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Although other high-risk industries are led by people with training in and appreciation for engineered solutions, health care rarely has an engineer on a leadership team. Comment & Response B In Reply b We appreciate the opportunity to respond to Dr Oxman's Letter about our Viewpoint.[1] We agree with Oxman that the current use of algorithms to diagnose sepsis has caused unintended consequences. Health care is vastly underengineered and has few trained system engineers and examples of true systems engineering solutions. [Extracted from the article]

However, if the experience with sepsis is any lesson, diagnostic reasoning remains at its core a human endeavor. For example, computer-based algorithms used for the diagnosis of sepsis are a widespread systems-based effort designed to improve the timely diagnosis of a particular condition that has arguably facilitated widespread misdiagnosis of others.[[2]] Certainly, diagnostic algorithms and computer-generated alert systems have raised clinician awareness of sepsis and in many cases improved care. Comment & Response B To the Editor b I was pleased to read the recent Viewpoint[1] highlighting the serious problem of diagnostic error - a crucial issue not just in emergency departments. [Extracted from the article]

Correction The Viewpoint titled "Risks to the 340B Drug Pricing Program Related to Manufacturer Restrictions on Drug Availability", published in the May 3, 2022, issue of I JAMA i ,[1] misreported that the Health Resources and Services Administration (HRSA) sued 6 pharmaceutical manufacturers when the agency had instead issued enforcement letters. Reference 1 Knox RP, Kesselheim AS, Sarpatwari A. Risks to the 340B drug pricing program related to manufacturer restrictions on drug availability. The Viewpoint also should have used the words I interpretive guidance i instead of the word I rules i when talking about the history of court rulings on compliance with the HRSA interpretive guidance. [Extracted from the article]

Reminds us that the moment is as precious as I the bursting blossom of the columbine. i Lying prone, she waits to be seduced by I images as yet unseen. i B Section Editor: b Rafael Campo, MD, MA, Associate Editor. Awes at the April blossoms on branches greening in her window. Poetry and Medicine For Peggy She disagrees with her body. [Extracted from the article]

For many physicians, the prospect of being sued for medical malpractice is a singularly disturbing aspect of modern clinical practice. State legislatures have enacted tort reforms, such as caps on damages, in an effort to reduce the volume and costs of malpractice litigation. Attempts to introduce similar traditional reform measures at the federal level have so far failed. Much less prominent, but potentially more important, are proposed alternative approaches for resolving medical injuries; a number of these efforts are currently being tested in federally sponsored demonstration projects. These nontraditional reforms have considerable promise for addressing some of the system's most challenging issues, including high costs and barriers to accessing compensation. In this Special Communication, we review recent national trends in medical liability claims and costs, which indicate a sharp reduction in the rate of paid claims and flat or declining levels in compensation payments and liability insurance costs over the last 7 to 10 years. We discuss a number of nontraditional reform approaches--communication-and-resolution programs, presuit notification and apology laws, safe harbor legislation, judge-directed negotiation, and administrative compensation systems--and we conclude by describing several forces likely to shape change in the medical liability environment over the next decade. [ABSTRACT FROM AUTHOR]

IMPORTANCE Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. OBJECTIVE TO determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. DESIGN, SETTING, AND PARTICIPANTS Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. INTERVENTIONS Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. MAIN OUTCOMES AND MEASURES The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. RESULTS Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. CONCLUSIONS AND RELEVANCE Implementation ofa handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely. [ABSTRACT FROM AUTHOR]

