Research and applications: Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care

Background

Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment.

Objective

This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs.

Methods

From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported.

Results

Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting.

Conclusions

Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect.     

Computerized clinical decision support for medication prescribing and utilization in pediatrics

Background and objective

Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics.

Materials and methods

A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities.

Results and discussion

Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use.

Conclusion

Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.     

Adherence reporting in clinical trials of type 2 Diabetes Metellius in the field of Traditional Chinese Medicine

OBJECTIVE

To assess the medication adherence reporting in clinical trials the field of Traditional Chinese Medicine (TCM) and the impact factors of medication adherence.

The effect of intramuscular vitamin D (cholecalciferol) on serum 25OH vitamin D levels in older female acute hospital admissions

Introduction

Many studies have demonstrated the prevalence of vitamin D insufficiency in the older population.

Objective

This study sought to determine whether supplementation with intramuscular vitamin D improved 25OH vitamin D levels significantly.

Subjects

Ninety female inpatients aged over 65 years were assigned to receive 300,000 IU of intramuscular vitamin D3 (cholecalciferol) or no intervention.

Methods

Baseline 25OH vitamin D and intact parathyroid hormone (iPTH) levels were taken and repeated 3 months after supplementation.

Results

Patients who received treatment showed a significant improvement in 25OH vitamin D levels, from 25.5 to 81 nmol/L with 11% remaining deficient. No patient became hypercalcaemic after treatment.

Conclusions

Vitamin D deficiency is common throughout all age groups in the Irish population and particularly the older female population who have increased risk of osteoporosis and fractures. Intramuscular vitamin D significantly improves 25OH vitamin D levels compared to no treatment and may combat non-compliance with oral medication.     

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

Objective

To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.

Design

From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.

Measurements

A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies.

Results

Among 121 046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04).

Conclusions

When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider''s medical record.

Trial registration number

This study was registered at ClinicalTrials.gov ({"type":"clinical-trial","attrs":{"text":"NCT00251875","term_id":"NCT00251875"}}NCT00251875).     

DOCSS: doctors on-call smartphone study

Introduction

Smartphones have revolutionised our demands for constant access to information. The usage of smartphones in the clinical setting is becoming widespread. The aim of our study was to assess smartphone ownership and usage across a cohort of interns.

Methods

A voluntary novel questionnaire was distributed to interns in two university hospitals. Details regarding smartphone ownership and usage were assessed. Likert scales were utilised for analysis.

Results

Sixty-one (74.4 %) interns responded to the survey. Sixty (98.4 %) owned a smartphone with iPhone^® being the most popular (76.7 %). Fifty-five (91.6 %) interns have downloaded medical applications (‘apps’), while 29 (52.3 %) reported paying for them. Regarding smartphone use on-call, 30 (50 %) interns agreed it aids diagnoses, 26 (43 %) agree it helped in interpreting laboratory values, 31 (51.7 %) agreed it helped in dosing of medication and 33 (55 %) agreed it was of assistance in medical emergency protocols. Forty-two (70 %), 42 (70 %) and 46 (76.7 %) interns agreed or strongly agreed smartphones have a positive influence on them in terms of levels of stress, confidence and level of knowledge, respectively.

Conclusion

Smartphone usage is widespread among our intern cohort. The introduction of hospital applications with local guidelines would be welcomed; however, this may require informed patient consent regarding their use.     

Non-attendance at counselling therapy in cocaine-using methadone-maintained patients: lessons learnt from an abandoned randomised controlled trial

Background

Recently, the authors commenced a randomised controlled trial to study the effectiveness of cognitive behavioural coping skills (CBCS) to reduce cocaine usage in methadone-maintained patients?? in a clinical setting by assessing attendance at treatment sessions and outcomes in terms of cocaine use. However, recruitment into the study stopped when it became apparent that attendance at counselling sessions was poor.

Aims

The aim of the current study was to determine the reasons for both non-attendance and attendance from a patient??s perspective at counselling sessions.

Methods

A cross-sectional design was employed whereby participants who were recruited for the original study were interviewed utilising a semi-structured interview format.

Results

Motivational inconsistencies were most frequently cited as the reason for dropping out of counselling, whereas a good relationship with staff was cited by attenders as the most important factors which aided their attendance at counselling sessions.

