Major Harm Research Articles

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey.

Communication errors are considered one of the major causes of sentinel events. Our aim was to assess the process of patient handoff among junior surgical residents and to determine ways in which to improve the handoff process. We conducted nationwide surveys that included all accredited general surgery residency programs in the United States and Canada. Of the 244 American and 17 Canadian accredited surgical residency programs contacted, 65 (27%) and 12 (71%), respectively, participated in the survey. Of the American and Canadian respondents, 66% and 69%, respectively, were from postgraduate year (PGY) 1, and 32% and 29%, respectively, were from PGY 2; 85 (77%) and 50 (96%), respectively, had not received any training about patient handoff before their surgical residency, and 27% and 64%, respectively, reported that the existing handoff system at their institutions did not adequately protect patient safety. Moreover, 29% of American respondents and 37% of Canadian respondents thought that the existing handoffs did not support continuity of patient care. Of the American residents, 67% and 6% reported receiving an incomplete handoff that resulted in minor and major patient harm, respectively. These results mirrored those from Canadian residents (63% minor and 7% major harm). The most frequent factor reported to improve the patient handoff process was standardization of the verbal handoff. Our survey results indicate that the current patient handoff system contributes to patient harm. More efforts are needed to establish standardized forms of verbal and written handoff to ensure patient safety and continuity of care.

Abstract P389: Effects of Dietary Patterns on Vitamin D and Other Markers of Bone-Mineral Metabolism: Results From the Dash Trial

Background: The relationship of CVD with vitamin D levels and other markers of bone-mineral metabolism is of substantial interest. The Dietary Approaches to Stop Hypertension (DASH) diet effectively lowers blood pressure and is now recommended to promote CV health. The effects of the DASH diet on vitamin D and other markers of bone-mineral metabolism is unknown. Objective: To determine the effect of dietary patterns on blood levels of vitamin D, PTH, and ionized calcium, and urinary excretion of calcium and phosphate. Methods: Data on study outcomes were available in 334 participants from the original DASH trial. Baseline levels were obtained from blood and urine collected at the end of the run-in while on the control diet. Participants were then randomized to control diet (37% kcal total fat); fruits & vegetable diet (also 37% kcal total fat); or the DASH diet (27% kcal total fat). Follow-up levels were obtained during the last week of the eight-week intervention period. Results: Mean (±SD) baseline blood levels of vitamin D, PTH , and ionized calcium were 15.1±3.7ng/ml, 46.1±18.5 ng/ml and 1.3±0.06 mmol/l, respectively. For urinary calcium and phosphate were 126.8±45.3mg/dl and 715.0±277.3 mg/dl, respectively. See table for within-diet changes. The DASH diet, net of control, reduced vitamin D by -1.29ng/ml (P= 0.005). In stratified analyses, the reduction in vitamin D appeared more prominent in blacks, but the p-value for interaction (race*diet) was non-significant (P=0.21). Otherwise, the DASH diet had no significant effect on the other markers, net of control. Compared to control, the fruit & vegetable diet reduced urinary calcium and phosphorus excretion. Conclusion: The DASH diet modestly reduced vitamin D levels among all participants, with potentially larger effects in blacks. The reduction in vitamin D levels might have resulted from the lower fat content of the DASH diet. Overall, during the eight-weeks of intervention, no major harm or benefit of the DASH diet was documented on biomarkers related to bone-mineral metabolism.

Incidents resulting from staff leaving normal duties to attend medical emergency team calls

To determine the rate of adverse events and incidents occurring as a result of hospital staff leaving normal duties to attend medical emergency team (MET) calls. Single-centre, interview and questionnaire-based study of staff attending MET calls at a 650-bed university teaching hospital in Sydney, New South Wales, July to December 2013. The rate of adverse events and incidents directly related to MET staff leaving normal duties to attend MET calls. During the study period, 1490 structured interviews were conducted, and 279 written questionnaires were returned (overall response rate, 66.4%). There were no adverse events. There were 378 recorded incidents. The incident rate was 213.7 incidents per 1000 MET participant attendances (95% CI, 194.8-233.5), and 1.1 incidents per MET call. Using the severity assessment code, 99.5% of incidents were classified as minimum. The most commonly reported incidents were disruptions to normal duties, ward rounds, and patient reviews. Only 0.8% of incidents were reported on institutional incident reporting systems. Significant disruption to normal hospital routines and inconvenience to staff occurred, without causing major harm to patients, when MET staff temporarily left normal duties to attend MET calls. Normal hospital incident reporting systems cannot be used to monitor for these problems, as they are underreported.

