LEARNING FROM NEAR MISSES IN MEDICATION ERRORS: A BAYESIAN APPROACH

Medical errors originating in health care facilities are a significant source of preventable morbidity, mortality, and healthcare costs. Voluntary error report systems that collect information on the causes and contributing factors of medi- cal errors regardless of the resulting harm may be useful for developing effective harm prevention strategies. Some patient safety experts question the utility of data from errors that did not lead to harm to the patient, also called near misses. A near miss (a.k.a. close call) is an unplanned event that did not result in injury to the patient. Only a fortunate break in the chain of events prevented injury. We use data from a large voluntary reporting system of 836,174 medication errors from 1999 to 2005 to provide evidence that the causes and contributing factors of errors that result in harm are similar to the causes and contributing factors of near misses. We develop Bayesian hierarchical models for estimating the log odds of selecting a given cause (or contributing factor) of error given harm has occurred and the log odds of selecting the same cause given that harm did not occur. The posterior distribution of the correlation between these two vectors of log-odds is used as a measure of the evidence supporting the use of data from near misses and their causes and contributing factors to prevent medical errors. In addition, we identify the causes and contributing factors that have the highest or lowest log-odds ratio of harm versus no harm. These causes and contributing factors should also be a focus in the design of prevention strategies. This paper provides important evidence on the utility of data from near misses, which constitute the vast majority of errors in our data.

Pleomorphic adenoma in an atypical location near the temporomandibular joint: a case report

Pleomorphic adenomas primarily arise in the major salivary glands, especially in the parotid. The most common area is the lower pole superficial to the plane of the facial nerve. In this report, a pleomorphic adenoma in an atypical location--the region of the temporomandibular joint (TMJ)--is presented. The tumor was solitary, closely attached to the capsule of the TMJ and superior to the parotid gland, with clear demarcation. Clinically, the tumor resembled TMJ pathology, but MRI examination led to diagnosis of a benign tumor attached to the TMJ. This report shows that pleomorphic adenoma can be a possible diagnosis for lesions at the joint capsule.

Impact of copper mine tailings (stamp sand) on survival and development of aquatic organisms near Gay, Michigan

Heavy metal-rich copper mine tailings, called stamp sands, were dumped by mining companies directly into streams and along the Lake Superior shoreline, degrading Keweenaw Peninsula waterways. One of the largest disposal sites is near Gay, Michigan, where tailings have been moved along the shoreline by currents since mining ceased. As a result, the smallest sand particles have been washed into deeper water and are filling the interstitial spaces of Buffalo Reef, a critical lake trout spawning site. This research is the first to investigate if stamp sand is detrimental to survival and early development of eggs and larvae of lake sturgeon, lake trout, and Northern leopard frogs, and also examines if the presence of stamp sands influences substrate selection of earthworms. This study found that stamp sand had significantly larger mean particle sizes and irregular shapes compared to natural sand, and earthworms show a strong preference for natural substrate over any combination that included stamp sand. Additionally, copper analysis (Cu2+) of surface water over stamp sand and natural sand showed concentrations were significantly higher in stamp sand surface water (100 μg/L) compared to natural sand surface water (10 μg/L). Frog embryos had similar hatch success over both types of sand, but tadpoles reared over natural sand grew faster and had higher survival rates. Eggs of lake sturgeon showed similar hatch success and development over natural vs. stamp sand over 17 days, while lake trout eggs hatched earlier and developed faster when incubated over stamp sand, yet showed similar development over a 163 day period. Copper from stamp sand appears to impact amphibians more than fish species in this study. These results will help determine what impact stamp sand has on organisms found throughout the Keweenaw Peninsula which encounter the material at some point in their life history.

Assessment of flow in perforating arteries during intracranial aneurysm surgery using intraoperative near-infrared indocyanine green videoangiography

OBJECTIVE: Perforating arteries are commonly involved during the surgical dissection and clipping of intracranial aneurysms. Occlusion of perforating arteries is responsible for ischemic infarction and poor outcome. The goal of this study is to describe the usefulness of near-infrared indocyanine green videoangiography (ICGA) for the intraoperative assessment of blood flow in perforating arteries that are visible in the surgical field during clipping of intracranial aneurysms. In addition, we analyzed the incidence of perforating vessels involved during the aneurysm surgery and the incidence of ischemic infarct caused by compromised small arteries. METHODS: Sixty patients with 64 aneurysms were surgically treated and prospectively included in this study. Intraoperative ICGA was performed using a surgical microscope (Carl Zeiss Co., Oberkochen, Germany) with integrated ICGA technology. The presence and involvement of perforating arteries were analyzed in the microsurgical field during surgical dissection and clip application. Assessment of vascular patency after clipping was also investigated. Only those small arteries that were not visible on preoperative digital subtraction angiography were considered for analysis. RESULTS: The ICGA was able to visualize flow in all patients in whom perforating vessels were found in the microscope field. Among 36 patients whose perforating vessels were visible on ICGA, 11 (30%) presented a close relation between the aneurysm and perforating arteries. In one (9%) of these 11 patients, ICGA showed occlusion of a P1 perforating artery after clip application, which led to immediate correction of the clip confirmed by immediate reestablishment of flow visible with ICGA without clinical consequences. Four patients (6.7%) presented with postoperative perforating artery infarct, three of whom had perforating arteries that were not visible or distant from the aneurysm. CONCLUSION: The involvement of perforating arteries during clip application for aneurysm occlusion is a usual finding. Intraoperative ICGA may provide visual information with regard to the patency of these small vessels.

