Assessing the rates of error and adverse events in the ED.

BACKGROUND: The incidence of errors and adverse events in emergency medicine is poorly characterized. OBJECTIVE: The objective was to systematically determine the rates and types of errors and adverse events in an academic, tertiary care emergency department (ED). METHODS: Prospective data were collected on all patients presenting to a tertiary-care academic medical center ED with an annual census of 55,000 patients between January 2009 and November 2012. Cases of patients meeting predetermined criteria were systematically identified by an electronic medical record system. Criteria for review included patients who (1) returned to the ED within 72 hours and were admitted on their second visit, (2) were admitted from the ED to the floor and then transferred to the intensive care unit (ICU) within 24 hours, (3) expired within 24 hours of ED arrival, (4) required airway management, or (5) were referred to the QA committee as the result of complaints. Cases were randomly assigned to individual physicians not involved with the care. All cases were reviewed using a structured electronic tool that assessed the occurrence of error and adverse events. Institutional review board jurisdiction was waived by the Beth Israel Deaconess Medical Center IRB. RESULTS: During the study period, 152,214 cases were screened and 2131 cases (1.4%) met prespecified criteria for review. The incidence of error in these cases was 9.5% (95% confidence interval [CI], 8.3%-10.8%), representing an overall incidence of 0.13% among all ED patients. In cases that involved error, 50.5% occurred among patients who returned to the ED within 72 hours; 17.3% occurred among floor-to-ICU transfers; 5.4% occurred among mortality cases; 2.0% occurred among airway cases; and 24.8% occurred among cases referred as the result of complaints. The incidence of adverse events in the reviewed cohort was 8.3% (CI, 7.2%-9.6%), representing an overall incidence of 0.11% among all ED patients. In cases that involved adverse events, 48.6% occurred among patients who returned to the ED within 72 hours; 16.4% occurred among floor-to-ICU transfers; 9.0% occurred among mortality cases; 1.1% occurred among airway cases; and 24.9% occurred among cases referred as the result of complaints. CONCLUSION: Although the overall incidence of error and adverse events in EDs is low, the likelihood of such events is markedly increased among patients who return to the ED within 72 hours, among patients who require floor-to-ICU transfer within 24 hours, and among those whose cases come to attention as the result of complaints.

The Tuscan Emergency Medicine Initiative.

Italy lacks standardized specialty training in emergency medicine. There is no system of national or regional accreditation of the knowledge base or skill set of physicians working in regional emergency departments (ED), which results in variability of emergency medical care delivery not only between hospital EDs but also within individual EDs. To address this need, the Tuscan Minister of Health chose to develop a partnership with emergency medicine specialists from the United States to help expedite the growth of the specialty in Tuscany. The collaboration called the Tuscan Emergency Medicine Initiative consists of the regional health care service, the Tuscan university system, Harvard Medical International, and the Beth Israel Deaconess Medical Center Department of Emergency Medicine. We describe that effort and process, with an expectation of more than 625 physicians completing the program by June 2008.

Discrimination and characterization of environmental strains of Escherichia coli by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS).

A rapid and reliable bacterial source tracking (BST) method is essential to counter risks to human health posed by fecal contamination of surface waters. Genetic fingerprinting methods, such as repetitive sequence based-PCR (rep-PCR), have shown promise as BST tools but are time-consuming and labor-intensive. In this work, we investigate the ability of MALDI-TOF-MS to characterize and discriminate between closely related environmental strains of Escherichia coli and to classify them according to their respective sources. We compared the performance of a rapid MALDI-TOF-MS-based method to a commonly used rep-PCR-based method that employs the BOX-A1R primer. Among the criteria evaluated were repeatability and the ability of each method to group E. coli isolates according to their respective sources. Our data suggest that the MALDI-TOF-MS-based approach has a lower repeatability level compared to rep-PCR but offers an improved ability to correctly assign E. coli isolates to specific source groups. In addition, we have identified five biomarkers that appear conserved among avian species. We conclude that MALDI-TOF-MS may represent a promising, novel and rapid approach to addressing the problem of fecal contamination of surface waters and warrants further investigation.

Successful development and implementation of' a tactical emergency medical technician training program for United States federal agents.

INTRODUCTION: The emerging need for tactical operations in law enforcement often places personnel involved at risk. Tactical operations often are carried out in environments in which access to emergency care is limited. With the war against terrorism expanding, special operations involving United States federal agents are occurring worldwide. Currently, there are very few tactical medicine curricula training traditional emergency medical services (EMS) providers to operate in these high-risk missions. Trainees in existing programs must have previous EMS experience, and are selected from a wide range of backgrounds. The goal of this study is to examine a Special Agent Emergency Medical Technician (SAEMT) training curriculum developed specifically for federal special agents with prior experience in tactical operations, but without previous medical training. METHODS: An analysis of the SAEMT Program given to federal agents of the Drug Enforcement Administration (DEA) in Quantico, Virginia between July 2000 and April 2002 was performed. The SAEMT curriculum provided enrolled agents 181.5 hours of training in tactical emergency topics, including medical mission planning, logistics, operations, evacuation, and weapons training. In addition, SAEMT concurrently provides emergency medical technician (EMT) training. All of the participants were DEA agents with no previous medical training. Upon completion of the course, all participants took the National Registry of EMT-Basic examination. Measured endpoints included course completion rate and performance on certifying examinations. RESULTS: Ninety-five agents were enrolled and successfully completed the SAEMT course between July 2000 and April 2002. Of the agents enrolled, 84 (88%) passed the National Registry of EMTs-Basic examination within two attempts. CONCLUSION: The SAEMT Program provides basic emergency medical training to federal special agents with no previous medical experience. The design of this program provides a useful template to meet the expanding demand for tactical emergency medical personnel.