A controlled trial of smart infusion pumps to improve medication safety in critically ill patients

OBJECTIVE: Intravenous medications are vital during inpatient management. Errors associated with the administration of medications through intravenous infusion pumps to critically ill patients can result in adverse drug events. We sought to assess the impact of smart pumps with integrated decision support software on the incidence and nature of medication errors and adverse drug events. DESIGN: We performed a prospective, randomized time-series trial and compared the serious medication error rate between intervention (decision support on) and control (decision support off) periods. Serious medication errors included both near-misses and preventable adverse drug events. Pump software produced log reports to help identify potential events. Events were presented to physicians for rating of event type, preventability, and severity. SETTING: Cardiac surgical intensive care and step-down units between February and December 2002. PATIENTS: Pump data were available for 744 cardiac surgery admissions. INTERVENTIONS: Decision support during medication administration provided feedback including alerts, reminders, and unit-specific drug rate limits. MEASUREMENTS AND MAIN RESULTS: We found a total of 180 serious medication errors, including 14 and 11 preventable adverse drug events and 73 and 82 nonintercepted potential adverse drug events in the control and intervention periods, respectively. The serious medication error rates in the control and intervention periods were 2.03 and 2.41 per 100 patient-pump-days, respectively (p = .124). We also found numerous opportunities for safety improvement. Violations of infusion practice during the intervention periods included 571 (25%) bypasses of the drug library. Medications were also frequently administered without documentation of physician orders in both periods (n = 823; 7.7%). CONCLUSION: Intravenous medication errors and adverse drug events were frequent and could be detected using smart pumps. We found no measurable impact on the serious medication error rate, likely in part due to poor compliance. Although smart pumps have great promise, technological and nursing behavioral factors must be addressed if these pumps are to achieve their potential for improving medication safety.     

Vasculitis

Vasculitis is reviewed as a continuum of disease from asymptomatic to life-threatening. Therapeutic intervention predicated upon assessment of the significance of organ system involvement and the relative risks of the various forms of therapeutic intervention are discussed.     

Primate spondyloarthropathy

Spondyloarthropathy is a common occurrence in Old World primates, with only limited presence in New World monkeys. Clearly distinguished from rheumatoid arthritis, this erosive arthritis afflicts 20% of great apes, baboons, and rhesus macaques and had been increasing in frequency. Habitat-dependent infectious agent diarrhea-induced reactive arthritis is implicated on a background of genetic predisposition. A gorilla-derived therapeutic preventative approach has possible application in human clinical medicine.     

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors

Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.     

Sternal resection and reconstruction for primary malignant tumors

BACKGROUND: Primary malignant sternal tumors (PMST) are locally aggressive and their optimal surgical management still continues to evolve. METHODS: From 1986 to 2002, 38 patients (25 females/13 males) underwent radical resection of PMST. This series included 33 sarcomas, 17 of which had been radiation-induced, 3 hematologic tumors, and 2 carcinomas. Seventeen were high-grade tumors. Nine patients had received preoperative chemotherapy. Twelve patients required extensive skin excision. Eight total, seven subtotal, and 23 partial sternectomies were performed. Resection was extended to the anterior chest-wall in 4 patients, lung in 4, brachiocephalic vein in 3, superior vena cava in 2, and pericardium in 1. In 36 patients, chest wall stability was obtained by Marlex (n = 21) or Vicryl (n = 2) mesh and polytetrafluoroethylene patch (n = 13), with methylmethacrylate reinforcement in 12 patients. Soft tissue coverage was done by the pectoralis major muscles with skin advancement in 25 patients, a myocutaneous flap in 11, a breast transposition in 1, and a skin flap in 1. Omentoplasty was performed in 3 patients. RESULTS: One patient died from pneumonia. Two patients needed a tracheostomy after total sternectomy. No flap-related complication was observed. Four local septic complications required removal of the composite prosthesis with reoperations. Local recurrence occurred in 9 patients, 7 patients having a repeat resection. Metastases developed in eight. The 5-year overall and disease-free survival was 66% and 53%, respectively. The histologic grade of sarcomas was a survival predictor (high grade versus others p = 0.035). CONCLUSIONS: Wide resection of PMST is necessary to minimize local recurrence. Large sternal defects are safely reconstructed with a musculocutaneous flap. We suggest that the use of methylmethacrylate should be limited to reconstruction after total sternectomy.