The incidence and severity of adverse events affecting patients after discharge from the hospital

BACKGROUND

Studies of hospitalized patients identify safety as a significant problem, but few data are available regarding injuries occurring after discharge. Patients may be vulnerable during this transition period.

OBJECTIVE

To describe the incidence, severity, preventability, and "ameliorability" of adverse events affecting patients after discharge from the hospital and to develop strategies for improving patient safety during this interval.

DESIGN

Prospective cohort study.

SETTING

A tertiary care academic hospital.

PATIENTS

400 consecutive patients discharged home from the general medical service.

MEASUREMENTS

The three main outcomes were adverse events, defined as injuries occurring as a result of medical management; preventable adverse events, defined as adverse events judged to have been caused by an error; and ameliorable adverse events, defined as adverse events whose severity could have been decreased. Posthospital course was determined by performing a medical record review and a structured telephone interview approximately 3 weeks after each patient's discharge. Outcomes were determined by independent physician reviews.

RESULTS

Seventy-six patients had adverse events after discharge (19% [95% CI, 15% to 23%]). Of these, 23 had preventable adverse events (6% [CI, 4% to 9%]) and 24 had ameliorable adverse events (6% [CI, 4% to 9%]). Three percent of injuries were serious laboratory abnormalities, 65% were symptoms, 30% were symptoms associated with a nonpermanent disability, and 3% were permanent disabilities. Adverse drug events were the most common type of adverse event (66% [CI, 55% to 76%]), followed by procedure-related injuries (17% [CI, 8% to 26%]). Of the 25 adverse events resulting in at least a nonpermanent disability, 12 were preventable (48% [CI, 28% to 68%]) and 6 were ameliorable (24% [CI, 7% to 41%]).

CONCLUSION

Adverse events occurred frequently in the peridischarge period, and many could potentially have been prevented or ameliorated with simple strategies.

Some unintended consequences of information technology in health care: the nature of patient care information system-related errors

Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

Five years after To Err Is Human: what have we learned?

Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010.

Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

AIMS/BACKGROUND

This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care.

RESULTS

Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety-relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well-being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork.

CONCLUSION

In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care.

Communication failures: an insidious contributor to medical mishaps

PURPOSE

To describe how communication failures contribute to many medical mishaps.

METHOD

In late 1999, a sample of 26 residents stratified by medical specialty, year of residency, and gender was randomly selected from a population of 85 residents at a 600-bed U.S. teaching hospital. The study design involved semistructured face-to-face interviews with the residents about their routine work environments and activities, the medical mishaps in which they recently had been involved, and a description of both the individual and organizational contributory factors. The themes reported here emerged from inductive analyses of the data.

RESULTS

Residents reported a total of 70 mishap incidents. Aspects of "communication" and "patient management" were the two most commonly cited contributing factors. Residents described themselves as embedded in a complex network of relationships, playing a pivotal role in patient management vis-à-vis other medical staff and health care providers from within the hospital and from the community. Recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of medical mishaps.

CONCLUSION

The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

Medical errors related to discontinuity of care from an inpatient to an outpatient setting

OBJECTIVE

To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes.

PATIENTS

Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge.

DESIGN

Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors.

MEASUREMENTS

Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit.

MAIN RESULTS

Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations.

CONCLUSION

We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.

Patients' and physicians' attitudes regarding the disclosure of medical errors

CONTEXT

Despite the best efforts of health care practitioners, medical errors are inevitable. Disclosure of errors to patients is desired by patients and recommended by ethicists and professional organizations, but little is known about how patients and physicians think medical errors should be discussed.

OBJECTIVE

To determine patients' and physicians' attitudes about error disclosure.

DESIGN, SETTING, AND PARTICIPANTS

Thirteen focus groups were organized, including 6 groups of adult patients, 4 groups of academic and community physicians, and 3 groups of both physicians and patients. A total of 52 patients and 46 physicians participated.

MAIN OUTCOME MEASURES

Qualitative analysis of focus group transcripts to determine the attitudes of patients and physicians about medical error disclosure; whether physicians disclose the information patients desire; and patients' and physicians' emotional needs when an error occurs and whether these needs are met.