Acute traumatic stress among surgeons after major surgical complications by A. Pinto, O. Faiz, C. Bicknell, and C. Vincent

Pinto and coauthors have completed an important study that is a first step in the process of understanding potentially destructive as well as helpful behaviors for surgeons who are seeking to deal with the emotional turmoil that follows a major surgical complication that results in significant patient harm or death of the patient. Anyone who has practiced clinical surgery knows that a major complication, particularly one that is unexpected and produces major harm, is the prototypical “gut-punch” for the responsible surgeon.

Patent foramen ovale.

Patent foramen ovale.

Increased recombinant activated factor VII use and need for surgical reexploration following a switch from aprotinin to epsilon-aminocaproic acid in infant cardiac surgery

Study ObjectiveTo evaluate whether conversion from aprotinin to epsilon-aminocaproic acid (EACA) during infant cardiac surgery was associated with increased perioperative bleeding. DesignStructured retrospective chart review. SettingUniversity-affiliated large congenital cardiac surgery program. MeasurementsRecords from 145 infants (age < 1 yr) receiving aprotinin as antifibrinolytic therapy for cardiac surgery between 6/1/2006 and 12/31/2006 were compared with a cohort of infants receiving EACA for cardiac surgery between 6/1/2008 and 12/31/2008. Sixty-eight infants received aprotinin and 77 infants received EACA. Measured indicators of perioperative bleeding included transfusion volumes, recombinant activated clotting factor VIIa (rFVIIa) administration, need for reexploration, and perioperative chest tube output. Main ResultsEACA treated patients received significantly more rFVIIa for uncontrolled bleeding (19/77 [25%] vs 3/68 [4%]; P < 0.001) and required surgical reexploration more frequently (21/77 [27%] vs 7/68 [10%]; P = 0.01]. Median (25th-75th percentiles) intraoperative platelet transfusion requirements were also increased after the switch to EACA (28 mL [0-58 mL] vs 0 mL [0 mL - 34.5 mL]), but this difference did not reach statistical significance (P = 0.06). ConclusionsBleeding in infant cardiac surgery increased following the change in antifibrinolytic therapy from aprotinin to EACA. Given the potential for major harm, especially thrombotic complications, from rFVIIa use, prospective studies examining the safety of postcardiopulmonary bypass rFVIIa administration in infants are necessary before the routine off-label use may be recommended.

Ambiguous Beliefs on Damages and Civil Liability Theories

This paper analyzes the meaning of comparing the economic performance of strict liability and negligence rule in a unilateral standard accident model under Knightian uncertainty. It focuses on the cost expectation of major harm on which the injurers form beliefs. It shows first that, when the Court agree with the regulator, whatever the liability regime, the first best level of care is never reached but under both regimes the tortfeasors define the same level of care. Second, when, judge and regulator disagree, it is impossible to discriminate among liability standards because the issue depends on the injurer's optimism degree.

An Analysis of Patient Falls and Fall Prevention Programs Across Academic Medical Centers

UHC conducted an analysis of more than 25 000 patient fall reports entered into the UHC Patient Safety Net incident reporting tool. Gaps were found in the completion of fall risk assessments, the ability of tools to accurately assess risk, and prevention strategies in particular inpatient units and emergency department. Common factors in falls resulting in major harm or death included age more than 80 years, altered mental status, ambulation (often without assistance), toileting, and diuretics and anticoagulants.

Role of Aspirin in Cancer Prevention

Since its first synthesis in 1897, several medicinal roles and mechanisms of action of aspirin have become apparent; the latest among these being its role in cancer prevention and treatment. A large body of evidence supports aspirin's effect in reducing cancer incidence and cancer mortality, but duration of use needs to be at least 5 years. The beneficial effects are particularly large for colorectal, oesophageal and gastric cancers, with apparently smaller reductions for breast, prostate and lung cancer. The major harm is gastrointestinal bleeding, but serious sequelae are minimal at ages <70 years. It is very likely that use of prophylactic aspirin in the general population aged 50-70+ years will result in net overall benefit. Outstanding issues are: whether standard dose (~300 mg/day) can lead to greater net benefits than low dose (75-100 mg/day), the optimum duration of use, and appropriate ages for use in average-risk individuals.

