Physicians' knowledge and practice towards medical error reporting: a cross-sectional hospital-based study in Saudi Arabia.

Identifying reasons for under-reporting is crucial in reducing the incidence of medical errors. We studied physicians' knowledge of the occurrence, frequency and causes of medical errors and their actual practice toward reporting them. A cross-sectional, self-administered questionnaire was answered by 107 physicians at a tertiary-care hospital in Saudi Arabia. The questionnaire had 6 sections covering demographic data, knowledge, attitudes and practice towards reporting medical errors, perceived causes of and frequency of medical errors in their hospital and personal experiences of medical error reporting. Physicians tended not to report medical errors when no harm had occurred to patients. One-third of respondents feared punitive actions if they reported errors and only 56.4% felt that error reporting had led to positive changes in overall care. A majority of errors were related to late interventions and misdiagnosis. Under-reporting of medical errors was common in this hospital. Physicians did not appreciate attempts to improve the system of error reporting and a culture of blame still prevailed.

Physicians' knowledge and practice towards medical error reporting: a cross-sectional hospital-based study in Saudi Arabia

Identifying reasons for under-reporting is crucial in reducing the incidence of medical errors. We studied physicians' knowledge of the occurrence,frequency and causes of medical errors and their actual practice toward reporting them. A cross-sectional, self-administered questionnaire was answered by 107 physicians at a tertiary-care hospital in Saudi Arabia. The questionnaire had 6 sections covering demographic data,knowledge, attitudes and practice towards reporting medical errors, perceived causes of and frequency of medical errors in their hospital and personal experiences of medical error reporting. Physicians tended not to report medical errors when no harm had occurred to patients. One-third of respondents feared punitive actions if they reported errors and only 56.4% felt that error reporting had led to positive changes in overall care. A majority of errors were related to late interventions and misdiagnosis. Under-reporting of medical errors was common in this hospital. Physicians did not appreciate attempts to improve the system of error reporting and a culture of blame still prevailed

L'identification des raisons de la sous-notification est cruciale pour reduire l'incidence des erreurs medicales. Nous avons etudie les connaissances des medecins sur la survenue, la frequence et les causes des erreurs medicales ainsi que leur pratique reelle en termes de notification. Un autoquestionnaire transversal a ete rempli par 107 medecins dans un hopital de soins tertiaires en Arabie saoudite. Le questionnaire presentait six sections couvrant les donnees demographiques, les connaissances, les attitudes et les pratiques vis-a-vis de la notification des erreurs medicales, les causes percues et la frequence des erreurs medicales dans leur hopital ainsi que les experiences personnelles en matiere de notification. Les medecins avaient tendance a ne pas notifier les erreurs medicales lorsque les patients n'avaient souffert d'aucun dommage. Un tiers des repondants craignaient les actions punitives s'ils notifiaient des erreurs et seuls 56,4 % pensaient que la notification des erreurs entrainait des modifications positives pour l'ensemble des soins. Une majorite d'erreurs etait liee a des interventions tardives et des erreurs de diagnostic. La sous-notification des erreurs medicales etait frequente dans cet hopital. Les medecins ne percevaient pas positivement les tentatives d'amelioration du systeme de notification des erreurs et la culture du blame restait prevalente

Negative ethical behaviors in Saudi hospitals: How prevalent are they perceived to be? - Statement agreement study.

