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IntroductionPeople who use alcohol and/or drugs (PWUAD) are at high risk of medical complications, frequent hospitalisation and drug-related death following discharge from inpatient settings and emergency departments (EDs). Harm reduction strategies implemented in these settings may mitigate negative health outcomes for PWUAD. However, the scope of harm reduction strategies used globally within inpatient settings and EDs is unknown. The objective of this review is to identify and synthesise reported harm reduction strategies that have been implemented across inpatient settings and EDs for PWUAD.Methods and analysisThis review will include studies from any country and health service reporting on harm reduction strategies implemented in inpatient settings or EDs. The population of interest includes people of any race, gender and age identifying as PWUAD, or individuals who provided care to PWUAD. Studies which describe implementation strategies and barriers and enablers to implementation will be included. Studies published in English, or those available for English translation will be included. The following databases will be searched: MEDLINE All (Ovid), Embase (Elsevier Embase.com), CINAHL with Full Text (EBSCOhost), PsycINFO (EBSCOhost) and SCOPUS (Elsevier Scopus.com). A grey literature search will be conducted. There will be no date restrictions on the search. Titles, abstracts and full texts will be screened in duplicate. Data will be extracted using a standardised form. The results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews.Ethics and disseminationScoping reviews do not require ethical approval. Patient partners with lived experience and relevant knowledge users will be engaged as research team members throughout all phases of the research process. A report detailing context, methodology and findings from this review will be disseminated to knowledge users and relevant community stakeholders. This review will be submitted for publication to a relevant peer-reviewed journal.

Background Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings. Methods We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED. Results Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention). Conclusions This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.

Physician performance feedback (PPF) can help physicians gain insight into their practice, to identify areas for improvement, and to implement changes to improve care. There is increasing interest in the use of PPF in Canada. However, little is known about the different types of PPF methods and whether PPF can lead to improved physician performance and patient outcomes. We provide a primer for healthcare leaders interested in doing PPF by reviewing common PPF methods. We then describe our institution's experience with physician multi-source feedback and provide strategies to conduct meaningful PPF.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Our objective was to review and synthesize all organizational and professional intervention strategies in emergency practice settings that focus on improving the health outcomes of adults and children with asthma.

Background Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery. Methods Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes. Results Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03–33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29–3.62) and cognitive impairment (OR 2.01, 95% CI 1.44–2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00–1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78–8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22–2.56) and smoking (OR 2.43, 95% CI 1.32–4.46), were also associated with developing postoperative complications. Conclusion Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care. Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0986-2) contains supplementary material, which is available to authorized users.

Background Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. Methods Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. Results Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3–23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2–17.9), frailty (OR 4.1, 95% CI 1.4–11.7), cognitive impairment (OR 2.7, 95% CI 1.9–3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6–2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3–2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4–3.6) and smoking status (OR 1.8 95% CI 1.3–2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52–0.91). Discussion Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care. Electronic supplementary material The online version of this article (10.1007/s11606-017-4204-x) contains supplementary material, which is available to authorized users.

Faced with a variety of challenges in relation to performance, quality, staff engagement and morale in the Medical Device Reprocessing Department, managers at St. Michael's Hospital developed and implemented several innovative approaches including combining staff training and performance metrics. The results of these initiatives included a substantial reduction in the departmental budget along with higher productivity, output and quality; better staff morale; an improved relationship between management and the union; and a stronger partnership between the department and its institutional customers.

Objective: Relative to the global investment in hospital accreditation programs overall, both the total amount and methodological quality of existing accreditation research is mediocre. To address this apparent gap in knowledge, we undertook a study of the experiences and perspectives of hospital staff, those most underrepresented in the accreditation research literature, including those working on the front lines and non-leaders who may or may not have been directly involved in the preparation for the accreditation survey visit.Methods: Design: Qualitative descriptive interview study. Setting: Tertiary care teaching hospital in Toronto, Ontario Canada. Study Participants: Program directors, unit managers, physicians, nurses, health discipline professionals (HDP), and non-clinical staff.Results: We have grouped what we heard from the data into three major groups of findings which we have titled: a) perceptions of the purpose of accreditation; b) the “work” of accreditation; and c) dissemination gaps regarding results. Informative finding from this study include the fact that participants put surprising value on the accreditation process, although mistaken feel it is mandatory; that the “work” of accreditation can be disappointing and feels disconnected from the bigger QI picture, and that the disconnect also exists in terms of their knowledge of and belief in the actual results of the process.Conclusions: These findings point to potential gaps in the accreditation culture which can be detrimental to the impact of the accreditation process. Such gaps likely exist in other health care organizations and could inform similar evaluations in other settings.