IMPORTANCE The effect of surgeons' disrupted sleep on patient outcomes is not clearly defined. OBJECTIVE To assess if surgeons operating the night before have more complications of elective surgery performed the next day. DESIGN, SETTING, AND PARTICIPANTS Population-based, matched, retrospective cohort study using administrative health care databases in Ontario, Canada (2012 population, 13 505 900). Participants were 2078 patients who underwent elective laparoscopic cholecystectomies performed by surgeons who operated the night before, matched with 4 other elective laparoscopic cholecystectomy recipients (n = 8312). EXPOSURE In total, 94183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011. Of these surgeries, there were 2078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 AM the night before. Each "at-risk" surgery was randomly matched with 4 other elective laparoscopic cholecystectomies (n = 8312) performed by the same surgeon, who had no evidence of having operated the night before. MAIN OUTCOMES AND MEASURES The primary outcome was conversion from a laparoscopic cholecystectomy to open cholecystectomy. Secondary outcomes included evidence of iatrogenic injuries or death. Risks were quantified using generalized estimating equations. RESULTS NO significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night (46/2031 [2.2%] vs 157/8124 [1.9%]; adjusted odds ratio [OR], 1.18; 95% CI, 0.85-1.64). There was no association between operating the night before vs not operating the night before, and risk of iatrogenic injuries (14/2031 [0.7%] vs 72/8124 [0.9%]; adjusted OR, 0.77; 95% CI, 0.43-1.37) or death (<5/2031 [<0.2%] vs 7/8124 [0.1%]). CONCLUSIONS AND RELEVANCE No significant association was found between operating the night before and not operating the previous night for conversion to open cholecystectomy, risk of iatrogenic complications, or death for elective daytime cholecystectomy. These findings do not support safety concerns related to surgeons operating the night before performing elective surgery. [ABSTRACT FROM AUTHOR]

The article discusses a study which investigated paid malpractice claims for adverse events in both outpatient and inpatient settings in the U.S. from 2005 through 2009. Data from the National Practitioner Data Bank (NPDB), a repository of all malpractice claims in the U.S., were analyzed. Parameters evaluated include number of paid claims, types of errors, payment amounts, and outcomes of errors. The study concluded that the number of paid malpractice claims in 2009 for events in the outpatient setting was similar to the number of claims in the inpatient setting.

The article provides information on a study which determined whether recent experience with clinical problems triggers availability bias leading to diagnostic errors and whether reflection counteracts such bias. Participants in the experimental study carried out in 2009 were 18 first-year and 18 second-year internal medical residents enrolled at the Erasmus Medical Center in Rotterdam, the Netherlands. The phases of the clinical diagnosis that the participants were asked to perform are detailed. A discussion on the research findings is presented.

The article discusses the result of a study in which Martin A. Makary and Michael Daniel of the Johns Hopkins University School of Medicine asserted that medical errors is the third most common cause of death in the U.S. A comparison of the data on the medical error death rates used in the study and the data used by the Centers for Disease Control and Prevention (CDC) is made. It is noted that there is no reliable data on the total number of medical errors across areas of the health care system.

The article discusses a study which examined the association of fatigue and distress with self-perceived major medical errors among resident physicians. The study included 380 categorical and preliminary internal resident physicians at Mayo Clinic in Rochester, Minnesota who started their training from 2003 to 2008. It found that 39 percent of the study participants made at least one major medical error during the study period. Such errors were found to be associated with burnout, emotional exhaustion, depression, fatigue and distress.

The article discusses the highlights of a conference that took lace at the Surgery Grand Rounds at Beth Israel Deaconess Medical Center in Boston, Massachusetts on November 5, 2008. The conference discussed the case of a 62-year-old woman with skin cancer who experienced wrong-site surgery, who eventually experienced a shaken trust in clinicians. The author discusses the subject of medical error as well as the percentage of medical errors that can cause harm. The difference between medical error and adverse event is also discussed.

This article reports on a study that aimed to measure the effectiveness of rapid response teams in reducing the number of preventable deaths in U.S. hospitals. A report issued by the Institute of Medicine said as many as 98,000 deaths per year in the U.S. are the result of error and armed with this statistic the rapid response team (RRT) was formed. Studies have shown that the RRT reduces mortality outside of the intensive care unit in adults but there is a lack of information on how it works on children. This cohort study found a statistically significant decline in hospital-wide mortality and code rate in pediatric services outside the intensive care ward.

The article reports on a study investigating the duty hour regulations for medical physicians in training and the correlation with mortality of Medicare patients in teaching hospitals. Medical errors made by physicians working extended hours have caused concern, especially in relation to mortality rates in U.S. hospitals. The Accreditation Council for Graduate Medical Education implemented working limits for medical residents in order to lessen fatigue and impaired performance. The study's design, setting, patients, outcome, results and conclusion are detailed.

