Philip L. Henneman

Errors in a busy emergency department.

STUDY OBJECTIVE We describe errors occurring in a busy ED. METHODS This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.

Diagnostic peritoneal lavage : accuracy in predicting necessary laparotomy following blunt and penetrating trauma

The purpose of this study was to evaluate the ability of diagnostic peritoneal lavage (DPL) to predict intra-abdominal injuries that required surgical repair. To do this, we retrospectively reviewed 944 patients with blunt and penetrating abdominal trauma who underwent 975 DPLs. Initial DPL in 608 patients sustaining blunt trauma had a sensitivity of 87%, a specificity of 97%, an accuracy of 95%, a positive predictive value (PPV) of 85%, and a negative predictive value (NPV) of 97%. Initial DPL in 336 patients with penetrating trauma had a sensitivity of 87%, a specificity of 89%, an accuracy of 89%, a PPV of 75%, and a NPV of 95%. When utilizing final lavage results on the 944 patients, DPL had a sensitivity of 91%, a specificity of 94%, an accuracy of 93%, a PPV of 80%, and a NPV of 98% in predicting intra-abdominal injury requiring surgical repair.

Prevalence and heritability of the metabolic syndrome and its individual components in a Dutch isolate: the Erasmus Rucphen Family study

Background: Metabolic syndrome (MetS) is defined by a combination of abnormalities that are all individual risk factors for the development of type 2 diabetes and/or cardiovascular disease. The aetiology of MetS includes both an environmental and genetic component. We studied the prevalence and heritability of MetS and its individual components Dutch genetic isolate. Methods: The Erasmus Rucphen Family study (ERF) consists of some 3000 genealogically documented individuals from a Dutch genetic isolate. Data on waist circumference (WC), blood pressure (BP), high density lipoprotein cholesterol (HDL-C), triglycerides (TG) and fasting plasma glucose values (FPG) are available. MetS was defined according to the International Diabetes Federation (IDF) (2003) and National Cholesterol Education program Adult Panel III (NCEP ATPIII) criteria. Variance component analysis was applied to extended family data to test for evidence of heritability. Results: The prevalence of MetS in the ERF cohort ranged from 23–37% depending on MetS definition and gender considered. Low HDL-C and high WC are the main contributors to MetS. The heritability of MetS corrected for sibship effect was 10.6% (p = 0.01) according to IDF and 13.2% (p = 0.07) according to NCEP ATPIII criteria. In addition, the heritability of individual components of MetS were analysed and found to range from 21.9–42.9%. The highest heritability was found for HDL-C (42.9%, p<0.0001) and WC (37.8%, p<0.0001). In addition, WC, systolic BP, HDL-C and TG showed low to moderate genetic correlation (RhoG) between genders, whereas FPG and diastolic BP showed absolute genetic correlation between genders. Conclusion: Although the prevalence of MetS was high, the heritability of MetS in the ERF population was found to be moderate. The high heritability of the individual components of MetS indicates that the genetic dissection of MetS should be approached from its individual components.

Prospective Evaluation of Emergency Department Medical Clearance

STUDY OBJECTIVE To analyze a standardized medical evaluation of alert, adult emergency department patients with new psychiatric symptoms. DESIGN Prospective, descriptive case series. SETTING Urban, county hospital. PARTICIPANTS One hundred consecutive, alert patients, aged 16 to 65 years, seen over 9 months, with new psychiatric symptoms. Excluded patients included those with obvious alcohol or drug intoxication, psychiatric patients with previously diagnosed abnormal behavior, psychiatric patients with medical complaints, and overdose or suicide patients. INTERVENTIONS The following evaluation was performed: medical history, physical examination, complete blood count, SMA-7 (electrolytes, blood urea nitrogen, creatinine, and glucose), prothrombin time, calcium, oxygen saturation, creatine phosphokinase (CPK) if there was possible myoglobulinuria, alcohol level, urine drug screen (for cocaine, amphetamine, and phencyclidine), cranial computed tomography, lumbar puncture if febrile, and psychiatric evaluation when appropriate. Results were considered significant when they diagnosed the cause of the symptoms or resulted in medical admission. RESULTS Sixty-three of the 100 patients had an organic etiology of their symptoms. The medical history was significant in 27, physical examination in 6, CBC in 5, SMA-7 in 10, CPK in 6, alcohol and drug screen in 28, computed tomography scan in 8, and lumbar puncture in 3. CONCLUSION Most alert, adult patients with new psychiatric symptoms have an organic etiology. We recommend performing a medical history, physical examination, SMA-7, calcium, CPK if there is possible myoglobinuria, alcohol and drug screens, computed tomography scan, and lumbar puncture as part of the medical clearance of these patients.

