Medical Errors, Appropriate Dress for Physicians, Blood Cultures for Pneumonia Pts, and More
Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.
Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.
Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.
Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.
Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.
Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.
The Value of Obtaining Blood Cultures in Pneumonia Pts
Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.
Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.
Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.
Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.