The article discusses waste in the U.S. health care delivery system, which is described as unsafe, ineffective, inefficient, inequitable, untimely, and not patient-centered. The Dept. of Veterans Affairs' reforms in the 1990s are cited as exemplary at the macrosystem level. Other positive initiatives cited are the Leapfrog Group's agenda to reduce preventable medical errors and the Institute for Healthcare Improvement's 5 Million Lives Campaign, which is engaging U.S. hospitals to improve patient care and prevent avoidable deaths.

In this narrative medicine essay, a physician recounts an error in which his patient received double the dose of a medication he prescribed, and what he learned from asking the patient for forgiveness. [ABSTRACT FROM AUTHOR]

The article presents a medical study examining whether opiate analgesics affect the clinical examination and operative decision for patients with acute abdominal pain. The authors used MEDLINE, EMBASE, and hand searches to locate and evaluate medical studies of placebo-controlled randomized trials of opiate analgesia. According to the article, while opiate analgesics may change the physical examination findings, these changes do not cause a significant increase in management or diagnostic errors.

The article reports on the full disclosure of medical errors by physicians in the United States. This movement has gained momentum since the publication of the indepth study of the 1999 Institute of Medicine "To Err Is Human: Building a Safer Health System," and the 2001 Safety Standards of the Joint Commission on Accreditation of Healthcare Organizations on disclosure of patient harm. After physicians disclosed medical errors an apology was deemed the next step. This was followed by remorse and discussion of reparations. Patient safety and ethical commitments to honesty had a beneficial effect in that there was a reduction in the number and cost of malpractice claims.

The article provides research on the compliance of medical interns with work-hour limits that were implemented by the Accreditation Council for Graduate Medical Education. Included in the system are limits on consecutive hours worked, hours worked in a week, and number of days worked per week. The limits were implemented in an effort to limit the risk of serious medical errors in patients and motor vehicle crashes caused by interns due to sleep deprivation. The study reports on the number of violations to the requirements reported among interns.

The article reports on a study of how the occurrences of medical errors are linked with distress of physicians. In the study, physicians recorded the frequency of self-perceived medical errors. Associations of an error with distress and depression were determined using estimating equations. Statistics regarding numbers of medical errors made are provided. The article provides information on methods, participants, and data collection procedures. The results of the study suggest that personal distress is associated with increased self-perceived errors in a reciprocal cycle.

Context Since the Institute of Medicine (IOM) reports on medical errors and quality, national attention has focused on improving patient safety through changes in “systems” of care. These reports resulted in a new paradigm that, rather than centering on individual errors, focuses on the “systems” necessary to facilitate and enhance quality and protect patients. Objectives To assess the status of hospital patient safety systems since the release of the IOM reports and to identify changes over time in 2 states that collaborated on a patient safety project funded by the Agency for Healthcare Research and Quality. Design, Setting, and Participants Survey of all acute care hospitals in Missouri and Utah at 2 points in time, in 2002 and 2004, using a 91-item comprehensive questionnaire (n = 126 for survey 1 and n = 128 for survey 2). To assess changes over time, we also studied the cohort of 107 hospitals that responded to both surveys. Main Outcome Measures Responses to the 91-question survey as well as changes in responses to the survey questions over an 18-month period. Seven latent variables were constructed to represent the most important patient safety constructs studied: computerized physician order entry systems, computerized test results, and assessments of adverse events; specific patient safety policies; use of data in patient safety programs; drug storage, administration, and safety procedures; manner of handling adverse event/error reporting; prevention policies; and root cause analysis. For each hospital, the 7 latent variables were summed to give an overall measure of the patient safety status of the hospital. Results Development and implementation of patient safety systems is at best modest. Self-reported regression in patient safety systems was also found. While 74% of hospitals reported full implementation of a written patient safety plan, nearly 9% reported no plan. The area of surgery appears to have the greatest level of patient safety systems. Other areas, such as medications, with a long history of efforts in patient safety and error prevention, showed improvements, but the percentage of hospitals with various safety systems was already high at baseline for many systems. Some findings are surprising, given the overall trends; for example, while a substantial percentage of hospitals have medication safety systems, only 3% reported full implementation at survey 2 of computerized physician order entry systems for medications, despite the growth of computer technology in general and in hospital billing systems in particular. Conclusions The current status of hospital patient safety systems is not close to meeting IOM recommendations. Data are consistent with recent reports that patient safety system progress is slow and is a cause for great concern. Efforts for improvement must be accelerated. [ABSTRACT FROM AUTHOR]

