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Eric J Thomas

Publications and source records attributed to Eric J Thomas.

18 recordsLinked to original sources
PubMed2006

Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.

BACKGROUND: Although missed and delayed diagnoses have become an important patient safety concern, they remain largely unstudied, especially in the outpatient setting. OBJECTIVE: To develop a framework for investigating missed and delayed diagnoses, advance understanding of their causes, and identify opportunities for prevention. DESIGN: Retrospective review of 307 closed malpractice claims in which patients alleged a missed or delayed diagnosis in the ambulatory setting. SETTING: 4 malpractice insurance companies. MEASUREMENTS: Diagnostic errors associated with adverse outcomes for patients, process breakdowns, and contributing factors. RESULTS: A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. For 59% (106 of 181) of the errors, cancer was the diagnosis involved, chiefly breast (44 claims [24%]) and colorectal (13 claims [7%]) cancer. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]). The median number of process breakdowns and contributing factors per error was 3 for both (interquartile range, 2 to 4). LIMITATIONS: Reviewers were not blinded to the litigation outcomes, and the reliability of the error determination was moderate. CONCLUSIONS: Diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. Awareness of the most common types of breakdowns and factors could help efforts to identify and prioritize strategies to prevent diagnostic errors.

Adolescent↗
PubMed2006

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

STUDY OBJECTIVES: Diagnostic errors in the emergency department (ED) are an important patient safety concern, but little is known about their cause. We identify types and causes of missed or delayed diagnoses in the ED. METHODS: This is a review of 122 closed malpractice claims from 4 liability insurers in which patients had alleged a missed or delayed diagnosis in the ED. Trained physician reviewers examined the litigation files and the associated medical records to determine whether an adverse outcome because of a missed diagnosis had occurred, what breakdowns were involved in the missed diagnosis, and what factors contributed to it. Main outcome measures were missed diagnoses, process breakdowns, and contributing factors. RESULTS: A total of 79 claims (65%) involved missed ED diagnoses that harmed patients. Forty-eight percent of these missed diagnoses were associated with serious harm, and 39% resulted in death. The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58% of errors), failure to perform an adequate medical history or physical examination (42%), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%). The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%). The median numbers of process breakdowns and contributing factors per missed diagnosis were 2 and 3, respectively. CONCLUSION: Missed diagnoses in the ED have a complex cause. They are typically the result of multiple breakdowns in the diagnostic process and several contributing factors.

Adolescent↗
PubMed2006

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

BACKGROUND: There is widespread interest in measuring healthcare provider attitudes about issues relevant to patient safety (often called safety climate or safety culture). Here we report the psychometric properties, establish benchmarking data, and discuss emerging areas of research with the University of Texas Safety Attitudes Questionnaire. METHODS: Six cross-sectional surveys of health care providers (n = 10,843) in 203 clinical areas (including critical care units, operating rooms, inpatient settings, and ambulatory clinics) in three countries (USA, UK, New Zealand). Multilevel factor analyses yielded results at the clinical area level and the respondent nested within clinical area level. We report scale reliability, floor/ceiling effects, item factor loadings, inter-factor correlations, and percentage of respondents who agree with each item and scale. RESULTS: A six factor model of provider attitudes fit to the data at both the clinical area and respondent nested within clinical area levels. The factors were: Teamwork Climate, Safety Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition. Scale reliability was 0.9. Provider attitudes varied greatly both within and among organizations. Results are presented to allow benchmarking among organizations and emerging research is discussed. CONCLUSION: The Safety Attitudes Questionnaire demonstrated good psychometric properties. Healthcare organizations can use the survey to measure caregiver attitudes about six patient safety-related domains, to compare themselves with other organizations, to prompt interventions to improve safety attitudes and to measure the effectiveness of these interventions.

Ambulatory Care Facilities↗
PubMed2006

Patient safety problems in adolescent medical care.

PURPOSE: This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care. METHODS: This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and "critical incidence analysis" data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems. RESULTS: The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62-2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65-1.25), significantly higher than that of children 1-12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems. CONCLUSIONS: Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.