RESULTS

Both patients and physicians had unmet needs following errors. Patients wanted disclosure of all harmful errors and sought information about what happened, why the error happened, how the error's consequences will be mitigated, and how recurrences will be prevented. Physicians agreed that harmful errors should be disclosed but "choose their words carefully" when telling patients about errors. Although physicians disclosed the adverse event, they often avoided stating that an error occurred, why the error happened, or how recurrences would be prevented. Patients also desired emotional support from physicians following errors, including an apology. However, physicians worried that an apology might create legal liability. Physicians were also upset when errors happen but were unsure where to seek emotional support.

CONCLUSIONS

Physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients' desires for an apology and for information on the nature, cause, and prevention of errors. Institutions should also address the emotional needs of practitioners who are involved in medical errors.

Bloodstream infections caused by antibiotic-resistant gram-negative bacilli: risk factors for mortality and impact of inappropriate initial antimicrobial therapy on outcome

The marked increase in the incidence of infections due to antibiotic-resistant gram-negative bacilli in recent years is of great concern, as patients infected by those isolates might initially receive antibiotics that are inactive against the responsible pathogens. To evaluate the effect of inappropriate initial antimicrobial therapy on survival, a total of 286 patients with antibiotic-resistant gram-negative bacteremia, 61 patients with Escherichia coli bacteremia, 65 with Klebsiella pneumoniae bacteremia, 74 with Pseudomonas aeruginosa bacteremia, and 86 with Enterobacter bacteremia, were analyzed retrospectively. If a patient received at least one antimicrobial agent to which the causative microorganisms were susceptible within 24 h of blood culture collection, the initial antimicrobial therapy was considered to have been appropriate. High-risk sources of bacteremia were defined as the lung, peritoneum, or an unknown source. The main outcome measure was 30-day mortality. Of the 286 patients, 135 (47.2%) received appropriate initial empirical antimicrobial therapy, and the remaining 151 (52.8%) patients received inappropriate therapy. The adequately treated group had a 27.4% mortality rate, whereas the inadequately treated group had a 38.4% mortality rate (P = 0.049). Multivariate analysis showed that the significant independent risk factors of mortality were presentation with septic shock, a high-risk source of bacteremia, P. aeruginosa infection, and an increasing APACHE II score. In the subgroup of patients (n = 132) with a high-risk source of bacteremia, inappropriate initial antimicrobial therapy was independently associated with increased mortality (odds ratio, 3.64; 95% confidence interval, 1.13 to 11.72; P = 0.030). Our data suggest that inappropriate initial antimicrobial therapy is associated with adverse outcome in antibiotic-resistant gram-negative bacteremia, particularly in patients with a high-risk source of bacteremia.

Emergency department overcrowding in the United States: an emerging threat to patient safety and public health

Numerous reports have questioned the ability of United States emergency departments to handle the increasing demand for emergency services. Emergency department (ED) overcrowding is widespread in US cities and has reportedly reached crisis proportions. The purpose of this review is to describe how ED overcrowding threatens patient safety and public health, and to explore the complex causes and potential solutions for the overcrowding crisis. A review of the literature from 1990 to 2002 identified by a search of the Medline database was performed. Additional sources were selected from the references of the articles identified. There were four key findings. (1) The ED is a vital component of America's health care "safety net". (2) Overcrowding in ED treatment areas threatens public health by compromising patient safety and jeopardising the reliability of the entire US emergency care system. (3) Although the causes of ED overcrowding are complex, the main cause is inadequate inpatient capacity for a patient population with an increasing severity of illness. (4) Potential solutions for ED overcrowding will require multidisciplinary system-wide support.

Types of unintended consequences related to computerized provider order entry

OBJECTIVE

To identify types of clinical unintended adverse consequences resulting from computerized provider order entry (CPOE) implementation.

DESIGN

An expert panel provided initial examples of adverse unintended consequences of CPOE. The authors, using qualitative methods, gathered and analyzed additional examples from five successful CPOE sites.

METHODS

Using a card sort method, the authors developed a categorization scheme for the 79 unintended consequences initially identified and then iteratively modified the scheme to categorize 245 additional adverse consequences resulting from fieldwork. Because the focus centered on consequences requiring prevention or remedial action, the authors did not further analyze reported unintended beneficial (positive) consequences.

