Pulmonary Aspiration of Gastric Contents: A Closed Claims Analysis.

BACKGROUND: Perioperative pulmonary aspiration of gastric contents has been associated with severe morbidity and death. The primary aim of this study was to identify outcomes and patient and process of care risk factors associated with gastric aspiration claims in the Anesthesia Closed Claims Project. The secondary aim was to assess these claims for appropriateness of care. The hypothesis was that these data could suggest opportunities to reduce either the risk or severity of perioperative pulmonary aspiration. METHODS: Inclusion criteria were anesthesia malpractice claims in the American Society of Anesthesiologists Closed Claims Project that were associated with surgical, procedural, or obstetric anesthesia care with the year of the aspiration event 2000 to 2014. Claims involving pulmonary aspiration were identified and assessed for patient and process factors that may have contributed to the aspiration event and outcome. The standard of care was assessed for each claim. RESULTS: Aspiration of gastric contents accounted for 115 of the 2,496 (5%) claims in the American Society of Anesthesiologists Closed Claims Project that met inclusion criteria. Death directly related to pulmonary aspiration occurred in 66 of the 115 (57%) aspiration claims. Another 16 of the 115 (14%) claims documented permanent severe injury. Seventy of the 115 (61%) patients who aspirated had either gastrointestinal obstruction or another acute intraabdominal process. Anesthetic management was judged to be substandard in 62 of the 115 (59%) claims. CONCLUSIONS: Death and permanent severe injury were common outcomes of perioperative pulmonary aspiration of gastric contents in this series of closed anesthesia malpractice claims. The majority of the patients who aspirated had either gastrointestinal obstruction or acute intraabdominal processes. Anesthesia care was frequently judged to be substandard. These findings suggest that clinical practice modifications to preoperative assessment and anesthetic management of patients at risk for pulmonary aspiration may lead to improvement of their perioperative outcomes.

A cross-sectional study of medical students' knowledge of patient safety and quality improvement.

BACKGROUND: The Association of American Medical Colleges and the World Health Organization have endorsed formal patient safety and quality improvement (QI) education for medical students. We surveyed medical students to assess their current level of patient safety and QI knowledge and to identify factors associated with increased knowledge. METHODS: A literature review, focus groups with medical students, and local expert interviews were used to develop an electronic survey, which was distributed to all medical students at a single medical school in the spring of 2012. RESULTS: Fifty-seven percent of the medical school student body (N = 790) participated in the survey. A greater proportion of students reported previous exposure to patient safety education than to QI education (79% vs 47%). Students scored an average of 56% and 58% on the patient safety and QI knowledge tests, respectively. Having or pursuing an advanced degree (P = .02) and previous exposure to patient safety education (P = .02) were associated with higher knowledge scores. After adjusting for confounding variables, only previous exposure to QI education (P = .02) was associated with higher QI knowledge scores. LIMITATIONS: There is a risk of measurement bias due to the use of an unvalidated instrument. Students who have greater knowledge of patient safety or QI might recall exposure at a greater frequency, inflating the association between exposure and knowledge. Also, this is a cross-sectional study, so we cannot draw conclusions about causality. CONCLUSION: Medical students' knowledge of patient safety and QI is low. Previous formal or informal education about these topics is associated with increased knowledge.

Patient safety and quality improvement education: a cross-sectional study of medical students' preferences and attitudes.

BACKGROUND: Recent educational initiatives by both the World Health Organization and the American Association of Medical Colleges have endorsed integrating teaching of patient safety and quality improvement (QI) to medical students. Curriculum development should take into account learners' attitudes and preferences. We surveyed students to assess preferences and attitudes about QI and patient safety education. METHODS: An electronic survey was developed through focus groups, literature review, and local expert opinion and distributed via email to all medical students at a single medical school in the spring of 2012. RESULTS: A greater proportion of students reported previous exposure to patient safety than to quality improvement topics (79% vs. 47%). More than 80% of students thought patient safety was of the same or greater importance than basic science or clinical skills whereas quality improvement was rated as the same or more important by about 70% of students. Students rated real life examples of quality improvement projects and participation in these projects with actual patients as potentially the most helpful (mean scores 4.2/5 and 3.9/5 respectively). For learning about patient safety, real life examples of mistakes were again rated most highly (mean scores 4.5/5 for MD presented mistakes and 4.1/5 for patient presented mistakes). Students rated QI as very important to their future career regardless of intended specialty (mean score 4.5/5). CONCLUSIONS: Teaching of patient safety and quality improvement to medical students will be best received if it is integrated into clinical education rather than solely taught in pre-clinical lectures or through independent computer modules. Students recognize that these topics are important to their careers as future physicians regardless of intended specialty.

The temporal dynamics of object processing in visual cortex during the transition from distributed to focused spatial attention.

Several major cognitive neuroscience models have posited that focal spatial attention is required to integrate different features of an object to form a coherent perception of it within a complex visual scene. Although many behavioral studies have supported this view, some have suggested that complex perceptual discrimination can be performed even with substantially reduced focal spatial attention, calling into question the complexity of object representation that can be achieved without focused spatial attention. In the present study, we took a cognitive neuroscience approach to this problem by recording cognition-related brain activity both to help resolve the questions about the role of focal spatial attention in object categorization processes and to investigate the underlying neural mechanisms, focusing particularly on the temporal cascade of these attentional and perceptual processes in visual cortex. More specifically, we recorded electrical brain activity in humans engaged in a specially designed cued visual search paradigm to probe the object-related visual processing before and during the transition from distributed to focal spatial attention. The onset times of the color popout cueing information, indicating where within an object array the subject was to shift attention, was parametrically varied relative to the presentation of the array (i.e., either occurring simultaneously or being delayed by 50 or 100 msec). The electrophysiological results demonstrate that some levels of object-specific representation can be formed in parallel for multiple items across the visual field under spatially distributed attention, before focal spatial attention is allocated to any of them. The object discrimination process appears to be subsequently amplified as soon as focal spatial attention is directed to a specific location and object. This set of novel neurophysiological findings thus provides important new insights on fundamental issues that have been long-debated in cognitive neuroscience concerning both object-related processing and the role of attention.