BACKGROUND: There is limited information about the prevalence of unethical behavior and how is perceived among health care providers. The aim of this study is to assess such behavior and how is perceived. MATERIALS AND METHODS: This is a cross-sectional study among three groups of professionals. Total participants were 370 and included medical staff, medical residents, and nurses in five medical specialties in four tertiary hospitals in Saudi Arabia (two Ministry of Health Hospitals and two military Hospitals). Participants were asked to rate their agreement with occurrence of 15 "negative" unethical behavior scenarios in their workplace. The scenarios covered areas of "respect for persons", "interprofessional relationships", and "empathy with patients". RESULTS: Majority of respondents agreed that "unethical" behavior occurred in their workplace, including confidentiality being compromised (36.3%), informed consent not taken properly (60.2%), and bad news not well-delivered (62.2%). Other significant area agreement included doctors lacking empathy (47.8%), patient autonomy not fully respected (42.5%), discrimination (41.2%), and being pressurized to write inaccurate reports (31.2%). Respondents in medicine had the lowest rate of agreement and those in psychiatry had the highest (mean of 49.8% and 82.3%, respectively). Respondents with length of employment of less than 6 years had significantly higher agreement that unethical behavior occurs compared to those with length of employment of more than 6 years. Males were more likely than females to agree that unethical behavior occurs. The biggest difference was seen in the behavior of "informed consent not properly taken" with a gender margin of 18.7% (P = 0.001). CONCLUSION: There is high prevalence of behavior that is considered unethical as perceived by various health care workers at Saudi hospitals.

Global survey of national tuberculosis drug policies.

SETTING: National tuberculosis (TB) programmes (NTPs) in 100 countries. OBJECTIVES: To evaluate the relationship between the estimated prevalence of multidrug resistance in previously untreated TB cases and policies regarding sales and distribution of TB drugs, particularly rifampicin (RMP). DESIGN: Questionnaire survey of national TB drug control policies, completed by NTP managers. Results were correlated with recent World Health Organization estimates of prevalence of drug resistance in new cases of TB. RESULTS: Questionnaires were received from 100 countries, including 88 low- and middle-income countries (LMICs) and 17 of the 22 high-burden countries. Current policies were considered adequate in only 40 of the 88 LMICs (45%). A higher prevalence of multidrug resistance was associated with fewer years of free availability of TB drugs from the NTP (P = 0.02) and more years of availability of RMP from providers or pharmacies outside the NTP (P = 0.02). Eleven of the 20 countries with the highest prevalence of multidrug resistance had inadequate policies governing sales and distribution of TB drugs. CONCLUSIONS: These findings suggest that policies regarding sales and distribution of TB drugs should receive more emphasis as part of the global strategy to control drug resistance.

Clinical presentation and diagnostic workup for community-acquired pneumonia: the Gulf Corporation Council CAP Working Group consensus statement.

Community-acquired pneumonia (CAP) is diagnosed on the basis of a suggestive history and compatible physical findings and new infiltrates on a chest radiograph. No criteria or combination of criteria based on history and physical examination have been found to be gold standard. With the rise in elderly Gulf Cooperation Council (GCC) residents, CAP is likely to present with non-classical manifestations such as somnolence, new anorexia, and confusion and carries a worse outcome than CAP in their younger counterparts. Tuberculosis should be considered in the differential diagnosis of unresolving CAP in the GCC region. Diagnostic work up depends on severity of CAP, clinical course and underlying risk factors.

Yield of smear, culture and amplification tests from repeated sputum induction for the diagnosis of pulmonary tuberculosis.

OBJECTIVES: To assess the yield of repeated sputum induction for the diagnosis of active tuberculosis in patients who do not produce spontaneous sputum, or with smear-negative spontaneous samples. METHODS: Induced sputum was examined with fluorescent microscopy, two amplification methods (PCR Amplicor MTB, and MTD2), and cultured for mycobacteria using liquid (Bactec 12B) and Lowenstein-Jensen media. Bronchoscopy and collection of other specimens were performed at the discretion of the treating physician. RESULTS: A total of 1115 sputum inductions performed in 500 patients without adverse events yielded an adequate specimen in 1113 (99.8%), and microbiological confirmation in 43 of 44 (98%) culture-positive active TB cases. Yield increased with repeated sputum induction. The cumulative yield for acid-fast bacilli smear and mycobacterial culture was 64% and 70% respectively for one, 81% and 91% for two, 91% and 99% for three, and 98% and 100% for four induced samples. Yield of PCR also increased with the greater number of induced samples tested. CONCLUSIONS: Repeated sputum induction could considerably improve diagnostic accuracy for pulmonary TB.