Evaluation of suspected malignant hyperthermia events during anesthesia

BackgroundMalignant hyperthermia (MH), a metabolic myopathy triggered by volatile anesthetics and depolarizing muscle relaxants, is a potentially lethal complication of general anesthesia in susceptible patients. The implementation of modern inhalation anesthetics that research indicates as less potent trigger substances and the recommended limitations of succinylcholine use, suggests there may be considerable decline of fulminant MH cases. In the presented study, the authors analyzed suspected MH episodes during general anesthesia of patients that were referred to the Wuerzburg MH unit between 2007 and 2011, assuming that MH is still a relevant anesthetic problem in our days.MethodsWith approval of the local ethics committee data of patients that underwent muscle biopsy and in vitro contracture test (IVCT) between 2007 and 2011 were analyzed. Only patients with a history of suspected MH crisis were included in the study. The incidents were evaluated retrospectively using anesthetic documentation and medical records.ResultsBetween 2007 and 2011 a total of 124 patients were tested. 19 of them were referred because of suspected MH events; 7 patients were diagnosed MH-susceptible, 4 MH-equivocal and 8 MH-non-susceptible by IVCT. In a majority of cases masseter spasm after succinylcholine had been the primary symptom. Cardiac arrhythmias and hypercapnia frequently occurred early in the course of events. Interestingly, dantrolene treatment was initiated in a few cases only.ConclusionsMH is still an important anesthetic complication. Every anesthetist must be aware of this life-threatening syndrome at any time. The rapid onset of adequate therapy is crucial to avoid major harm and possibly lethal outcome. Dantrolene must be readily available wherever MH triggering agents are used for anesthesia.

The Generation and Treatment of Acid Mine Drainage

The paper analyses the major harm and the forming mechanism of acid mine drainage (AMD). Explain the treatment technology of acid mine drainage respectively from physical, chemical and biological aspects, and discuss the advantages and defects of various methods.

The benefits and harms of breast cancer screening: an independent review

The benefits and harms of breast cancer screening: an independent review

‘Ketamine-induced ulcerative cystitis’ is perhaps better labelled ‘ketamine-induced uropathy’

Morgan & Curran’s paper [1] on ketamine use concludedthat the major physical harm was ketamine-inducedurinary system damage, which they referred to asketamine-induced ulcerative cystitis. We would like todiscuss the symptoms of this condition, and whether itwould be more appropriate and concise to describe it asketamine-induced uropathy.The key symptoms of ketamine-induced uropathyare severe dysuria, painful haematuria, frequency andurgency of urination, urge incontinence and nocturia.Auxiliary examination often offered some importantfindings, including sterile pyuria, contracted bladderinvolving chronic inflammation with ulceration, ery-thematous swelling, necrotic mucosa, thin epitheliumwith neutrophilic and lymphoplasma cell infiltrationin bladder mucosa, collagen and adipose tissue andbladder wall fibrosis with or without vesico–uretericreflux and involvement of the upper urinary tract. Basedon the urinary symptoms, cystoscopy findings andpathology, earlier reports have described ketamine-induced uropathy as an interstitial cystitis-like condi-tion [2,3]. However, the cause of interstitial cystitisis unknown, while ketamine-induced uropathy ischaracterized as a series of common peculiarities withketamine abuse as the evident cause, and with symp-toms improving after cessation of ketamine use. Wesuspect that Morgan

Patient safety in dental care: A challenging quality issue? An exploratory cohort study

Objective. Little is known about patient safety in primary oral healthcare. The aim of this study was to describe and analyze patient safety incidents in primary oral health care. Materials and methods. A random sample of 1000 patient records from 20 dental practices was reviewed retrospectively over 60 months. All adverse events (AEs) were noted: unintended events happening during treatment that resulted or could have resulted in harm to the patient. Results. A total of 46 (95% CI = 33–59) AEs was identified, of which 18 (95% CI = 10–26) were considered preventable. From these, 15 related to treatment, 10 to diagnostics and one to communication. Conclusions. The low incidence of AEs and absence of major harm to patients suggests that primary oral care is safe for patients. However, the low quality of record keeping may imply underestimation.

