Making Diagnostic Instruction Explicit in US Pharmacy Education.

The profession of pharmacy and standards directing the education of student pharmacists are constantly evolving. The profession continues to emphasize patient-centered practice as a model for the future. The US health care system is faced with an impending shortage of primary care providers, which will affect the ability of patients to access the health care system. The pharmacy profession should position itself to contribute to meeting this need. The explicit instruction of differential diagnosis within Doctor of Pharmacy degree programs is a critical consideration in advancing pharmacy practice and potential contributions to the primary care gap.

Individual and Team-Based Medical Error Disclosure: Dialectical Tensions Among Health Care Providers.

Researchers from disciplines of education, health communication, law and risk management, medicine, nursing, and pharmacy examined communication tensions among interprofessional (IP) health care providers regarding medical error disclosure utilizing patient simulation. Using relational dialectics theory, we examined how communication tensions manifested in both individual-provided medical error disclosure and IP team-based disclosure. Two dialectical tensions that health care providers experienced in disclosure conversations were identified: (a) leadership and support, and (b) transparency and protectionism. Whereas these tensions were identified in an IP education setting using simulation, findings support the need for future research in clinical practice, which may inform best practices for various disclosure models. Identifying dialectical tensions in disclosure conversations may enable health communication experts to effectively engage health care providers, risk management, and patient care teams in terms of support and education related to communicating about medical errors.

Professional e-mail communication among health care providers: proposing evidence-based guidelines.

E-mail is now a primary method of correspondence in health care, and proficiency with professional e-mail use is a vital skill for physicians. Fundamentals of e-mail courtesy can be derived from lay literature, but there is a dearth of scientific literature that addresses the use of e-mail between physicians. E-mail communication between providers is generally more familiar and casual than other professional interactions, which can promote unprofessional behavior or misunderstanding. Not only e-mail content but also wording, format, and tone may influence clinical recommendations and perceptions of the e-mail sender. In addition, there are serious legal and ethical implications when unprofessional or unsecured e-mails related to patient-identifying information are exchanged or included within an electronic medical record. The authors believe that the appropriate use of e-mail is a vital skill for physicians, with serious legal and ethical ramifications and the potential to affect professional development and patient care. In this article, the authors analyze a comprehensive literature search, explore several facets of e-mail use between physicians, and offer specific recommendations for professional e-mail use.

Traumatic intracranial injury in intoxicated patients with minor head trauma.

OBJECTIVES: Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. METHODS: This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. RESULTS: A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. CONCLUSIONS: In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury.

A human cadaver fascial compartment pressure measurement model.

BACKGROUND: Fresh human cadavers provide an effective model for procedural training. Currently, there are no realistic models to teach fascial compartment pressure measurement. OBJECTIVES: We created a human cadaver fascial compartment pressure measurement model and studied its feasibility with a pre-post design. METHODS: Three faculty members, following instructions from a common procedure textbook, used a standard handheld intra-compartment pressure monitor (Stryker(®), Kalamazoo, MI) to measure baseline pressures ("unembalmed") in the anterior, lateral, deep posterior, and superficial posterior compartments of the lower legs of a fresh human cadaver. The right femoral artery was then identified by superficial dissection, cannulated distally towards the lower leg, and connected to a standard embalming machine. After a 5-min infusion, the same three faculty members re-measured pressures ("embalmed") of the same compartments on the cannulated right leg. Unembalmed and embalmed readings for each compartment, and baseline readings for each leg, were compared using a two-sided paired t-test. RESULTS: The mean baseline compartment pressures did not differ between the right and left legs. Using the embalming machine, compartment pressure readings increased significantly over baseline for three of four fascial compartments; all in mm Hg (±SD): anterior from 40 (±9) to 143 (±44) (p = 0.08); lateral from 22 (±2.5) to 160 (±4.3) (p < 0.01); deep posterior from 34 (±7.9) to 161 (±15) (p < 0.01); superficial posterior from 33 (±0) to 140 (±13) (p < 0.01). CONCLUSION: We created a novel and measurable fascial compartment pressure measurement model in a fresh human cadaver using a standard embalming machine. Set-up is minimal and the model can be incorporated into teaching curricula.

The use of a computer reminder system in an emergency department universal HIV screening program.

OBJECTIVE: We describe electronic medical record use in automated eligibility determination for an emergency department (ED)-based nontargeted HIV screening program. METHODS: We reviewed the electronic medical record system at an urban, inner-city ED from March 17 to April 14, 2008. During that period, patient eligibility for HIV screening was electronically determined according to preprogrammed criteria: (1) age between 18 and 64 years; (2) no known history of HIV disease; and (3) no known HIV screening in the previous year. This populated an electronic work list used by HIV testing counselors. RESULTS: Of 8,489 ED patients during the study period, the electronic medical record system determined 5,794 (68.3%) as eligible. Of 1,484 (25.6%) patients approached for screening, 1,121 (75.5%) consented, and 5 received confirmed positive results (0.4%). Reasons for ineligibility, as determined by the electronic medical record system, were previous screening 1,125 (41.7%), age 890 (33.0%), known HIV 111 (4.1%), and reason unknown 569 (21.1%). CONCLUSION: Clinical informatics solutions can provide automated delineation of ED subpopulations eligible for HIV screening, according to predetermined criteria, which could increase program efficiency and might accelerate integration of HIV screening into clinical practice.