Patient race/ethnicity, age, gender and education are not related to preference for or response to disclosure.

OBJECTIVE: The purpose of this study was to (a) characterise patients' preferences for disclosure of medical errors and reporting, (b) assess patients' responses to disclosure of error and (c) determine how these preferences differ by patient race/ethnicity, gender, age and level of education. METHODS: A survey was conducted of consecutive patients presenting at any hour to a tertiary care academic emergency department. Inclusion criteria were: >21 years, competent to conduct the interview (ie, conscious, not demented, delirious, intoxicated or undergoing a psychiatric evaluation), initial Glasgow Coma Scale >12, and patient not transferred from another institution and not in state custody. A four-scenario survey was used to assess patients' preferences for: disclosure, reporting and responses to disclosure. The responses to the scenarios were analysed using Somers D. Independent effects of study variables were assessed with a generalised estimating equation. RESULTS: Of 512 eligible patients, 394 (77% response rate) participated, and 238/394 (61%) met the criteria for analysis. Overall, in 902 (98%) responses to the scenarios, participants wanted disclosure, in 404 (45%), they wanted the error reported and in 311 (35%) they were less likely to seek legal action if informed of the error. In all three categories there was no relation with race/ethnicity, gender, age and education, with the exception of an increased desire for reporting in younger patients and those with less education. CONCLUSIONS: Interventions that aim to assist doctors with disclosure of medical error must emphasise the uniformity of patient preferences for disclosure and the diminished likelihood of legal action following disclosure.

Emergency medicine resident errors: identification and educational utilization.

OBJECTIVES: To evaluate the error management systems emergency medicine residency directors (EMRDs) use to identify and report clinical errors made by emergency medicine residents and their satisfaction with error-based teaching as an educational tool. METHODS: All 112 EMRDs listed by the Accreditation Council for Graduate Medical Education in 1996 were sent a 15-item survey. Five areas of error evaluation and management were assessed: 1) systems for tracking and reporting clinical errors; 2) resident participation in the systems; 3) resident remediation; 4) EMRD-perceived satisfaction with current error-reporting mechanisms, their educational value, and their ability to identify and prevent errors; and 5) EMRDs' perceptions of faculty and resident satisfaction with the systems. RESULTS: The response rate was 86%. All EMRDs indicated that methods are in place to track and report errors at their institutions. These include morbidity and mortality conference (94%), quality assurance case review conference (76%), and continuous quality improvement audits (60%). A majority of programs (58%) present resident cases anonymously in order to enhance teaching (39%), to avoid embarrassment (28%), and to avoid individual blame (24%). While mandated resident remediation is not required at 48% of the programs, 24% require lectures, 17% require written reports, and 6% require extra clinical shifts. The EMRDs rated the educational value of morbidity and mortality conference as outstanding (11%) or excellent (53%), and rated their systems for identifying key resident errors as outstanding (0%), excellent (14%), or good (47%). CONCLUSIONS: All emergency medicine residency programs have systems to track and report resident errors. Resident participation varies widely, as does resident remediation processes. Most EMRDs are satisfied with their systems but few EMRDs rate them as excellent in the detection or prevention of clinical errors.

Surgical biomaterials and differential colonization by Staphylococcus epidermidis.

The data presented in this communication demonstrate preferential colonization of certain biomaterials by Staphylococcus epidermidis. Using a laminar flow biomaterial colonization chamber and surgical-grade biomaterials (stainless steel, aluminium ceramic, methyl methacrylate and high-density polyethylene), the pattern of colonization was quantitated using plate count techniques and electron microscopy. Under comparable conditions, methyl methacrylate was colonized by S. epidermidis in greater numbers than the other biomaterials. Increased bacterial colonization and slime production on methyl methacrylate was time-dependent and 15 times higher than on stainless steel and aluminium and four times higher than on high-density polyethylene. The data reveal that certain biomaterials may promote infection by favouring colonization by potential pathogens. This variable should be explored extensively in an in vivo setting because of its implication in clinical infections.

Adhesive colonization of biomaterials and antibiotic resistance.

This study addresses the problem of antibiotic resistance in adhesive, biomaterial-centred infections. It is suggested that this anionic, extracapsular, polysaccharide slime produced by bacteria protects them from antibiotics and sequesters critical ions from the surface of biomaterials. Biofilm-enclosed bacteria on the surface of stainless steel substrata in a test chamber were challenged with incremental levels of tobramycin. In this setting, the minimum inhibitory concentration and minimum bactericidal level of tobramycin for Staphylococcus epidermis were well above normal.

