Contributing factors to errors in Swedish emergency departments.

OBJECTIVE: The Emergency Department (ED) is a complex and dynamic environment, often resulting in a somewhat uncontrolled and unpredictable workload. Contributing factors to errors in health care and in the ED are largely related to communication breakdowns. Moreover, the ED work environment is predisposed to multitasking, overcrowding and interruptions. These factors are assumed to have a negative impact on patient safety. Reported errors from care providers are mainly related to diagnostic procedures in Swedish EDs. However, there is a lack of knowledge and national oversight regarding contributing factors. The aim of this study was therefore to describe contributing factors in regards to errors occurring in Swedish EDs. METHOD: Descriptive design based on registry data from the Lex Maria database of the Swedish National Board of Health and Welfare. RESULTS: The results indicate that factors contributing to errors in Swedish EDs are multifactorial in nature. The most common contributing factor was human error followed by factors in the local ED environment and teamwork failure. CONCLUSION: Factors contributing to ED errors were multifactorial and included both organizational and teamwork failure in which human error was implicated. To reduce errors, further research is needed to develop methods that disclose latent working conditions such as high workload and interruptions. Patient safety research needs to include understanding of human behaviour in complex organizational systems and the impact of working conditions on patient safety and quality of care.

Amino-terminal pro-B-type natriuretic peptide and high-sensitivity C-reactive protein but not cystatin C predict cardiovascular events in male patients with peripheral artery disease independently of ambulatory pulse pressure.

BACKGROUND: Patients with peripheral arterial disease (PAD) are at high risk for cardiovascular (CV) events. We have previously shown that ambulatory pulse pressure (APP) predicts CV events in PAD patients. The biomarkers amino-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and cystatin C are related to a worse outcome in patients with CV disease, but their predictive values have not been studied in relation to APP. METHODS: Blood samples and 24-hour measurements of ambulatory blood pressure were examined in 98 men referred for PAD evaluation during 1998-2001. Patients were followed for a median of 71 months. The outcome variable was CV events defined as either CV mortality or any hospitalization for myocardial infarction, stroke, or coronary revascularization. The predictive values of log(NT-proBNP), log(hs-CRP), and log(cystatin C) alone and together with APP were assessed by multivariable Cox regression. Area under the curve (AUC) and net reclassification improvement (NRI) were calculated compared with a model containing other significant risk factors. RESULTS: During follow-up, 36 patients had at least 1 CV event. APP, log(NT-proBNP), and log(hs-CRP) all predicted CV events in univariable analysis, whereas log(cystatin C) did not. In multivariable analysis log(NT-proBNP) (hazard ratio (HR) = 1.62; 95% confidence interval (CI) = 1.05-2.51) and log(hs-CRP) (HR = 1.63; 95% CI = 1.19-2.24) predicted events independently of 24-hour PP. The combination of log(NT-proBNP), log(hs-CRP), and average day PP improved risk discrimination (AUC = 0.833 vs. 0.736; P < 0.05) and NRI (37%; P < 0.01) when added to other significant risk factors. CONCLUSIONS: NT-proBNP and hs-CRP predict CV events independently of APP and the combination of hs-CRP, NT-proBNP, and day PP improves risk discrimination in PAD patients.

Interruptions in emergency department work: an observational and interview study.

OBJECTIVE: Frequent interruptions are assumed to have a negative effect on healthcare clinicians' working memory that could result in risk for errors and hence threatening patient safety. The aim of this study was to explore interruptions occurring during common activities of clinicians working in emergency departments. METHOD: Totally 18 clinicians, licensed practical nurses, registered nurses and medical doctors, at two Swedish emergency departments were observed during clinical work for 2 h each. A semistructured interview was conducted directly after the observation to explore their perceptions of interruptions. Data were analysed using non-parametric statistics, and by quantitative and qualitative content analysis. RESULTS: The interruption rate was 5.1 interruptions per hour. Most often the clinicians were exposed to interruptions during activities involving information exchange. Calculated as percentages of categorised performed activities, preparation of medication was the most interrupted activity (28.6%). Face-to-face interaction with a colleague was the most common way to be interrupted (51%). Most common places for interruptions to occur were the nurses' and doctors' stations (68%). Medical doctors were the profession interrupted most often and were more often recipients of interruptions induced by others than causing self-interruptions. Most (87%) of the interrupted activities were resumed. Clinicians often did not regard interruptions negatively. Negative perceptions were more likely when the interruptions were considered unnecessary or when they disturbed the work processes. CONCLUSIONS: Clinicians were exposed to interruptions most often during information exchange. Relative to its occurrence, preparation of medication was the most common activity to be interrupted, which might increase risk for errors. Interruptions seemed to be perceived as something negative when related to disturbed work processes.

Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review.

OBJECTIVE: Despite an increase in research, there is still a lack of knowledge about patient safety in emergency departments (EDs) in many European countries. The aim of this study was therefore to describe the incidence and types of reported medical errors and complaints in ED care in Sweden. METHODS: Data reported in 2009 were gathered from national authorities, including the National Board of Health and Welfare, the Medical Responsibility Board, the Patients Advisory Committees, and local incident-reporting systems. Data were analyzed by content analysis. RESULTS: Among 428 cases reported by care providers to the National Board of Health and Welfare, 64 (15.0%) were related to ED care. As several cases contained more than one medical error, 92 errors were identified, out of which 39 (42.4%) were related to diagnostic procedures. Among the 4628 cases of complaints reported by patients to the Medical Responsibility Board, 306 (6.6%) were related to ED care. In total, 437 complaints regarding perceived medical errors were identified (several cases contained more than one error), with 189 (43.2%) pertaining to diagnostic procedures. A total of 1341 complaints about ED care were made by patients to the Patients Advisory Committees (n=21), of which 655 (48.8%) were related to care and treatment. There were 7434 medical errors reported to local incident-reporting systems at the EDs (n=45). Of these, 1450 (19.5%) referred to care and treatment. CONCLUSION: Medical errors and complaints at Swedish EDs, as reported by both patients and care providers, were related mainly to diagnostic procedures and treatments.

Predictors of systolic BP <140 mmHg and systolic BP level by randomly assigned treatment group (benazepril plus amlodipine or hydrochlorothiazide) in the ACCOMPLISH Study.

BACKGROUND: The ACCOMPLISH Trial investigated intensive antihypertensive combination treatment with benazepril + amlodipine (B+A) or benazepril + hydrochlorothiazide (B+H) on cardiovascular outcomes in patients with systolic hypertension. We analyzed the baseline predictors of achieving a systolic blood pressure (SBP) <140 mmHg and achieved SBP level by the end of 12 months in both treatment groups. METHODS: Baseline and 12-month SBP was available in 10,506 patients, of whom 6250 had diabetes. Univariate and multivariate logistic regression models were used for SBP control at 12 months and multivariable regression models were used for the prediction of SBP at 12 months. A stepwise procedure was used to select significant (p < 0.001) predictors in multivariate analyses. RESULTS: Mean (± SD) BP fell from 145.4/80.1 (± 18.3/10.7) mmHg at randomization to 132.8/74.7 (± 16.0/9.6) mmHg at 12 months. The main baseline predictors of SBP control <140 mmHg were region (USA >Nordic region) and Caucasian ethnicity in both randomization arms. A higher diastolic BP and the use of lipid lowering agents indicated favorable effects in the B+H arm only. The predictors of uncontrolled SBP were: (i) higher baseline SBP values, (ii) higher number of previous antihypertensive medications in both arms, (iii) the previous use of insulin in the B+A arm, and (iv) pre-trial calcium channel blocker (CCB) use in the B+H arm. Additionally, pre-trial use of thiazides and electrocardiogram (ECG)-left ventricular hypertrophy (LVH) at baseline predicted higher, and smoking lower absolute SBP in the B+A arm and the use of thiazides and proteinuria a higher SBP in the B+H arm. CONCLUSION: Irrespective of treatment, patients in the USA and Caucasians achieved better SBP control, whereas higher baseline SBP and more previous antihypertensive medications indicated less control. Concomitant use of lipid lowering treatment indicated a better SBP control in the benazepril + hydrochlorothiazide arm. Lastly, insulin use and ECG-LVH in the benazepril + amlodipine arm and proteinuria in the benazepril + hydrochlorothiazide arm indicated poor control.

Adherence to medication according to sex and age in the CHARM programme.

