Therapeutic errors among children in the community setting: nature, causes and outcomes.

AIM: This study aimed to determine the epidemiology of therapeutic errors among children in the community setting. METHODS: This was a prospective, observational study of 491 consecutive cases reported to the Victorian Poisons Information Centre, between January 2006 and March 2007. A total of 450 (91.7%) parents/carers were followed up by telephone approximately 48 h after the initial call. The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations given to avoid future errors. RESULTS: The majority of children (334, 68.0%, 95% confidence interval (CI) 63.7, 72.1) were aged

Prehospital noninvasive ventilation: a viable treatment option in the urban setting.

OBJECTIVE: To determine the viability of prehospital noninvasive ventilation (NIV) as a prelude to a definitive clinical trial. METHODS: This was a retrospective observational study of patients (aged > 55 years, severe shortness of breath) transported to a tertiary emergency department (10/5/03-12/28/04). Data were extracted from paramedic and hospital medical records. The primary outcome measure was the number of patients who could potentially benefit from prehospital NIV. They were defined as "conscious upon paramedic arrival and who required ventilatory support (bag/valve/mask ventilation [BVM], NIV or endotracheal intubation) during transport or within 30 minutes of arrival at the emergency department (ED)." The secondary outcome measures were the effectiveness of existing paramedic treatment regimens and paramedic management times. RESULTS: Two hundred sixty-four patients were enrolled (mean age 75.5 +/- 8.7 years, 59.1% male). Sixty-seven patients (25.4%, 95% CI: 20.3-31.2) met the primary outcome measure: 31 (11.7%, 95% CI: 8.2-16.4) received prehospital BVM, an additional 35 (13.3%, 95% CI: 9.5-18.1) received NIV in the ED and one (0.4%, 95% CI: 0.0-2.4) was intubated in the ED. Prehospital treatment resulted in significant (p < 0.001) improvements in systolic blood pressure (151.2 dropping to 144.2 mmHg), respiratory rate (29.4 dropping to 26.3 breaths/minute), and oxygen saturation (92.3% rising to 96.2%). Median paramedic management time was 33 minutes (IQR 29-40). CONCLUSION: Prehospital treatment significantly improved patient vital signs. However, a considerable proportion of patients still required ventilatory support either prehospital or early in their ED course. Further research is indicated to determine if these patients would benefit from prehospital NIV.

Bupivacaine in the emergency department is underused: scope for improved patient care.

AIMS: To determine patterns of local anaesthetic use, knowledge and perceived use of local anaesthetic by emergency department doctors, and barriers to bupivacaine use. METHODS: This was a multifaceted, observational study undertaken at two large metropolitan emergency departments. It comprised a retrospective chart review of patients who had been given local anaesthetic in the emergency department, an examination of ordering records of local anaesthetics in the emergency department, and a cross-sectional survey of emergency department doctors. RESULTS: The charts of 95 patients were reviewed. Most (93.7%) injuries were lacerations and the most common site was the hand (41.4%). 88 (92.6%), 4 (4.2%) and 3 (3.2%) patients were given lignocaine, prilocaine (Bier's blocks) and bupivacaine (digital blocks), respectively. Four (4.2%) cases were identified for which bupivacaine was likely to have been a better alternative than the lignocaine used. These were finger/hand injuries likely to be associated with considerable prolonged pain. The emergency department pharmacy records indicated that 30 times more lignocaine than bupivacaine was ordered in 2004-5. 30 (88.2%) of 34 doctors completed the survey. Knowledge of local anaesthetic pharmacology was variable: 33% and 66% did not know that bupivacaine was more cardiotoxic and that lignocaine was more painful, respectively. The main barriers to bupivacaine use were "habit" of using lignocaine (46.7%), cardiac toxicity (40%) and slower onset (30%). CONCLUSION: Bupivacaine seems to be underused in some appropriate circumstances. Accordingly, there is scope for improvement in patient care through critical evaluation of local anaesthetic practice. This is particularly necessary because barriers to bupivacaine use are often non-clinical (habit, availability, familiarity) rather than clinical (toxicity, onset time).