First case of combined blastomycosis and tuberculosis in a patient from Saudi Arabia.

Acute blastomycosis has not been reported on the Arabian Peninsula. We report an unusual case of dual pulmonary blastomycosis and tuberculosis. In addition, this is the first case of blastomycosis reported from Saudi Arabia, a disease not endemic in this region.

Upper airway obstruction due to rhinoscleroma: case report.

Rhinoscleroma is a very rare cause of upper airway obstruction with only isolated reports in the literature of rhinoscleroma with isolated tracheal obstruction. The course is usually chronic with the presentation most often being non-specific. We report a 54-year-old woman with progressive shortness of breath and wheezing over 7 years' duration. She was diagnosed and treated as bronchial asthma without improvement in her symptoms. At the time of referral to our institution, her flow-volume loop revealed fixed upper airway obstruction. Her chest radiography and other laboratory tests were normal. Bronchoscopy revealed a 70-80% irregular concentric stenosis of the trachea beginning immediately below the vocal cords and extending 4 cm distally. Biopsy showed characteristic Mikulicz histiocytes containing numerous gram-negative intracellular coccobacilli consistent with a diagnosis of rhinoscleroma. The patient was treated with laser resection of the stenosis followed by a course of ciprofloxcin and trimethoprim-sulfamethoxazole. She has remained asymptomatic over a year follow-up period and repeated biopsies have shown no evidence of recurrence.

Pulmonary changes in liver transplant candidates with hepatitis C cirrhosis.

OBJECTIVE: Several studies have shown that pulmonary abnormalities are common in patients with end-stage liver disease. However, most of these studies were conducted on patients with heterogeneous etiologies. Therefore, we studied these changes in a homogenous group of hepatitis C cirrhotic patients who were potential candidates for liver transplantation. METHODS: The charts of 81 patients from King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia with hepatitis C cirrhosis who were evaluated for liver transplantation were reviewed. The following data was retrieved: echocardiography with micro-bubble study, arterial blood gases, and pulmonary function tests of 81 candidates and reviewed over 3 years from 1994 to 1997. RESULTS: The mean age was 53 (+/-9) years with male to female ratio of 1.4:1. Echocardiographic micro-bubble study, revealed 4 of 62 (7%) had an intrapulmonary shunt. Arterial blood gases results were pH of 7.44 (+/-0.4), partial arterial tension of carbon dioxide of 33 mm Hg (+/-4), partial arterial tension of oxygen of 84 mm Hg (+/-12), and alveolar-arterial gradient of 30 mm Hg (+/-10). Eleven percent had obstructive airway disease, 17% had restrictive lung impairment, and 43% had reduced diffusion capacity. Seventy five percent of patients with reduced diffusion capacity had normal lung volumes. Various pulmonary function test abnormalities did not lead to significant differences in arterial blood gases. CONCLUSION: Pulmonary changes were frequent in liver transplant candidates with hepatitis C virus cirrhosis with reduced diffusion capacity being the most. Apart from the effect of hepatopulmonary syndrome on arterial oxygenation, other pulmonary abnormalities were not significantly different.

Accuracy and utility of commercially available amplification and serologic tests for the diagnosis of minimal pulmonary tuberculosis.