Adolescent↗
PubMed2006

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

BACKGROUND: The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist. METHODS: OR personnel in 60 US hospitals were surveyed using the Safety Attitudes Questionnaire. The teamwork climate domain of the survey uses six items about difficulty speaking up, conflict resolution, physician-nurse collaboration, feeling supported by others, asking questions, and heeding nurse input. To justify grouping individual-level responses to a single score at each hospital OR level, the authors used a multilevel confirmatory factor analysis, intraclass correlations, within-group interrater reliability, and Cronbach's alpha. To detect differences at the hospital OR level and by caregiver type, the authors used multivariate analysis of variance (items) and analysis of variance (scale). RESULTS: The response rate was 77.1%. There was robust evidence for grouping individual-level respondents to the hospital OR level using the diverse set of statistical tests, e.g., Comparative Fit Index = 0.99, root mean squared error of approximation = 0.05, and acceptable intraclasss correlations, within-group interrater reliability values, and Cronbach's alpha = 0.79. Teamwork climate differed significantly by hospital (F59, 1,911 = 4.06, P < 0.001) and OR caregiver type (F4, 1,911 = 9.96, P < 0.001). CONCLUSIONS: Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale. This tool and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.

Anesthesiology↗
PubMed2005

Total synthesis of milbemycins: a synthesis of (6R)-6-hydroxy-3,4-dihydromilbemycin E.

Following studies using benzyloxymethyl isopropenyl ketone 5 and ethyl 3-(3-furyl)-3-oxopropanoate 6, Robinson reactions between aryloxymethyl isopropenyl ketones 19 and 5 and ethyl 3-(2-trimethylsilyl-3-furyl)-3-oxopropanoate 20 were found to be stereoselective giving cyclohexanones 21 and 41, in which the 3-(arylmethoxy) substituents were cis to the 2-hydroxyl groups, as the major products. After reduction and protection of ketone 21, selective PMB-deprotection, oxidation and stereoselective reduction inverted the configuration at C3 to give the diol 30. Protection of the secondary 3-hydroxyl group followed by modification of the protected 4-alcohol then gave the hydroxybutenolides 36 and 37 after oxidation of the silylated furan using singlet oxygen. The 3-benzyloxycyclohexanone 41 was also converted into the hydroxybutenolide 37 via the (2-trimethylsilylethoxy)methyl (SEM) ether 35. The Wittig reaction between the ylid generated from 2-methylpropyl(triphenyl)phosphonium salt and hydroxybutenolide 36 gave predominantly the (2Z,4Z)-dienyl acid 38 which was taken through to the butenolide 40. Similarly, the racemic hydroxybutenolide 37 was condensed with the racemic ylid derived from phosphonium salt 53 to give, after SEM-deprotection and 5-membered lactone formation, a mixture of the (9Z,2'Z)-dienyl lactones 58 and 59 containing ca. 10% of the corresponding (9Z,2'E)-isomers 60 and 61. (2'Z)/(2'E)-Isomerisation of the dienes 58 and 59 using iodine followed by deprotection gave a mixture of the seco-acids 62 and 63. Selective macrocyclisation of the seco-acid 62 in which the relative configuration of the C1-C7 and C17-C19 fragments (milbemycin numbering) corresponded to that present in the natural milbemycins, gave the beta-milbemycin analogue 65 after butenolide reduction. The hydroxybutenolide 37 was also condensed with the ylid derived from the phosphonium salt 1 and the product taken through to (6R)-6-hydroxy-3,4-dihydromilbemycin E 77. Preliminary attempts to convert the beta-milbemycin analogues 65 and 77 into tetrahydrofurans corresponding to analogues of alpha-milbemycins by treatment with toluene p-sulfonyl chloride under basic conditions gave the primary allylic chlorides 78 and 79.

Crystallography, X-Ray↗
PubMed2005

A total synthesis of milbemycin G: approaches to the C1-C10-fragment and completion of the synthesis.