Presents a clinical study of a 38-year-old woman with fetal loss and hysterectomy due to medical errors. Description of the patient's labor and delivery; Performance of an emergency cesarean delivery on the patient; Report that the patient had a stillbirth; Report that the patient received physical therapy, occupational therapy, and other supportive care following her recovery; Views of the patient and her husband regarding the medical care she received; Question about the use of the drug misoprostol; View of the patient's obstetrician; Claim of the obstetrician that the patient was informed about the risks of using the drug misoprostol for the induction of labor; Changes made within the hospital following this case of fetal death.

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents the author's response to letters to the editor regarding a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Presents a letter to the editor in response to a study of computerized physician order entry systems and medication errors, published in the March 10, 2005 edition of the "Journal of American Medical Association."

Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly “changed the conversation” to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010. [ABSTRACT FROM AUTHOR]

Context The Institute of Medicine has recommended establishing mandatory error reporting systems for hospitals and other health settings. Objective To examine the opinions and experiences of hospital leaders with state reporting systems. Design and Setting Survey of chief executive and chief operating officers (CEOs/COOs) from randomly selected hospitals in 2 states with mandatory reporting and public disclosure, 2 states with mandatory reporting without public disclosure, and 2 states without mandatory systems in 2002-2003. Main Outcome Measures Perceptions of the effects of mandatory systems on error reporting, likelihood of lawsuits, and overall patient safety; attitudes regarding release of incident reports to the public; and likelihood of reporting incidents to the state or to the affected patient based on hypothetical clinical vignettes that varied the type and severity of patient injury. Results Responses were received from 203 of 320 hospitals (response rate = 63%). Most CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital’s own internal reporting system (69%) and encourage lawsuits (79%) while having no effect or a negative effect on patient safety (73%). More than 80% felt that the names of both the hospital and the involved professionals should be kept confidential, although respondents from states with mandatory public disclosure systems were more willing than respondents from the other states to release the hospital name (22% vs 4%-6%, P =.005). Based on the vignettes, more than 90% of hospital leaders said their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even when the incident was of sufficient consequence that they would tell the affected patient or family. Conclusions Most hospital leaders expressed substantial concerns about the impact of mandatory, nonconfidential reporting systems on hospital internal reporting, lawsuits, and overall patient safety. While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems. INSET: Three Vignettes of Hypothetical Errors Involving Harm.... [ABSTRACT FROM AUTHOR]

Context Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. Objective To identify and quantify the role of CPOE in facilitating prescription error risks. Design, Setting, and Participants We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. Main Outcome Measure Examples of medication errors caused or exacerbated by the CPOE system. Results We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. Conclusions In this study, we found that a leading CPOE system often facilitated medication error risks, with many... [ABSTRACT FROM AUTHOR]

Presents research to determine if Pap smear screening among women who have had hysterectomy decreased after a recommendation from the US Preventive Services Task Force that routine Papanicolaou smear screening is not necessary in these women. Design, study participants, main outcome measures, and results; Conclusion that many women are having Pap smears even though they are not at risk for cervical cancer.

