annually. Participants: All ED patients from September 2011 through January 2012 (4 months) were compared to those from September 2012 through January 2013 using the electronic medical record system. Results: Before the guideline was implemented, there were 33,046 total ED patients and 777 (2.4%) renal CT scans during the study period. After the guideline, there were 31,959 patients and 640 (2.0%) renal CT scans. After adjusting for the 3.3% decrease in total patients, the number of renal CT scans decreased by 14.8% (95% CI: 5.3% to 24.4%) (P¼.0001). The rate of positive CT scans did not significantly change (27.0% before and 24.8% after). The number of patients diagnosed with renal stones increased by 16.5% (95% CI: -0.07% to 33.9%) from 283 (before) to 319 (after) the guideline. Of those diagnosed with renal stones, 73 (25.8%) did not receive a renal CT scan before the guideline and 160 (50.2%) did not receive a renal CT after the guideline implementation (24.4% [95% CI: 16.7 to 31.6%]). Conclusions: A simple clinical guideline significantly reduced the number of renal CT scans for suspected renal stone patients without decreasing the number of renal stone diagnoses. Of those patients diagnosed with renal stones, almost twice as many were diagnosed without renal CT after the guideline was adopted. This study is limited by the single site and the lack of a renal stone diagnosis “gold standard.” Additional studies are needed to determine whether these findings can be generalized to other EDs. 282 Implementation of a Pulmonary Embolism Diagnostic Protocol Reduces Imaging Drescher M, Fried J, Delgado J, Brass R, Medoro A, Murphy T, Tilden F/Hartford Hospital, Hartford, CT; University of Connecticut Integrated Residency in Emergency Medicine, Farmington, CT; University of Connecticut School of Medicine, Farmington, CT Study Objective: Knowledge translation (KT) in health care is defined by the synthesis, dissemination, and application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system. Pulmonary artery computerized tomography (PACT) is considered the test of choice for diagnosis of pulmonary embolism (PE); however, it has well-known potential complications and implications for cost, throughput, patient satisfaction, and resource allocation. The Wells Criteria and pulmonary embolism rule-out criteria (PERC) are validated tools to rule out PE and can safely avoid PACT in patients; nonetheless they are not universally applied. In October 2012 ACEP sponsored a seminar on KT and the rational use of clinical rules in ruling out PE in the ED. Subsequently, to reduce the number of unnecessary PACTs in our department, and in keeping with the principles of KT, we implemented a rational, evidence-based protocol to reduce the number of PACTs performed in our emergency department (ED). We undertook to study the effectiveness of this protocol. Methods: This is a prospective observational before and after study. We compared the number of PACTs ordered in 2011 as a control to the number ordered in the 6 months after instituting a KT program followed by a departmentally mandated protocol for the ordering of PACT for all patients with suspected PE. The setting is an urban teaching tertiary care hospital with an ED census of 100,000. The patient population is those suspected of having PE. The protocol calls for a Wells score to be calculated for all patients. Low risk patients then have their PERC score calculated. No further testing is performed on PERC negative patients. Those who fail PERC criteria have d-dimer testing. Intermediate risk patients have immediate d-dimer testing, and high risk patients have a PACT ordered. Those patients who have negative d-dimer results have no further testing. An automatic report for all PACT for PE was generated. All providers who order a PACT outside the protocol are asked to explain why they thought the PACT necessary despite the negative evaluation. Primary endpoint was number of PACT ordered for which a sample size to detect a 20% reduction was determined to be 174 patients. Results: During the six-month study period, 361 PACT were reported ordered. This represents 7.39 scans per 1000 patient visits versus 11.27 in the control period or a reduction of 34% (P<.0001). However, of PACTs ordered, only 263 PACTs were performed, the difference due to cancelled orders, miscounted scans done for other diagnoses, etc. This represents 5.38 scans per 1000 visits or a reduction of 52% (P<.0001). Mean age was 60.9 (SD 19.8) and 57.8% were women. The overall prevalence of PE was 13.4%. There were a total of 70 protocol violations during the protocol period. The PE prevalence when the protocol was followed was 14.5% versus 5.7% when it was not (P¼.0368). The proportion of positive PE CTAs was significantly higher during the study period compared to a historical control from 2011 (13.4% versus 7.3%, P<.0001). Conclusion: The goal of this KT project was to reduce the number of PACTs performed in our ED by reinforcing the best evidence-based approach, and as departmental policy. We found the use of our protocol