UNASSIGNED: Despite considerable emphasis on delivering safe care, substantial patient harm occurs. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited.
UNASSIGNED: To measure AEs in the outpatient setting.
UNASSIGNED: Retrospective review of the electronic health record (EHR).
UNASSIGNED: 11 outpatient sites in Massachusetts in 2018.
UNASSIGNED: 3103 patients who received outpatient care.
UNASSIGNED: Using a trigger method, nurse reviewers identified possible AEs and physicians adjudicated them, ranked severity, and assessed preventability. Generalized estimating equations were used to assess the association of having at least 1 AE with age, sex, race, and primary insurance. Variation in AE rates was analyzed across sites.
UNASSIGNED: The 3103 patients (mean age, 52 years) were more often female (59.8%), White (75.1%), English speakers (90.8%), and privately insured (70.4%) and had a mean of 4 outpatient encounters in 2018. Overall, 7.0% (95% CI, 4.6% to 9.3%) of patients had at least 1 AE (8.6 events per 100 patients annually). Adverse drug events were the most common AE (63.8%), followed by health care-associated infections (14.8%) and surgical or procedural events (14.2%). Severity was serious in 17.4% of AEs, life-threatening in 2.1%, and never fatal. Overall, 23.2% of AEs were preventable. Having at least 1 AE was less often associated with ages 18 to 44 years than with ages 65 to 84 years (standardized risk difference, -0.05 [CI, -0.09 to -0.02]) and more often associated with Black race than with Asian race (standardized risk difference, 0.09 [CI, 0.01 to 0.17]). Across study sites, 1.8% to 23.6% of patients had at least 1 AE and clinical category of AEs varied substantially.
UNASSIGNED: Retrospective EHR review may miss AEs.
UNASSIGNED: Outpatient harm was relatively common and often serious. Adverse drug events were most frequent. Rates were higher among older adults. Interventions to curtail outpatient harm are urgently needed.
UNASSIGNED: Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.

We conducted a medical record review for healthcare utilization, risk factors, and clinical data among people who inject drugs (PWID) in Massachusetts to aid HIV outbreak response decision-making and strengthen public health practice.
Two large community health centers (CHCs) that provide HIV and related services in northeastern Massachusetts.
Between May and July 2018, we reviewed medical records for 88 people with HIV (PWH) connected to the outbreak. The review period included care received from May 1, 2016, through the date of review. Surveillance data were used to establish date of HIV diagnosis and assess viral suppression.
Sixty-nine (78%) people had HIV infection diagnosed during the review period, including 10 acute infections. Persons had a median of 3 primary care visits after HIV diagnosis and zero before diagnosis. During the review period, 72% reported active drug or alcohol use, 62% were prescribed medication assisted treatment, and 41% were prescribed antidepressants. The majority (68, 77%) had a documented ART prescription. HIV viral suppression at < 200 copies/mL was more frequent (73%) than the overall across the State (65%); it did not correlate with any of the sociodemographic characteristics studied in our population. Over half (57%) had been hospitalized at least once during the review period, and 36% had a bacterial infection at hospitalization.
Medical record review with a field investigation of an outbreak provided data about patterns of health care utilization and comorbidities not available from routine HIV surveillance or case interviews. Integration of HIV screening with treatment for HIV and SUD can strengthen prevention and care services for PWID in northeastern Massachusetts.

Background: Black women in the United States experience maternal mortality three to four times more often than white women (1, 2). States vary in degree of disparity, partially due to programs and policies available to pregnant people. In Massachusetts, Black women were approximately twice as likely as white women to experience pregnancy-associated mortality, with a large percentage of these deaths reported to be preventable (3). Methods: Using Massachusetts as a state-level comparison to national policies, we searched the US Congress and Massachusetts legislative databases for maternal health policies from 2010 to 2020. We screened 1,421 national and 360 Massachusetts bills, following set inclusion/exclusion criteria. Data analysis included (1) assessment of bill characteristics, (2) thematic analysis, and a (3) quality appraisal following an adapted model of the analytical framework for evaluating public health policy proposed by the National Collaborating Centre for Healthy Public Policy. Additionally, our data analysis identified the level of racism (internalized, interpersonal or institutional) that each policy addressed. Results: From 2010 to 2020, 31 national and 16 state-level policies were proposed that address maternal health and racial disparities. The majority of policies addressed racism at the institutional level alone (National: N = 19, 61.3%, Massachusetts: N = 14, 87.5%). Two national and two Massachusetts-level policies became law, while two national policies passed only the House of Representatives. Our critical appraisal revealed that the majority of unintended effects would be neutral or positive, however, some potential negative unintended effects were identified. The appraisal also identified 54.8% (n = 17) of national policies and 68.8% (n = 11) of Massachusetts with positive impact on health equity. Conclusions: There has been an increase in policies proposed addressing racial disparities and health equity in maternal health over the last 10 years. Although half of national policies proposed showed positive impact on health equity, shedding light on the work the U.S. is doing on a federal level to confront the Black maternal health crisis, only two policies made it to law, only one of which addressed racial disparities directly and had a positive impact on health equity.

