Factors Associated with Adverse Events Resulting From Medical Errors in the Emergency Department: Two Work Better Than One

Background

The Emergency Department (ED) is an environment at risk for medical errors.

Objective

Our aim was to determine the factors associated with the adverse events resulting from medical errors in the ED among patients who were admitted.

Methods

This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient’s hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events.

Results

From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p < 0.01).

Conclusions

In our study, the involvement of more than one physician was associated with a lower risk of adverse events.     

Patient Concerns about Medical Errors in Emergency Departments

OBJECTIVE: Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care. METHODS: Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care. RESULTS: Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED. CONCLUSIONS: The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.     

Medication errors in the emergency department: a systems approach to minimizing risk

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.     

The acute coronary syndrome--pre-hospital diagnostic quality

BACKGROUND AND OBJECTIVE: In the Austrian emergency medical service (EMS), emergency medical technician-staffed and physician-staffed vehicles are in operation. Patients with suspected acute coronary syndromes (ACS) are treated in the pre-hospital phase and transported to the hospital by an emergency physician (EP). This study evaluates the diagnostic performance of EPs in ACS and the impact of this emergency system on the outcome of ACS in an urban area. DESIGN: Retrospective case control study. METHODS: All protocol sheets from the emergency physicians were searched for the diagnosis of ACS. The database of the emergency department (ED) was searched for patients with ACS as an admission diagnosis or ACS as discharge diagnosis. For patients admitted to an intensive care unit (ICU), the medical history from the ICU was reviewed. According to the diagnosis and the aggressiveness of therapy, patients were divided in five categories of severity at each stage of care (pre-hospital category, ED category, ICU category). RESULTS: A total of 3585 patients was analysed. Only 17.8% of the patients with ACS as the admission diagnosis and 20.3% of the patients with ACS as the discharge diagnosis were transported by an EP. 46.8% of the ACS diagnosis by EPs were confirmed in hospital. Patients transported by EPs showed a higher all-cause mortality in hospital (1.6% vs. 0.6%; p=0.011). There was no significant correlation between the pre-hospital category of patients treated by EPs and the ED category. When a 12-lead-electrocardiogram was recorded, the correlation improved slightly (rho: 0.139; p=0.006). CONCLUSIONS: The percentage of ACS patients transported to hospital by an EP is very low, and EPs seem to be "over-aware" in the diagnosis of ACS.     

Emergency physician's perception of cultural and linguistic barriers in immigrant care:results of a multiple-choice questionnaire in a large Italian urban emergency department

BACKGROUND: A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians(EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department(ED) and their possible associations with demographic data, geographical origin and clinical characteristics.METHODS: In an ED with approximately 85 000 visits per year, a multiple-choice questionnaire was given to the EPs 4 months after discharge of each immigrant in 2011.RESULTS: Linguistic comprehension was optimal or partial in the majority of patients. Signifi cant barriers were noted in nearly one fourth of patients, for only half of them compatriots who were able to translate. Linguistic barriers were mainly found in older and sicker patients; they were also frequently seen in patients coming from western Africa and southern Europe. Non-linguistic barriers were perceived by EPs in a minority of patients, more frequently in the elderly and frequent attenders. Factors independently associated with a poor f inal comprehension led to linguistic barriers, non-linguistic obstacles, the absence of intermediaries, and the presence of patient's fear and hostility. The latter probably is a consequence, not the cause, of a poor comprehension.CONCLUSION: Linguistic and non-linguistic barriers, although quite infrequent, are the main factors that compromise communication with immigrants in the ED, with negative effects especially on elderly and more seriously ill patients as well as on physician satisfaction and appropriateness in using services.     

False-negative and False-positive Errors in Abdominal Pain Evaluation Failure to Diagnose Acute Appendicitis and Unnecessary Surgery

OBJECTIVES: To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. METHODS: This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). RESULTS: The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance. CONCLUSIONS: Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.     

