Are hospitals becoming high reliability organizations?

High Reliability Organizations (HROs) are complex systems in which many accidents and adverse events that could occur within those systems or at the interfaces with other systems are actually avoided or prevented. Many organizations in high-risk industries have successfully implemented HRO approaches. In recent years, initiatives have been undertaken aimed at transforming hospitals into HROs. Actually, despite some improvements, these initiatives have not shown the expected results. In this paper, we discuss the possible reasons for such outcomes. We will show that, when compared with traditional HROs, hospitals are undoubtedly high-risk organizations, but have specificities and experience systemic socio-organizational barriers that make them difficult to transform into HROs

Embolic stroke of undetermined source: a retrospective analysis from an Italian Stroke Unit

The new clinical construct of embolic stroke of undetermined source (ESUS) suggests that many cryptogenic strokes are related to minor-risk covert embolic cardiac sources or to embolus from non-occlusive plaques in the aortic arch or in the cerebral arteries. The authors analyzed the prevalence of ESUS in a real-life condition in Italy and compared the recurrence rates in cryptogenic strokes, cardioembolic strokes, and ESUS. The authors retrospectively reassessed according to ESUS criteria 391 consecutive admissions in a stroke unit where extensive diagnostic search was routinely performed. Recurrences in each stroke type within a 3-year follow-up period (mean time: 25.44 months - standard deviation: 9.42) were also compared. The prevalence of ESUS in the aforementioned cohort was 10.5%. All ESUS patients received antiplatelet agents. Warfarin was prescribed in 56.9% of cardioembolic strokes. The recurrence rate in ESUS patients was 4.4% per year, slightly higher than in cardioembolic strokes (3.5%) and significantly higher than in cryptogenic non-ESUS (1.2%) (P<0.0001). This is the first description of a cohort of ESUS patients in an Italian stroke unit. Patients with ESUS have a significantly higher risk of recurrence than in those with non-ESUS cryptogenic strokes, and slightly higher than in those with cardioembolic strokes. Results support the hypothesis of a more extensive diagnostic evaluation in cryptogenic strokes and the feasibility of such approach

704-3 Relation of Neurohormonal Activation to Functional Class in Patients with Primary or Precapillary Secondary Pulmonary Hypertension

Intense neurohormonal activation has been demonstrated in patients with primary or precapillary secondary pulmonary hypertension (PH) but the relation of neurohormons to functional impairment is not well known. Plasma levels of atrial natriuretic peptide (ANP), aldosterone (ALD), renin activity (PRA), epinephrine (PE), norepinephrine (PNE) and endothelin (ET) were assessed from the antecubital vein in 12 patients with primary PH, 7 patients with precapillary secondary PH (2 connective tissue disease, 2 chronic thromboembolic, 3 closed atrial septal defect) and 10 control subjects. Twelve patients were in NYHA functional class II (PH-II) and 7 in class III/IV (PH-III/IV). Mean PA pressure (PAP), cardiac index (CI), pulmonary vascular resistance (PVR) and right atrial pressure were assessed by heart catheterization:PAPCIPVRRAP(mmHg)(l/minlm2)(RU)(mmHg)PH-II53 ± 132.4 ± 0.412 ± 33 ± 2PH-III/IV61 ± 92.0 ± 0518 ± 611 ±5P0.170.070.0090.0001Neurohormons plasma levels in control subjects (C), PH-II and PH-III/IV patients were as follows:ANPALDPRAPEPNEET(pg/ml)(pg/ml)(ng/ml/h)(pg/ml)(pg/ml)(pg/ml)C58 ± 18110 ± 650.7 ± 0.433 ± 19220 ± 1011.7 ± 0.3PH-II167 ± 96*144 ± 10215 ± 2.0298 ± 263*420 ± 294*3.6 ± 1.4*PH-III/IV276 ± 153*†209 ± 2703.2 ± 3.9*462 ± 524*820 ± 693*†8.4 ± 3.9*°*p < 0.05 vs C° p < 0.001 vs PH-II †P < 0.09 vs PH-IIConclusionsNeurohormonal activation in primary or precapillary secondary PH is detectable also in patients without overt clinical and hemodynamic signs of right heart failure (PH-II). Neurohormonal activation seems to be progressive and is more severe in functional class III/IV patients. ET shows the best statistically significant relation with functional impairment