Second, do less harm: The state of states' medical error reporting programs

Statement of the problem and public health significance. Hospitals were designed to be a safe haven and respite from disease and illness. However, a large body of evidence points to preventable errors in hospitals as the eighth leading cause of death among Americans. Twelve percent of Americans, or over 33.8 million people, are hospitalized each year. This population represents a significant portion of at risk citizens exposed to hospital medical errors. Since the number of annual deaths due to hospital medical errors is estimated to exceed 44,000, the magnitude of this tragedy makes it a significant public health problem. ^ Specific aims. The specific aims of this study were threefold. First, this study aimed to analyze the state of the states' mandatory hospital medical error reporting six years after the release of the influential IOM report, "To Err is Human." The second aim was to identify barriers to reporting of medical errors by hospital personnel. The third aim was to identify hospital safety measures implemented to reduce medical errors and enhance patient safety. ^ Methods. A descriptive, longitudinal, retrospective design was used to address the first stated objective. The study data came from the twenty-one states with mandatory hospital reporting programs which report aggregate hospital error data that is accessible to the public by way of states' websites. The data analysis included calculations of expected number of medical errors for each state according to IOM rates. Where possible, a comparison was made between state reported data and the calculated IOM expected number of errors. A literature review was performed to achieve the second study aim, identifying barriers to reporting medical errors. The final aim was accomplished by telephone interviews of principal patient safety/quality officers from five Texas hospitals with more than 700 beds. ^ Results. The state medical error data suggests vast underreporting of hospital medical errors to the states. The telephone interviews suggest that hospitals are working at reducing medical errors and creating safer environments for patients. The literature review suggests the underreporting of medical errors at the state level stems from underreporting of errors at the delivery level. ^

Porosity and density of the AND-1B sediment core

A study of density and porosity is presented for the 1285-m-long AND-1B core recovered from a flexural moat in the McMurdo Sound (Antarctica) in order to interpret sediment consolidation in an ice-proximal location on the Antarctic shelf. Various lithologies imply environmental changes from open marine to subglacial, and are numerically expressed in high-resolution whole-core wet-bulk density (WBD). Grain density data interpolated from discrete samples range from 2.14 to 3.85 g/cm3 and are used to calculate porosity from WBD in order to avoid the 5%-15% overestimation and underestimation of porosities obtained by standard methods. The trend of porosity extends from 0.5 near the top (Pleistocene) to 0.2 at the bottom (Miocene). Porosity fluctuations in different lithologies are superimposed with 0.2-0.3 in sequences younger than ca. 1 Ma and 0.5-0.8 in Pliocene diatomites. The AND-1B porosities and void ratios of Pliocene diatomites and Pleistocene mudstones exhibit a large negative offset compared to modern lithological analogs and their consolidation trends. This offset cannot be explained in terms of the effective stress at the AND-1B site. The effective stress ranges from 0 to 4000 kPa in the upper 600 m, and reaches 13,000 kPa at the base of the AND-1B hole. We suggest an excess of effective overburden stress of ~1700 and ~6000 kPa to explain porosities in Pliocene diatomites and Pleistocene mudstones, respectively. This is interpreted as glacial preconsolidation by subsequently grounded ice sheets under subpolar to polar, followed by colder polar types of glaciations. Information on Miocene consolidation is sparse due to alteration by diagenesis.