Introduction Clinical trial data can be presented in ways that exaggerate treatment effectiveness. Physicians consider therapy more effective, and may be more likely to make inappropriate practice changes, when data are presented in relative terms such as relative risk reduction rather than in absolute terms such as absolute risk reduction and number needed to treat. Our purpose was to determine (1) how frequently continuing medical education (CME) speakers present research data in relative terms compared to absolute terms; (2) how knowledgeable CME speakers and learners are about these terms; and (3) how CME learners want these terms presented. Methods Analysis of videotapes and PowerPoint slides of 26 CME presentations, questionnaire survey of CME speakers and learners, and focus groups with learners. Results Speakers presented data more frequently in relative than absolute terms, but most frequently in general terms such as frequencies, percentages, graphs, and P-values with no data. Of 1367 PowerPoint slides, 269 presented research data, and of these, 225 (84%) presented data in general terms, 50 (19%) in relative terms and 19 (7%) in absolute terms. CME speakers understood relative and absolute terms better than learners. Approximately 25–35% of speakers and 45–65% of learners could not correctly calculate relative risk reduction, absolute risk reduction, and number needed to treat. Learners wished to have these terms presented in CME programs in a consistent and easily understood format and requested a brief review of them at the beginning of CME programs. Discussion Presentation of research data in most CME programs is inadequate to allow learners to make fully informed therapeutic decisions. Speakers and learners need professional development to improve their presentation and understanding of research data.

The medical community is giving increasing attention to issues of social class, gender, race, ethnicity, culture and other areas of difference in interprofessional education and patient care. The Changing Worlds: Diversity and Health Care Project, an interprofessional diversity education initiative, was designed with the aim of exploring social issues in the medical professions. This project brought together the Faculties of Medicine, Dentistry and Health Professions at Dalhousie University in an effort to address issues of difference related to multiplicities of races, ethnicities, cultures, languages, sexualities and religions. The findings of this paper include methods for the project implementation and future direction for education initiatives aimed at issues of social justice and equity in health care.

Objective:Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.Methods:Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10 000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.Results:Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.Conclusion:The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.

In a time of increased patient loads and emergency department (ED) exit block, the need for strategies to manage patient flow in the ED has become increasingly important. In March 2002 we contacted all 1282 members of the Canadian Association of Emergency Physicians and asked them to delineate strategies for enhancing ED patient flow and ED productivity without increasing stress levels, reducing care standards or compromising patient safety. Thirty physicians responded. Their suggested flow management strategies, which ranged from clinical decision-making to communication to choreography of time, space and personnel, are summarized here.

Health care in Canada is universal, accessible, transferable and publicly funded. Each of Canada's provinces has the responsibility for health care funding and delivery through its ministry of health, controlled by the governing provincial party and overseen by a Minister of Health. The Federal Government is responsible for ensuring the provinces conform to the spirit and regulations within the Canada Health Act and for broad programme funding, through the federal Minister of Health. As such, access to emergency health services is available to all Canadians free of direct charge. Some aspects of health care are the direct responsibility of citizens, such as ambulance services, medications (for those who can afford them), and 'non-essential' services. For most Canadians, however, care for acute illness and injury is provided without barriers in EDs while generalists such as family physicians and paediatricians provide primary care.

The last decade has witnessed a rapidly growing public and academic interest in medical error, an interest that has culminated in the emergence of the science of error prevention in health care. The impact of this new science will be felt in all areas of medicine but perhaps especially in emergency medicine (EM). The emergency department’s unique operating characteristics make it a natural laboratory for the study of error. These characteristics, combined with the complex and myriad activities of EM, predict vulnerability to a multitude of errors. Overcrowding and other resource limitations impair continuous quality improvement, and many errors result from high decision density, excessive cognitive load and flawed thinking in the decision-making process. A large proportion of these errors have serious outcomes but an even higher proportion are preventable. The historical practice of blaming individuals for errors needs to be replaced by root-cause analysis that identifies process and systemic weaknesses. Quantitative and qualitative methods are needed to detect, describe and classify error at all levels in the system. Research is needed into the processes that underlie EM error. Educational initiatives should be developed at all levels, for everyone from undergraduate trainees to practicing emergency physicians. Changes in societal attitudes will be an important component of the new culture of patient safety. A nationwide reporting system is proposed to disseminate error information expediently. Canadian EM providers are in a pivotal position to provide leadership to the Canadian health care system in this important area.

