On the edge of decision-making in trauma care: A focus group study on radiographers' experiences of interprofessional collaboration.

INTRODUCTION: The temporary trauma teams in trauma alerts consist of a diverse group of unique professionals requiring interprofessional collaboration and coordination to achieve efficient, high-quality care. The uncertain situation and complex care environment impose high demands on team dynamics such as individual attitudes and team behaviours. Within interprofessional teams, interaction and coordination reflect the collective success of collaboration and the achievement of goals. Interactions with radiographers have increased in trauma teams given computed tomography's prominent role in providing crucial knowledge for decision-making in trauma care. This study aimed to explore radiographers' experiences of interprofessional collaboration during trauma alerts. METHOD: The study was designed with focus group methodology, including 17 radiographers participating in five focus groups, analysed with an inductive focus group analysis. RESULTS: An overarching theme, "On the edge of decision-making", emerged along with three sub-themes: "Feeling included requires acknowledgement", "Exclusion precludes shared knowledge", and "Experience and mutual awareness facilitate team interaction". CONCLUSIONS: Interprofessional collaboration from the radiographer's perspective within trauma teams requires a sense of inclusion and the ability to interact with the team. Exclusion from vital decision-making obstructs radiographers' comprehension of situations and thereby the interdependence in interprofessional collaboration. IMPLICATIONS FOR PRACTICE: Common platforms are needed for knowledge sharing and team practices, including radiographers' areas of responsibility and relational coordination to foster interprofessional relationships. Through these means interdependence through awareness and shared knowledge can be facilitated on trauma teams.

The feasibility of existing JADAS10 cut-off values in clinical practice: a study of data from The Finnish Rheumatology Quality Register.

BACKGROUND: The ten-joint juvenile arthritis disease activity score (JADAS10) is designed to measure the level of disease activity in non-systemic juvenile idiopathic arthritis by providing a single numeric score. The clinical JADAS10 (cJADAS10) is a modification of the JADAS10 that excludes erythrocyte sedimentation rate (ESR). Three different sets of JADAS10/cJADAS10 cut-offs for disease activity states have been published, i.e., the Backström, Consolaro, and Trincianti cut-offs. The objective of this study was to investigate the performance of existing JADAS10 cut-offs in real-life settings using patient data from The Finnish Rheumatology Quality Register (FinRheuma). METHODS: Data were collected from the FinRheuma register. The proportion of patients with an active joint count (AJC) above zero when classified as being in clinically inactive disease (CID) or low disease activity (LDA) groups according to existing JADAS10/cJADAS10 cut-off levels were analyzed. RESULTS: A significantly larger proportion of the patients classified as being in CID had an AJC > 0 when using the JADAS10/cJADAS10 cut-offs by Trincianti et al. compared to those for the other cut-offs. In the LDA group, a significantly larger proportion of the polyarticular patients (35%/29%) had an AJC of two when Trincianti JADAS10/cJADAS10 cut-offs were used compared with when Backström (11%/10%) and Consolaro (7%/3%) JADAS10/cJADAS10 cut-offs were used. CONCLUSIONS: We found the cut-offs proposed by Consolaro et al. to be the most feasible, since these cut-off levels for CID do not result in the misclassification of active disease as remission, and the proportion of patients with AJC > 1 in the LDA group is lowest using these cut-offs.

Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial.

BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89-6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.

The effects of plasmalyte-148 vs. Hartmann's solution during major liver resection: a multicentre, double-blind, randomized controlled trial.