Context: Mortality and morbidity can be reduced if aneurysmal subarachnoid hemorrhage (SAH) is treated urgently. Objective: To determine the association of initial misdiagnosis and outcome after SAH. Design, Setting, and Participants: Inception cohort of 482 SAH patients admitted to a tertiary care urban hospital between August 1996 and August 2001. Main Outcome Measures: Misdiagnosis was defined as failure to correctly diagnose SAH at a patient's initial contact with a medical professional. Functional outcome was assessed at 3 and 12 months with the modified Rankin Scale; quality of life (QOL), with the Sickness Impact Profile. Results: Fifty-six patients (12%) were initially misdiagnosed, including 42 of 221 (19%) of those with normal mental status at first contact. Migraine or tension headache (36%) was the most common incorrect diagnosis, and failure to obtain a computed tomography (CT) scan was the most common diagnostic error (73%). Neurologic complications occurred in 22 patients (39%) before they were correctly diagnosed, including 12 patients (21%) who experienced rebleeding. Normal mental status, small SAH volume, and right-sided aneurysm location were independently associated with misdiagnosis. Among patients with normal mental status at first contact, misdiagnosis was associated with worse QOL at 3 months and an increased risk of death or severe disability at 12 months. Conclusions: In this study, misdiagnosis of SAH occurred in 12% of patients and was associated with a smaller hemorrhage and normal mental status. Among individuals who initially present in good condition, misdiagnosis is associated with increased mortality and morbidity. A low threshold for CT scanning of patients with mild symptoms that are suggestive of SAH may reduce the frequency of misdiagnosis. [ABSTRACT FROM AUTHOR]

Context: Although adverse drug events have been extensively evaluated by computer-based surveillance, medical device errors have no comparable surveillance techniques. Objectives: To determine whether computer-based surveillance can reliably identify medical device–related hazards (no known harm to patient) and adverse medical device events (AMDEs; patient experienced harm) and to compare alternative methods of detection of device-related problems. Design, Setting, and Participants: This descriptive study was conducted from January through September 2000 at a 520-bed tertiary teaching institution in the United States with experience in using computer tools to detect and prevent adverse drug events. All 20 441 regular and short-stay patients (excluding obstetric and newborn patients) were included. Main Outcome Measures: Medical device events as detected by computer-based flags, telemetry problem checklists, International Classification of Diseases, Ninth Revision (ICD-9) discharge code (which could include AMDEs present at admission), clinical engineering work logs, and patient survey results were compared with each other and with routine voluntary incident reports to determine frequencies, proportions, positive predictive values, and incidence rates by each technique. Results: Of the 7059 flags triggered, 552 (7.8%) indicate a device-related hazard or AMDE. The estimated 9-month incidence rates (number per 1000 admissions [95% confidence intervals]) for AMDEs were 1.6 (0.9-2.5) for incident reports, 27.7 (24.9-30.7) for computer flags, and 64.6 (60.4-69.1) for ICD-9 discharge codes. Few of these events were detected by more than 1 surveillance method, giving an overall incidence of AMDE detected by at least 1 of these methods of 83.7 per 1000 (95% confidence interval, 78.8-88.6) admissions. The positive predictive value of computer flags for detecting device-related hazards and AMDEs ranged from 0% to 38%. Conclusions: More intensive surveillance methods yielded higher rates of medical device problems than found with traditional voluntary reporting, with little overlap between methods. Several detection methods had low efficiency in detecting AMDEs. The high rate of AMDEs suggests that AMDEs are an important patient safety issue, but additional research is necessary to identify optimal AMDE detection strategies. [ABSTRACT FROM AUTHOR]

Context: Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal. Objective: To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause. Design, Setting, and Participants: Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals. Main Outcome Measures: Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors. Results: In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P = .001), more time was spent listening to invited speakers (43.1% vs 0%; P<.001), and less time was spent in audience discussion (15.2% vs 36.6%; P<.001). Fewer internal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; P<.001) or errors causing an adverse event (18 [18%] vs 98 [42%], respectively; P = .001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P = .02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; P<.001). In discussions of cases with errors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error. Conclusions: Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal medicine missed opportunities to model recognition of error and to use explicit language in error discussion by acknowledging their personal experiences with error. [ABSTRACT FROM AUTHOR]

Context: Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact. Objective: To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization. Design, Setting, and Patients: The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. Main Outcome Measures: Length of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs. Results: Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from $0 for obstetric trauma (without vaginal instrumentation) to $57 727 for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, $40 323 in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, $38 656 in excess charges, and 4.31% attributable mortality. Conclusion: Some injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable. [ABSTRACT FROM AUTHOR]

