To define a quality assurance instrument to evaluate errors in diagnostic processes made by physicians in the emergency department (ED).This was a retrospective clinical investigation of inpatient ED records. Over a six-year period, 5,000 medical records of admitted patients were randomly selected for evaluation. Each record was initially examined by one of five physician evaluators. If the primary ED diagnosis differed from the primary discharge diagnosis, the ED record was inspected to determine reasons for the misdiagnosis. The authors considered several aspects of the diagnostic process, including patient history, tests ordered, interpretation of clinical data, choice and performance of procedures, injury pattern recognition, reasoning, and evaluation. Records that demonstrated errors in the diagnostic process were reevaluated for the same diagnostic process errors by a sixth physician. Disagreements regarding suspected errors in the diagnostic process were settled by discussion. Finally, to determine potential medical consequences of the misdiagnosis, one individual reviewed the complete medical records of patients whose ED medical records were scored with errors by both evaluators. Interevaluator reliability was assessed using Cochran's Q-test with a selected series of medical records.Twenty-eight records (0.6%) were found to contain one or more errors in the diagnostic process that contributed to misdiagnosis. For these patients appropriate diagnosis was not made until one to 16 days after admission. Three patients of 18 whose records were available for detailed review may have suffered complications that resulted, in part, from the delay in diagnosis and subsequent treatment. Significant interevaluator reliability for identification of errors in the diagnostic process was obtained (p > 0.1).A two-tiered evaluation of ED records selected by inconsistent initial and final diagnoses can be used reliably to screen for errors in the diagnostic process made by emergency physicians (EPs). The rate of physician error contributing to a misdiagnosis is very low, suggesting that EPs are delivering quality patient care.
Abstract The outer pericarp thickness of fruit of tomato ( Lycopersicon esculentum Mill) ripened off the vine depended upon the maturity of the fruit when harvested. Immature fruit has thinner outer pericarps than fully mature green fruit. Similar results were obtained with 4 cultivars and 3 fruit sizes. The pericarp thickness did not change during a 6-day ripening period for any maturity. There was no difference in number of cells in the outer pericarp due to maturity or fruit size.
Abstract Florida 1011, an inbred line of tomato ( Lycopersicon esculentum Mill.) was developed at the Agricultural Research and Education Center in Homestead and Bradenton in cooperation with the H. J. Heinz Company. The line is designated Florida 1011 in recognition of its Southern Tomato Exchange Program (STEP) designation (3).
In reply: To respond to Dr. Wendel’s comments, we do not advocate the closure of emergency departments (EDs). Our specialty should continue to advocate for a sufficient number of well-trained practicing emergency physicians to serve the needs of all US communities. Our dedication to proper staffing of every ED must be considered a long-term goal; it won’t
The best EMS major incident response program comes from excellent day-to-day delivery of care, combinbed with common sense preparedness and an excellent relationship with hospitals, law enforcement and regional public health officials. Expansion of a few physical assets, understanding the regional resources that can be utilized for major incidents, and routine use of an incident management system will lay the necessary groundwork for a major terrorist incident response. System leaders must consider the adaptation of triage efforts and response, with security and responder safety issues becoming an immediate consideration.
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