Conclusions

Selecting opiate-dependent methadone-maintained cocaine abusers on the basis of their urine toxicology and offering them counselling as a way of reducing their harmful drug use did not prove efficacious. Attempting to address cocaine misuse within this cohort may need a more stepped approach including brief interventions, such as motivational interviewing, or other enhancers of motivation before we can test the effectiveness of CBCS in this population.     

Completeness and accuracy of the drug treatment reporting system in Dublin, Ireland

Background

The National Drug Treatment Reporting System (NDTRS) is the Irish treated-drug misuse surveillance system.

Aim

To measure completeness and accuracy of the NDTRS

Methods

Cross-sectional survey of clinical records and matching NDTRS reporting forms of a random sample of 520 clients attending 4 Dublin treatment centres. Using clients’ clinical records as the gold standard, system completeness (proportion of sample reported to the NDTRS) and accuracy of selected variables (proportion of reported clients’ information on the NDTRS that matched clinical record information) were measured.

Results

452/520 (87%) selected records were retrieved. The NDTRS was only 61.1% (95% Cl 56.5–65.5) complete; completeness differed across treatment centres (21.8%–85.6%, p< 0.0001) and was greater for new and returning clients than for continuing clients (81.7% versus 53.9% respectively, p< 0.0001). Problems were identified with the accuracy of some key variables.

Conclusions

Urgent actions have been taken to improve the completeness and accuracy of the reporting system.     

Is point of care testing in Irish hospitals ready for the laboratory modernisation process? An audit against the current national Irish guidelines

Background

The Laboratory modernisation process in Ireland will include point of care testing (POCT) as one of its central tenets. However, a previous baseline survey showed that POCT was under-resourced particularly with respect to information technology (IT) and staffing.

Aims

An audit was undertaken to see if POCT services had improved since the publication of National Guidelines and if such services were ready for the major changes in laboratory medicine as envisaged by the Health Service Executive.

Methods

The 15 recommendations of the 2007 Guidelines were used as a template for a questionnaire, which was distributed by the Irish External Quality Assessment Scheme.

Results

Thirty-nine of a possible 45 acute hospitals replied. Only a quarter of respondent hospitals had POCT committees, however, allocation of staff to POCT had doubled since the first baseline survey. Poor IT infrastructure, the use of unapproved devices, and low levels of adverse incident reporting were still major issues.

Conclusions

Point of care testing remains under-resourced, despite the roll out of such devices throughout the health service including primary care. The present high standards of laboratory medicine may not be maintained if the quality and cost-effectiveness of POCT is not controlled. Adherence to national Guidelines and adequate resourcing is essential to ensure patient safety.     

Taxane-resistant lymphoepithelial-like carcinoma: Excellent response to VIP chemotherapy

Background

Lymphoepithelial-like carcinoma is a rare tumour type. The optimal treatment for this disease is not known. No effective therapies are described in the literature.

Aims

This report describes a case of lymphoepithelial-like carcinoma and documents a therapeutic strategy which has proved effective.

Results

The patient was initially treated with a common platinum-based chemotherapy regimen incorporating a taxane (Carbplatin and Docetaxel). Disease stabilization initially occurred but the patient soon progressed. The patient was then treated with VIP chemotherapy and had a complete response.

Conclusion

VIP chemotherapy appears to be an effective therapeutic strategy in lymphoepithelial-like carcinoma.     

Transforming management of patients undergoing splenectomy in an Irish teaching hospital

Background

Post-splenectomy infection has a mortality rate of up to 70%. Previously we have published data confirming the poor adherence to best practice guidelines with relation to management of the asplenic patient. A defined protocol of care was established, staff education commenced and a ‘patient information leaflet’ made available.

Aim

To ascertain whether management of the asplenic patient has improved since the implementation of a structured programme of care.

Method

Retrospective chart review of all splenectomies performed in Beaumont Hospital between 2002 and 2008.

Results

Overall, 75.9% of patients were documented as having received the recommended vaccinations. Of these, 48.7% were not timed according to recommended guidelines. Prophylactic antibiotics were documented as prescribed in all but five patients discharged.

Conclusions

These results demonstrate an improvement in post-splenectomy care between 2002 and 2008. However, further improvements are necessary.     