Handover in the emergency department: deficiencies and adverse effects.

OBJECTIVE: To determine problems resulting from ED handover, deficiencies in current procedures and whether patient care or ED processes are adversely affected. METHODS: A prospective observational study at three large metropolitan ED comprising three components: observation of handover sessions, 2 h post-handover surveys of the receiving doctors and a general survey of ED doctors. RESULTS: The handovers of 914 patients were observed during 60 handover sessions in a 3-month period. Medical information, including presenting complaints, was handed over better than communication and disposition information. Seven hundred and seven (77.4%) of 914 potential post-handover interviews were undertaken. Most (88.3%) doctors thought the handover was 'adequate/good'. However, information was perceived as lacking in 109 (15.4%) handovers, especially details of management (35, 5.0%), investigations (33, 4.7%) and disposition (33, 4.7%). There was a significant difference in the perceived quality of handovers (1-5 scale where 5 = excellent) when all required information was handed over and when it was not (median scores 4.0 vs 3.0, respectively, P < 0.001). As a result of perceived inadequate handovers, the doctor/ED and patient were affected adversely in 62 (8.8%) and 33 (4.7%) cases, respectively, for example, repetition of assessment, delays in disposition and care. Fifty doctors completed the general survey. Most believed communications made to inpatient units, inaccurate/incomplete information and disorganization were problematic. CONCLUSION: Deficiencies in handover processes exist, especially in communication and disposition information. These affect doctors, the ED and patients adversely. Recommendations for improvement include guideline development to standardize handover processes, the greater use of information technology facilities, ongoing feedback to staff, and quality assurance and education activities.

Therapeutic errors involving adults in the community setting: nature, causes and outcomes.

OBJECTIVE: To compare the nature of therapeutic errors made by adults in community residential units (CRU) and private homes (Home). METHODS: This was an analytical case series of therapeutic errors, involving adults, reported to the Victorian Poisons Information Centre (January 2006 to March 2007). The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations for avoidance. RESULTS: Ninety-seven CRU and 611 Home residents (cases) were enrolled. These groups took 243 (median 2) and 785 (median 1) medications in error, respectively (p<0.001). The medication administrators were predominately staff members (94.8%) and the cases themselves (95.9%), respectively (p<0.001). The CRU cases more frequently had an incorrect medication(s) or another person's medication(s) and the Home cases a double dose or incorrect dose (p<0.001). Wide ranges of medications were taken in error with cardiac and respiratory medications being more common among the Home cases. Four (4.1%, 95% CI 1.3-10.8) CRU and 16 (2.6%, 95% CI 1.6-4.3) Home cases were referred to hospital. No case followed up had a serious outcome. Error cause differed significantly between the groups (p<0.001). Staffing issues and human factors were common within the CRU and Home groups, respectively. CONCLUSIONS: Therapeutic errors in the community are preventable and differ considerably between the CRU and Home settings. IMPLICATIONS: Prevention initiatives are indicated with particular attention to CRU staffing, training and procedural issues.

Review article: leaving the emergency department without being seen.

Patients who leave the ED without being seen (LWBS) are unlikely to be satisfied with the quality of the service provided and might be at risk from conditions that have not been assessed or treated. We therefore examined the available research literature to inform the following questions: (i) In patients who attend for ED care, what factors are associated with the decision to LWBS? (ii) In patients who attend for ED care, are there adverse health outcomes associated with the decision to LWBS? (iii) Which interventions have been used to try to reduce the number of patients who attend for ED care and LWBS? From the available literature, there was insufficient evidence to draw firm conclusions; however, the literature does suggest that patients who LWBS have conditions of lower urgency and lower acuity, are more likely to be male and younger, and are likely to identify prolonged waiting times as a central concern. LWBS patients generally have very low rates of subsequent admission, and reports of serious adverse events are rare. Many LWBS patients go on to seek alternative medical attention, and they might have higher rates of ongoing symptoms at follow-up. Further research is recommended to include comprehensive cohort or well-designed case-control studies. These studies should assess a wide range of related factors, including patient, hospital and other relevant factors. They should compare outcomes for groups of LWBS patients with those who wait and should include cross-sectoral data mapping to truly detect re-attendance and admission rates.

