Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis.

BACKGROUND: In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital. METHODS: An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA. RESULTS: During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope. CONCLUSIONS: Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Abdominal pregnancy: a case report and review of 17 cases.

PURPOSE: To analyze the clinical characteristics of abdominal pregnancy, and to explore the diagnosis and prognosis of different treatment methods. METHODS: The cases of patients with abdominal pregnancy admitted to Peking Union Medical College Hospital between January 1, 1989 and January 1, 2021, were analyzed retrospectively. RESULTS: The median age of 17 patients was 34 years (22-42 years); the median gestational duration was 57 days (from 41 days to 32 weeks). Among all 17 patients, 15 (88.24%) presented with abdominal pain. The implantation sites of the gestational sac included the bladder peritoneal reflection, anterior wall of the rectum, omentum, serous membrane of the uterus, and inside or on the surface of uterosacral ligament. In all, only 29.41% cases (5/17) were diagnosed before surgery. All 17 patients were treated via surgery. Further, 58.82% (10/17) patients recovered without complications, 29.41% (5/17) developed fever, 5.88% (1/17) underwent reoperation because of intra-abdominal bleeding, and 5.88% (1/17) developed double lower limb venous thrombosis. All 17 patients survived. CONCLUSION: The preoperative diagnosis rate of abdominal pregnancy is low. Planting sites in the pelvic peritoneum and pelvic organs are more common than the others. Laparoscopic surgery in the first trimester of pregnancy can achieve better therapeutic effects. However, the blood supply of the placenta should be fully evaluated before surgery. When it is expected that attempts to remove the placenta will cause fatal bleeding, the placenta can be left in place, but long-term close follow-up should be paid attention to.

Types of deviation and review criteria in pretreatment central quality control of tumor bed boost in medulloblastoma-an analysis of the German Radiotherapy Quality Control Panel in the SIOP PNET5 MB trial.

PURPOSE: In Germany, Austria, and Switzerland, pretreatment radiotherapy quality control (RT-QC) for tumor bed boost (TB) in non-metastatic medulloblastoma (MB) was not mandatory but was recommended for patients enrolled in the SIOP PNET5 MB trial between 2014 and 2018. This individual case review (ICR) analysis aimed to evaluate types of deviations in the initial plan proposals and develop uniform review criteria for TB boost. PATIENTS AND METHODS: A total of 78 patients were registered in this trial, of whom a subgroup of 65 patients were available for evaluation of the TB treatment plans. Dose uniformity was evaluated according to the definitions of the protocol. Additional RT-QC criteria for standardized review of target contours were elaborated and data evaluated accordingly. RESULTS: Of 65 initial TB plan proposals, 27 (41.5%) revealed deviations of target volume delineation. Deviations according to the dose uniformity criteria were present in 14 (21.5%) TB plans. In 25 (38.5%) cases a modification of the RT plan was recommended. Rejection of the TB plans was rather related to unacceptable target volume delineation than to insufficient dose uniformity. CONCLUSION: In this analysis of pretreatment RT-QC, protocol deviations were present in a high proportion of initial TB plan proposals. These findings emphasize the importance of pretreatment RT-QC in clinical trials for MB. Based on these data, a proposal for RT-QC criteria for tumor bed boost in non-metastatic MB was developed.

Rheumatic heart disease in The Gambia: clinical and valvular aspects at presentation and evolution under penicillin prophylaxis.

