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Objective: To create an operational definition and framework to study diagnostic error in the emergency department setting., Methods: We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting., Results: The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis., Conclusions: The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm., Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED., Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings., Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Background: High rates of uncontrolled pain in critically ill patients remain common. Patient-controlled analgesia is more effective than traditional intravenous as-needed dosing regimens for managing postoperative pain in older children and adults., Objective: To determine whether pain-related clinical outcomes in patients from age 10 years to adult following cardiac surgery are improved by using patient-controlled analgesia as a pain management strategy., Methods: Using the plan-do-study-act method of quality improvement, a process was instituted to have both staff and patients' families support the use of patient-controlled analgesia postoperatively as opposed to traditional pain control with as-needed analgesics. Use of as-needed medications and pain scores were retrospectively compared from before to after initiation of patient-controlled analgesia., Results: The cumulative mean pain score from the time of extubation through the following 24 hours decreased from 4.14 (on a scale from 0 to 10) when strictly as-needed medications were used to 2.8 with patient-controlled analgesia. Further, the mean amount of opioid consumed decreased from 14.98 mg of morphine and 22.27 mg of oxycodone to 13.58 mg of morphine and 3.33 mg of oxycodone after implementation of patient-controlled analgesia., Conclusions: Standardized use of patient-controlled analgesia for postoperative pain management in patients 10 years of age through adulthood is efficient and effective, as evidenced by less medication being consumed by patients and lower mean pain scores., (©2017 American Association of Critical-Care Nurses.)

Pneumothorax is a rare complication of pneumoperitoneum. We report a case of spontaneous bilateral pneumothorax during laparoscopic cholecystectomy. The history, pathogenesis, and therapeutic options of this unusual occurrence are discussed. Because laparoscopic operations have become increasingly popular in recent years, we call attention to this rare but potentially life-threatening complication.

The football field, an ideal setting for research in trauma by radiotelemetry, has allowed collection of data on man's response to impact. The physiologic response adds a new dimension to the measurement of impact tolerance. The present study has demonstrated the protective response of the athlete and explains how he is able to dissipate forty times more kinetic energy than his helmet is capable of absorbing.

Intraovular pressure was measured in 20 patients undergoing anesthesia for electroshock therapy. Compared to control values, determined on the day before electroshock therapy, statistically significant elevations of intraocular pressure followed the post-electroshock therapy convulsions and were still significant 5 minutes later, but not of sufficient magnitude or duration to cause concern.

Plasma cholinesterase activity was periodically measured in bank blood. Of the initial plasma cholinesterase activity 87% was retained after 21 days of storage at 4 C in citrate-phosphate-dextrose solution. In addition, plasma frozen for 7 weeks at -70 C showed no decrease in enzyme activity. No difference could be demonstrated in the stability of the enzyme related to whether the blood was stored in citrate-phosphate-dextrose or in acid-citrate-dextrose solution. Bank blood transfusion prior to or during succinylcholine administration should not significantly alter the duration of action of succinylcholine, and would probably be effective in the management of prolonged apnea resulting from a deficiency of this enzyme.

The extended x-ray absorption fine structure (EXAFS) spectrum of aluminum has been measured with a nanosecond pulse of soft x-rays generated by a laser-produced plasma. This technique provides a practical alternative to synchrotorn radiation for the acquisition of EXAFS data. It also provides a unique capability for the analysis of molecular structure in highly transient chemical species.