Breast reconstruction is most frequently performed using implants or expanders. Adjunctive materials such as acellular dermal matrix and synthetic meshes are used to support the implant or expander. A paucity of large studies exist on the use of synthetic mesh for breast reconstruction.
A retrospective chart review of all patients over the past 7 years who had implant reconstruction with synthetic absorbable mesh at the Massachusetts General Hospital was performed. Data were collected on demographic and surgical outcomes. Statistical analysis was performed.
A total of 227 patients (376 mastectomies) were treated with direct-to-implant subpectoral reconstruction with absorbable mesh from 2011 to 2017. The infection rate was 2.1 percent. The rate of capsular contracture was 4.8 percent. Patients who had radiation therapy either preoperatively or postoperatively had a higher rate of complications, including capsular contracture. Cost savings for using mesh instead of acellular dermal matrix surpassed $1.2 million.
Synthetic absorbable mesh is a safe alternative to acellular dermal matrix in prosthetic breast reconstruction and provides stable results along with significant cost savings.
Therapeutic, IV.

Cardiac involvement with COVID-19 is increasingly being recognised. Clinical characteristics and outcomes of patients with COVID-19 complicated by secondary Takotsubo cardiomyopathy (TC) is poorly understood.
This retrospective case series was conducted between March and April 2020 at four hospitals of Steward Health Care Network of Massachusetts, USA. Seven patients out of 169 who had echocardiogram were identified to have features of TC. Demographic, clinical, laboratory, management and outcome were gathered from their electronic medical records. We also reviewed all the published cases of COVID-19 and TC in the literature to recognise their common clinical characteristics, risk factors and outcomes.
In our series of seven patients, three typical, two inverted, one biventricular and one global TC were recognised. Three were females and four were males. The mean age was 71±11 years. In-hospital death was observed in 57% of patients. Patients who belonged to the high-risk group and had high-risk echocardiographic features in our series had a 100% mortality rate.
COVID-19 complicated by TC has a high mortality rate. Early identification of patients with COVID-19 who are at higher risk for developing secondary TC is important for the prevention of complications, and thus improved outcomes.

Little is known about the long-term outcomes of repeated ketamine infusions for depression. We conducted a retrospective chart review to investigate outcomes of maintenance intravenous ketamine treatment at Massachusetts General Hospital.
Eighty-five patients with treatment-resistant depression (TRD) who started intravenous ketamine from October 2018 to November 2019 were examined. Symptom severity was evaluated with the 16-item Quick Inventory of Depressive Symptomatology-Self Report scale (QIDS-SR16) at every visit prior to administration. The initial ketamine dose was usually 0.5 mg/kg infused over 40 min. Intravenous ketamine was administered twice-weekly for three weeks in an induction phase, followed by maintenance with a variable administration schedule and dose. Response was defined as a ≥50% reduction in total QIDS-SR16 score from baseline.
Forty (47.1%) of the 85 patients who started treatment discontinued during or right after the induction phase; 3 (3.5%) were still on induction at the time of this report, and 42 (49.4%) transitioned to maintenance after completing induction. Among these patients, 14 (16.5%) discontinued during maintenance and 28 (32.9%) continued on maintenance. The mean ketamine dosage during maintenance was 0.91±0.28 mg/kg. Fifteen out of 82 patients (18.3%) responded to induction treatment and 6 (7.3%) remained in responder status at the time of data analysis during maintenance. Three patients discontinued ketamine due to side-effects.
Despite the apparently low response rate in QIDS-SR16 scores and considerable out-of-pocket costs, almost half of real-world outpatients with TRD decided to continue with maintenance ketamine treatment due to perceived significant improvement.