resulted in a significant reduction in PACTs. Our results show that KT can benefit patients with suspected PE in the ED by reducing unnecessary PACT. 283 Unexpected Death Within 72 Hours After Emergency Department Visit: Were Those Deaths Preventable? Goulet H, Guerand V, Samb P, Beauchet A, Aegerter P, Casalino E, Riou B, Freund Y/ Goupe Hospitalier Pitié-Salpêtrière, Paris, France; Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Hôpital Ambroise Paré, Boulogne-Billancourt, France; Hôpital Bichat - Claude-Bernard, Paris, France; Groupe Hospitalier Pitié Salpêtrière, Paris, France Study Objectives: Amongst patients with short term unexpected deaths after an emergency department (ED) visit, we seek to evaluate the preventability of lethal outcome. Methods: This was a retrospective multicenter (n¼4) study from January 2007 to December 2011. Unexpected death was defined as death within 72 hours of ED visits, in the absence of intensive care unit admission either because they were not considered critically ill, or because they had care limitations in place. We electronically retrieved all charts (n¼1279 on a total census of 1 130 000) pertaining to patients with in-hospital death within 72 hours after their ED visit and no ICU admission. Two abstractors independently reviewed a random sample of 100 charts per center to exclude those with care limitations. In cases where the abstractors disagreed, the opinion of another pair of abstractors was sought. For each selected patient with unexpected death, two trained experts, blinded to each other, assessed their chart for medical errors and rated on a 1 to 4 Likert scale (from very unlikely to very likely) the preventability of the death. The agreement for the condition of “unexpected death” and the preventability was assessed among the two abstractors using the Kappa Cohen coefficient. The primary outcome was the likely preventable death, rated as 3 or 4 on the Likert scale. Secondary outcomes included types of medical error (Proficiency, Procedure, Communication, Violation or Decision) and process breakdowns. Results: Amongst the 400 charts retrieved, 39 were incomplete and could not underwent analysis, 327 were excluded for limitation of care. Thirty-four patients were analysed. Agreement for the condition of “unexpected death” and inclusion in the analysis was strong (Kappa¼0.8). Mean age of the sample was 71 years (standard deviation 13), and 69% were male. Twelve patients (35%) died in the ED, 7 (21%) in the ED observation unit, 15 (44%) in the ward and 2 (6%) in the operation room. There were 71 medical errors identified in these 34 patients, 47 (66%) of which were proficiency errors, ie, due to a lack of knowledge. At least one medical error occurred in 22 (64%) patients. The two most common breakdowns were medication (or lack thereof) error, and failure to order appropriate diagnostic tests. “Preventable Death” was classified as “very unlikely” in 7 patients (21%), “somewhat unlikely” in 8 patients (24%), “somewhat likely” in 12 (35%) and “very likely” in 7 patients (20%). Overall, 56% of deaths were considered preventable: 95% confidence interval (40%-72%). Agreement between experts was almost perfect with a Kappa of 0.94. Conclusion: In patients with unexpected death, the rate of medical error is high, and more than half of these deaths could have been avoided. 284 Preventability and Severity Scoring of Drug-Related Problems in the Emergency Department Perinpam L, Haag JD, Baudoin MR, Fowler CL, Sunga KL, Bellamkonda VR, Bradley PJ, Rudis MI/Mayo Clinic and Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, DK, Rochester, MN; Mayo Clinic, Rochester, MN; Mayo Clinic, Rochester, MN; Mayo Clinic, Rochester, MN Study Objectives: Drug-related problems (DRPs) represent a potentially preventable burden on health care system resources. The study objective was to describe the severity and preventability of DRPs in patients presenting to the emergency department (ED). Methods: This study was part of a larger prospective derivation (December 2011 to November 2012) and validation (December 2012 to March 2013) cohort to develop clinical decision rules (CDRs) to detect DRPs in the ED. The study was conducted at an urban, tertiary care, teaching facility with 73,000 ED annual visits. Eligible patients were randomly selected from a real-time ED electronic tracking board. Inclusion criteria were age 18 and assignment of a room within the ED. We excluded ED patients assigned to a psychiatric or fast track room; and those with intentional medication or illicit drug overdose or alcohol-related abuse. A DRP was defined as a medication-related issue directly contributing to the ED visit. Potential DRPs were first identified through a prospective review of each patient’s presentation by an on-duty ED pharmacist. Subsequently each case was reviewed through independent assessment by a trained team of 2 emergency physicians and 2 pharmacists (gold standard). All clinical information was obtained from the ED Research Forum Abstracts S100 Annals of Emergency Medicine Volume 64, no. 4s : October 2014