Residence near power lines and mortality from neurodegenerative diseases: longitudinal study of the Swiss population

The relation between residential magnetic field exposure from power lines and mortality from neurodegenerative conditions was analyzed among 4.7 million persons of the Swiss National Cohort (linking mortality and census data), covering the period 2000-2005. Cox proportional hazard models were used to analyze the relation of living in the proximity of 220-380 kV power lines and the risk of death from neurodegenerative diseases, with adjustment for a range of potential confounders. Overall, the adjusted hazard ratio for Alzheimer's disease in persons living within 50 m of a 220-380 kV power line was 1.24 (95% confidence interval (CI): 0.80, 1.92) compared with persons who lived at a distance of 600 m or more. There was a dose-response relation with respect to years of residence in the immediate vicinity of power lines and Alzheimer's disease: Persons living at least 5 years within 50 m had an adjusted hazard ratio of 1.51 (95% CI: 0.91, 2.51), increasing to 1.78 (95% CI: 1.07, 2.96) with at least 10 years and to 2.00 (95% CI: 1.21, 3.33) with at least 15 years. The pattern was similar for senile dementia. There was little evidence for an increased risk of amyotrophic lateral sclerosis, Parkinson's disease, or multiple sclerosis.

Physical modeling of air injection as a scour remediation technique near gated weir stilling basins

The South Florida Water Management District (SFWMD) manages and operates numerous water control structures that are subject to scour. In an effort to reduce scour downstream of these gated structures, laboratory experiments were performed to investigate the effect of active air-injection downstream of the terminal structure of a gated spillway on the depth of the scour hole. A literature review involving similar research revealed significant variables such as the ratio of headwater-to-tailwater depths, the diffuser angle, sediment uniformity, and the ratio of air-to-water volumetric discharge values. The experimental design was based on the analysis of several of these non-dimensional parameters. Bed scouring at stilling basins downstream of gated spillways has been identified as posing a serious risk to the spillway’s structural stability. Although this type of scour has been studied in the past, it continues to represent a real threat to water control structures and requires additional attention. A hydraulic scour channel comprised of a head tank, flow straightening section, gated spillway, stilling basin, scour section, sediment trap, and tail-tank was used to further this analysis. Experiments were performed in a laboratory channel consisting of a 1:30 scale model of the SFWMD S65E spillway structure. To ascertain the feasibility of air injection for scour reduction a proof-of-concept study was performed. Experiments were conducted without air entrainment and with high, medium, and low air entrainment rates for high and low headwater conditions. For the cases with no air entrainment it was found that there was excessive scour downstream of the structure due to a downward roller formed upon exiting the downstream sill of the stilling basin. When air was introduced vertically just downstream of, and at the same level as, the stilling basin sill, it was found that air entrainment does reduce scour depth by up to 58% depending on the air flow rate, but shifts the deepest scour location to the sides of the channel bed instead of the center. Various hydraulic flow conditions were tested without air injection to verify which scenario caused more scour. That scenario, uncontrolled free, in which water does not contact the gate and the water elevation in the stilling basin is lower than the spillway crest, would be used for the remainder of experiments testing air injection. Various air flow rates, diffuser elevations, air hole diameters, air hole spacings, diffuser angles and widths were tested in over 120 experiments. Optimal parameters include air injection at a rate that results in a water-to-air ratio of 0.28, air holes 1.016mm in diameter the entire width of the stilling basin, and a vertically orientated injection pattern. Detailed flow measurements were collected for one case using air injection and one without. An identical flow scenario was used for each experiment, namely that of a high flow rate and upstream headwater depth and a low tailwater depth. Equilibrium bed scour and velocity measurements were taken using an Acoustic Doppler Velocimeter at nearly 3000 points. Velocity data was used to construct a vector plot in order to identify which flow components contribute to the scour hole. Additionally, turbulence parameters were calculated in an effort to help understand why air-injection reduced bed scour. Turbulence intensities, normalized mean flow, normalized kinetic energy, and anisotropy of turbulence plots were constructed. A clear trend emerged that showed air-injection reduces turbulence near the bed and therefore reduces scour potential.