BACKGROUND: The acid-base, biochemical and hematological effects of crystalloid solutions have not been comprehensively evaluated in patients with liver resection. DESIGN: multicenter, prospective, double-blind randomized controlled trial investigating the biochemical effects of Hartmann's solution (HS) or Plasmalyte-148 (PL) in 60 patients undergoing major liver resection. PRIMARY OUTCOME: base excess immediately after surgery. SECONDARY OUTCOMES: changes in blood biochemistry and hematology. RESULTS: At completion of surgery, patients receiving HS had equivalent mean standard base excess (-1.7±2.2 vs. -0.9±2.3 meq/L; P=0.17) to those treated with PL. However, patients treated with HS were more hyperchloremic (difference 1.7 mmol/L, 95% CI: 0.2 to 3.2, P=0.03) and hyperlactatemic (difference 0.8 mmol/L, 95% CI: 0.2 to 1.3; P=0.01). In contrast, patients receiving PL had higher mean plasma magnesium levels and lower ionized calcium levels. There were no significant differences in pH, bicarbonate, albumin and phosphate levels. Immediately after surgery, mean PT and aPTT were significantly lower in the PL group. Intraoperatively, the median (IQR) blood loss in the PL group was 300 mL (200:413) vs. 500 mL (300:638) in the HS group (P=0.03). Correspondingly, the postoperative hemoglobin was higher in the PL group. Total complications were more frequent in the HS Group (56% vs. 20%, relative risk 2.8; 95% CI: 1.3 to 6.1; P=0.007). CONCLUSION: In liver resection patients, HS and PL led to similar base excess values but different post operative plasma biochemistry and hematology values. Understanding of these effects may help clinicians individualize fluid therapy in these patients.

Assessment of PCDD/Fs levels in soil at a contaminated sawmill site in Sweden--a GIS and PCA approach to interpret the contamination pattern and distribution.

Polychlorinated dibenzo-p-dioxins and polychlorinated dibenzo-p-furans (PCDD/Fs) were analysed in soil from a Swedish sawmill site where chlorophenols (CPs) had been used more than 40 years ago. The most contaminated area at the site was the preservation subarea where the PCDD/F WHO2005-TEQ level was 3450 times higher than the current Swedish guideline value of 200 ng TEQ/kg soil for land for industrial use. It was also shown that a fire which destroyed the sawmill might have affected the congener distribution at the concerned areas. To get a broader picture of the contamination both GIS (spatial interpolation analysis) and multivariate data analysis (PCA) were applied to visualize and compare PCDD/F levels as well as congener distributions at different areas at the site. It is shown that GIS and PCA are powerful tools in decisions on future investigations, risk assessments and remediation of contaminated sites.

Attitudes among hospital physicians to the reporting of adverse drug reactions in Sweden.

OBJECTIVES: This study was designed to investigate attitudes to and incentive for reporting adverse drug reactions (ADRs) in general and towards nurses as reporters of ADRs in particular in a sample of hospital physicians. METHOD: A questionnaire was sent to 1,201 randomly selected hospital physicians. RESULTS: The main factors for the decision to report an ADR were the severity of the reaction, a reaction to a new drug, and an unusual reaction. The most important factor for refraining from reporting was that the reaction was well known. There were no significant differences between males and females or between age groups in these aspects. A majority were positive or neutral to nurses as reporters. Only 6% stated that their willingness to report ADRs would be affected in a negative way if nurses were involved in the program for reporting. CONCLUSIONS: The results of this survey showed that inclusion of hospital nurses as reporters will not decrease the reporting rate from the physicians.

Adverse drug reaction reporting by nurses in Sweden.

AIM: To investigate whether nurses could be a useful tool for improving the reporting rate of adverse drug reactions (ADRs). Furthermore, we wanted to study how physicians working at the study departments would respond to nurses as reporters of ADRs and if the reporting from the nurses affected the reporting rate from the physicians. METHOD: Three departments of internal medicine and one unit for orthopaedics were selected for the study. Nurses with special drug responsibilities were invited to participate. At the start of the study period, the nurses received an introduction with background, objective, method and other practical issues concerning the study. After this, an education programme about ADR reporting, definitions, and ADR classification according to mechanism and organ system was given. To study their knowledge about and attitude towards ADRs, a questionnaire was handed out to the nurses. A questionnaire was also handed out to all physicians at the participating departments in order to investigate their attitude towards nurses as reporters of ADRs. RESULTS: Fifty-four nurses participated in the study. During the study period, a total number of 23 reports with 39 ADRs were sent to the regional centres by the nurses. Seventeen (74%) of the reports were assessed as serious. Eight of the 39 ADRs were unlabelled and all reports were considered appropriate. The reporting rate from the physicians during the study period was similar to the previous year, indicating that the nurses contributed with additional reports. At the end of the study, the nurses thought that they had enough knowledge to report ADRs. Sixty-eight percent of the physicians did not object to nurses being included as reporters of suspected ADRs. CONCLUSION: Adverse drug reaction reporting by nurses could improve the overall safety of drugs.