Pitfalls in the Diagnosis of Cerebellar Infarction

Background
Cerebellar infarctions are an important cause of neurologic disease. Failure to recognize and rapidly diagnose cerebellar infarction may lead to serious morbidity and mortality due to hydrocephalus and brain stem infarction.
Objectives
To identify sources of preventable medical errors, the authors obtained pilot data on cerebellar ischemic strokes that were initially misdiagnosed in the emergency department.
Methods
Fifteen cases of misdiagnosed cerebellar infarctions were collected, all seen, or reviewed by the authors during a five-year period. For each patient, they report the presenting symptoms, the findings on neurologic examination performed in the emergency department, specific areas of the examination not performed or documented, diagnostic testing, the follow-up course after misdiagnosis, and outcome. The different types of errors leading to misdiagnosis are categorized.
Results
Half of the patients were younger than 50 years and presented with headache and dizziness. All patients had either incomplete or poorly documented neurologic examinations. Almost all patients had a computed tomographic scan of the head interpreted as normal, and most of these patients underwent subsequent magnetic resonance imaging showing cerebellar infarction. The initial incorrect diagnoses included migraine, toxic encephalopathy, gastritis, meningitis, myocardial infarction, and polyneuropathy. The overall mortality in this patient cohort was 40%. Among the survivors, about 50% had disabling deficits. Pitfalls leading to misdiagnosis involved the clinical evaluation, diagnostic testing, and establishing a diagnosis and disposition.
Conclusions
This study demonstrates how the diagnosis of cerebellar infarction can be missed or delayed in patients presenting to the emergency department.     

Medical Errors—What and When: What Do Patients Want to Know?

OBJECTIVES: 1) To determine how and when emergency department (ED) patients and their families wish to learn of health care errors. 2) To assess the error threshold this population believes should trigger reporting to government agencies, state medical boards, and hospital patient safety committees. 3) To evaluate the role patients and families believe medical educators should play in this process. METHODS: A 12-item survey was administered to a convenience sample of ED patients and families during evaluation in a tertiary care academic ED. Results were tabulated and data were reported as percentages. Statistical significance was analyzed using the chi-square test. RESULTS: 258 surveys were returned (80%). A majority of respondents wished to be informed immediately of any medical error (76%) and to have full disclosure of the error's extent (88%). An overwhelming majority of respondents endorse reporting of errors to government agencies (92%), state medical boards (97%), and hospital committees (99%). Most respondents believe medical educators should focus on teaching students to be honest and compassionate (38%) or on how to tell patients about mistakes (25%). The frequency of hospital admission or physician visits per year had no impact on any response pattern (ns with chi(2) test). CONCLUSIONS: Regardless of health care utilization, a majority of respondents want full disclosure of medical error and wish to be informed of error immediately upon its detection. Respondents support reporting of errors to government agencies, the state medical board, and hospital committees focused on patient safety. Teaching physicians error disclosure techniques, honesty, and compassion were endorsed as a priority for educators who teach error management.     

Emergency Department CK-MB: A Predictor of Ischemic Complications

ABSTRACT
Objective : To demonstrate that a positive CK-MB in the emergency department (ED) predicts an increased risk for complications of myocar-dial ischemia in patients admitted to the hospital for evaluation of chest pain.
Methods : 53 academic and community hospital EDs participated in this prospective observational cohort analysis of 5,120 patients with chest pain without ST-segment elevation on the initial ED 12-lead electrocardiogram. All patients were admitted for evaluation of chest pain in one of the participating hospitals as part of the National Cooperative CK-MB Project. Patients were stratified by whether or not they had an elevated CK-MB level in the ED. CK-MB measurements were made on ED presentation and two hours later. Patient medical records were reviewed for inpatient diagnoses—myocardial infarction (MI) or other diagnosis —and for ischemic complications—cardiac-related death, recurrent or delayed in-hos-pital MI, significant ventricular arrhythmias, new conduction defects, congestive heart failure, and cardiogenic shock.
Results : 369 (7.2%) of the 5,120 patients had MI. The proportion of patients with any complication in the MI group was 24%, while the complication rate in the non-MI group was 0.4%. In all patients, regardless of final diagnosis, the relative risk of any complication was 16.1 (95% CI 11.0–23.6) in those with a positive ED CK-MB versus negative ED CK-MB patients. Similarly, the relative risk of death was 25.4 (95% CI 10.8— 60.2) in positive ED CK-MB versus negative ED CK-MB patients.
Conclusions : Multicenter data support the hypothesis that CK-MB measurements can help risk-stratify ED chest pain patients whose initial ECGs are without diagnostic ST-segment elevation.     

