In this retrospective study of 10 hospitals, harms to patients resulting from medical care were common (25 per 100 admissions) and did not decline significantly between 2002 and 2007.
In December ...1999, the Institute of Medicine (IOM) reported that medical errors cause up to 98,000 deaths and more than 1 million injuries each year in the United States.
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In response, accreditation bodies, payers, nonprofit organizations, governments, and hospitals launched major initiatives and invested considerable resources to improve patient safety.
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Some interventions have been shown to reduce errors, such as implementing computerized provider order-entry systems,
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limiting residents' work shifts to 16 consecutive hours,
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and implementing evidence-based care bundles.
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However, many of these interventions have not been evaluated rigorously
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or implemented reliably on a large scale.
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Abstract
Objective
Motivated by the coronavirus disease 2019 (covid-19) pandemic, we developed a novel Shewhart chart to visualize and learn from variation in reported deaths in an epidemic.
Context
...Without a method to understand if a day-to-day variation in outcomes may be attributed to meaningful signals of change—rather than variability we would expect—care providers, improvement leaders, policy-makers, and the public will struggle to recognize if epidemic conditions are improving.
Methods
We developed a novel hybrid C-chart and I-chart to detect within a geographic area the start and end of exponential growth in reported deaths. Reported deaths were the unit of analysis owing to erratic reporting of cases from variability in local testing strategies. We used simulation and case studies to assess chart performance and define technical parameters. This approach also applies to other critical measures related to a pandemic when high-quality data are available.
Conclusions
The hybrid chart detected the start of exponential growth and identified early signals that the growth phase was ending. During a pandemic, timely reliable signals that an epidemic is waxing or waning may have mortal implications. This novel chart offers a practical tool, accessible to system leaders and frontline teams, to visualize and learn from daily reported deaths during an epidemic. Without Shewhart charts and, more broadly, a theory of variation in our epidemiological arsenal, we lack a scientific method for a real-time assessment of local conditions. Shewhart charts should become a standard method for learning from data in the context of a pandemic or epidemic.
The purpose of this article is to determine if conversion from eating wild game harvested with lead-based ammunition to nonlead-based ammunition results in lower blood lead levels. Supersonic ...injection of toxin-leeching frangible projectiles into food is intuitively bad. As much as 95% of the ~13.7 million hunters in the United States choose shrapnel-inducing lead bullets to kill game; in addition, not harvesting meat is an incarcerable crime. A lead ammunition ban on certain federal lands was recently rescinded and the National Rifle Association refutes any risk from eating lead bullet-harvested game.
A patient subsisting solely on lead-shot meat was converted to non-lead ammunition and his blood lead level tracked. Concomitant with his conversion to nonlead ammunition, a controlled experiment was performed using the patient's bullets to determine his daily lead intake from lead-shot meat.
While eating lead-shot meat, the patient was consuming 259.3 ± 235.6 µg of lead daily and his blood lead level was 74.7 µg/dL. Conversion to nonlead ammunition was associated with a reduced blood lead level.
Unsafe blood lead levels can occur from eating game harvested with lead ammunition. Physicians should warn hunting patients of this potential risk and counsel them about the availability of nonlead ammunition alternatives.
Patients treated with perioperative Invisalign for orthognathic surgery may experience less postoperative swelling than those with fixed appliances because of a lack of mucosal irritation from bonded ...brackets and wires. The aims of this study were to (1) compare facial swelling after orthognathic surgery in subjects with Invisalign to those with fixed appliances using 3-dimensional (3D) subtraction imaging and (2) determine if the type of operation influences differences in swelling.
This is a retrospective case-control study. To be included in the case group (Invisalign), patients had to have had: (1) LeFort I and/or bilateral sagittal split osteotomies, with or without genioplasty, (2) perioperative orthodontic treatment using Invisalign, and (3) 3D photographs at postoperative timepoints 1 week (T1), 3-4 weeks (T2), and 5-7 weeks. A sex and operation-matched control group with fixed appliances (standard) was also included. The primary outcome variable was the volume of facial swelling, measured by subtraction imposition of the T1 and T2 3D images using reference images (5-7 weeks).
Twenty-two subjects (36% female; mean age 20.7 ± 3.15 years) were included: Invisalign (n = 11) and standard (n = 11). For each group, 7 subjects had 1 operation (LeFort I or bilateral sagittal split osteotomies), and 4 had bimaxillary surgery ± genioplasty. At T1, the Invisalign group had significantly less swelling than the standard group (17.52 ± 10.79 cm3 vs 37.53 ± 14.62 cm3; P <0.001). By T2, the differences were no longer significant (6.62 ± 5.19 cm3 for Invisalign; 5.85 ± 4.39 cm3 for standard, P = 0.728).
Subjects with Invisalign had significantly less facial swelling in the first postoperative week than those with fixed appliances.
•Invisalign is associated with less swelling after orthognathic surgery compared with braces.•Invisalign’s swelling advantage is most significant for single-jaw surgery.•Swelling is similar between Invisalign and braces by 3 weeks after surgery.
Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the ...severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization's (WHO's) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO's International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients.
Abstract Intensive efforts are underway across the world to improve the quality of health care. It is important to use evaluation methods to identify improvement efforts that work well before they ...are replicated across a broad range of contexts. Evaluation methods need to provide an understanding of why an improvement initiative has or has not worked and how it can be improved in the future. However, improvement initiatives are complex, and evaluation is not always well aligned with the intent and maturity of the intervention, thus limiting the applicability of the results. We describe how initiatives can be grouped into 1 of 3 improvement phases—innovation, testing, and scale-up and spread—depending on the degree of belief in the associated interventions. We describe how many evaluation approaches often lead to a finding of no effect, consistent with what has been termed Rossi’s Iron Law of Evaluation. Alternatively, we recommend that the guiding question of evaluation in health care improvement be, “How and in what contexts does a new model work or can be amended to work?” To answer this, we argue for the adoption of formative, theory-driven evaluation. Specifically, evaluations start by identifying a program theory that comprises execution and content theories. These theories should be revised as the initiative develops by applying a rapid-cycle evaluation approach, in which evaluation findings are fed back to the initiative leaders on a regular basis. We describe such evaluation strategies, accounting for the phase of improvement as well as the context and setting in which the improvement concept is being deployed. Finally, we challenge the improvement and evaluation communities to come together to refine the specific methods required so as to avoid the trap of Rossi’s Iron Law.
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