In the literature to date, there are no studies that directly evaluate microscopic urine examination results obtained by a physician compared to those of a trained laboratory technician. Our purpose in undertaking this study was to determine whether there would be comparable results obtained by these two groups. The study took place in an Emergency Medicine Department with 45,000 visits annually. Each urine sample obtained on patients presenting to the Emergency Department was divided into two lots: one was sent to the laboratory and the other was analyzed by the emergency physician. A comparison of both dipstick and microscopic results by physician and laboratory staff was then made using sensitivity, specificity, and Kappa analysis. Statistical analysis of the data revealed close agreement between the emergency physician and laboratory technician with respect to the following components of urinalysis: red blood cell urinalysis and microscopy, leukocyte esterase, and nitrite testing. Microscopy for white cells and bacteria and testing for proteinuria were not in close agreement. Urinalysis by emergency physicians is comparable to laboratory technicians for a number of the testing components. However, in this limited pilot study, emergency physicians were not able to consistently perform urinalysis for the laboratory standard.

STUDY OBJECTIVE: To compare two dosing regimens of salbutamol in acute asthma.DESIGN: Prospective randomized double-blind trial.SETTING: Urban emergency department.TYPE OF PARTICIPANTS: Patients who presented to the emergency department with moderate to severe asthma.INTERVENTIONS: All patients had pulmonary function testing and were randomized to group A (control; n=25) or group B (experimental; n=23). Group A (control) patients received salbutamol 2.5 mg delivered by wet aerosol at 0, 1 and 2 h (total dose 7.5 mg). At 20, 40, 80 and 100 mins a placebo aerosol was given. Group B patients received salbutamol 5 mg at 0 min and one-third the initial dose every 20 mins for a total of six doses by wet aerosol (total dose 15 mg).RESULTS: There were no differences in age, sex, preadmission medications or initial forced expiratory volume in 1 s (FEV1) between the groups. Forty-eight patients completed the study. Both groups of patients improved with mean absolute change in FEV1of 700 mL in group A and 590 mL in group B. There were no statistical differences between the two groups in terms of treatment response, admission rates or side effects.CONCLUSIONS: This study of patients presenting with acute asthma demonstrated no differences in improvement during the initial 3 h of treatment with a standard dose of aerosolized salbutamol given at hourly intervals (total dose 7.5 mg) compared with a higher total dose given at 20 min intervals (total dose 15 mg).

Study objective The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. Methods This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. Results A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. Conclusion The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.

Introduction The Colleges of Physicians and Surgeons of Alberta and Nova Scotia (CPSNS) use a standardized multisource feedback program, the Physician Achievement Review (PAR/NSPAR), to provide physicians with performance assessment data via questionnaires from medical colleagues, coworkers, and patients on 5 practice domains: consultation communication, patient interaction, professional self-management, clinical competence, and psychosocial management of patients. Physicians receive a confidential report; the intent is practice improvement. However, research indicates that feedback from medical colleagues appears to be less understood than that from coworkers or patients, due to a lack of specificity and concerns regarding feedback credibility. The purpose of this study was to determine how physicians make decisions about performance ratings for family physician (FP) colleagues in the 5 practice domains. Methods This was an exploratory qualitative study using focus groups—one with 11 family physicians and one with 12 specialists—who had served as NSPAR “medical colleague'' reviewers. We analyzed focus group transcripts using content analysis. Results Family and specialist physicians provided examples of behaviors indicative of both high- and low-scoring performance for items within the 5 practice domains. From these, an assessment rubric was created to inform both external reviewers and the physicians being reviewed of performance expectations. Reviewers reported using varied sources of information to make assessments, including shared patients, medical records, referral letters, feedback from others, and self-reference. Discussion The CPSNS has used the assessment rubric to create an online resource to inform medical colleague assessment and enhance the usefulness of their NSPAR scores. Further research will be required to determine its impact.

Despite the growing involvement of multinational firms in foreign-based R&D during the past fifteen years, little research has been done on why and how firms internationalize their R&D and what effects it might have on firm competitiveness. The present paper calls attention to this neglect and seeks to advance the management of multinational R&D as an area of study for international business scholars. To this end, the paper first examines the key contributing factors to increased foreign R&D investments among multinationals. It then reviews the research literature to find out what we presently know about the management of multinational R&D. Finally, a research agenda is proposed to provide a foundation and stimulus for future investigations. Seven research directions are recommended, with an emphasis on interdisciplinary inquiry and a focus on issues that have both theoretical and practical significance.

Disparities exist between rural and urban emergency departments with respect to knowledge resources such as online journals and clinical specialists. As knowledge is a critical element in the delivery of quality care, a web-based learning project was proposed to address the knowledge needs of emergency clinicians. One objective of this project was to evaluate the effectiveness of the online environment for knowledge exchange among rural and urban emergency clinicians. Descriptive and content analysis of the online discussion board revealed 202 postings with rural participants contributing the largest number of postings (75%; 152/202). Postings were used to establish a clinical presence (87/202), seek clinical information (52/202), and share clinical information (63/202). Postintervention survey results indicate that this modality introduced participants to new clinical experts and resources. The results provide direction for design of a virtual community of practice, which may reduce current knowledge resource disparities.

INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.OBJECTIVES: To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.METHODS: A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.RESULTS: Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; PCONCLUSIONS: Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

Achieving high reliability and yield in the design and manufacture of telecommunications products requires detailed assessment of the materials, product design, manufacturing processes, and use environment. The key prerequisites for eliminating the root causes of failure are both scientific understanding and engineering evaluations that use statistical experimental methods and accelerated-life tests to uncover potential failure mechanisms. This paper illustrates these principles through several examples that pertain to product design, materials selection, performance evaluation, and manufacturing processes. The examples were selected from our work with design, process, field, and system engineers and reliability practitioners throughout AT&T.

Emergency department (ED) overcrowding has been an international phenomenon for more than 10 years. It is important to understand that ED overcrowding is a measure of health system efficiency and is not strictly related to ED volumes or capacity. ED overcrowding is defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time. The major factor resulting in ED overcrowding is the presence of admitted patients in the ED for prolonged periods of time, not a high volume of low-acuity patients. While limited data are available for paediatric EDs, winter respiratory illnesses set the stage for ED overcrowding, which are epidemic in adult or general EDs. Prehospital-, ED- and hospital-related factors are described in the present article, and these may help prevent or manage this important patient safety problem.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Principle research objective To determine the effectiveness of organisational and professional interventions on the uptake of research evidence in Emergency Practice Settings. Secondary research objective To determine which factors might modify the uptake of research evidence in Emergency Practice Settings. We will explore the following possible effect modifiers across studies: 1. Content: interventions that target a specific topic or behavior in emergency medicine. 2. Type of ED: rural or urban; pediatric, adult or mixed; private or public; primary or tertiary; public or private. 3. Health professional targeted (single or interdisciplinary). 4. Type of intervention. 5. Cost of intervention. To address the objectives the following comparisons will be explored: 1. Effectiveness of single organisational interventions compared with no intervention. 2. Effectiveness of multiple organisational interventions compared with no intervention. 3. Effectiveness of multiple organisational interventions compared with single interventions. 4. Effectiveness of clinical practice guidelines compared with no intervention. 5. Effectiveness of organisational interventions and clinical practice guidelines compared with no intervention. 6. Effectiveness of clinical practice guidelines with other professional interventions compared with clinical practice guidelines and no intervention.

Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.

To describe responses of family physicians, their medical colleagues, and coworker raters to a multisource feedback assessment process.Data collection tools included multisource feedback self-assessment and medical colleague, coworker, and patient rating forms; and program evaluation physician and rater questionnaires.The pilot study included 142 physicians and their raters, with 113 (80%) physicians completing evaluations. Positive correlations were found between familiarity scores and medical colleague and coworker mean ratings. Peer medical colleagues were significantly more familiar with physicians than were consultants. Consultants were unable to rate items most frequently. Physicians disagreed with colleague feedback more frequently. Agreement was positively correlated with scores.Familiarity, ability to observe physicians appropriately to rate them, and physicians' responses to feedback are factors to consider when multisource feedback is used.

Objectives: To describe in detail the implementation of an acute care home care program (quick response program; QRP) for the emergency department (ED). Methods: A prospective observational study with key process and outcome indicators, including number of referrals, time to initiate service, type of home care provided, number of return patients to the ED, and outcome for all patients, defined at the beginning of the project. Patients are identified for the QRP and services are in place within four hours of patient discharge. Results: Of 177 eligible patients, 121 were entered into the program. Sixty-eight percent were more than 65 years old, and 54% lived alone. All patients met the time target of services in place within four hours of discharge from the ED. Patient satisfaction was high as measured by an independent survey instrument. Fifty percent of the patients required no further service after the QRP, but 20% were admitted to hospital within 30 days. Conclusions: A QRP can be successfully implemented in the ED to discharge patients home, most of whom would have been admitted to hospital.

Study objective: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures. Methods: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. Results: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents—not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. Conclusion: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources. [Sinclair D, Green R: Emergency department observation unit: Can it be funded through reduced inpatient admission? Ann Emerg Med December 1998;32:670-675.]

I am writing on behalf of the continuing medical education and continuing professional development offices at the 17 Canadian medical schools. For many years, we have had the same concerns as those expressed by Paul Hebert and the Editorial-Writing Team in a recent CMAJ editorial,[1][1] and we have

A patient with traumatic disruption of the thoracic duct resulting in a chylothorax and a 'chyloma' in the left supraclavicular region is described. Supradiaphragmatic ligation of the thoracic duct was necessary for treatment of the chyloma.