Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.

OBJECTIVE: To assess whether patients' perceptions of a hypothetical medical error are influenced by staff responsiveness, disclosure of error, and health consequences of the error. DESIGN: Hypothetical scenario describing a medication error submitted by mail. Three factors were manipulated at random: rapid v slow staff responsiveness to error; disclosure v non-disclosure of the error; and occurrence of serious v minor health consequences. PARTICIPANTS: Patients discharged from hospital. MEASURES: Assessment of care described in the scenario as bad or very bad, rating of care as unsafe, and intent to not recommend the hospital. RESULTS: Of 1274 participants who evaluated the scenario, 71.4% rated health care as bad or very bad, 60.2% rated healthcare conditions as unsafe, and 25.5% stated that they would not recommend the hospital. Rating health care as bad or very bad was associated with slow reaction to error (odds ratio (OR) 2.8, 95% CI 2.1 to 3.6), non-disclosure of error (OR 2.0, 95% CI 1.5 to 2.6), and serious health consequences (OR 3.4, 95% CI 2.6 to 4.5). Similar associations were observed for rating healthcare conditions as unsafe and the intent to not recommend the hospital. Younger patients were more sensitive to non-disclosure than older patients. CONCLUSIONS: Former patients view medical errors less favorably when hospital staff react slowly, when the error is not disclosed to the patient, and when the patient suffers serious health consequences.

Injury prevention education in medical schools: an international survey of medical students.

BACKGROUND: Injuries account for an estimated 9% of global mortality. Health professionals worldwide receive little formal injury prevention training, especially in developing countries. OBJECTIVE: To identify injury prevention training topics taught in a sample of medical schools throughout the world. DESIGN AND SETTING: Cross sectional survey of 82 medical schools from 31 countries. Based on a convenience sample, respondents recalled the injury prevention concepts they were taught, estimated the time dedicated to these topics, specified the courses and rotations where these concepts were taught, and noted whether they were compulsory or elective sessions. PARTICIPANTS: Medical students in their last year of medical training. MAIN EXPOSURE MEASURES: Student recall of classes and rotations where topics of injury prevention and control were discussed. RESULTS: Basic injury prevention concepts including risk factors for injuries and injury classification systems were not covered in 60% of medical schools. Concepts related to child abuse and neglect and emergency care were more commonly taught than others such as traffic injury prevention and youth violence prevention. In general, injury prevention and control concepts were less frequently taught in Middle Eastern and African universities compared with other regions and some topics such as violence prevention were more frequently taught in medical schools in the Americas. Injury prevention concepts were taught most frequently in preventive medicine, forensic medicine, emergency medicine, surgery and pediatrics courses, and rotations. CONCLUSIONS: Injury prevention and control education is infrequent and fragmented in medical schools around the world. Inclusion or further development of curricula on this subject could benefit prevention and control efforts.

Effect of a ban on carrying firearms on homicide rates in 2 Colombian cities.

CONTEXT: Homicide is a leading cause of death in Colombia, with much of the fatal interpersonal violence concentrated in the country's largest cities. Firearms are involved in as much as 80% of homicides in Colombia. OBJECTIVE: To evaluate the effect of an intermittent police-enforced ban on carrying firearms on the incidence of homicide in urban Colombia. DESIGN: Interrupted time-series study with multiple replications. SETTING: Cali, Colombia, during 1993 and 1994 and Bogotá, Colombia, from 1995 through August 1997. PARTICIPANTS: The populations of Cali and Bogotá. INTERVENTION: Carrying of firearms was banned on weekends after paydays, on holidays, and on election days. Enforcement included establishment of police checkpoints and searching of individuals during traffic stops and other routine law enforcement activity. MAIN OUTCOME MEASURE: Homicide rates during intervention days were compared with rates during similar days without the intervention; estimates were based on comparisons within the same month, day of week, and time of day. RESULTS: There were 4078 homicides in Cali during 1993 and 1994 (114.6 per 100,000 person-years). In Bogotá, 9106 homicides occurred from 1995 through August 1997 (61 per 100,000 person-years). The incidence of homicide was lower during periods when the firearm-carrying ban was in effect compared with other periods (multivariate-adjusted rate ratio, 0.86 [95% confidence interval [CI], 0.76-0.97] for Cali, and 0.87 [95% CI, 0.77-0.98] for Bogotá). CONCLUSION: An intermittent citywide ban on the carrying of firearms in 2 Colombian cities was associated with a reduction in homicide rates for both cities.