BACKGROUND: Rheumatic heart disease (RHD) remains the leading cause of cardiac-related deaths and disability in children and young adults worldwide. In The Gambia, the RHD burden is thought to be high although no data are available and no control programme is yet implemented. We conducted a pilot study to generate baseline data on the clinical and valvular characteristics of RHD patients at first presentation, adherence to penicillin prophylaxis and the evolution of lesions over time. METHODS: All patients registered with acute rheumatic fever (ARF) or RHD at two Gambian referral hospitals were invited for a clinical review that included echocardiography. In addition, patients were interviewed about potential risk factors, disease history, and treatment adherence. All clinical and echocardiography information at first presentation and during follow-up was retrieved from medical records. RESULTS: Among 255 registered RHD patients, 35 had died, 127 were examined, and 111 confirmed RHD patients were enrolled, 64% of them females. The case fatality rate in 2017 was estimated at 19.6%. At first presentation, median age was 13 years (IQR [9; 18]), 57% patients had late stage heart failure, and 84.1% a pathological heart murmur. Although 53.2% of them reported history of recurrent sore throat, only 32.2% of them had sought medical treatment. A history suggestive of ARF was reported by 48.7% patients out of whom only 15.8% were adequately treated. Two third of the patients (65.5%) to whom it was prescribed were fully adherent to penicillin prophylaxis. Progressive worsening and repeated hospitalisation was experienced by 46.8% of the patients. 17 patients had cardiac surgery, but they represented only 18.1% of the 94 patients estimated eligible for cardiac surgery. CONCLUSION: This study highlights for the first time in The Gambia the devastating consequences of RHD on the health of adolescents and young adults. Our findings suggest a high burden of disease that remains largely undetected and without appropriate secondary prophylaxis. There is a need for the urgent implementation of an effective national RHD control programto decrease the unacceptably high mortality rate, improve case detection and management, and increase community awareness of this disease.

Contextualising missed care in two healthcare inquiries using a socio-ecological systems approach.

AIMS AND OBJECTIVES: To examine missed care within two patient safety public inquiries using a socio-ecological model. BACKGROUND: Missed care is a care which has been omitted or rendered incomplete. Possible outcomes of missed care have been identified including poor patient outcomes such as higher mortality rates, reduced care quality and lower patient satisfaction, job dissatisfaction, staff burnout and higher attrition rates. DESIGN: A qualitative design, specifically document analysis, was used to review two serious case reviews. METHODS: Between August-December 2018, two public patient safety inquiries were examined using a document analysis method. Both inquiries are based in acute hospital care settings of nursing (UK) and midwifery (Ireland). The Standards for Reporting Qualitative Research checklist provided a framework to report the study methods, context, findings, analysis and interpretation. RESULTS: Findings highlighted instances of missed care related to practice which contributed to poor patient outcomes. Missed care was located within contingency factors, such as unintended negative patient health and safety outcomes in multiple system levels which resulted in care deficits. CONCLUSIONS: A socio-ecological model enabled consideration of how multi-system deficits combine to impact nursing and midwifery care delivery. To tackle current and future practice challenges, broader contextual issues that influence front-line cases should be identified and addressed before they create conditions which result in substandard care. RELEVANCE TO CLINICAL PRACTICE: This paper adds to the scholarship on missed care by incorporating a greater contextual lens. Findings suggest that some factors contributing to missed care events may be systemic in origin. Practice, policy, research and education should foster nurses' and midwives' review of the totality of influencing factors impacting missed care and care deficits. Consequently, early warning signs and proactive responses at a system level should be inherent in all settings that nurses' and midwives' practice.

Incidence of paragonimiasis in Chongqing China: a 6-year retrospective case review.

Paragonimiasis is an important infectious disease in Chongqing, China. However, no epidemiological surveys of paragonimiasis have been carried out in Chongqing since it became a municipality in 1997. We conducted a retrospective case review of 683 patients who were referred to our laboratory and diagnosed as having paragonimiasis during 2010-2015. Patients were diagnosed with paragonimiasis based on immunodiagnostic tests in addition to clinical and laboratory findings. Patient data extracted from the epidemiologic form were analysed. The majority of patients were distributed on the east side of the Wujiang River, which belongs to the Three Gorges Reservoir region. Consumption of raw or undercooked freshwater crab or crayfish in the family Cambaridae was the main reason for infection. Notably, more than 50·0% of patients were diagnosed between March and July, indicating that serious clinical symptoms only appear approximately 6 months post-infection. Paragonimiasis remains a public health issue in Chongqing, and an epidemiological study of Paragonimus in the Three Gorges region is strongly recommended.