Historical pollution of seldom monitored trace elements in Sweden--Part A: sediment properties and chronological indicators.

Sediment cores from four small oligotrophic boreal lakes, with minor acidification, in remote regions of central Sweden were used for historical interpretation of their metal content, with focus on Cu, Cd, Pb and Zn in Lake Stensjön, which has the longest sediment record (at least two centuries according to (210)Pb dating). Comparison is made with the other three lakes. Major and trace elements in lake water, porewater and the acid-leached (HNO(3)) solid sediment phase was analysed with ICP-MS. In addition, general lake water chemistry, TOC and principal anions were measured in the aqueous phases. Redistribution processes were interpreted from geochemical modelling. The solid/solution distribution of pe/pH sensitive elements, indicates a minor diagenetic redistribution and the concentration profiles are therefore suitable for chronological evaluation. The ratios of Al, Ti, Sc and V, indicated a qualitative shift of sedimenting material a century ago, which did not have any impact on the retention of trace elements. Lead had a concentration profile, supported by the (206)Pb/(207)Pb ratio, where it was possible to distinguish preindustrial conditions, early industrialisation in Europe, industrialisation in Sweden, and the use of leaded petrol after the Second World War. Cadmium showed a similar concentration pattern. The zinc profile resembled that of cadmium, but with less enrichment. Local lithogenic sources are believed to be quantitatively important. The solid/solution distribution (K(d)) was independent of depth for all four elements. The sediment concentrations of copper and zinc are not related to early industrialisation but its concentration has doubled since the Second World War.

A small economic inducement to stimulate increased reporting of adverse drug reactions--a way of dealing with an old problem?

PURPOSE: To assess the effect of a small economic inducement on the rate of spontaneous reporting of adverse drug reactions (ADRs) and the attitudes of general practitioners and physicians towards reporting of ADRs. METHOD: One intervention and one control county were selected for the study. Written information about the main purpose of spontaneous reporting of ADRs was personally addressed to all physicians in the two counties. The information was identical, except for the addition that during a period of 6 months two lottery tickets would be given to the receivers in the intervention area with the standard personal feedback to the reporter of the ADR. After the 6-month study period, the actual number of reported ADRs and the seriousness of the reported ADRs were assessed. To investigate the attitude towards this stimulation of reporting, a questionnaire was addressed to all physicians within the intervention area (IA). RESULTS: From the IA a total number of 57 ADR reports were received containing 62 suspected ADRs, 40% of which were assessed as serious reactions. From the control area (CA), 49 reports containing 50 suspected ADRs were received, 32% of which were assessed as serious reactions. The increase of ADR reports from the IA compared to the same time period the previous year was 59% as compared to an unchanged reporting from the CA. Of those responding to the questionnaire, 80% did not believe that a small economic bonus would be a useful tool to improve the reporting rate. CONCLUSION: A small economic inducement is associated with an increase in the reporting of suspected ADRs.

Bone structure and volumetric density in young adults born prematurely: a peripheral quantitative computed tomography study.

Prematurity is known to be associated with reduced bone mineral density (BMD) in childhood, but whether this condition has long-term detrimental consequences on adult bone structure is not known. In this study, we measured with peripheral quantitative computed tomography (pQCT) the total bone cross-sectional area, cortical area and wall thickness, cortical and trabecular density, and a density-weighed polar section modulus as a bone strength index (BSI) at distal and shaft sites of right radius and tibia in a group of 40 prematurely born, otherwise normally developed and healthy young adults (17 women and 23 men, aged 18 to 27 years) and compared their data to corresponding data obtained from a group of 42 control subjects born term (20 women and 22 men, aged 18 to 28 years). Body height and weight were similar in both groups, but the preterm group had significantly lower BSI values at distal sites of tibia (approximately -16%) and radius (approximately -13%) and at tibial shaft (approximately -11%) as compared to control group. In the weight-bearing tibia, BMC was lower and the lower BSI values were mainly due to smaller total bone cross-sectional area. For unknown reason, this prematurity-associated detrimental effect seemed to concern more men than women. In contrast, prematurity was not associated with volumetric trabecular and cortical densities at any measured bone site while the typical sex differences in bone density were observed. We conclude that prematurity is associated with somewhat smaller cross-sectional bone dimensions in terms of body size in young adulthood. Due to the cross-sectional design, this study could not reveal specific reasons but they may pertain to nutrition during the neonatal period and living habits in general.

Under-reporting of serious adverse drug reactions in Sweden.

INTRODUCTION: Adverse drug reactions (ADR) constitute a major problem, both from a medical point of view and as an economical burden. Spontaneous reporting of ADRs is one of the methods for post marketing surveillance of drug safety. Under-reporting can also provide an important obstacle to rapid and relevant signal detection. AIM: To investigate the rate of under-reporting serious ADRs of selected ICD 10 diagnoses. METHOD: In order to investigate the under-reporting rate we investigated at five hospitals within the county of Norrbotten in Sweden the total number of diagnosed cases during a period of 5 years (1996-2000) with the following diagnoses: cerebral haemorrhage (I 61.0-I 61.9), pulmonary embolism (I 26.0 and I 26.9), embolism or thrombosis (I 74.0-I 74.9), phlebititis, thrombophlebitits or venous thrombosis (I 80.0-I 80.3, I 80.8 and I 80.9) and portal vein thrombosis and other thrombosis or emboli (I 82.0-I 82.3, I 82.8 and I 82.9). The identity of these patients was obtained through a database search. The patients' case records were then scrutinized by a specially trained nurse and the drugs used at the time of the event were noted. An assessment of the possibility of an ADR was performed using standard WHO causality criteria. Later, database search in the Swedish ADR registry was performed in order to investigate whether these suspected ADRs had been reported to the national authority in Sweden or not. RESULTS: In total 1349 case records were found and scrutinized. Of these, 107 patients had received drugs that could have been a probable or possible cause to the diagnoses. Of these 92 cases had not been reported and only 15 patients were found in the database, giving an overall under-reporting rate of all ADRs of 86%. The most commonly occurring diagnoses were cerebral haemorrhage followed by venous thrombosis, 545 and 468 respectively. Among those cases that should have been reported according to the existing rules for spontaneous reporting of suspected ADRs the most frequently occurring diagnosis was cerebral haemorrhage (I 61.0) in connection to treatment with anticoagulants. CONCLUSION: The rate of spontaneous ADR reporting is very low, also for serious and fatal reactions.

Bioprocess development for the production of a recombinant MUC1 fusion protein expressed by CHO-K1 cells in protein-free medium.

The mucin MUC1 is a candidate for use in specific immunotherapy against breast cancer, but this requires the large-scale production of a MUC1 antigen. In this study, a bioprocess for the expression of a recombinant MUC1 fusion protein with a cancer associated glycosylation in CHO-K1 cells has been developed. Cells permanently expressing parts of the extracellular portion of MUC1 fused to IgG Fc were directly transferred from adherent growth in serum-containing medium to suspension culture in the protein-free ProCHO4-CDM culture medium. Using the Cellferm-pro system, optimal culture parameter as pH and pO(2) were determined in parallel spinner flask batch cultures. A pH of 6.8-7.0 and a pO(2) of 40% of air saturation was found to give best cell growth and productivity of secreted recombinant protein. Specific productivity strongly depended the pO(2) and correlated with the online monitored oxygen uptake rate (OUR) of the cells, which indicates a positive influence of the rate of oxidative phosphorylation on productivity. The optimised conditions were applied to continuous perfusion culture which gave very high cell densities and space time yields of the recombinant MUC1 fusion protein, allowing production at gram scale. The product degradation was much lower in supernatants from continuous perfusion culture compared to batch mode. Antibodies reacting with cancer associated MUC1 glycoforms strongly bound to the fusion protein, indicating that the desired glycoforms were obtained and suggesting that the recombinant MUC1 protein could be tested for use in immunotherapy.

Personality and self-variables: important determinants of subjective quality of life in schizophrenia out-patients.

OBJECTIVE: To investigate factors determining severely mentally ill patients' self-rated quality of life. The study hypothesized that objective life circumstances, personality, self-variables, and psychopathology would be determinants of quality of life. METHOD: A total of 117 individuals with schizophrenia and related disorders were investigated. Structural equation modelling was used to: 1). investigate if one or more subfactors best described the covariance within each potential determinant and quality of life, 2). explore the relations between all variables and factors extracted in step 1. RESULTS: A multi-factorial model indicated that a self-factor and two psychopathology factors worked as mediators of self-rated quality of life, in turn composed of an internal and an external aspect. Personality dimensions and objective life circumstances accounted directly or indirectly for substantial parts of quality of life. CONCLUSION: The relative importance of individual characteristics and objective indices was shown. Trait-like properties, such as the self-factor and personality, explained most of the variation in self-rated quality of life.

Seasonal variations in road runoff quality in Luleå, Sweden.

In regions with cold climate the urban drainage and highway runoff processes become much more complex, compared to temperate regions. Therefore, climatic conditions should be taken into account in planning and design of BMPs and snow handling strategies. In order to increase the knowledge of road runoff quality during melt and rain periods, respectively, measurements were carried out at a field site during a two-month period. The field site was situated at Södra Hamnleden, a road with 7,400 vehicles/day, in the central part of Luleå. Runoff samples were analysed for suspended solids and heavy metals (Pb, Cu, Cd, Ni and Zn). The results showed that the concentrations of suspended solids, lead, copper and cadmium were higher for the melt period, compared to rain generated runoff on the catchment without snow, and the highest concentrations were found during the rain-on-snow events. The results indicate a flow dependent increase in the concentration of suspended solids during the melt period. A comparison of the total mass of suspended solids over a one-month period showed that the melt period produced about 3 times more suspended solids. Metal elements during melt period were more particulate bound as compared to the rain period characterised by a higher percentage of the dissolved fraction.

Grassed swales for stormwater pollution control during rain and snowmelt.

The retention of suspended solids, particles and heavy metals in different grassed swales during rain events and snowmelt is discussed. The experimental results derived from investigations performed in existing grassed swales in the Luleå region, Northern Sweden. During high pollutant loading rates, grassed swales retain significant amounts of pollutants, mainly due to sedimentation of particulate matter. Low to moderate removal efficiencies could be expected for heavy metals, especially metals in solution (i.e. the dissolved phase). When grassed swales receive urban runoff with low pollutant concentrations, they may release rather than retain pollutants. Swales are important snow deposit areas in the city and particle bound pollutants do to a large extent remain in the swale after snowmelt. However, dissolved pollutants (i.e. dissolved heavy metals) are likely to escape the swale with the melt water. Grassed swales may be regarded as facilities that even out the peaks in pollutant loads without being capable of producing consistent high removal rates. This suggests that swales should be considered as primary treatment devices. Possible design parameters for grassed swales are mean hydraulic detention time, surface loading rate or specific swale area.

Stormwater management in a catchbasin perspective--best practices or sustainable strategies?

A strategy for sustainable stormwater management is needed. This study has focused on the relative importance of stormwater as a pollutant source in a catchbasin, if Best Management Practices (BMPs) result in pollutant removal or pollutant redistribution, and methods for screening of stormwater strategies. Stormwater is most likely an important pathway for pollutants in a catchbasin perspective. True pollutant removal can only be achieved if the pollutant sources are eliminated. Until that is reached, we should have the best possible control of the pollutant fluxes in the watershed. This study indicates that the search for a sustainable stormwater strategy could be easier to handle if different "screens" could be used. The Swedish environmental objectives, which try to encapsulate all aspects of sustainability, may be used as a foundation for a "sustainability screen". By using this screen, the "unsustainable" features of different stormwater strategies could be pointed out. A "standards and legislation screen" will be based on the EU Water Framework Directive. As this study has shown, it is doubtful whether the conventional BMPs, such as stormwater ponds and infiltration facilities, produce a sufficient pollutant control.