Context: Despite the best efforts of health care practitioners, medical errors are inevitable. Disclosure of errors to patients is desired by patients and recommended by ethicists and professional organizations, but little is known about how patients and physicians think medical errors should be discussed. Objective: To determine patients' and physicians' attitudes about error disclosure. Design, Setting, and Participants: Thirteen focus groups were organized, including 6 groups of adult patients, 4 groups of academic and community physicians, and 3 groups of both physicians and patients. A total of 52 patients and 46 physicians participated. Main Outcome Measures: Qualitative analysis of focus group transcripts to determine the attitudes of patients and physicians about medical error disclosure; whether physicians disclose the information patients desire; and patients' and physicians' emotional needs when an error occurs and whether these needs are met. Results: Both patients and physicians had unmet needs following errors. Patients wanted disclosure of all harmful errors and sought information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented. Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. Although physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians were also upset when errors happen but were unsure where to seek emotional support. Conclusions: Physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients' desires for an... [ABSTRACT FROM AUTHOR]

Presents correspondence between medical practitioners as of November 20, 2002. Use of sertraline for the treatment of depression in acute coronary syndrome; Improvements in counting deaths due to medical errors; Virologic outcomes of complex drug regimens for human immunodeficiency viruses.

Discusses the benefits for patient safety of a primary focus on medical injury based on the injury prevention model from the United States Institute of Medicine. Differences between medical injury and medical error; Difficulty in identifying medical errors; Institutional and personal barriers to the reporting of medical errors, including fear of lawsuits; Advantages of the injury prevention model.

Argues that patient safety efforts should focus on medical errors rather than medical injuries. Case of a patient who died because a computer system was not working; Definition of an error; Methods for discovering causes of injury; Suggestion that errors in policy making and organization are prime causes of injury.

Discusses concerns that the working conditions of physicians may contribute to the frequency and severity of medical errors. Study which will test the hypothesis that long hours with little sleep jeopardizes the health of clinicians and safety of patients; Intervention study which will examine the impact of minimized sleep deprivation in interns; Petition calling for the establishment of national work-hour limits for resident physicians in the United States.

Presents a study to evaluate cross-reactivity of quinolone antimicrobials in common opiate screening assays and to assess the in vivo implications of this phenomenon, in light of how common medications may cross-react with frequently used testing assays and cause false-positive results. Context; Objective; Design, setting, and participants; Main outcome measure; Results; Conclusion that greater attention to cross-reactivity of quinolones with immunoassays for opiates is needed to minimize the potential for invalid test interpretation.

Presents letters to the editor concerning medical topics. Relation between cardiovascular events and cyclooxygenase 2 inhibitors; Risk factors for dating violence in adolescents; Preventable deaths from medical errors.

Presents a study to examine the reliability of reviewer ratings of medical error and the implications of a death described as 'preventable by better care' in terms of the probability of immediate and short-term survival if care had been optimal. Design; Setting and participants; Main outcome measures; Results; Conclusions.

Presents a study on errors in medicine. Description of alternative litigation that does not predicate compensation on proof of practitioner fault; Suggests how this litigation might be operationalized; Need to test the litigation process; Criticism of no-fault compensation systems for medical injury.

Reports on the problem of medication errors with a focus on a woman who found an error with her HIV medication. Statement from patient about the mistake; Evaluation of the possible medical complications from the error; Epidemiology of medication errors; Data about adverse drug reactions (ADEs); Causes and prevention strategies for errors; Effect on the public; Conclusions.

Presents several letters to the editor dealing with medical issues. Discussion of barriers to patients seeking emergency care for acute coronary heart disease; Analysis of the United States health care system; Concern over the Institute of Medicine's report on the number of deaths in the U.S. as a result of medical errors; Others.

Presents a study that explored the epidemiology of adverse events (AE), which were defined as injuries due to medical treatment. Variation in AE rates; Percentage of AE due to negligence; AE rates in primary teaching institutions.

Presents a study that examined the mistakes reported by internal medicine house officers at their academic training programs in the U.S. Types of mistakes and outcomes of the mistakes; Causes of the medical errors; Effect of the changes in practice on the incidence of medical mistakes.

Presents a study that evaluates the efficacy of two interventions for preventing nonintercepted serious medication errors. Design; Setting; Participants; Interventions; Main outcome measure; Results; Conclusions.