The type I interferon response during viral infections: a “SWOT” analysis

SUMMARYThe type I interferon (IFN) response is a strong and crucial moderator for the control of viral infections. The strength of this system is illustrated by the fact that, despite some temporary discomfort like a common cold or diarrhea, most viral infections will not cause major harm to the healthy immunocompetent host. To achieve this, the immune system is equipped with a wide array of pattern recognition receptors and the subsequent coordinated type I IFN response orchestrated by plasmacytoid dendritic cells (pDCs) and conventional dendritic cells (cDCs). The production of type I IFN subtypes by dendritic cells (DCs), but also other cells is crucial for the execution of many antiviral processes. Despite this coordinated response, morbidity and mortality are still common in viral disease due to the ability of viruses to exploit the weaknesses of the immune system. Viruses successfully evade immunity and infection can result in aberrant immune responses. However, these weaknesses also open opportunities for improvement via clinical interventions as can be seen in current vaccination and antiviral treatment programs. The application of IFNs, Toll‐like receptor ligands, DCs, and antiviral proteins is now being investigated to further limit viral infections. Unfortunately, a common threat during stimulation of immunity is the possible initiation or aggravation of autoimmunity. Also the translation from animal models to the human situation remains difficult. With a Strengths–Weaknesses–Opportunities–Threats (“SWOT”) analysis, we discuss the interaction between host and virus as well as (future) therapeutic options, related to the type I IFN system. Copyright © 2011 John Wiley & Sons, Ltd.

Enron: Fraud Detection Timeliness

This paper examines one of the biggest corporate bankruptcies in the history of the United States of America. The United States of America witnessed the biggest corporate collapse in its corporate history in the early days of December, 2001, which sent shock waves across the whole business world. Enron, until the collapse, was held in high esteem by well-known corporate observers, analysts and corporate rating agencies in the United States of America. The paper looks at the history of Enron, from formation till time of filing for bankruptcy and beyond, with main emphasis placed on the period between 1997 and 2001, during when it is believed, the main fraud and manipulations occurred, which resulted in the collapse of the company and its attendant negative impact on the company’s shareholders, employees and the investing public as a whole. The main thrust of the paper is determination of the earliest possible time at which the fraud that took place in Enron could have been detected, using the financial statements and records filed by Enron in the U.S. SEC Edgar database. The exercise is conducted with the aid of some well-known fraud detection tools and guidelines propounded by some renowned fraud experts. The paper explains how certain top executives used loopholes in the available principles and rules governing the accounting profession in the United States to exploit, manipulate and cheat on several people and institutions to cause major harm, particularly to employees and shareholders, who lost billions of their life-time savings, investment and pension. The case of Enron, as analyzed by the paper, shows how greed served as the main factor in the ill-fated and ill-conceived initiatives of some of the top executives of Enron, who engaged in the massive fraud, whilst managing to gain some apparent support from both internal and external high-powered officials and institutions. The collapse of Enron serves as a major lesson point for all institutions and the public as a whole, particularly, institutions who are charged with the duty to protect the investing public, employees and shareholders from unscrupulous public corporations. It is not surprising that, as noted in this paper, at the post Enron’s collapse, the United States began to strengthen its corporate governance regime, including introduction of the Sarbanes-Oxley Act of 2002, which among others, aims at ensuring independence of external auditors from their clients, strengthening the oversight duties of corporate board of directors, enhancing disclosure requirements by public corporations and improving the overall controls needed to prevent and detect material errors, misstatements and falsification of financial records and statements by corporations for the whims and caprices of the very people charged with the duty of managing affairs of corporations.

