Code status discussions between attending hospitalist physicians and medical patients at hospital admission.

J Gen Intern Med. 2011 Apr;26(4):359-66

Authors: Anderson WG, Chase R, Pantilat SZ, Tulsky JA, Auerbach AD

Abstract
BACKGROUND: Bioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).
OBJECTIVE: To determine whether attending hospitalist physicians' discussions meet these recommendations.
DESIGN: Cross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.
PARTICIPANTS: Attending hospitalist physicians and patients who were able to communicate verbally about their medical care.
MAIN MEASURES: We identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen's kappa was 0.64-1 for all reported elements.
KEY RESULTS: Audio-recordings of 80 patients' admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2-14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2-8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients' preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.
CONCLUSIONS: Code status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.

PMID: 21104036 [PubMed - indexed for MEDLINE]

Incidence of adverse drug events and medication errors in Japan: the JADE study.

J Gen Intern Med. 2011 Feb;26(2):148-53

Authors: Morimoto T, Sakuma M, Matsui K, Kuramoto N, Toshiro J, Murakami J, Fukui T, Saito M, Hiraide A, Bates DW

Abstract
BACKGROUND: The epidemiology of adverse drug events (ADEs) and medication errors has received little evaluation outside the U.S. and Europe, and extrapolating from these data might not be valid, especially regarding selecting and prioritizing solutions.
OBJECTIVE: To assess the incidence and preventability of ADEs and medication errors in Japan.
DESIGN: The Japan Adverse Drug Events (JADE) study was a prospective cohort study.
PATIENTS: A cohort of 3,459 adults admitted to a stratified random sample of seven medical and eight surgical wards and three intensive care units in three tertiary care hospitals over 6 months.
MAIN MEASURES: We measured ADE and medication error rates from daily reviews of charts, laboratories, incident reports, and prescription queries by on-site reviewers; presence of a signal was considered an incident. Two independent physicians reviewed incidents to determine whether they were ADEs or medication errors and to assess severity and preventability.
KEY RESULTS: We identified 1,010 ADEs and 514 medication errors (incidence: 17.0 and 8.7 per 1,000 patient-days, respectively) during the study period. Among ADEs, 1.6%, 4.9% and 33% were fatal, life-threatening and serious, respectively. Among ADEs, 14% were preventable. The rate per admission was 29 per 100 admissions, higher than in U.S. studies because associated with of the long length of hospital stay in Japan (mean, 17 days).
CONCLUSIONS: The epidemiology and nature of ADEs and medication errors in Japan were similar to other countries, although more frequent per admission. Solutions that worked in these countries might thus improve medication safety in Japan, as could shortening hospital length of stay.

PMID: 20872082 [PubMed - indexed for MEDLINE]