Advising on Preferred Reporting Items for Patient-Reported Outcome Instrument Development: the PRIPROID

Objective

The reporting of patient-reported outcomes (PRO) instrument development is vital for both researchers and clinicians to determine its validity, thus, we propose the Preferred Reporting Items for PRO Instrument Development (PRIPROID) to improve the quality of reports.

Methods

Abiding by the guidance published by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network, we had performed 6 steps for items development: identified the need for a guideline, performed a literature review, obtained funding for the guideline initiative, identified participants, conducted a Delphi exercise and generated a list of PRIPROID items for consideration at the face-to-face meeting.

Results

Twenty three items subheadings under 7 topics were included: title and structured abstract, rationale, objectives, intention, eligibility criteria, conceptual framework, items generation, response options, scoring, times, administrative modes, burden assessment, properties assessment, statistical methods, participants, main results, and additional analysis, summary of evidence, limitations, clinical attentions, and conclusions, item pools or final form, and funding.

Conclusions

The PRIPROID contains many elements of the PRO research, and this assists researchers to report their results more accurately and to a certain degree use this instrument to evaluate the quality of the research methods.     

Regional variation in prescribing for chronic conditions among an elderly population using a pharmacy claims database

Background

Age, gender and geographical regions are recognised factors in inequalities in prescribing for chronic diseases in the elderly.

Aim

To compare the health board regional distribution of chronic disease among the elderly and to examine variation in quality prescribing across age, gender and regions.

Methods

Population based study of prescribing for chronic disease using a national pharmacy claims database. All individuals aged 70 years and over (n=271,518) were eligible.

Results

Over 60% of the elderly in all regions received cardiovascular related medication. The South Eastern, North Western and Western Health Boards had below average prescribing for many chronic conditions. Logistic regression identified age, gender and regional variations in prescribing of preventative therapies for CVD and diabetes.

Conclusion

There is a high prevalence of prescribing for chronic conditions in the elderly in Ireland, and there is evidence of gender, age and residing health board inequalities in prescribing.     

A cross-sectional observation of burnout in a sample of Irish junior doctors

Background

Stress and burnout are common among doctors. Excess levels of stress have been shown to have detrimental personal and professional effects as well as a negative influence on patient care.

Aim

The aim of our pilot study was to assess the levels of burnout among a cohort of interns.

Methods

A voluntary written self-assessment of burnout levels was distributed to interns in two teaching hospitals. The Maslach Burnout inventory is a 22-question survey assessing the three components of the burnout syndrome—emotional exhaustion (EE), depersonalisation (DP) and personal achievement (PA).

Results

Twenty-seven surveys were distributed to interns in two hospitals with a 96.3 % (n = 26) response rate. The mean age was 25.1 years (range 24–31 years). 14 were medical interns, 12 were surgical interns at the time of completion. Overall, the mean EE score was 23.4 (range 11–29), representing moderate levels of EE. The mean DP score was 9.4 (range 4–14), representing moderate levels of DP. The mean PA score was 18.9 (range 12–29), representing high levels of PA. There were no significant differences noted between levels of EE, DP or PA among male or female interns, medical or surgical interns or those who worked in a peripheral or university hospital.

Conclusion

Burnout is reported among interns in our pilot study. Measures need to be taken to heighten awareness of burnout among doctors and to educate physicians regarding self-awareness and personal health.     

Elective surgery: a comparison of in-patient versus day surgery practices in Ireland

Background

Currently, there is a paucity of research which has assessed practices at the point of care for day surgery patient.

Aim

To outline the patient journey from first referral for surgery and identify structures and processes which facilitate or constrain the provision of day surgery.

Method

A retrospective medical charts review of 200 consecutively presenting patients undergoing elective surgery in two Irish teaching hospitals. Data collection was completed from January 2009 to March 2009. This analysis spanned from first referral to the hospital until discharge and follow up.

Results

Great variability was noted in practices between the two hospitals. While some of the differences in practice become barriers to increased rates of day surgery, others did not have an impact.

Conclusion

This study echoes findings of other similar studies in that management of patients undergoing elective surgery which varies significantly across Irish hospitals.     

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

Objective

To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.

Design

CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs).

Measurement

Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors.

Results

Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered.

Conclusions

Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.