AIMS: Although many patients with heart failure have incomplete adherence to prescribed medications, predisposing factors remain unclear. This analysis investigates factors associated with adherence, with particular emphasis on age and sex. METHODS AND RESULTS: A multivariable regression analysis of 7599 heart failure patients from the CHARM trial was done to evaluate factors associated with adherence. Adherence was measured as the proportion of time patients took more than 80% of study medication. The mean age was 66 years (SD 11) and 31.5% (n = 2400) were women. Women were slightly less adherent than men (87.3 vs. 89.8%, P = 0.002), even in adjusted, multivariable models (treatment, P = 0.006; placebo P = 0.004; and overall P < 0.001). However, all-cause mortality was lower in women (21.5%) than in men (25.3%) (adjusted hazard ratio, 0.77; 95% CI, 0.69-0.86; P < 0.001), but patients with a low adherence regardless of sex had a higher mortality. Age, severity of heart failure, number of medications, and smoking status were not associated with adherence. CONCLUSION: Women, particularly those <75 years of age, were less likely to be adherent in this large sample of patients with symptomatic heart failure. Understanding factors associated with adherence may provide opportunities for intervention.

Predictors of development of diabetes in patients with chronic heart failure in the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) program.

OBJECTIVE: The purpose of this study was to identify predictors of incident diabetes during follow-up of nondiabetic patients with chronic heart failure (CHF) in the Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) program. RESEARCH DESIGN AND METHODS: A total of 1,620 nondiabetic patients had full baseline datasets. We compared baseline demographic, medication, and laboratory data for patients who did or did not develop diabetes and conducted logistic regression and receiver operator characteristic curve analyses. RESULTS: Over a median period of 2.8 years, 126 of the 1,620 patients (7.8%) developed diabetes. In multiple logistic regression analysis, the following baseline characteristics were independently associated with incident diabetes in decreasing order of significance by stepwise selection: higher A1C (odds ratio [OR] 1.78 per 1 SD increase; P < 0.0001), higher BMI (OR 1.64 per 1 SD increase; P < 0.0001), lipid-lowering therapy (OR 2.05; P = 0.0005), lower serum creatinine concentration (OR 0.68 per 1 SD increase; P = 0.0018), diuretic therapy (OR 4.81; P = 0.003), digoxin therapy (OR 1.65; P = 0.022), higher serum alanine aminotransferase concentration (OR 1.15 per 1 SD increase; P = 0.027), and lower age (OR 0.81 per 1 SD increase; P = 0.048). Using receiver operating characteristic curve analysis, A1C and BMI yielded areas under the curve of 0.723 and 0.712, respectively, increasing to 0.788 when combined. Addition of other variables independently associated with diabetes risk minimally improved prediction of diabetes. CONCLUSIONS: In nondiabetic patients with CHF in CHARM, A1C and BMI were the strongest predictors of the development of diabetes. Other minor predictors in part reflected CHF severity or drug-associated diabetes risk. Identifying patients with CHF at risk of diabetes through simple criteria appears possible and could enable targeted preventative measures.

Impact of cigarette smoking in high-risk patients participating in a clinical trial. A substudy from the Heart Outcomes Prevention Evaluation (HOPE) trial.

BACKGROUND: In recent large cardiovascular trials done in stable patients, 14-31% of the participants were smokers; the consequences of smoking in these trials using medications known to reduce cardiovascular events, have not been assessed. DESIGN: We evaluated the cardiovascular outcomes according to smoking status of men and women participating in the Heart Outcomes Prevention Evaluation trial. METHODS: The occurrence of cardiovascular events was documented among participants who did not change their smoking status during the trial. There were 2728 'never smokers', 5241 'former smokers' and 936 'current smokers', and all had stable cardiovascular disease or diabetes with at least one other risk factor. None had previous congestive heart failure or known left ventricular ejection fraction < 0.40. RESULTS: During the 4.5-year follow-up, there were 641 cardiovascular deaths, 978 myocardial infarctions, 358 strokes and 1021 deaths. In comparison to 'never smokers', smokers had relative risks adjusted for confounding variables including medications known to reduce cardiovascular mortality and morbidity, for cardiovascular death of 1.65 [95% confidence interval (CI), 1.28-2.14], for myocardial infarction of 1.26 (95% CI, 1.01-1.58), for stroke of 1.42 (95% CI, 1.00-2.04), and for total mortality of 1.99 (95% CI, 1.63-2.44). The rates of these events among 'former smokers' were not different from those of 'never smokers'. CONCLUSIONS: Smoking increased the risk of mortality and morbidity among high-risk patients despite the use of medications known to reduce cardiovascular events. Smoking cessation programs should be reinforced even for patients participating in clinical trials.