A synthesis of the hydroxybutenolide (-)-6 required for synthesis of alpha-milbemycins and the completion of a total synthesis of milbemycin G 7 is reported. Following preliminary studies, an optimised synthesis of the hydroxybutenolide (-)-6 from the hydroxyketone 38 was developed which involved the resolution of 38 by separation of the 3-(O-chloroacetyl)-(S)-mandelates 80 and 83. Ester 80, which corresponded to the required enantiomer of the hydroxyketone 38, crystallized from the mixture of the diastereoisomeric esters 80 and 83 giving the (-)-hydroxyketone (-)-38 in an overall yield of 47%(based on racemic 38) after ethanolysis. Hydroxyketone (-)-38 was oxidised to the enolic diketone (-)-39 and phenylselenation and stereoselective reduction gave the trihydroxycyclohexyl selenide (-)-43. The regioselective introduction of the non-conjugated double-bond into the six-membered ring was then achieved by esterification of the 4-hydroxyl group using trichloroacetic acid to give the trichloroacetate (-)-69. Oxidative elimination from the trichloroacetate using tert-butyl hydroperoxide was highly regioselective and gave the endo- and exocyclic alkenes (-)-44 and (-)-46 in a ratio of 95 : 5 after ethanolysis of the trichloroacetates. Selective O-methylation of the 4-hydroxyl group via the cyclic stannylene 55 and protection of the 3-hydroxyl group as its 2-trimethylsilylethoxymethyl (SEM) ether gave the ester (-)-57. Following saponification of the ethyl ester, re-esterification using 2-trimethylsilylethanol and oxidation of the 2-trimethylsilylfuryl fragment using singlet oxygen gave the required hydroxybutenolide (-)-6. The Wittig reaction between the phosphonium salt 2 and the hydroxybutenolide (-)-6 gave a ca. 2 : 1 mixture of the (4Z)- and (4E)-isomers of the ester 84 which on treatment with a catalytic amount of iodine was converted into the (4E)-isomer (4E)-84. Deprotection gave the seco-acid 85 but attempts to macrocyclise this were unsuccessful, the elimination product 86 being the only product isolated. The Wittig product 84 was taken through to the butenolide (2'E)-91 by removal of the SEM group, cyclisation to form the butenolide ring and diene isomerization, but this could not be converted into the corresponding seco-acid 92. However, removal of the SEM group from the seco-acid 85 gave the trihydroxy-acid 93 which was cyclized under modified Yamaguchi conditions to give the macrolide 94 together with a small amount of the macrocyclic butenolide 95. Reduction of this mixture using diisobutylaluminium hydride gave (6R)-6-hydroxymilbemycin E 96 which was converted to milbemycin G 7 by cyclisation of the primary chloride 97. The synthetic milbemycin G 7 was identical to a sample prepared by methylation of a commercial sample of milbemycin D 98, 7-O-methylmilbemycin G 99 being a side-product of this methylation.

Crystallography, X-Ray↗
PubMed2005

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units[ISRCTN85147255] [corrected].

BACKGROUND: Executive walk rounds (EWRs) are a widely used but unstudied activity designed to improve safety culture in hospitals. Therefore, we measured the impact of EWRs on one important part of safety culture -- provider attitudes about the safety climate in the institution. METHODS: Randomized study of EWRs for 23 clinical units in a tertiary care teaching hospital. All providers except physicians participated. EWRs were conducted at each unit by one of six hospital executives once every four weeks for three visits. Providers were asked about their concerns regarding patient safety and what could be done to improve patient safety. Suggestions were tabulated and when possible, changes were made. Provider attitudes about safety climate measured by the Safety Climate Survey before and after EWRs. We report mean scores, percent positive scores (percentage of providers who responded four or higher on a five point scale (agree slightly or agree strongly), and the odds of EWR participants agreeing with individual survey items when compared to non-participants. RESULTS: Before EWRs the mean safety climate scores for nurses were similar in the control units and EWR units (78.97 and 76.78, P = 0.458) as were percent positive scores (64.6% positive and 61.1% positive). After EWRs the mean safety climate scores were not significantly different for all providers nor for nurses in the control units and EWR units (77.93 and 78.33, P = 0.854) and (56.5% positive and 62.7% positive). However, when analyzed by exposure to EWRs, nurses in the control group who did not participate in EWRs (n = 198) had lower safety climate scores than nurses in the intervention group who did participate in an EWR session (n = 85) (74.88 versus 81.01, P = 0.02; 52.5% positive versus 72.9% positive). Compared to nurses who did not participate, nurses in the experimental group who reported participating in EWRs also responded more favorably to a majority of items on the survey. CONCLUSION: EWRs have a positive effect on the safety climate attitudes of nurses who participate in the walk rounds sessions. EWRs are a promising tool to improve safety climate and the broader construct of safety culture.

Adult↗
PubMed2004

Working together in the neonatal intensive care unit: provider perspectives.

