Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

CONTEXT: - Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. OBJECTIVES: - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. DESIGN: - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department. RESULTS: - Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient. CONCLUSIONS: - All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.

The reliability of AHRQ Common Format Harm Scales in rating patient safety events.

OBJECTIVES: A study was conducted to determine the reliability of Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale versions 1.1 and 1.2 in rating patient safety events among users of the UHC Patient Safety Net, a Web-based incident reporting tool. METHODS: To test interrater agreement, UHC developed a survey tool consisting of patient event scenarios. In 2011, a survey evaluating Harm Scale v.1.1 was distributed to 921 quality, risk, and safety (QRS) managers at 89 organizations; in 2012, a second survey evaluating Harm Scale v.1.2 was sent to 13,280 managers at 102 organizations. RESULTS: Regardless of the version used, in 3 of 9 scenarios, fewer than 60% of respondents agreed on a single score. Interrater agreement increased for certain event scenarios with v.1.2 but decreased for other scenarios. Interrater reliability was moderate for both v.1.1 (k = 0.51) and v.1.2 (k = 0.47). Interrater agreement improved in v.1.2 when results were limited to more experienced raters but still remained in the moderate range (k = 0.58). CONCLUSIONS: AHRQ Common Format Harm Scale v.1.1 and v.1.2 both had moderate interrater reliability. Using Harm Scale v.1.1, respondents had difficulty distinguishing "injury limited to additional treatment" from "temporary harm," whereas, using Harm Scale v.1.2, respondents had difficulty distinguishing moderate harm from one of the adjacent levels-mild or severe harm. This study provides valuable data that can inform harm scale revision to improve the quality of aggregate safety data used to define and direct safety efforts.

Stereoselective inhibition of glutamate carboxypeptidase by organophosphorus derivatives of glutamic acid.

A series of alkyl and aryl phosphonyl, thiophosphonyl, and dithiophosphonyl derivatives of (S)- and (R)-glutamic acid were prepared and examined for inhibitory potency against glutamate carboxypeptidase (carboxypeptidase G). The acquisition of the phosphonamidodithioic acids and the individual phosphonamidothioic acid diastereomers was achieved through a common phosphonamidothiolate precursor, which also allowed for the chromatographic resolution of the chiral phosphorus center of the phosphonamidothioic acids. The most potent inhibitor of the series was the n-butylphosphonamidate derivative of the natural isomer of glutamic acid. Although each diastereomeric pair of three phosphonamidothionates exhibited stereoselective inhibition consistent with the configuration of the chiral phosphorus center, this effect was generally not remarkable. More important, was the effect of carbon stereochemistry upon glutamate carboxypeptidase inhibition as exemplified by a limited series of enantiomeric pairs of phosphonamidate and phosphonamidodithionate derivatives of glutamic acid. The phosphonamidate analogs derived from the unnatural stereoisomer of glutamic acid were devoid of inhibitory potency in contrast to their enantiomers. Surprisingly, the phosphonamidodithionates derived from the unnatural stereoisomer of glutamic acid demonstrated greater inhibitory potency than their naturally-derived antipodes.