Citations

Importance Diagnostic errors represent a major patient safety concern, with the potential to significantly impact patient outcomes. To address this, various trigger-based strategies have been developed to identify diagnostic errors, aiming to enhance clinical decision-making and improve patient safety. Objective To evaluate the performance of three pre-established triggers (T) in the emergency department (ED) setting and assess their effectiveness in detecting diagnostic errors. Design Consecutive cohort, retrospective observational design. Setting Academic ED with 80 000 annual visits. Participants Adults and children presenting to a single ED in the USA between 1 May 2018 and 1 January 2020. Intervention/outcomes Electronic health records (EHRs) were retrieved and categorised into trigger-positive and trigger-negative cases using the following criteria: T1—unscheduled returnvisits to the ED with admission within 7–10 days of theinitial visit; T2—care escalation from the inpatient unitto the intensive care unit (ICU) within 6, 12 or 24 hoursof ED admission; and T3—all deaths in the ED or within24 hours of ED admission, excluding palliative care. A random sample of trigger-positive cases was reviewed using the SaferDx tool to determine the presence or absence of a diagnostic error. Results A total of 5791 trigger-positive and 118262 trigger-negative cases were identified. Among trigger-positive cases, 4159 (72%) were associated with T1, 1415 (24%) with T2, and 217 (4%) with T3. A preliminary chart review of 462 trigger-positive and 251 trigger-negative cases showed most were error-negative (279 and 217, respectively). Detailed reviews found 32 diagnostic errors among 183 trigger-positive cases, yielding PPVs of 5.4% (T1), 8.9% (T2), and 6.9% (T3). No errors were found in 34 reviewed trigger-negative cases, resulting in a 100% NPV. Sepsis was the most common diagnosis among error-positive cases (n=11, 34.4%). Those with non-specific chief complaints like altered mental status or shortness of breath had higher diagnostic error risk. Conclusion and relevance While previously proposed EHR-based triggers can identify some diagnostic errors, they are insufficient for detecting all cases. To improve error detection performance, we recommend exploring data-driven strategies, such as machine learning techniques, to more effectively identify underlying contributing factors to diagnostic errors and enhance detection accuracy in the ED.

Background/objectives: Falls are a leading cause of traumatic injury and hospitalization for adults over the age of 65. While common, bed-related falls are relatively understudied when compared to ambulatory falls. The aim of this study is to characterize the risk factors for the hospitalization of older adults presenting to U.S. emergency departments (EDs) after a fall from bed. Methods: This was a cross-sectional study using publicly available data from the U.S. Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS) from 2014 to 2023, including all adults over the age of 65 presenting to the NEISS’s participating EDs with bed-related fall injuries. We identified fall injuries using a keyword search of the NEISS narratives and determined how the fall occurred by manually reviewing a randomized 3% sample of the narratives. We summarized demographics and injury patterns with descriptive statistics. We constructed a multivariable logistic regression model to identify risk factors for hospitalization and used Poisson regression to assess temporal trends in fall incidence and hospital admissions. Results: An estimated average of 320,751 bed-related fall injuries presented to EDs annually from 2014 to 2023. ED visits increased by 2.85% per year, while hospital admissions rose by 5.67% per year (p < 0.001). The most common injury patterns were superficial injuries (contusions, abrasions, lacerations, avulsions, and punctures) (28.6%), fractures (21.7%), and internal injuries (including concussions) (21.6%). Most of the falls occurred while transitioning into or out of bed (34.4%) or falling out of bed (56.8%). Hospitalization was required in 34.1% of cases and was associated with male sex, medication use at time of injury, and fracture injuries. Conclusions: Bed-related falls and associated hospitalizations are increasing among older adults. ED providers should understand risk factors for hospitalization in these common injuries such as male sex, medication use at time of injury, and high-risk injury patterns. Additionally, prevention efforts should focus on helping older adults remain safely in bed and then assisting with transitions into or out of bed.