Identifying characteristics and practices of multidisciplinary team reviews for patients with severe mental illness: a systematic review.

OBJECTIVES: Multidisciplinary teams in mental health receive limited guidance, leading to inconsistent practices. We undertook a systematic review of the characteristics and practices of multidisciplinary team reviews for patients with severe mental illness or in relevant mental health service settings. METHODS: Sources published since 2000 were located via academic database and web searches. Results were synthesised narratively. RESULTS: A total of 14 sources were analysed. Important characteristics and practices identified included routine monitoring and evaluation, good communication, equality between team members, and clear documentation practices. Success factors included defined leadership and clear team goals. Four sources described considerations for patients with complex clinical needs, including allocating sufficient time for discussion, maintaining connections with community providers, and ensuring culturally sensitive practices. CONCLUSIONS: No single best practice model was found, due to variations in team caseload, casemix, and resourcing levels. However, key ingredients for success were proposed. Sources were mostly descriptive; there remains a lack of evidence-based guidance regarding multidisciplinary team review characteristics and practices.

What physicians reason about during admission case review.

Research suggests that physicians perform multiple reasoning tasks beyond diagnosis during patient review. However, these remain largely theoretical. The purpose of this study was to explore reasoning tasks in clinical practice during patient admission review. The authors used a constant comparative approach-an iterative and inductive process of coding and recoding-to analyze transcripts from 38 audio-recorded case reviews between junior trainees and their senior residents or attendings. Using a previous list of reasoning tasks, analysis focused on what tasks were performed, when they occurred, and how they related to the other tasks. All 24 tasks were observed in at least one review with a mean of 17.9 (Min = 15, Max = 22) distinct tasks per review. Two new tasks-assess illness severity and patient decision-making capacity-were identified, thus 26 tasks were examined. Three overarching tasks were identified-assess priorities, determine and refine the most likely diagnosis and establish and refine management plans-that occurred throughout all stages of the case review starting from patient identification and continuing through to assessment and plan. A fourth possible overarching task-reflection-was also identified but only observed in four instances across three cases. The other 22 tasks appeared to be context dependent serving to support, expand, and refine one or more overarching tasks. Tasks were non-sequential and the same supporting task could serve more than one overarching task. The authors conclude that these findings provide insight into the 'what' and 'when' of physician reasoning during case review that can be used to support professional development, clinical training and patient care. In particular, they draw attention to the iterative way in which each task is addressed during a case review and how this finding may challenge conventional ways of teaching and assessing clinical communication and reasoning. They also suggest that further research is needed to explore how physicians decide why a supporting task is required in a particular context.

A Case Review: Integrating Lewin's Theory with Lean's System Approach for Change

The complexity of healthcare calls for interprofessional collaboration to improve and sustain the best outcomes for safe and high quality patient care. Historically, rehabilitation nursing has been an area that relies heavily on interprofessional relationships. Professionals from various disciplines often subscribe to different change management theories for continuous quality improvement. Through a case review, authors describe how a large, Midwestern, rehabilitation hospital used the crosswalk methodology to facilitate interprofessional collaboration and develop an intervention model for implementing and sustaining bedside shift reporting. The authors provide project background and offer a brief overview of the two common frameworks used in this project, Lewin's Three-Step Model for Change and the Lean Systems Approach. The description of the bedside shift report project methods demonstrates that multiple disciplines are able to utilize a common framework for leading and sustaining change to support outcomes of high quality and safe care, and capitalize on the opportunities of multiple views and discipline-specific approaches. The conclusion discusses outcomes, future initiatives, and implications for nursing practice.

A retrospective study of 29 fatal cases of insulin overdose.

