Responding to patient safety incidents: the "seven pillars".

BACKGROUND: Although acknowledged to be an ethical imperative for providers, disclosure following patient safety incidents remains the exception. The appropriate response to a patient safety incident and the disclosure of medical errors are neither easy nor obvious. An inadequate response to patient harm or an inappropriate disclosure may frustrate practitioners, dent their professional reputation, and alienate patients. METHODS: The authors have presented a descriptive study on the comprehensive process for responding to patient safety incidents, including the disclosure of medical errors adopted at a large, urban tertiary care centre in the United States. RESULTS: In the first two years post-implementation, the "seven pillars" process has led to more than 2,000 incident reports annually, prompted more than 100 investigations with root cause analysis, translated into close to 200 system improvements and served as the foundation of almost 106 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care causing harm to patients. CONCLUSIONS: Adopting a policy of transparency represents a major shift in organisational focus and may take several years to implement. In our experience, the ability to rapidly learn from, respond to, and modify practices based on investigation to improve the safety and quality of patient care is grounded in transparency.

Monitoring intensive care unit performance using statistical quality control charts.

This paper discusses results of a study in which mortality rates and APACHE II severity of illness scores of Intensive Care Unit (ICU) patients were monitored for a five-year period (1986-1990) using statistical quality control charts. The purpose of the study was to determine whether severity of illness of patients and mortality rates had changed significantly over this time horizon. The results show that the Intensive Care Unit process is stable and in statistical control. There is no apparent trend in the severity of illness scores nor mortality rates measured both at ten days and six months from the last ICU admission. Quality control charts, which have been used extensively to detect changes in industrial processes on a short term basis, provide a simple method of monitoring the ICU process over an extended time horizon.

Diagnostic peritoneal lavage in intra-abdominal sepsis.

Despite the advent of sophisticated diagnostic technology the diagnosis of the surgical abdomen in the Intensive Care Unit continues to pose a problem for the surgeon. A retrospective analysis was carried out to evaluate the utility of diagnostic peritoneal lavage to diagnose intra-abdominal surgical disease. Diagnostic peritoneal lavage was carried out in patients in whom the physical exam was deemed unreliable, such as in patients with cardiopulmonary instability or mental obtundation. Patients were included in the study if autopsy or laparotomy confirmation of the lavage data was available. Forty four patients met the inclusion criteria and formed the basis of this study. Of the twenty three patients with a positive lavage, three false-positive diagnostic peritoneal lavages were discovered, either at laparotomy or postmortem exam. Of the twenty one patients where diagnostic peritoneal lavage was negative, no false-negatives were discovered at autopsy or laparatomy. Therefore, this test is 100 per cent sensitive and 88 per cent specific. It is concluded that a negative diagnostic peritoneal lavage makes intra-abdominal surgical disease highly unlikely. However, a positive lavage may require further diagnostic work-up.

Fluosol-DA as a red-cell substitute in acute anemia.

We assessed the safety and efficacy of Fluosol-DA as a red-cell substitute in acute anemia. Twenty-three surgical patients with blood loss and religious objections to receiving blood transfusions were evaluated. Fifteen moderately anemic patients with a mean hemoglobin level (+/- SE) of 7.2 +/- 0.5 g per deciliter had no evidence of a physiologic need for increased arterial oxygen content and did not receive Fluosol-DA. Eight severely anemic patients with a mean hemoglobin level of 3.0 +/- 0.4 g per deciliter met the criteria of need and received the drug until the physiologic need disappeared or a maximal dose of 40 ml per kilogram of body weight was reached. We observed no adverse reactions to Fluosol-DA. The average peak increment in arterial oxygen content with the drug was only 0.7 +/- 0.1 ml per deciliter. There were no appreciable beneficial effects of Fluosol-DA, perhaps because of the small increase in arterial oxygen content, the brief half-life of the drug (24.3 +/- 4.3 hours), and the limited total dose. Six of the eight patients receiving Fluosol-DA died. One of the survivors received red-cell transfusions against his wishes, under a court order, after his total Fluosol-DA dose. Fourteen of the 15 moderately anemic patients survived. The data in this select group of patients refusing blood products suggest that, after blood loss, Fluosol-DA is unnecessary in moderate anemia and ineffective in severe anemia.

Extended use of disposable pressure transducers. A bacteriologic evaluation.

In a prospective randomized study, contamination rates of disposable pressure transducers changed every two days (n = 81) were compared with those changed at four (n = 26) or eight days (n = 50); the mean daily incidence of contamination was 3% for each group. After four days of use, the cumulative prevalences of contamination were similar. However, after eight days, the cumulative prevalence was significantly higher in transducers used without change (6.9%) than in those changed every two days (2.9%). Gram-negative bacilli were present in 63% of contaminated transducers; over half were from the patients' own flora. The only definite transducer-related bacteremia occurred on a day of initial contamination and should have been unaffected by the interval of change. Routine use of disposable transducers can be safely extended to four days, even in a busy intensive care unit.

Occult duodenal perforation complicating cerebral infarction: new problems in diagnosis of Cushing's ulcer.

Cushing's ulcers of the duodenum are well known complications of neurosurgery, head trauma, and other causes of increased intracranial pressure. Perforation of Cushing's ulcer of the duodenum is infrequently described. That the use of high-dose corticosteroids for cerebrovascular infarct in an aphasic patient may obscure the symptomatology and physical findings of a perforated Cushing's ulcer has not been described to our knowledge. We report a patient with a large left hemispherical infarct and resultant aphasia who developed a perforated duodenal ulcer and extensive chemical peritonitis while receiving high dose corticosteroids for increased intracranial pressure. She was unable to register any complaints and the typical physical findings of perforated duodenal ulcer with chemical peritonitis were virtually absent. A high index of suspicion must be maintained for a perforated Cushing's duodenal ulcer in the patient receiving high dose dexamethasone despite the presence of nonspecific symptomatology and abdominal findings. Elevated serum gastrin levels, as in this patient, may also indicate the patients with increased intracranial pressure who are at greater risk for developing Cushing's ulcer.

Shock and noncardiogenic pulmonary edema following meglumine diatrizoate for intravenous pyelography.

In a 25 year old man shock and pulmonary edema developed following the intravenous administration of meglumine diatrizoate for an intravenous pyelogram. A pulmonary-capillary wedge pressure of 3 torr and a high protein content in the pulmonary edema effluent confirmed the diagnosis of noncardiogenic pulmonary edema. We suggest that the basis of the increased capillary permeability in this patient may be related to an immunologic reaction to intravenous pyelogram dye.