RESULTS

Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency): 1) more/new work for clinicians; 2) unfavorable workflow issues; 3) never ending system demands; 4) problems related to paper persistence; 5) untoward changes in communication patterns and practices; 6) negative emotions; 7) generation of new kinds of errors; 8) unexpected changes in the power structure; and 9) overdependence on the technology. Clinical decision support features introduced many of these unintended consequences.

CONCLUSION

Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.

Language proficiency and adverse events in US hospitals: a pilot study

OBJECTIVE

To examine differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals.

SETTING

Six Joint Commission accredited hospitals in the USA.

METHOD

Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy.

RESULTS

About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary harm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%).

CONCLUSIONS

Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.

The John Charnley Award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital

BACKGROUND

Few studies have examined factors that affect acetabular cup positioning. Since cup positioning has been linked to dislocation and increased bearing surface wear, these factors affecting cup position are important considerations.

QUESTION/PURPOSES

We determined the percent of optimally positioned acetabular cups and whether patient and surgical factors affected acetabular component position.

METHODS

We obtained postoperative AP pelvis and cross-table lateral radiographs on 2061 consecutive patients who received a THA or hip resurfacing from 2004 to 2008. One thousand nine hundred and fifty-two hips had AP pelvic radiographs with correct position of the hip center, and 1823 had both version and abduction angles measured. The AP radiograph was measured using Hip Analysis Suite™ to calculate the cup inclination and version angles, using the lateral film to determine version direction. Acceptable ranges were defined for abduction (30°-45°) and version (5°-25°).

RESULTS

From the 1823 hips, 1144 (63%) acetabular cups were within the abduction range, 1441 (79%) were within the version range, and 917 (50%) were within the range for both. Surgical approach, surgeon volume, and obesity (body mass index > 30) independently predicted malpositioned cups. Comparison of low versus high volume surgeons, minimally invasive surgical versus posterolateral approach, and obesity versus all other body mass index groups showed a twofold (1.5-2.8), sixfold (3.5-10.7), and 1.3-fold (1.1-1.7) increased risk for malpositioned cups, respectively.

CONCLUSIONS

Factors correlated to malpositioned cups included surgical approach, surgeon volume, and body mass index with increased risk of malpositioning for minimally invasive surgical approach, low volume surgeons, and obese patients. Further analyses on patient and surgical factors' influence on cup position at a lower volume medical center would provide a valuable comparison.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective

OBJECTIVE

To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury.

SUMMARY BACKGROUND DATA

Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error.

METHODS

The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations.

RESULTS

The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot.

CONCLUSIONS

These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.

A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians

OBJECTIVE

The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being.

METHODS

A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale.

RESULTS

Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment.

CONCLUSIONS

PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.

Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"?

OBJECTIVE

Although interruptions have been shown in aviation and other work settings to result in error with serious and sometimes fatal consequences, little is known about interruptions in the emergency department (ED). The authors conducted an observational, time-motion task-analysis study to determine the number and types of interruptions in the ED.

METHODS

Emergency physicians were observed in three EDs located in an urban teaching hospital, a suburban private teaching hospital, and a rural community hospital. A single investigator followed emergency staff physicians for 180-minute periods and recorded tasks, interruptions, and breaks-intask. An "interruption" was defined as any event that briefly required the attention of the subject but did not result in switching to a new task. A "break-intask" was defined as an event that required the attention of the physician for more than 10 seconds and subsequently resulted in changing tasks.

RESULTS

The mean (+/-SD) total number of patients seen at all three sites during the 180-minute study period was 12.1 +/- 3.7 patients (range 5-20). Physicians performed a mean of 67.6 +/- 15.7 tasks per study period. The mean number of interruptions per 180-minute study period was 30.9 +/- 9.7 and the mean number of breaks-in-task was 20.7 +/- 6.3. Both the number of interruptions (r = 0.63; p < 0.001) and the number of breaks-in-task (r = 0.56; p < 0.001) per observation period were positively correlated with the average number of patients simultaneously managed.

CONCLUSIONS

Emergency physicians are "interruptdriven." Emergency physicians are frequently interrupted and many interruptions result in breaks-in-task.

Human factors and cardiac surgery: a multicenter study

OBJECTIVE

To study the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model.

METHODS

The following data were collected: patient-specific and procedural variables, self-assessment questionnaires, and a written report from a human factors researcher who observed the operation. The relationship of patient-specific variables to outcomes (death and death and/or near miss) was used to develop a multivariable baseline model to analyze the role of human factors after adjustment for these variables.