PURPOSE: To summarize recent cases of fatal insulin poisoning both domestically and internationally, thereby offering valuable insights for the forensic identification of insulin overdose cases. METHODS: Literature published since 2000 on fatal insulin overdose were systematically searched and screened. Data encompassing variables such as year, age, sex, cause of death, scene conditions, occupations, medical histories of victims and perpetrators, autopsy timing, dosage and administration methods, forensic pathology, and toxicological analysis, were compiled for rigorous statistical analysis. RESULTS: Among the 29 fatal cases of insulin poisoning, suicides and homicides accounted for 55.2 % and 41.4 %, respectively. Precisely 34.5 % of victims or perpetrators were associated with the medical industry, 27.6 % had diabetes, and 24.1 % had mental illnesses such as depression. Intravenous injection resulted in quicker death than did subcutaneous injection. In some cases, immunohistochemical staining of insulin and protamine at injection sites yielded positive results. The average molar ratio of insulin to C-peptide in post-mortem blood was 13.76 ± 5.167, indicating a significant diagnostic value for insulin poisoning. CONCLUSION: Assessment of cases of fatal insulin overdose should be thorough, incorporating case investigation, scene examination, medical records review, autopsy findings, pathological examinations, and laboratory tests, alongside considering the condition of the body and timing of death autopsy. Using mass spectrometry to detect insulin proves valuable, particularly in cases of poor body preservation.

Death of the suicide law: A changing standard of liability for clinicians.

High rates of suicide continue to plague the modern world, with clinicians, researchers, and policymakers working urgently to ameliorate what has been recognized as a worldwide public health crisis. Under American Law, individuals- including health care providers, could generally not be held liable for causing the suicide of another person. This article presents a review of suicide law in the United States in the context of a recent civil case in which a physician with expertise in mental health was sued for the death of an ex-partner who committed suicide in his home. Historical events and landmark legal cases spanning the 15th century to now are examined and presented as a narrative review to inform society and mental health clinicians a-like towards interpreting the changing medical-legal landscape. As modern advances in science continue to discern the critical biopsychosocial factors that contribute to the act of suicide, there is an inevitably growing concern that suicide may no longer be an incomprehensible nor irrational event as has been assumed for centuries. Thus, it may be considered that individual with expertise and qualification to treat a group of individuals at higher risk of suicide (severe mental illness) may be subject to a different standard than the average individual. This article seeks to present a complex matter where no simple or broad-sweeping conclusions can yet be drawn, however remains a critically important matter for mental health clinicians.

AARS and CACNA1A mutations: diagnostic insights into a case report of uncommon epileptic encephalopathy phenotypes in two siblings.

Epilepsy, characterized by recurrent seizures, impacts 70-80% of patients, leading to cognitive deficits. The intricate relationship between seizure control and cognitive impairment remains complex. Epileptic encephalopathy (EE), an intensified form often rooted in genetic factors, is detectable through next-generation sequencing, aiding in precise diagnoses, family counseling, and potential treatment strategies. We present a case involving two sisters with refractory generalized seizures evolving into dysarthria, dysphagia, ataxia, and cognitive decline. Despite normal physical exams, abnormal electroencephalogram results consistent with epilepsy were noted. Whole Exome Sequencing identified heterozygous variants in the alanyl-tRNA synthetase (AARS) and Calcium Voltage-Gated Channel Subunit Alpha 1 (CACNA1A) genes. The AARS variant (c.C2083T, p.R695*) was maternal, while the CACNA1A variant (c.G7400C, p.R2467P) was paternal. Patients A and B exhibited a unique blend of neurological and psychiatric conditions, distinct from common disorders that begin adolescence, like Juvenile Myoclonic Epilepsy. Whole Exome Sequencing uncovered an AARS gene and CACNA1A gene, linked to various autosomal dominant phenotypes. Presence in both parents, coupled with familial reports of migraines and seizures, provides insight into accelerated symptom progression. This study underscores the importance of genetic testing in decoding complex phenotypes and emphasizes the value of documenting family history for anticipating related symptoms and future health risks.

A Multi-dimensional Data Mining-based Study on the Prescriptions Developed by Professor Xu Zhiyin in Treating Thyroid Nodules.

