Common contributing factors of diagnostic error:A retrospective analysis of 109 serious adverse event reports from Dutch hospitals

Introduction: Although diagnostic errors have gained renewed focus within the patient safety domain, measuring them remains a challenge. They are often measured using methods that lack information on decision-making processes given by involved physicians (eg, record reviews). The current study analyses serious adverse event (SAE) reports from Dutch hospitals to identify common contributing factors of diagnostic errors in hospital medicine. These reports are the results of thorough investigations by highly trained, independent hospital committees into the causes of SAEs. The reports include information from involved healthcare professionals and patients or family obtained through interviews. Methods:All 71 Dutch hospitals were invited to participate in this study. Participating hospitals were asked to send four diagnostic SAE reports of their hospital. Researchers applied the Safer Dx Instrument, a Generic Analysis Framework, the Diagnostic Error Evaluation and Research (DEER) taxonomy and the Eindhoven Classification Model (ECM) to analyse reports.Results: Thirty-one hospitals submitted 109 eligible reports. Diagnostic errors most often occurred in the diagnostic testing, assessment and follow-up phases according to the DEER taxonomy. The ECM showed human errors as the most common contributing factor, especially relating to communication of results, task planning and execution, and knowledge. Combining the most common DEER subcategories and the most common ECM classes showed that clinical reasoning errors resulted from failures in knowledge, and task planning and execution. Follow-up errors and errors with communication of test results resulted from failures in coordination and monitoring, often accompanied by usability issues in electronic health record design and missing protocols. Discussion: Diagnostic errors occurred in every hospital type, in different specialties and with different care teams. While clinical reasoning errors remain a common problem, often caused by knowledge and skill gaps, other frequent errors in communication of test results and follow-up require different improvement measures (eg, improving technological systems).</p

Psychological impact of preconception counseling: Assessment of anxiety before and during pregnancy

Objective: Assessment of anxiety levels in women and men before and after preconception counseling and during the first trimester of pregnancy. Methods: Couples were recruited from the fertility clinic of the University Medical Center Nijmegen, the Netherlands. Anxiety was assessed using the 40-item Spielberger State-Trait Anxiety Inventory (STAI). Results: 53 women and 51 men (74%) completed the STAI both before and after counseling. Anxiety levels did not change significantly after counseling or during the first trimester of pregnancy. 83.4% would recommend preconception counseling to others. Conclusion: Preconception counseling is valued by the majority of women and men and does not lead to adverse psychological effects. Copyrigh

Characteristics of Escherichia coli sequence type 131 isolates that produce extended-spectrum β-lactamases: global distribution of the H30-Rx sublineage

We designed a study to describe the characteristics of sequence type 131 (ST131) lineages, including the H30-Rx sublineage, among a global collection of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli isolates from 9 countries collected from 2000 to 2011. A total of 240 nonrepeat isolates from Canada, the United States, Brazil, the Netherlands, France, the United Arab Emirates (UAE), India, South Africa, and New Zealand were included. Established PCR, sequencing, and typing methods were used to define ST131 lineages, H30 and H30-Rx phylogenetic groups, gyrA and parC mutations, virotypes, and plasmid-mediated quinolone resistance determinants. The majority of the isolates produced CTX-M-15 with aac(6′)-lb-cr, belonged to phylogenetic group B2, and were positive for the H30 lineage with the gyrA1AB and parC1aAB mutations. ST131 showed 15 distinct pulsotypes; 43% of the isolates belonged to four pulsotypes, with a global distribution. Seventy-five percent of the ST131 isolates belonged to H30-Rx; this sublineage was present in all the countries and was associated with multidrug resistance, blaCTX-M-15, aac(6′)-lb-cr, and virotypes A and C. The H41 lineage was negative for the ST131 pabB allele-specific PCR. The multidrug-resistant H30-Rx sublineage poses an important public health threat due to its global distribution, association with virotype C, and high prevalence among ST131 isolates that produce CTX-M-15

Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial

BACKGROUND: In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. MATERIALS AND METHODS: Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. RESULTS: In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively ( p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively ( p = 0.82). The time courses for MDR/HRMO development were also similar for both groups ( p = 0.33). CONCLUSIONS: In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences

The presence of genes encoding for different virulence factors in clonally related Escherichia coli that produce CTX-Ms

Successful international clones have recently emerged among Escherichia coli that produce CTX-M beta-lactamases as important causes of community-onset urinary tract and bloodstream infections. One hundred and seven isolates that belong to sequence types (STs) ST38, ST131, ST405, ST648, and 38 nonrelated CTX-M producing E. coli from Canada and the Netherlands were assigned to phylogenetic groups and tested for the presence of genes encoding for virulence factors (VFs) using established multiplex polymerase chain reaction. The STs E. coli were significantly more resistant to antibiotics-ST38, ST405, and ST648 belonged to phylogenetic group D while ST131 belonged to B2. Secreted autotransporter toxin (sat), aerobactin receptor, and pathogenicity island marker were significantly more common among the STs; the heat-resistant agglutinin (hra) was present in ST38, sat, and uropathogenic-specific protein, and putative adhesin-siderophore receptor was more common in ST131, while outer membrane protease T was present in ST648. ST131 had a significantly higher VF score. In conclusion, the precise role of these VFs remains to be elucidated; however, we have identified certain putative VFs that possibly contribute to the fitness and success of certain sequence types. (C) 2012 Elsevier Inc. All rights reserved.Calgary Laboratory ServicesCalgary Laboratory Services [73-6350]MerckMerckAstraZenecaAstra Zenec

