Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.

Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.

Setting: 15 hospitals participating in the California Patient Safety Consortium.

Subjects: A sample of 6312 employees generally comprising all the hospital’s attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.

Main outcome measures: Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.

Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.

Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

This abstract was presented at the Academy Health 20th Annual Research Meeting on June 28, 2003, in Nashville, Tennessee.

Measures based on routinely collected data would be useful to examine the epidemiology of patient safety. Extending previous work, we established the face and consensual validity of twenty Patient Safety Indicators (PSIs). We generated a national profile of patient safety by applying these PSIs to the HCUP Nationwide Inpatient Sample. The incidence of most nonobstetric PSIs increased with age and was higher among African Americans than among whites. The adjusted incidence of most PSIs was highest at urban teaching hospitals. The PSIs may be used in AHRQ's National Quality Report, while providers may use them to screen for preventable complications, target opportunities for improvement, and benchmark performance.

Background: Patient-controlled analgesia (PCA) pumps are widely used after surgery, but their association with various outcomes is not completely understood. Is PCA pump use related to the incidence of postoperative surgical site infections among patients undergoing open intestinal surgery?

Materials and Methods: We undertook a comprehensive retrospective chart review of 515 randomly selected patients over age 18 who had major rectal or intestinal surgery (Diagnosis Related Groups [DRGs] 146-149) between January 1994 and March 1997 from eight community or teaching hospitals along the U.S. west coast. Of these patients, 214 used PCA pumps. Outcome measures were in-hospital postoperative surgical site infections, respiratory complications, ileus/abdominal distention, urinary tract infection/urinary retention, and length of stay.

Results: Use of a PCA pump was significantly associated with increased in-hospital postoperative surgical site infections (10.7% for PCA, 4.0% for no PCA). The odds ratio for PCA use was about 4.0 after controlling for many variables, including severity of illness at admission, body mass index, preadmission use of corticosteroids, perforated viscus, number of previous abdominal operations, wound classification category, hypothermia, malnutrition on admission, preoperative antibiotic use within 2 h before incision, time from hospital admission to surgery, skin prep to incision time, anesthesia start to incision time, surgical skin to skin time, wound closure type, time from incision closure to the start of PCA, use of drains, blood product use, central line use, line infection, mobility assistance required, hospital, DRG, and surgeon.

Conclusion: No confounding variables explained the significant association between PCA pump use and in-hospital surgical site infection. These results stand firmly on data that merit additional study to further elucidate possible immunologic effects of PCA pumps.

Objective: Most infections occur during childhood, but the health effects of childhood infection are poorly understood. We investigated whether growth decreases in the 2 months after acute seroconversion.

Methods: We performed a nested case-control study among children 6 months to 12 years of age in a community on the outskirts of Lima, Peru. Health interviews were completed daily. Anthropometric measurements were taken monthly. Sera were collected every 4 months and tested for immunoglobulin G. Two-month height and weight gains of seroconverters were compared with gains of sex, age, and size-matched seronegative controls.

Results: In the 2 months after infection, 26 seroconverters gained a median of 24% less weight than 26 matched controls (interquartile range, 63% less to 21% more). In multivariate analysis, infection attenuated weight gain only among children aged 2 years or older. This decrease was not explained by increased diarrhea.

Conclusions: Seroconversion is associated with a slowing of weight gain in children aged 2 years or older. Reasons for this finding merit additional study.

Although the fields of organization theory and social movement theory have long been viewed as belonging to different worlds, recent events have intervened, reminding us that organizations are becoming more movement-like - more volatile and politicized - while movements are more likely to borrow strategies from organizations. Organization theory and social movement theory are two of the most vibrant areas within the social sciences. This collection of original essays and studies both calls for a closer connection between these fields and demonstrates the value of this interchange. Three introductory, programmatic essays by leading scholars in the two fields are followed by eight empirical studies that directly illustrate the benefits of this type of cross-pollination. The studies variously examine the processes by which movements become organized and the role of movement processes within and among organizations. The topics covered range from globalization and transnational social movement organizations to community recycling programs.

The Institute of Medicine recently issued a landmark report on medical error. In light of this report, every aspect of health care is subject to new scrutiny regarding patient safety. Informatics technology can support patient safety by correcting problems inherent in older technology; however, new information technology can also contribute to new sources of error. We report here a categorization of possible errors that may arise in deploying a system designed to give guideline-based advice on prescribing drugs, an approach to anticipating these errors in an automated guideline system, and design features to minimize errors and thereby maximize patient safety. Our guideline implementation system, based on the EON architecture, provides a framework for a knowledge base that is sufficiently comprehensive to incorporate safety information, and that is easily reviewed and updated by clinician-experts.

Also published in the Proceedings of the American Medical Informatics Association's 2001 Symposium.

BACKGROUND: Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.

OBJECTIVES: To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.

DESIGN: Cohort study.

SETTING: All nongovernment hospitals in the United States.

PATIENTS: 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.

MEASUREMENTS: Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 micromol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.

RESULTS: Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.

CONCLUSIONS: Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.