OBJECTIVE: To provide an updated overview of feline orbital neoplasia, to compare diagnostic utility of cytology and histopathology, and to evaluate minimally invasive sampling modalities.
METHODS: A medical records search was performed to identify cats with orbital neoplasia. Data were collected regarding signalment, diagnosis, vision status, imaging modalities, and sample collection methods. A reference population with orbital neoplasia was also identified via literature search for comparison with regard to final diagnosis.
RESULTS: Eighty-one cats met selection criteria and 140 cases were identified in the literature. In the study and reference populations, respectively, diagnoses were grouped as follows: round cell tumors 47% and 24%, epithelial tumors 38% and 40%, mesenchymal tumors 14% and 34%, and neurologic origin tumors 1% and 2%. The most common diagnoses in both groups were lymphoma and squamous cell carcinoma (SCC). Feline restrictive orbital myofibroblastic sarcoma (FROMS) was common in the reference population but not diagnosed in the study population. Cytology results were available for 41 cats; histopathology results were available for 65 cats. Both cytology and histopathology results were available for 25 cats, in 44% of which cytologic results were overturned. No significant complications were associated with any sampling method. Lack of cats with multiple samples available for histopathology limited comparison between tissue sampling methods.
CONCLUSIONS: Orbital neoplasia is common in cats, with round cell and epithelial tumors diagnosed most commonly in the study population. Histopathology is superior to cytology in providing a definitive diagnosis. Minimally invasive tissue biopsy techniques appear to be safe and effective.

Death due to preventable medical error is a leading cause of death, with varying estimates of preventable death rates (14%-56% of total deaths based on national extrapolated estimates, 3%-11% based on single-centre estimates). Yet, how best to reduce preventable mortality in hospitals remains unknown.
In this article, we detail lessons learnt from implementing a hospital-wide, automated, real-time, electronic mortality reporting system that relies on the opinions of front-line clinicians to identify opportunities for improvement. We also summarise data obtained regarding possible preventability, systems issues identified and addressed, and challenges with implementation. We outline our process of survey, evaluation, escalation and tracking of opportunities identified through the review process.
We aggregated and analysed 7 years of review data regarding deaths, review responses categorised by ratings of possible preventability and inter-rater reliability of possible preventability. A qualitative analysis of reviews was performed to identify care delivery opportunities and institutional response.
Over the course of 7 years, 7856 inpatient deaths occurred, and 91% had at least one review completed. 5.2% were rated by front-line clinicians as potentially being preventable (likely or possibly), and this rate was consistent over time. However, there was only slight inter-rater agreement regarding potential preventability (Cohen\'s kappa=0.185). Nevertheless, several major systems-level opportunities were identified that facilitated care delivery improvements, such as communication challenges, need for improved end-of-life care and interhospital transfer safety.
Through implementation, we found that a hospital-wide mortality review process that elicits feedback from front-line providers is feasible, and provides valuable insights regarding potential preventable mortality and prioritising actionable opportunities for care delivery improvements.

To assess missed opportunities for reducing fatal opioid overdoses, characteristics of decedents by opioid overdose with and without problematic opioid use who received health care services within one year of death were examined.
Of 157 decedents in the Worcester, Massachusetts, area between 2008 and 2012, 112 had contact with the health care system. Electronic medical records were reviewed for clinical characteristics, health service use, universal precautions, and substance use disorder management. Problematic opioid use was defined as individuals having documented opioid use disorders or aberrant drug-related behavior. Data were analyzed with chi-square tests with adjusted residual for categorical variables and t tests for continuous variables.
Decedents were predominantly Caucasian males with a mean±SD age of 41.0±11.7. Problematic opioid use by definition meant users (N=53) had opioid use disorder as a principal diagnosis and were likely to have a comorbid substance use disorder. Decedents with nonproblematic opioid use had diagnoses of chronic pain and mental illness. They were more likely to have been seen last in surgical and subspecialty settings (29% versus 11%). The proportion with an opioid prescription was higher among those with problematic use (72% versus 37%) who also had a higher total daily morphine equivalent, compared with those with nonproblematic use (165.4±282.7 versus 55.6±117.7 mg per day).
Persons with problematic opioid use are a recognizable group with a high risk of death by opioid overdose whose therapeutic management needs improvement to reduce fatal outcomes. Different strategies must be developed for identifying and treating nonproblematic opioid use to reduce risk of death.

Mass gathering events can substantially impact public safety. Analyzing patient presentation and transport rates at various mass gathering events can help inform staffing models and improve preparedness.
A retrospective review of all patients seeking medical attention across a variety of event types at a single venue with a capacity of 68,756 from January 2010 through September 2015.
We examined 232 events with a total of 8,260,349 attendees generating 8157 medical contacts. Rates were 10 presentations and 1.6 transports per 10,000 attendees with a non-significant trend towards increased rates in postseason National Football League games. Concerts had significantly higher rates of presentation and transport than all other event types. Presenting concern varied significantly by event type and gender, and transport rate increased predictably with age. For cold weather events, transport rates increased at colder temperatures. Overall, on-site physicians did not impact rates.
At a single venue hosting a variety of events across a 6-year period, we demonstrated significant variations in presentation and transport rates. Weather, gender, event type, and age all play important roles. Our analysis, while representative only of our specific venue, may be useful in developing response plans and staffing models for similar mass gathering venues. (Disaster Med Public Health Preparedness. 2018;12:752-758).