OBJECTIVES: To elicit healthcare provider perceptions of working together in a neonatal intensive care unit (NICU). STUDY DESIGN: We conducted focus groups to elicit descriptions of how providers work together. The groups included one each of transport nurses, staff nurses, residents, fellows, attending physicians and two multiple provider groups. To identify themes and their descriptive elements we performed qualitative data analysis. RESULTS: There were three to seven participants per group for a total sample of 36. Provider responses to questions about working together centered around three major themes: (1) Provider Characteristics; (2) Workplace Factors and; (3) Group Influences. Provider Characteristics were defined by personal attributes, reputation, and expertise. Workplace Factors included staffing, work organization, and work environment. Group Influences were described by communication and relationships. CONCLUSIONS: Providers in this NICU described three broad organizational and interpersonal factors that influence how they work together, yet no consistent descriptions of teams or teamwork were found. The organizational factors, often far removed from bedside, should be considered when evaluating how providers work together.

Adult↗
PubMed2003

Remote stereocontrol using allylstannanes: reversal in stereoselectivity using indium(III) and bismuth(III) halides as promoters.

Allyl-indium(III) and -bismuth(III) dihalides, generated by transmetallation of 5-benzyloxy-4-methylpent-2-enyl(tributyl)stannane 1, react with aldehydes with useful levels of 1,5-stereocontrol, a 93:7 ratio of 1,5-epimers in favour of the 1,5-anti-(E)-stereoisomers 7 and 11 typically being obtained using bismuth(III) iodide. The 4-benzyloxypent-2-enylstannane 4 similarly gives the 1,5-syn-(E)-hex-3-enols 13 also with ca. 93:7, stereoselectivity.

Journal Article↗
PubMed2003

Measuring errors and adverse events in health care.

In this paper, we identify 8 methods used to measure errors and adverse events in health care and discuss their strengths and weaknesses. We focus on the reliability and validity of each, as well as the ability to detect latent errors (or system errors) versus active errors and adverse events. We propose a general framework to help health care providers, researchers, and administrators choose the most appropriate methods to meet their patient safety measurement goals.

Adverse Drug Reaction Reporting Systems↗
PubMed2003

Discrepant attitudes about teamwork among critical care nurses and physicians.

OBJECTIVE: To measure and compare critical care physicians' and nurses' attitudes about teamwork. DESIGN: Cross-sectional surveys. SETTING: Eight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SUBJECTS: Physicians and nurses who worked in the intensive care units. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus ( [7, 163] = 8.37; p <.001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. CONCLUSIONS: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.

Adult↗
PubMed2003

Impact of the National Practitioner Data Bank on resolution of malpractice claims.

Policymakers and commentators are concerned that the National Practitioner Data Bank (NPDB) has influenced malpractice litigation dynamics. This study examines whether the introduction of the NPDB changed the outcomes, process, and equity of malpractice litigation. Using pre- and post-NPDB analyses, we examine rates of unpaid claims, trials, resolution time, physician defense costs, and payments on claims with a low/high probability of negligence. We find that physicians and their insurers have been less likely to settle claims since introduction of the NPDB, especially for payments less than dollars 50,000. Because this disruption appears to have decreased the proportion of questionable claims receiving compensation, the NPDB actually may have increased overall tort system specificity.

Attitude of Health Personnel↗
PubMed2002

The reliability of medical record review for estimating adverse event rates.

BACKGROUND: The data used by the U.S. Institute of Medicine to estimate deaths from medical errors come from a study that relied on nurse and physician reviews of medical records to detect the errors. OBJECTIVE: To measure the reliability of medical record review for detecting adverse events and negligent adverse events. DESIGN: Medical record review. SETTING: Hospitalizations in Utah and Colorado in 1992. MEASUREMENTS: After three independent reviews of 500 medical records, the following were measured: reliability and the effect of varying criteria for reviewer confidence in and reviewer agreement about the presence of adverse events. RESULTS: For agreements in judgments of adverse events among the three sets of reviews, the kappa statistics ranged from 0.40 to 0.41 (95% CIs ranged from 0.30 to 0.51) for adverse events and from 0.19 to 0.23 (CIs, 0.05 to 0.37) for negligent adverse events. Rates for adverse events and for negligent adverse events varied substantially depending on the degree of agreement and the level of confidence that was required among reviewers. CONCLUSION: Estimates of adverse event rates from medical record review, including those reported by the Institute of Medicine in its 2000 report on medical errors, are highly sensitive to the degree of consensus and confidence among reviewers.

Colorado↗