Alcohol problems in women admitted to a level I trauma center: a gender-based comparison.

BACKGROUND: Male patients constitute such a large proportion of trauma patients that most studies of alcohol problems in trauma patients have been carried out with clinical data largely or totally contributed by male patients. It may be incorrect to assume that the nature of alcoholism in women and men is identical, or that the size of the problem among women is small, eliminating the need to specifically study female patients. The purpose of this study was to perform a gender-based comparison of alcohol problems in trauma patients. METHODS: Admitted injured patients underwent routine screening, including a blood alcohol concentration, serum gamma-glutamyl transpeptidase, and the Short Michigan Alcohol Screening Test. A random sample of screen positive women and men underwent a comprehensive alcohol use and psychosocial assessment, and the results were compared by gender. RESULTS: The screen-positive rate was higher for men, 51% versus 34% (p < 0.01). However, screen-positive women and men had similar problem severity as reflected by mean blood alcohol concentration (162 mg/dL vs. 142 mg/dL, p = 0.16) and Short Michigan Alcohol Screening Test scores (4.6 vs. 5.0, p = 0.32). The Alcohol Use Disorders Identification Test, NIMH-DIS, and Severity of Alcohol Dependence Data form showed that female trauma patients with alcohol problems have the same severity of dependence symptoms as men. However, women were significantly more likely to have liver dysfunction, depression, psychological distress, and recent physical, emotional, or sexual abuse. CONCLUSION: Alcohol problems are more common in male trauma patients, but women with alcohol problems are just as severely impaired, have at least as many adverse consequences of alcohol use as their male counterparts, and have more evidence of alcohol-related physical and psychological harm.

Detection of acute alcohol intoxication and chronic alcohol dependence by trauma center staff.

BACKGROUND: Trauma patients with acute alcohol intoxication or chronic alcohol dependence are at greater risk for morbidity and mortality. We hypothesized that relying on clinical suspicion to detect acute alcohol intoxication and chronic alcohol dependence in trauma patients is inaccurate, influenced by injury factors, and biased by race, gender, age, and socioeconomic status. METHODS: Trauma patients were screened with a blood alcohol concentration and with the Short Michigan Alcohol Screening Test and CAGE questionnaire. Before screening, physicians and emergency department nurses were asked whether the patient was acutely intoxicated (blood alcohol concentration > 100 mg/ dL) or had a chronic alcohol problem. Sensitivity, specificity, positive, and negative predictive values were determined by comparing responses with blood alcohol concentration, Short Michigan Alcohol Screening Test, and CAGE questionnaire results, stratified by injury and demographic factors. RESULTS: Clinical evaluations were obtained on 462 patients. Overall, 23% of acutely intoxicated patients were not identified by physicians. The miss rate increased to one third in severely injured, chemically paralyzed, or intubated patients. Specificity was also poor. Patients with a negative blood alcohol concentration were more likely to be falsely suspected of intoxication if they were either young, male, perceived as disheveled, uninsured, or having a low income (p < 0.05). Staff identified < 50% of patients with a positive Short Michigan Alcohol Screening Test or CAGE, and falsely identified 26% of patients as alcoholic. CONCLUSIONS: Formal alcohol screening should be routine because clinical detection of acute alcohol intoxication and dependence is inaccurate. Screening should also be routine to avoid discriminatory bias attributable to patient characteristics.

Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence.

OBJECTIVE: Alcoholism is the leading risk factor for injury. The authors hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and would decrease the rate of trauma recidivism. METHODS: This study was a randomized, prospective controlled trial in a level 1 trauma center. Patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and short Michigan Alcoholism Screening Test (SMAST). Those with positive results were randomized to a brief intervention or control group. Reinjury was detected by a computerized search of emergency department and statewide hospital discharge records, and 6- and 12-month interviews were conducted to assess alcohol use. RESULTS: A total of 2524 patients were screened; 1153 screened positive (46%). Three hundred sixty-six were randomized to the intervention group, and 396 to controls. At 12 months, the intervention group decreased alcohol consumption by 21.8+/-3.7 drinks per week; in the control group, the decrease was 6.7+/-5.8 (p = 0.03). The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they had 21.6+/-4.2 fewer drinks per week, compared to an increase of 2.3+/-8.3 drinks per week in controls (p < 0.01). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p = 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up). CONCLUSION: Alcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counseling for alcohol problems should be routine.