Ketamine use: a review

Ketamine remains an important medicine in both specialist anaesthesia and aspects of pain management. At the same time, its use as a recreational drug has spread in many parts of the world during the past few years. There are now increasing concerns about the harmful physical and psychological consequences of repeated misuse of this drug. The aim of this review was to survey and integrate the research literature on physical, psychological and social harms of both acute and chronic ketamine use. The literature on ketamine was systematically searched and findings were classified into the matrix of Nutt et al.'s (2007) rational scale for assessing the harms of psychoactive substances. A major physical harm is ketamine induced ulcerative cystitis which, although its aetiology is unclear, seems particularly associated with chronic, frequent use of the drug. Frequent, daily use is also associated with neurocognitive impairment and, most robustly, deficits in working and episodic memory. Recent studies suggest certain neurological abnormalities which may underpin these cognitive effects. Many frequent users are concerned about addiction and report trying but failing to stop using ketamine. The implications of these findings are drawn out for treatment of ketamine-induced ulcerative cystitis in which interventions from urologists and from addiction specialists should be coordinated. Neurocognitive impairment in frequent users can impact negatively upon achievement in education and at work, and also compound addiction problems. Prevention and harm minimization campaigns are needed to alert young people to these harmful and potentially chronic effects of ketamine.

Lessons learnt from incidents reported by postgraduate trainees in Dutch general practice. A prospective cohort study

BackgroundThere is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and...

Lyprinol—Is It a Useful Anti‐Inflammatory Agent?

The New Zealand green lipped mussel preparation Lyprinol is available without a prescription from a supermarket, pharmacy or Web. The Food and Drug Administration have recently warned Lyprinol USA about their extravagant anti-inflammatory claims for Lyprinol appearing on the web. These claims are put to thorough review. Lyprinol does have anti-inflammatory mechanisms, and has anti-inflammatory effects in some animal models of inflammation. Lyprinol may have benefits in dogs with arthritis. There are design problems with the clinical trials of Lyprinol in humans as an anti-inflammatory agent in osteoarthritis and rheumatoid arthritis, making it difficult to give a definite answer to how effective Lyprinol is in these conditions, but any benefit is small. Lyprinol also has a small benefit in atopic allergy. As anti-inflammatory agents, there is little to choose between Lyprinol and fish oil. No adverse effects have been reported with Lyprinol. Thus, although it is difficult to conclude whether Lyprinol does much good, it can be concluded that Lyprinol probably does no major harm.

Which medical error to disclose to patients and by whom? Public preference and perceptions of norm and current practice

BackgroundDisclosure of near miss medical error (ME) and who should disclose ME to patients continue to be controversial. Further, available recommendations on disclosure of ME have emerged largely in Western culture; their suitability to Islamic/Arabic culture is not known.MethodsWe surveyed 902 individuals attending the outpatient's clinics of a tertiary care hospital in Saudi Arabia. Personal preference and perceptions of norm and current practice regarding which ME to be disclosed (5 options: don't disclose; disclose if associated with major, moderate, or minor harm; disclose near miss) and by whom (6 options: any employee, any physician, at-fault-physician, manager of at-fault-physician, medical director, or chief executive director) were explored.ResultsMean (SD) age of respondents was 33.9 (10) year, 47% were males, 90% Saudis, 37% patients, 49% employed, and 61% with college or higher education. The percentage (95% confidence interval) of respondents who preferred to be informed of harmful ME, of near miss ME, or by at-fault physician were 60.0% (56.8 to 63.2), 35.5% (32.4 to 38.6), and 59.7% (56.5 to 63.0), respectively. Respectively, 68.2% (65.2 to 71.2) and 17.3% (14.7 to 19.8) believed that as currently practiced, harmful ME and near miss ME are disclosed, and 34.0% (30.7 to 37.4) that ME are disclosed by at-fault-physician. Distributions of perception of norm and preference were similar but significantly different from the distribution of perception of current practice (P < 0.001). In a forward stepwise regression analysis, older age, female gender, and being healthy predicted preference of disclosure of near miss ME, while younger age and male gender predicted preference of no-disclosure of ME. Female gender also predicted preferring disclosure by the at-fault-physician.ConclusionsWe conclude that: 1) there is a considerable diversity in preferences and perceptions of norm and current practice among respondents regarding which ME to be disclosed and by whom, 2) Distributions of preference and perception of norm were similar but significantly different from the distribution of perception of current practice, 3) most respondents preferred to be informed of ME and by at-fault physician, and 4) one third of respondents preferred to be informed of near-miss ME, with a higher percentage among females, older, and healthy individuals.