OBJECTIVES: In this study, we employed a multi-dimensional data mining approach to examine the clinical instances where Professor Xu Zhiyin treated thyroid nodules. Our aim is to understand the patterns of symptoms, underlying causes, and treatment approaches used for thyroid nodules. By doing so, the intention is to distill the essential aspects, compile Professor Xu Zhiyin's clinical insights, and investigate his scholarly perspectives. METHODS: Professor Xu Zhiyin's clinical diagnoses and treatments spanning from 2009 to 2019 were entered into Microsoft Excel. Subsequently, the collected data was imported into the Medcase V5.2 system to facilitate data mining. Various techniques, such as frequency-based method, association rule analysis, and clustering, including a decentralized system clustering approach, were employed on a set of 346 cases involving patients with thyroid nodules that conformed to the specified criteria. The primary focus was on extracting insights regarding symptoms and the underlying causes from the medical records. By integrating these findings with Professor Xu Zhiyin's clinical expertise, we examined and summarized the outcomes of the data mining process. RESULTS: The fundamental prescriptions were successfully extracted using the techniques for mining across multiple dimensions. Utilizing the scattered grouping of these prescriptions and with reference to the cluster analysis of the frequency-linked system, the fundamental prescriptions proposed by Professor Xu Zhiyin for addressing thyroid nodules encompass the following ingredients: Glycyrrhiza uralensis Fisch, Cortex Moutan, Paeoniae radix rubra, Curcuma longa L., Radix Curcumae, persica seed, Citri Reticulatae Viride Pericarpium, Pinellia ternata, Spica Prunellae, Ostreae concha, Gleditsia sinensis spine, Tuckahoe and Radix Codonopsis. CONCLUSION: The fundamental prescriptions were acquired using the frequency approach, association rule technique, k-means clustering approach, and systematic clustering approach. The research findings corroborate one another, demonstrating that Professor Xu Zhiyin's approach to distinguishing and treating thyroid nodules is embodied in distinct prescriptions tailored to specific diseases.

Examining Passively Collected Smartphone-Based Data in the Days Prior to Psychiatric Hospitalization for a Suicidal Crisis: Comparative Case Analysis.

BACKGROUND: Digital phenotyping has seen a broad increase in application across clinical research; however, little research has implemented passive assessment approaches for suicide risk detection. There is a significant potential for a novel form of digital phenotyping, termed screenomics, which captures smartphone activity via screenshots. OBJECTIVE: This paper focuses on a comprehensive case review of 2 participants who reported past 1-month active suicidal ideation, detailing their passive (ie, obtained via screenomics screenshot capture) and active (ie, obtained via ecological momentary assessment [EMA]) risk profiles that culminated in suicidal crises and subsequent psychiatric hospitalizations. Through this analysis, we shed light on the timescale of risk processes as they unfold before hospitalization, as well as introduce the novel application of screenomics within the field of suicide research. METHODS: To underscore the potential benefits of screenomics in comprehending suicide risk, the analysis concentrates on a specific type of data gleaned from screenshots-text-captured prior to hospitalization, alongside self-reported EMA responses. Following a comprehensive baseline assessment, participants completed an intensive time sampling period. During this period, screenshots were collected every 5 seconds while one's phone was in use for 35 days, and EMA data were collected 6 times a day for 28 days. In our analysis, we focus on the following: suicide-related content (obtained via screenshots and EMA), risk factors theoretically and empirically relevant to suicide risk (obtained via screenshots and EMA), and social content (obtained via screenshots). RESULTS: Our analysis revealed several key findings. First, there was a notable decrease in EMA compliance during suicidal crises, with both participants completing fewer EMAs in the days prior to hospitalization. This contrasted with an overall increase in phone usage leading up to hospitalization, which was particularly marked by heightened social use. Screenomics also captured prominent precipitating factors in each instance of suicidal crisis that were not well detected via self-report, specifically physical pain and loneliness. CONCLUSIONS: Our preliminary findings underscore the potential of passively collected data in understanding and predicting suicidal crises. The vast number of screenshots from each participant offers a granular look into their daily digital interactions, shedding light on novel risks not captured via self-report alone. When combined with EMA assessments, screenomics provides a more comprehensive view of an individual's psychological processes in the time leading up to a suicidal crisis.

