, identified from the bibliography of clinical guidelines maintained by the Department of Health Services Research at the University of Aberdeen (assembled fromDHSS‐DATA, Embase, GratefulMed, Medline andSIGLE) has also been consulted.The legal status of a guideline turns on whether its development and application have statutory backing, and whether the guideline embodies clinical practices accepted as proper by a responsible body of doctors. The mandatory effects of guidelines can be gauged, to some extent, by the sanctions that apply in the event of non‐compliance. US courts have ruled that guideline developers can be held liable for faulty guidelines, and that doctors cannot pass off their liability by claiming that adherence to guidelines has corrupted clinical judgement.Protocols and guidelines provide the courts with examples of clinical standards across a wide range of medical practice. As guidelines proliferate, so they will increasingly be used in court. However, adherence to guidelines has not automatically been equated with reasonable practice, and the courts seem unlikely to follow the standards enunciated in clinical guidelines without critically evaluating their authority, flexibility and scope of applicat

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00007.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00008.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00009.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1995.tb00010.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY