Electronic health records and adverse drug events after patient transfer.

BACKGROUND: Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care. METHODS: 469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters. RESULTS: The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI -0.81 to 0.85), high-risk medication discrepancies (-0.18; 95%CI -0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01). CONCLUSIONS: There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

BACKGROUND: Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing. METHODS: We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs. RESULTS: 208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1-2 and >/=3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively. CONCLUSIONS: Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

Development of definitions for acute illness in nursing home residents based on chart-recorded physical exam findings.

OBJECTIVES: To develop and test simple, chart-based criteria for acute illness in nursing home residents for clinical and epidemiological study. DESIGN: Observational study. SETTING: A 409-bed not-for-profit nursing home. PARTICIPANTS: 102 custodial care residents. MEASUREMENTS: Physical exam findings commonly performed in nursing home residents were used to define 10 acute conditions. Residents were observed prospectively to test the clinical relevance of these definitions. Episodes of acute illness satisfying definition criteria were identified, as well as treatment changes, hospitalizations, and deaths. RESULTS: During a median follow-up of 60 days, 43 acute illnesses occurred, affecting 30 (29%) residents. Of these episodes, 77% were associated with treatment changes, hospitalization, or death. The new definitions captured 79% of all episodes of acute illness. The most common diagnoses were urinary tract infection, lower respiratory infection, and gastroenteritis/gastrointestinal upset. Independent risk factors for acute illness were gastrostomy feeding, depression, and history of fracture. CONCLUSIONS: Acute illness in the nursing home is common and frequently associated with treatment changes, hospitalization and death. It can be identified using a small number of chart-recorded physical exam-based findings as criteria.

Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument.

BACKGROUND: Acute illness causes considerable morbidity and mortality in nursing home residents but is often difficult to recognize early. Nursing assistants often notice early signs of acute illness but do not methodically document or communicate their observations with medical staff. OBJECTIVE: To enhance nursing assistants' observation and documentation of signs of acute illness by developing a validated, standardized instrument for communication with medical staff. DESIGN: Observational cohort study. SETTING: Urban not-for-profit nursing home. SUBJECTS AND METHODS: Candidate instrument items were generated in focus group interviews with nursing home staff. Twenty-three nursing assistants completed the instrument on 74 nursing home residents over 4 weeks. Acute illness, the primary outcome, was identified by nurse report and chart review and determined according to preset criteria. MEASUREMENTS: Predictive validity was assessed by determining the relationship between instrument responses and development of acute illness within 7 days. Interobserver agreement was calculated between morning and afternoon nursing assistants' responses. Convergent validity was assessed by comparing instrument responses with three standard status indicators. RESULTS: The instrument consisted of 12 items that assessed behavioral and functional status changes. Residents with an instrument-recorded change were more likely to develop an acute illness within 7 days than those with no change (risk ratio 4.1, 95% confidence interval 2.6, 6.3). A final five-item instrument had a sensitivity of 53% and a specificity of 93% for acute illness. Nursing assistants' documentation of signs of illness preceded chart documentation by an average of 5 days. Interobserver agreement between morning and afternoon nursing assistants was 76%. Correlation of responses with standard indicators of functional, mental, and global status was high. CONCLUSIONS: A new instrument developed for nursing assistants to document behavioral and functional status changes in nursing home residents demonstrates fair sensitivity and high specificity for acute illness. Close monitoring of patients with a positive instrument might avert morbidity and mortality from acute illness by allowing earlier treatment.

Nitric oxide produced during murine listeriosis is protective.

Nitric oxide (NO) has been shown to be important for intracellular microbiostasis in vitro. To determine the role of NO in immune function in vivo, groups of C57BL/6 mice were given a sublethal intravenous inoculum of Listeria monocytogenes EGD, and their urine was monitored daily for nitrate, the mammalian end product of NO metabolism. Urinary nitrate levels peaked at 5 to 10 times the basal level on days 5 to 6, when spleen and liver Listeria counts declined most steeply, and decreased thereafter, when spleens and livers were nearly sterile. Peritoneal macrophages explanted from Listeria-infected mice produced nitrite spontaneously, whereas macrophages from uninfected mice did not. The inducible NO synthase mRNA was detectable in the spleens of infected mice on days 1 to 4 of infection. When Listeria-infected mice were treated orally throughout the infection with NG-monomethyl-L-arginine (NMMA), a specific NO synthase inhibitor they showed no detectable rise in urinary nitrate excretion. Mean Listeria counts in the livers and spleens NMMA-treated mice were 1 to 3 orders of magnitude greater than counts in control mice on days 4 through 8 of infection. Compared with control mice, NMMA-treated mice also showed worse clinical signs of infection, namely, weight loss, hypothermia, decreased food and water intake, and decreased urine output. Histologically NMMA-treated mice had many more inflammatory foci in their livers and spleens than control mice. The histologic observation that mononuclear cells are present at sites of infection suggests that inhibiting NO production did not block the flux of macrophages into infected viscera. As controls for possible drug toxicity, a group of uninfected mice given NMMA orally showed no detrimental effects on weight, temperature, and food and water intake. These experiments demonstrate that inhibition of NO production in Listeria-infected mice results in an exacerbated infection and thus that NO synthesis is important for immune defense against Listeria infection in mice.

Iridoid glycosides ofChelone glabra (Scrophulariaceae) and their sequestration by larvae of a sawfly,Tenthredo grandis (Tenthredinidae).

Analysis ofChelone glabra (Scrophulariaceae) by gas chromatography showed that leaves of this plant contained primarily the iridoid glycoside catalpol, and in a few individuals some aucubin was also detected. There was no difference in the iridoid glycoside content of damaged compared to undamaged plants, nor was there a difference between plants collected from a population in Leverett, Massachusetts, and those from plants in an experimental garden in Cambridge, Massachusetts. Larvae and prepupae of the sawfly,Tenthredo grandis (Tenthredinidae) contained catalpol sequestered from the larval host plant. The exuvia also contained catalpol, whereas the frass contained only aucubin. These results indicate that larvae of this sawfly selectively sequester catalpol, eliminating the aucubin in the frass.