Ultrasound-guided hip arthrocentesis in the ED

In patients presenting with atraumatic joint pain and swelling, diagnosis is typically made by synovial fluid analysis. Management of an acute suspected hip joint arthritis can present a challenge to the emergency physician (EP). Hip joint effusions are somewhat more difficult to identify and aspirate than effusions in other joints that are commonly managed by EPs. Identification and aspiration of a hip joint effusion under ultrasound guidance is a well-established procedure in the fields of orthopedic surgery and interventional radiology. Here, we report 4 cases of ultrasound-guided hip arthrocentesis at the bedside by EPs; relevant technical details of the procedure are reviewed. These cases demonstrate the feasibility of ultrasound-guided hip arthrocentesis in the emergency department (ED) by EPs. With increasing availability of bedside ultrasound in the ED, suspected hip joint arthritis or infection may be evaluated and managed by the trained EP in a fashion similar to other joint arthritides.     

Agreement between Emergency Physicians and Psychiatrists Regarding Admission Decisions

Objective: To determine the level of agreement between emergency physicians (EPs) and psychiatrists regarding the need for acute psychiatric hospitalization and treatment for patients presenting with alleged psychiatric complaints.
Methods: A prospective, cross-sectional assessment of concordance between EPs and psychiatrists in psychiatric admission decisions was performed at an urban county, teaching hospital ED. The participants had been brought to the ED for psychiatric evaluation. The patients were interviewed by an attending EP or a senior-level resident, and a tentative impression and disposition were determined pfior to an independent examination and final disposition by a psychiatrist. Strength of physician group agrement was determined using the k statistic.
Results: The patient mean age was 37.5 ± 15 years; 51% were men. The most common reasons for evaluation were disruptive behavior (28%), overdose (24%), and danger to self (23%). Of the 156 patients, 47 (28.7%) were sent home without treatment, 10 (6.3%) were determined to need only medical treatment, and 6 (3.7%) were released with outpatient psychiatric treatment. There were 84 (55.7%) patients admitted for psychiatric treatment. The EPs and psychiatrists had only moderate agreement regarding danger to self (k = 0.44), danger to others (k = 0.40). substance abuse as the primary problem (k = 0.50), and need for psychiatric hospitalization (k = 0.54).
Conclusion: Moderate agreement between EPs and psychiatrists in key impressions and admission decisions suggests that shared training in psychiatric decision making, especially during residency training, is desired in this setting.     

Emergency department medication lists are not accurate

Background: Medication errors are a common source of adverse events. Errors in the home medication list may impact care in the Emergency Department (ED), the hospital, and the home. Medication reconciliation, a Joint Commission requirement, begins with an accurate home medication list. Objective: To evaluate the accuracy of the ED home medication list. Methods: Prospective, observational study of patients aged > 64 years admitted to the hospital. After obtaining informed consent, a home medication list was compiled by research staff after consultation with the patient, their family and, when appropriate, their pharmacy and primary care doctor. This home medication list was not available to ED staff and was not placed in the ED chart. ED records were then reviewed by a physician, blinded to the research-generated home medication list, using a standardized data sheet to record the ED list of medications. The research-generated home medication list was compared to the standard medication list and the number of omissions, duplications, and dosing errors was determined. Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–93%). Conclusion: Our findings now add the ED to the list of other areas within health care with inaccurate medication lists. Strategies are needed that support ED providers in obtaining and communicating accurate and complete medication histories.     

Preventable deaths in patients admitted from emergency department

Background

There is limited data about how appropriate medical care is in the emergency department (ED).

Objectives

To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED.

Methods

We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED ) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen κ statistic.

Results

Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen κ statistic of 0.81.

Conclusions

Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.     

A description of emergency department-related malpractice claims in The Netherlands: closed claims study 1993-2001.