Diagnosis of patients with minimal active tuberculosis (TB) is difficult, as there is no single test with high sensitivity and specificity. The yield and clinical utility of a combination of diagnostic tests were prospectively studied among 500 consecutive patients referred for sputum induction for diagnosis of possible active TB. Patients underwent sputum induction, chest X-ray, tuberculin testing, and had blood drawn for serologic testing (Detect-TB test; Biochem ImmunoSystems). Sputum was examined with fluorescent microscopy and PCR (Amplicor MTB-Roche) and cultured for mycobacteria using liquid (BACTEC) and solid media. For the diagnosis of the 60 cases of active TB, sensitivity and specificity, respectively, of the following diagnostic tests were mycobacterial culture, 73% and 100%; PCR, 42% and 100%; chest X-ray, 67-77% and 66-76%; tuberculin testing, 94% and 20%; and serology, 33% and 87%. After consideration of PCR and radiographic and clinical characteristics, a positive serologic test was independantly associated with diagnosis of active disease (adjusted odds of disease if positive, 2.6; 95% confidence limits, 1.1,6.1). No currently available test has sensitivity and specificity high enough for the accurate diagnosis of minimal pulmonary TB. Utilization of a combination of tests, together with consideration of key clinical characteristics, could improve diagnostic accuracy.

Does size matter? Utility of size of tuberculin reactions for the diagnosis of mycobacterial disease.

It is a common belief that larger tuberculin reactions are more serious, and more likely to indicate patients with active tuberculosis (TB) or at high risk of disease in the future. Among 182 close contacts, and 502 patients suspected of possible active TB, 529 underwent tuberculin skin testing (TST) and 605 had a chest radiograph. Final diagnoses, based on all available clinical, microbiological, histological, and radiographic information, were active TB, 68; inactive TB, 274; nontuberculous mycobacterial disease, 14; conditions associated with anergy, 36; no detectable abnormality (except a positive TST) or condition unrelated to TB, 213; and negative TST, no further evaluation, 79. Among these patients, TST of 5 mm or larger was significantly more likely to indicate active or inactive TB (p < 0.001). However, among patients with TST of 5 mm or greater, the size and frequency distribution of tuberculin reactions were not different between subjects with different diagnoses, nor between subjects with different types or extent of radiographic findings. As well, TST reactions were no different in 121 subjects with or 176 subjects without a history of BCG vaccination. In close contacts or patients suspected of active TB, reactions less than 5 mm indicated lower likelihood of active or inactive disease, but above that threshold, size of tuberculin reaction did not matter.

Clinical aspects of miliary tuberculosis in Saudi adults.

OBJECTIVE: To review all cases of miliary tuberculosis (MT) over a period of 7 years in a Saudi Arabian population, to determine the clinical and laboratory characteristics and diagnostic methods, and to compare our data with others reported in the literature. DESIGN: A retrospective case review. RESULTS: Of 780 cases of active tuberculosis seen over period of 7 years, 47 (6%) had MT. The majority of the patients were aged over 60 years (68%). The most common symptoms were fever and weight loss. Risk factors were present in 70% of cases, mainly diabetes mellitus, history of prior tuberculosis, chronic liver and renal disease, immunosuppressive drug therapy and malignancy. Miliary pattern on chest radiography was seen in 89%. The most common laboratory abnormalities were anemia (66%), lymphopenia (89%), low albumin (87%), and high alkaline phosphatase (80%). Fiberoptic bronchoscopy was diagnostic in 7/10 (70%), bone marrow examination in 8/11 (73%), and liver biopsy in 14/16 (88%). High alkaline phosphatase and lymphopenia were associated with high yield of liver biopsies and bone marrow examination: 13/14 (93%) and 7/8 (88%), respectively. Death occurred in 10/47 (21%); all of these had radiological evidence of miliary pattern, and 80% had comorbid conditions. CONCLUSION: These data confirm and extend the results of other studies and suggest that MT is a disease of the elderly and immunocompromised, and is associated with high mortality. A high index of suspicion is required for diagnosis.

Accuracy of oximetry with thermistor (OxiFlow) for diagnosis of obstructive sleep apnea and hypopnea.