Animal and human bite injuries in Victoria, 1998-2004.

OBJECTIVE: To describe the epidemiology of mammal (human and non-human) bite injuries in Victoria. PARTICIPANTS, DESIGN AND SETTING: Retrospective case series of injuries recorded in the Victorian Emergency Minimum Dataset (VEMD) (1998-2004) and deaths recorded in the National Coroners Information System (1 July 2000 - 1 June 2006). MAIN OUTCOME MEASURES: Frequency, nature and outcome of injury as a function of mammal, victim demographics and season. RESULTS: Of 12 982 bite injuries identified in the VEMD, dogs, humans, and cats were implicated in 79.6%, 8.7%, and 7.2% of cases, respectively. Dog bite injuries were commonly sustained to the hands/wrists (31.3%) and face/head (25.4%); cat bites to the hands/wrists (67.6%) and arms (16.0%); and human bites to the hands/wrists (37.1%), arms (20.5%) and face/head (20.4%). Males comprised 73.7% and 56.3% of human and dog bite victims, respectively, while females comprised 64.1% of cat bite victims. A third of dog bite victims (33.4%) were children aged 14 years or less. Most human bite victims (79.8%) were adults aged 20-49 years, inclusive. More injuries were sustained on weekends and during the summer, 55.4% of injuries occurred in the home, and 11.6% of patients required hospital admission. Dog bites resulted in three deaths. CONCLUSIONS: Mammal bite injuries are common and often require inpatient care. Patterns of bite injuries relate to the type of mammal involved. These epidemiological data will inform prevention initiatives to decrease the incidence of mammal bites.

Handheld mobile telephone use among Melbourne drivers.

OBJECTIVE: To evaluate change in handheld mobile telephone (mobile) use among motor vehicle drivers between 2002 and 2006. DESIGN AND SETTING: Observational study of motor vehicle drivers at three times (10:00-11:00; 14:00-15:00; 17:00-18:00) on three consecutive Tuesdays in October 2006 at 12 highway sites in metropolitan Melbourne. MAIN OUTCOME MEASURES: Rates of handheld mobile use overall and by the sex and age of drivers, highway site (major metropolitan road, central business district, freeway exit ramp) and time of day. RESULTS: In 2002, 315 of 17 023, and in 2006, 331 of 20 207 drivers were observed using handheld mobiles. This represented a non-significant rate decrease from 18.5 to 16.3 users/1000 drivers (rate difference, 2.1 users/1000 drivers; 95% CI,- 0.6 to 4.8; P = 0.07). Unlike 2002, the rate of handheld mobile use among men in 2006 was significantly higher than for women (rate difference, 3.7 mobiles/1000 drivers; 95% CI, 0.1-7.3; P = 0.03). In both 2002 and 2006, mobile use was most common in the central business district. In 2002, there was significantly more mobile use in the evening, while in 2006, the evening rate was significantly lower than the morning rate (rate difference, 4.3; 95% CI, - 0.1 to 8.7; P = 0.03) and slightly lower than the afternoon rate (rate difference, 3.0; 95% CI, - 1.1 to 7.1; P = 0.08). The effect of age remained unchanged between 2002 and 2006, with older drivers using mobiles least (P < 0.001). CONCLUSION: The number of drivers at risk from handheld mobile phone use remains almost unchanged. However, a slight reduction in the rate of use overall and variations in use among driver subgroups are apparent. Policing and public awareness campaigns need to further address this preventable risk of injury.