Background and importance Rapid sequence intubation in emergency settings may involve opioid pretreatment to blunt hemodynamic responses during laryngoscopy and intubation; however, opioids may lead to postintubation hypotension, increasing morbidity and mortality. Global clinical practice varies significantly, reflecting uncertainty about opioids’ benefits and risks. Objective Our goal was to evaluate the association between opioid pretreatment and hemodynamic instability, focusing on postintubation hypotension in adult patients undergoing emergency intubation. Design, settings, and participants We performed a systematic review of randomized controlled trials and observational studies comparing opioid administration vs. no opioids before adult emergency intubations. Searches included Cochrane, Embase, Medline, Scopus, and Web of Science databases until November 2024. Elective intubations were excluded. Eight (6708 patients) studies met criteria. Outcomes measure and analysis The primary outcome was postintubation hypotension, variably defined across studies. Secondary outcomes included hypoxemia, first-attempt success, cardiac arrest, and vasopressor use. Independent reviewers conducted data extraction, risk-of-bias assessments, and certainty evaluation. Results were qualitatively synthesized. Main results Among 6708 (2757 opioids and 3951 controls) patients, postintubation hypotension incidence varied widely (risk differences: −12.5% favoring opioids to +13.2% favoring controls). The single low-risk randomized study reported opioids increased hypotension (risk difference: 13%, odds ratio: 2.15, 95% confidence interval: 1.22–3.78). Observational studies yielded inconsistent results. Secondary outcomes showed no consistent differences. Evidence certainty was very low because of risk of bias, inconsistency, and imprecision. Conclusions Current evidence regarding opioid pretreatment effect on postintubation hypotension risk during emergency intubation is limited and conflicting.

Background Family participation in the delivery of nonpharmacological measures has shown in past studies to prevent 17-75% of incident delirium. A scalable and sustainable method to partner with family (i.e., care partners) and support their delivery of nonpharmacologic measures is needed. Objectives To test the feasibility, acceptability, and usability of iPREPARED in a pilot randomized controlled clinical trial (RCT). iPREPARED is a mobile health technology co-designed with patients and care partners containing resources on nonpharmacological interventions to prevent delirium. Methods Hospitalized adults ( > 65 years) with > 1 delirium risk factor and a care partner (family or friend > 18yo) willing to participate were enrolled. The primary outcomes were feasibility, acceptability, and usability. Descriptive statistics are reported. Results In total, 23 dyads completed the study (median age 72 years (IQR 64, 79), 60% male, and 100% Caucasian). Dyads reported that iPREPARED was acceptable, with moderate usability. Recruitment in the emergency department was feasible whereas recruitment once hospitalized and admitted was more difficult. Conclusion The study design was feasible. iPREPARED was acceptable and usable as an intervention.

Abstract Objectives There is limited knowledge on how providers and patients in the emergency department (ED) use electronic health records (EHRs) to facilitate the diagnostic process. While EHRs can support diagnostic decision-making, EHR features that are not user-centered may increase the likelihood of diagnostic error. We aimed to identify how EHRs facilitate or impede the diagnostic process in the ED and to identify opportunities to reduce diagnostic errors and improve care quality. Materials and Methods We conducted semistructured interviews with 10 physicians, 15 nurses, and 8 patients across 4 EDs. Data were analyzed using a hybrid thematic analysis approach, which blends deductive (ie, using multiple conceptual frameworks) and inductive coding strategies. A team of 4 coders performed coding. Results We identified 4 themes, 3 at the care team level and 1 at the patient level. At the care team level, the benefits of the EHR in the diagnostic process included (1) customizing features to facilitate diagnostic workup and (2) aiding in communication. However, (3) EHR-driven protocols were found to potentially burden the care process and reliance on asynchronous communication could impede team dynamics. At the patient-level, we found that (4) patient portals facilitated meaningful patient engagement through timely delivery of results. Discussion While EHRs can improve the diagnostic process, they can also impair communication and increase workload. Electronic health record design should leverage provider-created tools to improve usability and enhance diagnostic safety. Conclusions Our findings have important implications for health information technology design and policy. Further work should assess optimal ways to release patient results via the EHR portal.