OBJECTIVES: To evaluate the diagnostic accuracy for obstructive sleep apnea and hypopnea (OSAH) of the OxiFlow (OF) device which combines oximetry with recording of thermistor airflow. DESIGN & SETTING: Patients scheduled for overnight diagnostic polysomnography (PSG) were studied with OF either simultaneously during laboratory PSG (L-OF, n=86), at home on a separate night (H-OF, n=66), or both (n=55). PATIENTS: 97 patients with suspected OSAH, of whom 40 had OSAH defined as an apnea-hypopnea index (AHI) of more than 15 events per hour of sleep on PSG. INTERVENTIONS: NA. MEASUREMENTS & RESULTS: The automated respiratory disturbance index (RDI) generated by the OF software considerably underestimated the AHI by PSG for both L-OF and H-OF. Altering the parameters for hypopnea identification by the software did not improve this. Visual inspection of the computerized OF tracings added considerable diagnostic information, but a manual count of RDI during visual review overestimated AHI. For the identification of cases vs. non-cases of OSAH, receiver operating characteristic area-under-the-curve statistics ranged from 0.77-0.90 for L-OF and from 0.71-0.77 for H-OF. Combining automated analysis with subsequent visual inspection of OF tracings yielded an overall sensitivity of 86% and specificity of 74% for the diagnosis of OSAH during H-OF recordings. Analysis of potential technician time saved indicated a benefit from the use of OF. CONCLUSIONS: OF has diagnostic utility for the identification of OSAH. However, because of hardware and software limitations, it is unclear whether this device is superior to oximetry alone.

Complications of carbon monoxide poisoning.

OBJECTIVE: Acute carbon monoxide poisoning is a common problem that occurs during winter and leads to serious complications. METHODS: We retrospectively studied 24 consecutive cases admitted with the aim of finding the causes and outcome of acute carbon monoxide poisoning. RESULTS: The source of poisoning was charcoal in 71% of patients, motor gasoline in 21%, and other causes in 8%. Immediate complications included altered consciousness level in 54% of patients, metabolic acidosis in 46%, pneumonia in 42%, cardiac arrhythmia in 29% and rhabdomyolysis in 25%. Late neurological complications occurred in 17% of patients. All the patients received 100% oxygen. Eleven patients (46%) required mechanical ventilation. Ultimately, 19 patients (79%) recovered completely, 4 (17%) had neurological or cardiac disorders, and 1 (4%) died. CONCLUSION: Immediate and late complications are common in carbon monoxide poisoning cases admitted to the hospital especially when they arrive late. Time lapse between exposure and presentation may have a role in predicting the outcome.

Chronic cough due to bronchobiliary fistula.

Bronchobiliary fistula is a rare cause of chronic cough. Here we describe a 70-year-old woman complaining of chronic cough and copious dark-yellow watery sputum. The presence of air in the biliary tract in the lower cuts of a computerized tomography scan of the chest and positive bile in the sputum led to the suspicion of bronchobiliary fistula. The diagnosis was confirmed by percutaneous transhepatic cholangiography. Drainage of the intrahepatic biliary tract resulted in complete resolution of her symptoms.

Heterogeneous antibody responses in tuberculosis.

Antibody responses during tuberculosis were analyzed by an enzyme-linked immunosorbent assay with a panel of 10 protein antigens of Mycobacterium tuberculosis. It was shown that serum immunoglobulin G antibodies were produced against a variety of M. tuberculosis antigens and that the vast majority of sera from tuberculosis patients contained antibodies against one or more M. tuberculosis antigens. The number and the species of serologically reactive antigens varied greatly from individual to individual. In a given serum, the level of specific antibodies also varied with the antigen irrespective of the total number of antigens recognized by that particular serum. These findings indicate that person-to-person heterogeneity of antigen recognition, rather than recognition of particular antigens, is a key attribute of the antibody response in tuberculosis.

Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum.

A 40 year old woman with known Crohn's disease of the ileum but no abscess was found to have hepatic portal venous gas by computed tomography. Aggressive antibiotic treatment led to recovery and the ileum was resected two weeks later.