Adhesive bacterial colonization of exposed traumatized tendon.

Recent studies of compromised or damaged tissues, as well as biomaterials, have shown that they provide a particularly fertile substratum for bacterial colonization. Colonization in these environments is mediated by a process of microbial adhesion to surfaces of the substrata. In this report, we present electron microscopic studies of a portion of damaged and infected tendon. These studies demonstrate colonies of bacteria surrounded by a ruthenium red-staining exopolysaccharide biofilm and adhesion to the surface of the tendon by means of an exopolysaccharide polymer. We suggest that this adhesive form of bacterial colonization may partially explain the resistance of exposed tendon to effective debridement by simple mechanical measures and to coverage with granulation tissue, partial-thickness skin grafts, and vascularized tissue grafts.

Inhibition of bacterial adhesion by antibacterial surface pretreatment of vascular prostheses.

Polytetrafluoroethylene grafts were pretreated with oxacillin, with the cationic detergent benzalkonium, or with both substances, either at room temperature or at 90 degrees C. Inhibition zones ranging from 6.4 to 15.2 mm formed around all grafts incubated on Staphylococcus aureus-streaked agar plates except control disks and those treated with oxacillin. Treated grafts were exposed in vitro to S. aureus in high concentration, followed by distilled water lavage. The graft surface was then stained with ruthenium red to stain polysaccharides and studied by scanning and transmission electron microscopy. Colonization of the graft surface by adhesive bacteria was demonstrated in all cases, although it was less prevalent on grafts pretreated with benzalkonium bound at 90 degrees C.

Nosocomial pulmonary infection: possible etiologic significance of bacterial adhesion to endotracheal tubes.

Biomaterials are essential for life support and monitoring of critically ill patients, but their use increases the risk of nosocomial infection. Of the various plastics used for life support and monitoring devices, polyvinylchloride is one to which bacteria most readily adhere. Through the use of qualitative culture techniques and scanning and transmission electron microscopy, we studied the surfaces of polyvinylchloride endotracheal tubes removed from 25 ICU patients, to determine if bacterial adhesion to those tubes was sufficient to provide a possible source for repeated contamination of the tracheobronchial tree. Of the surfaces studied, 16% were partially covered and 84% were completely covered by an amorphous bacteria-containing matrix. Some biofilm-enclosed bacterial aggregates projected from the matrix into the lumen of the tube. The mechanism by which endotracheal tubes repeatedly inoculate the lungs of intubated patients may prove to be dislodgment of such aggregates by suction apparatus.

Bacterial colonization of percutaneous sutures.

The direct electron microscopic examination of 15 sutures and 15 staples removed from 10 healed surgical wounds showed, on the intradermal portions, consistent colonization by bacteria growing in adherent biofilms. This clearly demonstrable bacterial colonization of biomaterials within the wound tract had not resulted in infection or perceptible inflammation in any of the wounds. These bacterial cells were of several morphotypes, including gram-positive cocci, and all specimens yielded cultures of the autochthonous (native) skin bacterium, Staphylococcus epidermidis. The bacteria within the wound tracts were enveloped by extracellular material that appeared on scanning electron microscopy to be a condensed amorphous residue and on transmission electron microscopy to be a fibrous extracellular matrix. We suggest that this mode of growth, in which the colonizing bacteria are enveloped in a copious exopolysaccharide glycocalix, protects the bacteria from host defense factors and accounts for their persistence on the suture surfaces until they are removed with the sutures.

Adherent bacterial colonization in the pathogenesis of osteomyelitis.

Direct scanning electron microscopy of material obtained during surgical debridement of osteomyelitic bone showed that the infecting bacteria grew in coherent microcolonies in an adherent biofilm so extensive it often obscured the infected bone surfaces. Transmission electron microscopy showed this biofilm to have a fibrous matrix, to contain some host cells, and to contain many bacteria around which matrix fibers were often concentrated. Many bacterial morphotypes were present in these biofilms, and each bacterium was surrounded by exopolysaccharide polymers, which are known to mediate formation of microcolonies and adhesion of bacteria to surfaces in natural ecosystems and in infections related biomaterials. The adherent mode of growth may reduce the susceptibility of these organisms to host clearance mechanisms and antibiotic therapy and thus may be a fundamental factor in acute and chronic osteomyelitis.