Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

OBJECTIVE: To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. DESIGN: Multicenter pragmatic parallel randomized controlled trial. SETTING: Six emergency departments in the United States. PARTICIPANTS: 898 adults (aged \u3e17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. INTERVENTIONS: Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. RESULTS: Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P CONCLUSIONS: Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240

New Perspectives on Implementing Health Information Technology

The importance of studying challenges in implementing information technology solutions in health care organizations is highlighted by the huge investments in health care information technology (HIT) which has been spurred by recent government mandates. Information technology can help improve health care delivery cost by facilitating the standardization of work processes or routines and reducing variations among them. Set in a premier 950+ bed hospital in the south eastern part of US, this dissertation consists of two studies examining the challenges involved in implementing HIT solutions. In the first study, we seek to gain deep insights into how the process of creating a patient’s chart evolves over time in a health care institution. The second study focuses on the users of Electronic Health Records (EHR) system, investigating the compliance behavior of various providers with respect to patient records in the system. In the first study, through the lens of Activity theory our results show that the charting routine is implicated by the following environmental factors: (1) Tools, (2) Rules, (3) Community, and (4) Roles, and by individual factors: (5) Computer Self-Efficacy and (6) Risk Propensity. In the second study, our results indicate that there is a substantial effect of subculture of the different occupational groups on IT security compliance intent and behavior in a health care institution

Depersonalization In The Emergency Department

DEPERSONALIZATION IN THE EMERGENCY DEPARTMENT. Damian Apollo, Karen Jubanyik. Department of Emergency Medicine, Yale University, School of Medicine, New Haven, CT. Yale medical students have given feedback about the emergency medicine rotations via the end of clerkship feedback and the annual student mistreatment questionnaires collected by the medical school and stated that they felt distress and that patient depersonalization occurred during resuscitations. Accordingly, the objectives of this study were to assess medical students’ perspectives with regards to resuscitation exposure, depersonalization, utilization of support services, and support services that students thought would be helpful as well as the timeframe in which these interventions should occur. We hypothesized that many students are exposed to resuscitations, awareness of support services is high while utilization is low, and that students value a post-resuscitation intervention proximate to the event. Our study revealed that 54.76% (n = 215) of medical students are exposed to a code during their training with 43.43% exposed to 5 or more codes during their training. The majority of code exposures occurred in emergency medicine (50.60%), internal medicine (27.11%), and surgery (7.83%). Of those students involved in codes, 57.55% were directly involved in the resuscitation. Of the students involved in emergency resuscitations, 74.00% felt depersonalization occurred with 59.18% seeing it as necessary/natural and 40.82% seeing it as problematic/something that warrants intervention. It was determined that 92.39% of respondents have not used support services. Awareness of resources available was low, with only 20.18% of respondents aware that meeting with the Dean of Student affairs (the category with the greatest awareness) was a possible support service and some students not being aware of any resources. Many students (43.09%) felt that the department of emergency medicine did not offer adequate support services, with 56.82% of respondents believing that additional resources are needed for students exposed to emergency resuscitations. Students preferred an intervention proximate to the event with 29.25% favoring an intervention immediately after the event, 30.61% within 1 day, and 29.25% within 1 week. A preference was placed on an intervention that involved a trained debriefer, a peer/clinical individual, and an individual who does not grade the student. These results suggest that depersonalization during resuscitations is experienced by medical students and that a significant amount of students believe that an intervention could be helpful if implemented as part of the emergency medicine curriculum

Fair Labor Association 2007 Annual Report

Assesses the progress made by companies in the move towards sustainable corporate responsibility in their labor standards. Breaks up data by company