Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Background: Resident physicians are known to be infrequent reporters of patient safety events (PSE). Previous studies assessing barriers to resident PSE reporting have not considered possible cultural barriers faced by international medical graduates (IMG). This study aimed to assess the knowledge and attitudes of residents regarding PSE and possible barriers contributing to poor resident reporting.

Methods: A cross sectional survey of all house staff undergoing post-graduate residency training at two independent community hospital based academic medical centers was conducted through an online questionnaire. Sample case vignettes were created to assess the residents’ ability to identify safety events and classify them as near miss, adverse events or sentinel events and decide whether they were reportable.

Results: The Reporting of PSE increased significantly by year of residency training (p < 0.005), with time taken to file a PSE being the strongest perceived barrier. There was no difference in PSE reporting between IMG’s and non- IMG’s. We identified major knowledge gaps with only 73.9%, 79.6% and 94.3% of respondents correctly identifying sentinel events, adverse events, and near misses, respectively. 58.1% of respondents did not think near misses were reportable.

Conclusions: A lack of knowledge is the most important barrier towards PSE reporting. A different cultural background and lack of previous exposure to patient safety report by IMGs is not a significant barrier towards safety event reporting. In the short-term, it appears that focusing limited institutional resources on education rather than acculturation issues would have the greatest benefit.

Comparison of Blood Oxygenation Level-Dependent fMRI and Provocative DSC Perfusion MR Imaging for Monitoring Cerebrovascular Reserve in Intracranial Chronic Cerebrovascular Disease

BACKGROUND AND PURPOSE

Loss of hemodynamic reserve in intracranial cerebrovascular disease reduces blood oxygenation level-dependent activation by fMRI and increases asymmetry in MTT measured by provocative DSC perfusion MR imaging before and after vasodilation with intravenous acetazolamide. The concordance for detecting hemodynamic reserve integrity has been compared.

MATERIALS AND METHODS

Patients (n = 40) with intracranial cerebrovascular disease and technically adequate DSA, fMRI and provocative DSC perfusion studies were retrospectively grouped into single vessels proximal to and distal from the circle of Willis, multiple vessels, and Moyamoya disease. The vascular territories were classified as having compromised hemodynamic reserve if the expected fMRI blood oxygenation level-dependent activation was absent or if MTT showed increased asymmetry following vasodilation. Concordance was examined in compromised and uncompromised vascular territories of each group with the Fischer exact test and proportions of agreement.

RESULTS

Extensive leptomeningeal collateral circulation was present in all cases. Decreased concordance between the methods was found in vascular territories with stenosis distal to but not proximal to the circle of Willis. Multivessel and Moyamoya diseases also showed low concordance. A model of multiple temporally displaced arterial inputs from leptomeningeal collateral flow demonstrated that the resultant lengthening MTT mimicked compromised hemodynamic reserve despite being sufficient to support blood oxygenation level-dependent contrast.

CONCLUSIONS

Decreased concordance between the 2 methods for assessment of hemodynamic reserve for vascular disease distal to the circle of Willis is posited to be due to well-developed leptomeningeal collateral circulation providing multiple temporally displaced arterial input functions that bias the perfusion analysis toward hemodynamic reserve compromise while blood oxygenation level-dependent activation remains detectable.

Acute symptoms associated with asphalt fume exposure among road pavers

BACKGROUND

Although asphalt fume is a recognized irritant, previous studies of acute symptoms during asphalt paving have produced inconsistent results. Between 1994 and 1997, the National Institute for Occupational Safety and Health (NIOSH) evaluated workers at seven sites in six states.

METHODS

NIOSH (a) measured exposures of asphalt paving workers to total (TP) and benzene-soluble particulate (BSP), polycyclic aromatic compounds, and other substances; (b) administered symptom questionnaires pre-shift, every 2 hr during the shift, and post-shift to asphalt exposed and nonexposed workers; and (c) measured peak expiratory flow rate (PEFR) of asphalt paving workers when they completed a symptom questionnaire.