BACKGROUND: The aim of this study was to assess the quality of care provided at emergency departments (ED) in the Netherlands by analysing medical liability insurance claims. METHODS: A retrospective study performed by reviewing records at MediRisk, presently the largest insurer for medical liability in the Netherlands. The following data were abstracted from the files available for analysis: medical discipline involved, physician involved (resident or consultant), nature and gravity of the complaint, and final claim disposition. RESULTS: Between 1993 and 2001 a total of 326 claims involving the ED were filed at MediRisk. Of these, 256 claims (79%) were closed and were available for analysis. Medical liability claims were filed primarily for alleged errors in diagnosis and treatment. The majority of claims involved minor surgical conditions: fractures, luxations (joint dislocations), wounds and tendon injuries (210/256, 82%). Residents were involved in 76% of the claims; resident supervision by a consultant was documented in only 15% of the medical records. Permanent patient disability resulting from improper ED treatment was alleged in 22% of the claims. Four per cent of the claims involved the death of a patient. Physicians accepted liability in 16% of the claims filed. Indemnity payments during the 8-year study period totalled Euros 504,000. CONCLUSION: The number of medical liability claims is low compared with the number of patients treated in ED in the Netherlands. Claims primarily concerned alleged mistakes in diagnosis and the treatment of minor trauma. Residents were involved in the majority of the claims. More resident supervision is needed, as are specific training programmes for emergency physicians.     

Unrecognized delirium in ED geriatric patients

To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. All patients were assessed by an attending ED physician in the customary fashion. In addition, a study nurse interviewed patients using the CAM and followed patient outcomes for three months. The ED record for all patients with delirium or “probable” delirium, as determined by the CAM, were reviewed for physician diagnosis and disposition to determine how often delirium had been recognized by the emergency physician. Thirty-eight of the 385 patients screened (10%) met criteria for delirium or “probable” delirium; ED charts were complete for 35 of these, which constituted the study sample. The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection “rule out sepsis” (n = 7). Six of 13 patients discharged (46%) were diagnosed as “status post fall” without evidence of significant injury. The 3-month mortality rate for patients with delirium or “probable” delirium was 14% versus 8% for the non-delirium group (P = .20). These results suggest that the diagnosis of delirium may frequently be missed by the use of a conventional work-up in elderly patients who present to the ED. Educational efforts and/or use of formal assessment instruments may improve diagnostic sensitivity; however, formal evaluations of these strategies will be required.     

The influence of physician seniority on disparities of admit/discharge decision making for ED patients

Objectives

Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients.

Methods

In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively.

Results

Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found.

Conclusions

EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.     

Diffusion of Medical Progress: Early Spinal Immobilization in the Emergency Department

Objectives: To examine the spread of new techniques of spinal care through one state's emergency departments (EDs).
Methods This was a telephone survey of all 36 EDs in a single state. One physician from each ED was contacted and given a short structured survey instrument to determine when patients who arrived at the ED on backboards were removed from the backboards. Removal was classified as "immediate" if it was done before clinical or radiographic exclusion of cervical spine injury and "delayed" if it was done only after interpretation of any indicated diagnostic radiologic procedures. Further questions were asked to determine if all physicians in the group used the same technique and how this technique had been adopted.
Results In all but four hospitals, patients were removed from backboards in the same manner by all physicians, using a protocol or standard procedure. Fifteen of these did immediate and seventeen did delayed removal. In all but one case, the approach of immediate removal was initiated at the hospital by a physician trained or recently working at a university facility. Eight respondents stated that transport service requirements influenced their decision.
Conclusions Although logic and the medical literature support removing all patients from a backboard immediately, physicians were unlikely to change their practice after their formal training had been completed until a new member of their group had done so.     

致死性紧张综合征的误诊与误治研究

目的：探讨致死性紧张综合征语诊和误治的有关因素。方法：作依有关献的症状群病因诊断标准为依据，将会诊所见其他科和精神科的致死性紧张综合征１５例误诊病例进行了系统分析，结果：提示１５例中１０例综合医院病例皆未确定致死性紧张综合征的诊断，病因学互为误诊率为１００％。专科医院误诊病例５例中有２例精神分裂症、２例恶性综合征均误诊为散发性脑炎，另１例将中毒性肺炎误诊为紧张型精神分裂症。１５例中死亡２例，病死率为１３.3%。结论：致死性紧张综合征为跨学科的错综复杂的综合征，且为多因学说，而人为因素成为误诊的主要因素之一，不仅专科医生而且综合医院医生也需要掌握，以防误诊。