Error identification and recovery by student nurses using human patient simulation: Opportunity to improve patient safety

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance.

Analyzing medical processes

This paper shows how software engineering technologies used to define and analyze complex software systems can also be effective in detecting defects in human-intensive processes used to administer healthcare. The work described here builds upon earlier work demonstrating that healthcare processes can be defined precisely. This paper describes how finite-state verification can be used to help find defects in such processes as well as find errors in the process definitions and property specifications. The paper includes a detailed example, based upon a real-world process for transfusing blood, where the process defects that were found led to improvements in the process.

Emergency Department Medication Lists Are Not Accurate

BACKGROUND Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. OBJECTIVE To evaluate the accuracy of the ED home medication list. METHODS Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. RESULTS There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46-66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70-87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78-93%). CONCLUSION Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.

Effect of crystalloid infusion on hematocrit and intravascular volume in healthy, nonbleeding subjects.

We evaluated the effect of IV crystalloid administration on hematocrit in 28 healthy, nonbleeding volunteers. Normal saline boluses of 10, 20, and 30 mL/kg were delivered at a mean rate of 115 +/- 4 mL/min, followed by a continuous infusion of either 1 or 5 mL/kg/hr. Hematocrit values determined immediately after bolus infusion declined from baseline a mean +/- SEM of 4.5 +/- 0.6 (P less than .001), 6.1 +/- 0.4 (P less than .001) and 6.3 +/- 0.6 points (P less than .001) in the 10, 20, and 30 mL/kg groups, respectively. Twenty minutes into the maintenance infusion, hematocrits had risen 1.5 +/- 0.8 (P = .03), 2.4 +/- 0.4 (P = .004) and 2.3 +/- 0.7 points (P = .005) when compared with post-bolus hematocrits in the 10, 20, and 30 mL/kg groups, respectively. These data show that in healthy, nonbleeding subjects, crystalloid infusion may cause significant changes in hematocrit. Calculations reveal that approximately 60% of infused saline, when delivered as a bolus, will diffuse from the intravascular space within 20 minutes of administration.

Simulating patient flow through an Emergency Department using process-driven discrete event simulation

This paper suggests an architecture for supporting discrete event simulations that is based upon using executable process definitions and separate components for specifying resources. The paper describes the architecture and indicates how it might be used to suggest efficiency improvements for hospital Emergency Departments (EDs). Preliminary results suggest that the proposed architecture provides considerable ease of use and flexibility for specifying a wider range of simulation problems, thus creating the possibility of carrying out a wide range of comparisons of different approaches to ED improvement. Some early comparisons suggest that the simulations are likely to be of value to the medical community and that the simulation architecture offers useful flexibility.

Primary Varicella in Adults: Pneumonia, Pregnancy, and Hospital Admission☆☆☆★

STUDY OBJECTIVE To define the rate of complications of adult varicella, including pneumonia, and to determine the association of such complications with pregnancy. METHODS Retrospective, descriptive case series of consecutive adult emergency department patients with primary varicella seen over a 31-month period in an urban county hospital. RESULTS A total of 130 patients were identified, with a mean age of 23.9 +/- 6.1 years; 69 (53%) were female. Thirteen patients (10.0%) had pneumonia; 6 of these were hospitalized. Two patients admitted with pneumonia had significant underlying comorbid disease and expired from respiratory failure. The remaining 4 admitted patients recovered uneventfully. Four of the 7 patients discharged with pneumonia were known to have recovered uneventfully. Twenty-eight (41%) of the 69 female study patients were pregnant; 7 of these (25%) were admitted, with admission diagnoses of pneumonia (1), active labor (2), and pregnancy with varicella (4). Incidence of pneumonia in pregnant patients was 3.6% (1 of 28; 95% confidence interval, 1% to 18.3%). All 7 admitted pregnant patients and the 19 (of 21) discharged pregnant patients who were contacted recovered uneventfully. No congenital anomalies or perinatal complications were noted in the infants of the 26 mothers with documented follow-up. CONCLUSION Hospital admission should be considered for adults with varicella pneumonia, especially if they have significant comorbid disease. It does not appear that pregnant women are at increased risk of developing varicella pneumonia.