Older adults take almost one-third of the drugs prescribed today yet represent only about 12 percent of the population. Adverse drug events are common in this population, but often these events appear to be preventable. Interest in adverse events related to the use of prescription drugs has rarely been higher or broader. The research community continues to develop new tools to study adverse effects of drugs in individuals and populations. However, the published literature on drug-related adverse events is fraught with problems, starting with the original reports and extending to systematic reviews. Prospective data are missing, adverse drug events are poorly described, and analytical methods are questionable. This leads to problems with imprecise estimates and generalizability of results.
Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital.
At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified.
During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54-81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%-28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%-16%).
Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.
Cites: JAMA. 1991 Apr 17;265(15):1977-812008027
Cites: JAMA. 1991 Apr 17;265(15):1957-602008024
Cites: Med J Aust. 1995 Nov 6;163(9):458-717476634
Antibiotic use at a pediatric teaching hospital was reviewed for a month. A total of 188 courses of therapy were evaluated with respect to choice of antibiotic, dosage and necessity of treatment. Errors in therapy were noted in 30% of the medical orders and 63% of the surgical orders. The most frequent error, unnecessary therapy, was found in 13% and 45% of the medical and surgical orders respectively. Error rates were highest for the most frequently ordered antibiotics, notably the penicillins. The magnitude of the problem appeared to be similar to that previously reported from general ana adult hospitals. The difficulties with solutions such as educational programs and compulsory consultation are discussed.
Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals.
We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability.
At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7- 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%-41.8%) and death in 20.8% (95% CI 7.8%-33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016).
The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
The topic of patient safety within the health care system is receiving increasing attention. The Academy of Canadian Executive Nurses conducted a national survey on nurses' perceptions of patient safety, using focus groups from Academic Health Science Centres. Over a three month time frame, 22 organizations, and 33 focus groups comprised of 503 nurses provided responses to six questions regarding patient safety in hospitals. The study was designed as a preliminary fact finding initiative resulting in this descriptive report of the concerns as identified within the focus groups. With each issue identification, they were coded and grouped into 23 themes. Nurses overwhelmingly responded that the health care environment, in which they provide care, presents escalating risk to their patients. In particular, Workload/Pace of Work, Human Resources, Nursing Shortage/Staffing, Restructuring/Bed Closures, Patients/Clients, Systems Issues, Physical Environment and Technology/Specialization were themes emphasized as contributing to increased risk in patient care. Health care leaders must play a key role in developing strategies to address the issues nurses have identified and demonstrate a commitment to controlling the situation. This study encourages research into a more explicit understanding of the issues and identification of strategies to address patient safety in health care.
Erratum In: Can J Nurs Leadersh. 2002 Nov-Dec;15(4):5.
To evaluate the adequacy of Canadian ophthalmology residency programs in achieving the competencies outlined by the International Council of Ophthalmology (ICO) and to assess residents' satisfaction with their training programs.
Canadian residents enrolled in the final 2 years of English and French ophthalmology programs, as well as recent graduates from 2005 to 2008.
Graduates and eligible residents were invited to participate in the 43-item survey during the autumn of 2008. Data were categorized by demographic variables, and basic statistics were done.
Of the 99 individuals surveyed, 40 (40%) responded, representing 26 current residents and 14 graduates. The vast majority (85%) of respondents were satisfied with their residency program. Clinic-based training was generally rated satisfactorily; however, respondents reported insufficient exposure to low-vision rehabilitation (77.5%), refraction and glasses prescription (65%), and neuro-ophthalmology (45%). Respondents were similarly satisfied with their surgical experiences, most of them (>60%) rating case volume, complexity, and variety as satisfactory or better. However, many stated that they had insufficient exposure to extracapsular cataract extraction (72.5%), refractive surgery (72.5%), and orbital surgery (57.5%). Of the graduates surveyed, all passed their Royal College licensing examinations on the first attempt and felt that residency adequately prepared them for the examinations. They reported insufficient training in certain nonclinical areas, such as practice management, and staffing and administration skills.
Canadian ophthalmology residents express high levels of satisfaction with their residency training programs. Although most programs appear to adequately address most ICO core objectives, certain curriculum modifications are required.
Few studies have reported the amount of physical activity (PA) and its associations to physical performance of warfighters during military field training (MFT). The purpose of this study was to investigate changes in neuromuscular performance and PA among male Finnish Army conscripts during a 21-d MFT and to evaluate their recovery during 4 d after MFT.
Body composition and physical performance were measured four times during the study (before MFT (PRE), after 12 d (MID), post training (POST) and after 4 d of recovery (RECO)). PA was measured throughout MFT in a group of healthy young male conscripts (n=49) by using a tri-axial accelerometer. The study was approved by the Finnish Defence Forces and was granted ethics approval by the Ethics Committee of the University of Jyväskylä.
Body mass declined significantly from 73.5 ± 8.7 to 71.6 ± 8.2 kg, but it recovered close to the PRE values (73.0 ± 8.3 kg). The same trend was also found in skeletal muscle mass and fat mass. The change in body mass and in skeletal muscle mass correlated negatively with the change in vigorous physical activity (r = -0.374, p = 0.016, and r = -0.337, p = 0.031, respectively). Muscular endurance decreased significantly (p
This study identified and compared characteristics of 'best' and 'worst' clinical teachers as perceived by university nursing faculty and students. The Nursing Clinical Teacher Effectiveness Inventory (NCTEI) was distributed to 201 volunteer subjects. This survey instrument, developed by the authors, contains 48 clinical teacher characteristics grouped into five categories. Each participant was asked to rate, using the NCTEI, the 'best' and them the 'worst' clinical teacher from past observations. Results showed both groups perceived that being a good role model was the highest rated characteristic for 'best' teachers and the 'lowest' rated characteristic for 'worst' teachers. Faculty and students' perceptions were fairly similar as to highest rated characteristics of 'best' clinical teachers. Less agreement was noted about the characteristics of 'worst' clinical teachers. When categories of clinical teacher characteristics were compared, there were significant differences between the ratings of faculty and students for 'best' clinical teachers, but none for 'worst' clinical teachers.
Checklists have been used extensively as a cognitive aid in aviation; now, they are being introduced in many areas of medicine. Although few would dispute the positive effects of checklists, little is known about the process of introducing this tool into the health care environment. In 2008, a pre-induction checklist was implemented in our anaesthetic department; in this study, we explored the nurses' and physicians' acceptance and experiences with this checklist.
Focus group interviews were conducted with a purposeful sample of checklist users (nurses and physicians) from the Department of Anaesthesia and Intensive Care in a tertiary teaching hospital. The interviews were analysed qualitatively using systematic text condensation.
Users reported that checklist use could divert attention away from the patient and that it influenced workflow and doctor-nurse cooperation. They described senior consultants as both sceptical and supportive; a head physician with a positive attitude was considered crucial for successful implementation. The checklist improved confidence in unfamiliar contexts and was used in some situations for which it was not intended. It also revealed insufficient equipment standardisation.
Our findings suggest several issues and actions that may be important to consider during checklist use and implementation.