RESULTS

Full-shift time-weighted average exposures to TP and BSP ranged from 0.01 to 1.30 mg/m(3) and 0.01 to 0.82 mg/m(3), respectively. Most BSP concentrations were <0.50 mg/m(3). Asphalt workers had a higher occurrence rate of throat irritation than nonexposed workers [13% vs. 4%, odds ratio (OR) = 4.0, 95% confidence interval (CI): 1.2-13]. TP, as a continuous variable, was associated with eye (OR = 1.34, 95% CI: 1.12-1.60) and throat (OR = 1.40, 95% CI: 1.06-1.85) symptoms. With TP dichotomous at 0.5 mg/m(3), the ORs and 95% CIs for eye and throat symptoms were 7.5 (1.1-50) and 15 (2.3-103), respectively. BSP, dichotomous at 0.3 mg/m(3), was associated with irritant (eye, nose, or throat) symptoms (OR = 11, 95% CI: 1.5-84). One worker, a smoker, had PEFR-defined bronchial lability, which did not coincide with respiratory symptoms.

CONCLUSIONS

Irritant symptoms were associated with TP and BSP concentrations at or below 0.5 mg/m(3).

Blood pressure, left ventricular mass, and lead exposure in battery manufacturing workers

BACKGROUND

Although debate about the relationship between lead and blood pressure has focused on low environmental lead levels, industrial exposure remains a concern.

METHODS

We measured blood pressure and left ventricular mass (LVM) in 108 battery manufacturing workers, and calculated cumulative and historic average measures of blood lead.

RESULTS

Diastolic pressure increased with increasing lead levels, with a significant (P = 0.04) 5 mmHg difference in mean pressure between the highest and lowest cumulative exposure levels. Diastolic pressure increased with the log of cumulative lead (P = 0.06). Both hypertension (defined as currently medicated or systolic > 160 mmHg or diastolic > 95 mmHg) and LVM increased nonsignificantly with increasing lead exposure (P-values > or = 0.17 for hypertension and > or = 0.20 for LVM).

CONCLUSIONS

We found a small effect of blood lead on diastolic blood pressure, particularly for a cumulative measure of exposure, but no convincing evidence of associations between lead and other blood-pressure-related outcomes. Published 2001 Wiley-Liss, Inc.

Interpretation and communication of the results of medical field investigations

Since the controversy over cytogenetic test results at the Love Canal in New York State, there has been increasing concern about the communication of medical test results to participants in field studies. To identify the range of issues that arise and to present examples of practices that might be useful for consideration, we have drawn from 15 years of experience in interpreting and communicating the results of medical field investigations by the National Institute for Occupational Safety and Health. The investigations were qualitatively characterized according to study type and design, substances involved, language used in the notification of results, and the nature of the efforts to put results in perspective. Based on this evaluation, the following recommendations are made: (1) provide a comprehensible consent form, (2) interpret results for study participants, (3) use clear language, (4) be explicit about uncertainty of findings, (5) where appropriate, indicate the need for medical follow-up, (6) provide results promptly, (7) provide overall study results, (8) evaluate the impact of the notification, (9) train investigators in the practice of communicating results.

Investigation of occupational cancer clusters: theory and practice

Local and federal government agencies are often asked to investigate apparent clusters of cancer in communities or workplaces. Often these investigations cannot utilize the methods that have been developed for evaluation of disease clusters because the clusters are too small, and the populations to be studied and the periods of time to be covered are determined in an a posteriori manner. Still, government investigators are called upon to render an official opinion of the apparent clusters. Application of a theoretical approach to cluster analysis must give way to a more pragmatic approach. A review of 61 investigations of apparent clusters conducted by the National Institute for Occupational Safety and Health (NIOSH) during the period 1978-84 showed that most of the clusters contained five or fewer cases and had no plausible occupational etiology. Despite the few clusters that were identified, these investigations generally provided a service to workers and employers who were concerned about occupational cancer.

Neurologic dysfunction from exposure to 2-t-butylazo-2-hydroxy-5-methylhexane (BHMH): a new occupational neuropathy

Seven cases of subacute central and peripheral neurologic dysfunction developed in 18 workers employed in the manufacture of reinforced plastic bathtubs. Cases were characterized by weight loss, dizziness, paresthesias, muscle weakness, incontinence, memory loss, and loss of peripheral, color, and night vision. Neuropathies began distally, involved both sensory and motor function, and were associated with prolonged sensory latency, muscle fibrillation, and reduced numbers of functioning motor units. One patient developed posterior lenticular cataracts. Slow improvement occurred on removal from exposure, but residual neuropathies persisted for as long as two years. Epidemiologic investigation disclosed that the first case developed approximately two weeks after introduction of a new plastic foaming agent, 2-t-butylazo-2-hydroxy-5-methylhexane (BHMH). All cases occurred in workers exposed directly to BHMH. No new cases developed after use of BHMH was discontinued. A survey of the firm which produced BHMH and of 68 user firms found two additional clusters of mild neuropathy which may have been caused by BHMH. BHMH was withdrawn from distribution following discovery of these cases. Subsequently, BHMH has been shown in rats to be a potent neurotoxin. Adequate premarket testing could have averted this outbreak.

