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Errors resulting in adverse events in the medical care system are ubiquitous and underreported. Critical incident techniques that have been used to reduce errors in aviation have recently been applied to evaluate adverse events in the critical care arena. We report an evaluation of interrater agreement on responses to questions concerning adverse event reporting using a computer-based medical incident reporting system (MIRS). Thirty-four intensive care unit staff volunteers reviewed five fabricated test cases containing iatrogenic factors, then completed an incident report for each case using the MIRS. Interrater agreement was significant for all five cases (p < 0.01). The time required to complete a report decreased significantly from the first case to the last (p < 0.01). Overall, the MIRS was perceived as a relatively quick (< 6 minutes) and comprehensive reporting tool. The results indicate that health care providers report adverse events similarly, suggesting that the MIRS would be a useful tool in the reduction of errors (as a process improvement program) and to facilitate the continuing process of health care improvement.

Abstract. Objective: To determine whether admission source is a potential risk factor for appendiceal rupture. Methods: Administrative data were obtained from the California Office of Statewide Health Planning and Development for all patients in San Diego County with the primary diagnosis of appendicitis during 1993. The appendiceal rupture ratio was defined as those coded as ruptured (ICD‐9‐CM codes 540.0 and 540.1) divided by both ruptured and non‐ruptured cases (540.9). The odds ratio of appendiceal rupture from routine outpatient office or clinic venues vs those admitted through the ED were calculated using multivariate logistic regression analysis to adjust for age, sex, race, comorbidity, insurance status, and home address to hospital proximity. Results: There were a total of 1,906 patients, of whom 663 (34.8%) had appendiceal ruptures. Of the 1,360 (71.4%) admitted from the ED, 422 (31.0%) had ruptures, compared with 211 (43.3%) of the 487 admitted from outpatient sources (p < 0.0001). Patients with appendicitis directly admitted from outpatient sources were more likely to be complicated by appendiceal rupture than were those admitted through the hospital ED (adjusted odds ratio 1.62, 95% CI = 1.28 to 2.05, p < 0.0001). Conclusion: Patients with appendicitis admitted from outpatient sources are more likely to have appendiceal rupture than are those admitted from the ED.

OBJECTIVE: To determine the accuracy of diagnostic peritoneal lavage (DPL) for the evaluation of intraabdominal injury in patients with a pelvic fracture as a result of blunt trauma. DESIGN: Retrospective cohort analysis. SETTING: Level I trauma center in metropolitan Seattle, Wash. PATIENTS: Four hundred ninety-seven consecutive patients admitted with pelvic fractures following blunt trauma during a 60-month period. OUTCOME MEASURES: Positive results of DPL, defined by one of the following: an immediate aspiration of more than 10 mL of gross blood; a red blood cell count of more than 0.0001 × 1012/L; a white blood cell count greater than 0.0005 × 109/L; an elevated amylase, bilirubin, or creatinine level; or organic particles or bacteria in the effluent returned after installation of 1 L of crystalloid fluid lavaged in the peritoneal cavity. RESULTS: Two hundred eighty-six patients underwent DPL. For 80 patients (28.0%), results of DPL were positive and for 194 patients (67.8%) the results of DPL were negative. For two patients (0.7%), results of DPL were false positive for a sensitivity of 94%. For another two patients (0.7%), the results of DPL were false negative for a specificity of 99%. As a diagnostic modality, DPL has a positive predictive value of 98% and a negative predictive value of 97%. CONCLUSIONS: Diagnostic peritoneal lavage is a reliable method for the evaluation of intra-abdominal injury and should remain a standard component in the evaluation of patients following blunt injury with or without pelvic fractures.(Arch Surg. 1994;129:477-482)

OBJECTIVE: To evaluate the long-term survival and factors that influence survival among a cohort of elderly trauma patients compared with an uninjured cohort. DESIGN: A retrospective cohort analysis. DATA SOURCES: Health Care Finance Administration, Baltimore, Md, Medicare data. SUBJECTS: A cohort of elderly patients (n=9424) hospitalized for injury in 1987 was identified using Medicare hospital discharge abstract data. An uninjured comparison group (n=37 787) was identified from Medicare eligibility files. For injured patients, an Injury Severity Score was generated from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) codes. For both cohorts, preexisting illness was assessed by ICD-9CM codes from Health Care Finance Administration outpatient and inpatient data files for 1986 and 1987. MAIN OUTCOME MEASURES: Relative risk for mortality within 5 years subsequent to injury, adjusted for age, sex, and preexisting illness, using Cox proportional hazard regression. RESULTS: The injured cohort had a significantly reduced 5-year survival when compared with the uninjured group (relative risk [RR] = 1.71; 95% confidence interval, 1.66-1.77). The lower survival persisted even among patients who survived at least 3 years after injury. Coexisting disease, age, and Injury Severity Score were strong predictors of survival. CONCLUSIONS: The adverse effect of trauma on survival in elderly patients is not isolated to the immediate postinjury period, but lasts years after the trauma episode. Further study is required to identify the reasons for this persistent effect of trauma on subsequent survival.Arch Surg. 1997;132:1010-1014.

The control of hemorrhage in hypothermic patients with platelet and clotting factor depletion is often impossible. Determining the cause of coagulopathic bleeding (CB) will enable physicians to appropriately focus on rewarming, clotting factor repletion, or both.

C14-labeled cholesterol was incubated with growing cells of A. aerogenes.Following hydrolysis of the incubation medium, a significant portion of the sterol was recovered in the saponifiable fraction. Apparently, the solubility of the sterol was modified by a substance produced during the growth of the Aerobacter.