Plan quality association between dummy run and individual case review in a prospective multi-institutional clinical trial of postoperative cervical cancer patients treated with intensity-modulated radiotherapy: Japan clinical Oncology Group study (JCOG1402).

BACKGROUND AND PURPOSE: The Japan Clinical Oncology Group (JCOG) 1402 conducted a multicenter clinical trial of postoperative intensity-modulated radiotherapy (IMRT) for high-risk uterine cervical cancer patients. We assess effectiveness of the quality assurance (QA) program in central review through dummy runs (DRs) performed before patient enrollment and post-treatment individual case review (ICR), and clarify the pitfalls in treatment planning. MATERIAL AND METHODS: The ICRs were conducted using the same QA program as the DR for 214 plans. The deviations were compared with those demonstrated in the DRs, and the pitfalls were clarified. Fifteen face-to-face meetings were held with physicians at participating institutions to provide feedback. RESULTS: Two-hundred and eighty-eight deviations and nine violations were detected in the 214 plans. The patterns of the deviations observed in the ICRs were similar to that in the DR. Frequent deviations were observed in clinical target volume (CTV) delineations, 50% in the DRs and 37% in the ICRs, respectively. In the ICRs, approximately 1.4 deviations/violations were observed per plan, which was lower than DR. Nine violations included inaccurate CTV delineation and improper PTV (planning target volume) margin, which had risks in loco-regional failures by inadequate dose coverage. CONCLUSIONS: Our developed QA program commonly used in DR and ICR clarified the pitfalls in treatment plans. Although the frequent deviations in CTV delineations were observed in the ICR, the deviations decreased compared to that in the DR. More specified face-to-face meetings with participating institutions will be necessary to maintain the quality of IMRT in the clinical protocol.

Implementation of morbidity and mortality conference in a community hospital NICU and narrative review.

Background: The process of morbidity and mortality review (MMR) is recognized as an essential component of quality improvement, patient safety, attitudes towards patient safety, and continuing education. Despite the common use of MMR for all disciplines of medical care, recommendations have not been published regarding the implementation of MMR in a community hospital setting in the United States. Objectives: Review the literature on MMR conferences. Describe the implementation of an MMR conference in a community hospital neonatal intensive care unit (NICU). Conclusions: The establishment of a case overview method of MMR is feasible for a community hospital NICU. It increases staff and physician group awareness and education over common and complex mortality and morbidity etiologies, improves staff participation with unit management, links case presentation with open discussion and action items, and identifies opportunities for systemic changes to improve patient care.

Clinical Spectrum and CSF Findings in Patients with West-Nile Virus Infection, a Retrospective Cohort Review.

West Nile Virus (WNV) infection is a world-wide zoonotic disease transmitted by mosquitoes. The infection is usually self-limiting; however, elderly patients or those with comorbidities are predisposed to developing severe, and sometimes fatal complications of the infection. Recently, the incidence of WNV infection in Europe had seen a sharp increase, as compared to previous years. We are currently reporting on the clinical presentation and laboratory findings in 23 cases of WNV infection, of which one resulted in a fatal outcome. The clinical picture was predominantly that of meningitis/meningoencephalitis of varying severity. One patient suffered a fatal outcome, and a rare manifestation of chorioretinal lesions and iridocyclitis was also reported as a result of WNV infection. Cerebrospinal fluid analysis predominantly showed lymphocytic pleocytosis, and total protein levels were increased in all but three of the patients. Levels of total protein in CSF samples were found to show a positive correlation with age. Given the ever-increasing incidence of WNV infection in Europe, a high index of clinical suspicion should always accompany cases of meningitis, especially during the summer period, as a similar epidemic pattern is predicted to recur.

Learning from Missed Opportunities Through Reflective Practice.