Creating an indoor environmental problem from a nonproblem: a need for cautious evaluation of antibodies against hapten-protein complexes

An epidemic of illness in three schools in New York State occurred in early 1983. An epidemiological review of the problem led to the conclusion that some of the symptoms could have been explained by irritant reactions to boiler exhaust gases but that a major factor was likely public concern about environmental contamination and heightened awareness of common minor symptoms and of exacerbations of chronic illnesses. Diphenylmethane diisocyanate (MDI) from polyurethane insulation had previously been suspected as a potential cause. An earlier investigation had found low levels of anti MDI-human serum albumin in a small number of subjects who did not have typical symptoms of identified MDI or other hypersensitivity syndromes. Similar antibodies were found in two of nine unaffected children in Chicago, who served as a comparison group. The identification of these antibodies, however, was inappropriately used to support the idea of a school contaminated with MDI in spite of the absence of detectable MDI in the environment. The availability of highly sensitive immunoassays should not be inappropriately used to accelerate the fear of environmental toxins when there is no clinical correlation.

An epidemic of psychogenic illness in an electronics plant

We investigated an outbreak of illness in electronics plant workers. Questionnaire data revealed that 98 employees experienced symptoms, including light- headedness , headache, sleepiness, and numbness/tingling of the face or extremities. Attack rates by work station followed no apparent pattern. Extensive medical and environmental evaluation, including air sampling for numerous solvents and gases, provided no physical or chemical explanation for the epidemic. Compared with well employees, ill employees were more commonly female, complained more frequently of bothersome odors, and believed that greater danger existed of the illness recurring. Blood gas analyses of seven of 11 ill workers showed respiratory alkalosis, consistent with hyperventilation. The poorly defined nature of this illness, the absence of exposures to environmental contaminants in concentrations exceeding recommended limits, and the evidence of hyperventilation suggest that this outbreak was an incident of industrial psychogenic illness.

The efficacy of a population-based comparison group in cross-sectional occupational health studies

The availability and the choice of appropriate comparison groups are essential for valid occupational epidemiologic studies. Too often, however, adequate comparison groups cannot easily be found within a workplace environment or extracted from the general population. An evaluation of the efficacy of using a pool of comparison subjects from the health and Nutrition Examination Survey (HANES) was performed on data gathered by the National Institute for Occupational Safety and Health in 1979. Comparison groups from the HANES pool were derived for 246 workers at four different commercial/industrial facilities in the Niagara Falls, New York, area and the comparability between the groups was assessed for several demographic, behavioural, and biomedical variables. The HANES groups exhibited a high degree of comparability with regard to most variables, excluding ancestry. The HANES pool may serve as a useful source of subjects to allow for the comparison of disease rates where occupational exposure is the key distinguishing feature between groups.

An outbreak of introduced malaria in California possibly involving secondary transmission

During 1974, 12 cases of Plasmodium vivax malaria were reported from an agricultural area in California's Sacramento Valley. At least three of these cases resulted from local mosquito transmission. The imported cases were in Punjabi immigrants except for one in an American-born visitor to the Punjab. This is the 11th reported outbreak of introduced malaria in the United States since 1952, and the first in California since 1957. A unique aspect of this outbreak is the likelihood that secondary transmission occurred. Extensive surveillance activities, including a house-to-house case-finding survey in a 15-square-kilometer area of suspected transmission, yielded no new malaria cases, but the activities may have increased awareness of malaria among both the medical community and the public, and thus facilitated the detection of later cases. The occurrence of local malaria transmission coincided with unusually high numbers of Anopheles freeborni. The increase in imported malaria cases probably reflects a resurgence of malaria in Punjab State, India.

Trichinosis acquired at sea--report of an outbreak

In 1974, at least 13 persons acquired trichinosis aboard a luxury liner en route to Alaska. Epidemiologic investigation implicated ground beef served on the ship as the vehicle of transmission. The beef is thought to have been contaminated by pork which had previously been frozen, though presumably not under trichinacidal conditions. To our knowledge, this is the first report of trichinosis acquired at sea.