Internationaler Vergleich von 19 Leitlinien-Programmen--Eine Ubersicht der AGREE Collaboration

Clinical practice guidelines are being developed in many countries throughout the world to improve quality of patient care. However, the methods used to develop guidelines vary among organisations. Therefore an international task group, the AGREE (Appraisal Guideline Research and Evaluation Europe) Collaboration, started in 1998 to work on the harmonisation and coordination of guideline development. Within this context a survey of national guideline programmes was conducted. Nineteen programmes from nine European countries, Australia, Canada, New Zealand and United States were described using a questionnaire. The items concerned the type of organisation, scope and purpose of the guidelines, people involved, methodology, products, implementation, evaluation, update procedure, and future plans. The results of this survey revealed a growing international consensus on the essential features of good guideline programmes. Most guideline programmes combine an evidence-based approach with informal and/or formal consensus procedures. No significant differences were found between governmental agencies and professional organisations. The budget for developing a single guideline varies from 10,000 to 200,000 EUR

Trends in Expanded-Spectrum Cephalosporin-Resistant Escherichia coli and Klebsiella pneumoniae among Dutch Clinical Isolates, from 2008 to 2012

We investigated time trends in extended-spectrum cephalosporin-resistant Escherichia coli and Klebsiella pneumoniae isolates from different patient settings in The Netherlands from 2008-2012. E. coli and K. pneumoniae isolates from blood and urine samples of patients > = 18 years were selected from the Dutch Infectious Disease Surveillance System-Antimicrobial Resistance (ISIS-AR) database. We used multivariable Poisson regression to study the rate per year of blood stream infections by susceptible and resistant isolates, and generalized estimating equation (GEE) log-binomial regression for trends in the proportion of extended-spectrum cephalosporin-resistant isolates. Susceptibility data of 197,513 E. coli and 38,244 K. pneumoniae isolates were included. The proportion of extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates from urine and blood samples increased in all patient settings, except for K. pneumoniae isolates from patients admitted to intensive care units. For K. pneumoniae, there was a different time trend between various patient groups (p<0.01), with a significantly higher increase in extended-spectrum cephalosporin-resistant isolates from patients attending a general practitioner than in isolates from hospitalized patients. For E. coli, the increasing time trends did not differ among different patient groups. This nationwide study shows a general increase in extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates. However, differences in trends between E. coli en K. pneumoniae underline the importance of E. coli as a community-pathogen and its subsequent influence on hospital resistance level, while for K. pneumoniae the level of resistance within the hospital seems less influenced by the resistance trends in the community

Ziekenhuisuitbraken en resistente micro-organismen

OBJECTIVE: To determine the number and duration of nosocomial outbreaks caused by highly resistant microorganisms (HRMO) posing a potential threat to public health, in order to undertake a risk assessment. DESIGN: Descriptive study. METHOD: Data on nosocomial outbreaks were collected from April 2012 to June 2014. The following characteristics were recorded at the start and end of each outbreak: type of microorganism, reason for reporting, phase of outbreak, number of patients colonised and infected, and infection prevention measures implemented. RESULTS: 47 medical institutions reported 87 outbreaks (mean: 3 outbreaks per month). 20 outbreaks were reported in 2012 (2.2/month), 39 in 2013 (3.3/month), and 28 in the first six months of 2014 (4.7/month). Outbreaks of vancomycin-resistant enterococci (n = 26), methicillin-resistant Staphylococcus aureus (MRSA; n = 23) and resistant or highly resistant Enterobacteriaceae (n = 17) were reported most frequently. 65 outbreaks (75%) were controlled within two months of reporting. CONCLUSION: Transparent reporting of HRMO outbreaks is important for correct public perceptions of the safety of hospitals and nursing homes in the Netherlands. Reports to the Hospital-acquired Infection and Antimicrobial Resistance Monitoring Group show that HRMO outbreaks are an almost daily occurrence in Dutch hospitals. However, most outbreaks are quickly controlled without posing a threat to public health

Ziekenhuisuitbraken en resistente micro-organismen

OBJECTIVE: To determine the number and duration of nosocomial outbreaks caused by highly resistant microorganisms (HRMO) posing a potential threat to public health, in order to undertake a risk assessment. DESIGN: Descriptive study. METHOD: Data on nosocomial outbreaks were collected from April 2012 to June 2014. The following characteristics were recorded at the start and end of each outbreak: type of microorganism, reason for reporting, phase of outbreak, number of patients colonised and infected, and infection prevention measures implemented. RESULTS: 47 medical institutions reported 87 outbreaks (mean: 3 outbreaks per month). 20 outbreaks were reported in 2012 (2.2/month), 39 in 2013 (3.3/month), and 28 in the first six months of 2014 (4.7/month). Outbreaks of vancomycin-resistant enterococci (n = 26), methicillin-resistant Staphylococcus aureus (MRSA; n = 23) and resistant or highly resistant Enterobacteriaceae (n = 17) were reported most frequently. 65 outbreaks (75%) were controlled within two months of reporting. CONCLUSION: Transparent reporting of HRMO outbreaks is important for correct public perceptions of the safety of hospitals and nursing homes in the Netherlands. Reports to the Hospital-acquired Infection and Antimicrobial Resistance Monitoring Group show that HRMO outbreaks are an almost daily occurrence in Dutch hospitals. However, most outbreaks are quickly controlled without posing a threat to public health