Adverse events among patients registered in high-acuity areas of the emergency department: a prospective cohort study.

OBJECTIVE: To enhance patient safety, it is important to understand the frequency and causes of adverse events (defined as unintended injuries related to health care management). We performed this study to describe the types and risk of adverse events in high-acuity areas of the emergency department (ED). METHODS: This prospective cohort study examined the outcomes of consecutive patients who received treatment at 2 tertiary care EDs. For discharged patients, we conducted a structured telephone interview 14 days after their initial visit; for admitted patients, we reviewed the inpatient charts. Three emergency physicians independently adjudicated flagged outcomes (e.g., death, return visits to the ED) to determine whether an adverse event had occurred. RESULTS: We enrolled 503 patients; one-half (n = 254) were female and the median age was 57 (range 18-98) years. The majority of patients (n = 369, 73.3%) were discharged home. The most common presenting complaints were chest pain, generalized weakness and abdominal pain. Of the 107 patients with flagged outcomes, 43 (8.5%, 95% confidence interval 8.1%-8.9%) were considered to have had an adverse event through our peer review process, and over half of these (24, 55.8%) were considered preventable. The most common types of adverse events were as follows: management issues (n = 18, 41.9%), procedural complications (n = 13, 30.2%) and diagnostic issues (n = 10, 23.3%). The clinical consequences of these adverse events ranged from minor (urinary tract infection) to serious (delayed diagnosis of aortic dissection). CONCLUSION: We detected a higher proportion of preventable adverse events compared with previous inpatient studies and suggest confirmation of these results is warranted among a wider selection of EDs.

Corticotropin-releasing factor and neuropeptide Y mRNA levels are modified by glucocorticoids in rainbow trout, Oncorhynchus mykiss.

The primary stress response involves neuronal activation that ultimately leads to the release of glucocorticoids. Circulating glucocorticoids are thought to influence their own synthesis and release through a negative feedback mechanism that inhibits the activity of the hypothalamic and pituitary components of the stress axis. This study was designed to address the hypothesis that glucocorticoids modify corticotropin-releasing factor (CRF) and neuropeptide Y (NPY) mRNA levels in the rainbow trout (Oncorhynchus mykiss) brain. Cortisol implantation significantly reduced CRF1 and NPY mRNA levels in fish exposed to an isolation stress. In contrast, cortisol implantation did not prevent the stress-induced elevation of CRF1 and NPY mRNA levels during confinement. Treatment with the glucocorticoid receptor antagonist RU-486 reduced CRF1 mRNA levels in both isolated and confined fish, but had no effect on NPY mRNA. Although the cytochrome P450 inhibitor metyrapone reduced ACTH-induced cortisol secretion in vitro, plasma cortisol levels were elevated in isolated trout treated with metyrapone. Nevertheless, metyrapone implantation increased CRF1 and NPY mRNA levels in confined fish. Together, these results implicate cortisol as a modulator of CRF and NPY mRNA levels in the preoptic area of the trout brain, but that cortisol is only one such regulating mechanism.