RESULTS

The overall mortality was 6.6% with 24.3% of cases resulting in death and death and/or near misses. The self-assessment questionnaires were found to be unhelpful. Major and minor human failures were extracted from the written report. Major negative events were potentially life-threatening failures, whereas minor events were failures that, in isolation, were not expected to have serious consequences. Major events were closely related to death (P <.001) and death and/or near misses (P <.001). Appropriate compensation, however, sharply reduced the risk of death (P =.003). The total number of minor events was also closely related to both death and death and/or near misses (P <.001).

CONCLUSION

The study highlights the role of human factors in negative surgical outcomes. Even in the most eventful circumstances, however, appropriate human factors defense mechanisms can lead to a successful outcome.

The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review

OBJECTIVES

This study reviews the current state of the published peer-reviewed literature related to physician burnout and two quality of care dimensions. The purpose of this systematic literature review is to address the question, 'How does physician burnout affect the quality of healthcare related to the dimensions of acceptability and safety?'

DESIGN

Using a multiphase screening process, this systematic literature review is based on publically available peer-reviewed studies published between 2002 and 2017. Six electronic databases were searched: (1) MEDLINE Current, (2) MEDLINE In-process, (3) MEDLINE Epub Ahead of Print, (4) PsycINFO, (5) Embase and (6) Web of Science.

SETTING

Physicians practicing in civilian settings.

PARTICIPANTS

Practicing physicians who have completed training.

PRIMARY AND SECONDARY OUTCOME MEASURES

Quality of healthcare related to acceptability (ie, patient satisfaction, physician communication and physician attitudes) and safety (ie, minimising risks or harm to patients).

RESULTS

4114 unique citations were identified. Of these, 12 articles were included in the review. Two studies were rated as having high risk of bias and 10 as having moderate risk. Four studies were conducted in North America, four in Europe, one in the Middle East and three in East Asia. Results of this systematic literature review suggest there is moderate evidence that burnout is associated with safety-related quality of care. Because of the variability in the way patient acceptability-related quality of care was measured and the inconsistency in study findings, the evidence supporting the relationship between burnout and patient acceptability-related quality of care is less strong.

CONCLUSIONS

The focus on direct care-related quality highlights additional ways that physician burnout affects the healthcare system. These studies can help to inform decisions about how to improve patient care by addressing physician burnout. Continued work looking at the relationship between dimensions of acceptability-related quality of care measures and burnout is needed to advance the field.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital

AIMS

To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy.

METHODS

Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year.

RESULTS

There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%.

CONCLUSION

The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Are language barriers associated with serious medical events in hospitalized pediatric patients?

OBJECTIVE

Language barriers may lead to medical errors by impeding patient-provider communication. The objective of this study was to determine whether hospitalized pediatric patients whose families have language barriers are more likely to incur serious medical errors than patients whose families do not have language barriers.

METHODS

A case-control study was conducted in a large, academic, regional children's hospital in the Pacific Northwest. Case patients (n = 97) included all hospitalizations of patients who were younger than 21 years and had a reported serious medical event from January 1, 1998, to December 31, 2003. Control patients (n = 475) were chosen from hospitalizations without a reported serious medical event and were matched with case patients on age, admitting service, admission to intensive care, and date of admission. The main exposure was a language barrier defined by self- or provider-reported need for an interpreter. Serious medical events were defined as events that led to unintended or potentially adverse outcomes identified by the hospital's quality improvement staff.

RESULTS

Fourteen (14.4%) of the case patients and 53 (11.2%) of the control patients were assigned an interpreter during their hospitalization. Overall, we found no increased risk for serious medical events in patients and families who requested an interpreter compared with patients and families who did not request an interpreter (odds ratio: 1.36; 95% confidence interval: 0.73-2.55). Spanish-speaking patients who requested an interpreter comprised 11 (11.3%) of the case patients and 26 (5.5%) of the control patients. This subgroup had a twofold increased risk for serious medical events compared with patients who did not request an interpreter (odds ratio: 2.26; 95% confidence interval: 1.06-4.81).

CONCLUSIONS

Spanish-speaking patients whose families have a language barrier seem to have a significantly increased risk for serious medical events during pediatric hospitalization compared with patients whose families do not have a language barrier.