Utilization pattern of metamizole in northern Sweden and risk estimates of agranulocytosis.

OBJECTIVE: This study was carried out in order to investigate the utilization pattern of metamizole to better estimate the quantitative risk of agranulocytosis since a cluster of such cases have been observed in Sweden. METHODS: Cases of agranulocytosis submitted to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) between 1996 and 1999 were identified. Based on the utilization pattern of metamizole in inpatients at three hospitals and in outpatients in two counties in northern Sweden risk estimates of agranulocytosis during metamizole treatment were estimated. The utilization of metamizole was investigated by scanning 3567 case records at 10 hospital departments as well as stored prescriptions at six pharmacies during a 3-month study period. RESULTS: Ten cases of agranulocytosis during treatment with metamizole have been reported to SADRAC over the period 1996 to 1999. During the 3-month study period metamizole was prescribed to 666 (19%) inpatients. Of these, approximately 96% received the drug for less than 1 week, 7.2% had used the drug previously. At the participating pharmacies 112 metamizole prescriptions for outpatients were found. The drug was prescribed in 34% for less than 1 week, in 28% for 7-15 days, and in 38% for more than 15 days. The mean prescribed daily dose was 2.7 g. Given certain assumptions including the actual amounts prescribed the calculated risks of agranulocytosis would be approximately one out of every 31,000 metamizole-treated inpatients and one of every 1400 metamizole-treated outpatients. CONCLUSION: This study indicates that in most inpatients the use of metamizole in northern Sweden was within the approved indications for the drug. However, a considerable number of outpatients received the drug for a longer time than recommended and this may carry an increased risk for developing agranulocytosis.

Sediment transport in grassed swales during simulated runoff events.

Particle trapping in nine different grassed swales was measured successfully with a standardised runoff event simulation procedure. The percentage of total suspended solids removed ranged from 79 to 98%. It was found that sedimentation processes, rather than grass filtration governed the overall particle trapping efficiency. The highest particle trapping efficiency was observed in the field swales with dense, fully developed turf. A high infiltration rate was beneficial for the particle trapping and an increased swale length made it possible for smaller particles to be captured. A densely vegetated, ten metre long swale, receiving a stormwater flow of 1.0 litres per second, may capture a majority of the waterborne particles with settling velocities larger than 0.1 metres per hour. A simple model of particle trapping efficiency in grassed swales was developed and tested. It was found that mean swale residence time could be used as a design parameter for particle removal in grassed swales. The suggested exponential relationship between mean swale residence time and particle settling velocity associated with a certain trapping efficiency is so far only valid for a limited range of swale designs and residence times.

Spontaneous reporting of adverse drug reactions by nurses.

BACKGROUND: Spontaneous reporting of adverse drug reactions (ADRs) remains one of the most effective methods to detect new and serious drug reactions. However, it is well known that there is a high degree of under-reporting. OBJECTIVE: This study was carried out as an attempt to improve and increase the reporting of ADRs by investigating the utility of nurses reporting in addition to physicians, as usual. METHODS: During a 12-month study period, nurses working at two departments of geriatric medicine in northern Sweden received special instruction regarding drugs and ADRs, ADR reporting and special aspects of ADRs in elderly people. The reports from the nurses were scrutinized concerning the seriousness of the reaction, reported drugs and type of reaction (type A or B). All nurses working at the two departments (117) were eligible to report but in practice only those attending the teaching sessions did so. A comparison with historical reporting and with reporting from other geriatric departments in Sweden was also carried out. At the end of the study all participating nurses received a questionnaire aimed at investigating their attitudes towards ADR reporting. RESULTS: After the 12-month study period 18 ADR reports involving 22 reactions had been received. Seven of these were assessed as serious reactions. All of the reactions were of type A. In comparison, during the corresponding time period from the study clinics during the preceding year, only two reports were registered. During the study period only 15 reports were registered from the other 50 geriatric departments in Sweden. CONCLUSION: Even though the total number of ADR reports was small, our data indicate a substantial increase in the reporting rate. This indicates that instructed and interested nurses could play an important role in detecting and reporting suspected ADRs.