Identification of diagnostic errors is difficult but is not alone sufficient for performance improvement. Instead, cases must be reflected on to identify ways to improve decision-making in the future. There are many tools and modalities to retrospectively reflect on action to study medical decisions and outcomes and improve future performance. Reflection in action-in which diagnostic decisions are considered in real-time-may also improve medical decision-making especially through strategies such as structured reflection. Ongoing regular feedback can normalize the discussion about improving decision-making, enable reflective practice, and improve decision making.

Single-Port Robotic Radical Prostatectomy: Short-Term Outcomes and Learning Curve.

Introduction and Objective: In 2018, the U.S. Food and Drug Administration approved the da Vinci single-port (SP) system, in which four instruments are still utilized, but enter through a single-site access trocar. Herein, we report the largest case series for SP robot-assisted radical prostatectomy (RARP) to date. Our primary aim is to analyze the perioperative and short-term outcomes of this procedure. Our secondary aim is an assessment of the learning curve with this new platform. Methods: A total of 157 patients underwent SP RARP by two surgeons who have completed >3000 multiport robotic surgeries collectively. Institutional Review Board-approved prospectively collected data were used. Basic demographic preoperative variables and perioperative outcomes were analyzed. Results: Median patient age and prostate-specific antigen was 63 years and 6.3 ng/mL before treatment (interquartile range [IQR] 4.7-8.2 ng/mL). Average prostate weight was 47 g. The median operating time was 195 minutes (IQR 165-221.25 minutes) with a median estimated blood loss of 100 mL (IQR 100-200 mL). Surgeon 1's operating time stabilized around case #56, and Surgeon 2 around case #26. Surgeon 2 used the transperitoneal approach for the first 7 cases. There were no intraoperative complications. There were six total postoperative complications (3.8%) and four (2.5%) were Clavien-Dindo scale ≥IIIa. One hundred ten patients went home same day, 45 stayed 1 night at the hospital, with only 2 patients requiring stay in the hospital for more than 1 night (70%, 29%, and 1% respectively). With the median follow-up period of 9 months, rates of biochemical recurrence, pad-free, and potency preservation were 8.3%, 82.5%, and 64.4%, respectively. Conclusions: This case series confirms the safety and efficacy of SP RARP with acceptable short-term outcomes. There is a significant learning curve for this new modality. Shorter hospital stay appears to be an early benefit of the SP platform.

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

OBJECTIVES: To test a structured electronic health record (EHR) case review process to identify diagnostic errors (DE) and diagnostic process failures (DPFs) in acute care. METHODS: We adapted validated tools (Safer Dx, Diagnostic Error Evaluation Research [DEER] Taxonomy) to assess the diagnostic process during the hospital encounter and categorized 13 postulated e-triggers. We created two test cohorts of all preventable cases (n=28) and an equal number of randomly sampled non-preventable cases (n=28) from 365 adult general medicine patients who expired and underwent our institution's mortality case review process. After excluding patients with a length of stay of more than one month, each case was reviewed by two blinded clinicians trained in our process and by an expert panel. Inter-rater reliability was assessed. We compared the frequency of DE contributing to death in both cohorts, as well as mean DPFs and e-triggers for DE positive and negative cases within each cohort. RESULTS: Twenty-seven (96.4%) preventable and 24 (85.7%) non-preventable cases underwent our review process. Inter-rater reliability was moderate between individual reviewers (Cohen's kappa 0.41) and substantial with the expert panel (Cohen's kappa 0.74). The frequency of DE contributing to death was significantly higher for the preventable compared to the non-preventable cohort (56% vs. 17%, OR 6.25 [1.68, 23.27], p<0.01). Mean DPFs and e-triggers were significantly and non-significantly higher for DE positive compared to DE negative cases in each cohort, respectively. CONCLUSIONS: We observed substantial agreement among final consensus and expert panel reviews using our structured EHR case review process. DEs contributing to death associated with DPFs were identified in institutionally designated preventable and non-preventable cases. While e-triggers may be useful for discriminating DE positive from DE negative cases, larger studies are required for validation. Our approach has potential to augment institutional mortality case review processes with respect to DE surveillance.