Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.

PURPOSE: Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration (BCMA) system were evaluated. METHODS: All patients receiving warfarin who were admitted to a university medical center between July 1, 2008, and February 6, 2009, in inpatient units with BCMA systems were candidates for inclusion in this study. Medication-error alerts displayed to the nurse administering the warfarin were reviewed to determine whether a true potential error was detected. Each alert was converted to a scenario, and its potential to require treatment or cause patient harm was rated using a validated severity scale of 0-10, where a score of 0 indicated no probable effect on the patient and 10 indicated that the error would likely result in patient death. A severity score was obtained by averaging the scores of four pharmacist reviewers. RESULTS: Of the 18,393 warfarin doses ordered during the study period for 2,404 patients, error alerts associated with only 99 warfarin doses were found to be clinically meaningful. The mean ± S.D. severity rating of these alerts was low (2.93 ± 1.42), with a standardized Cronbach's coefficient alpha of 0.845. The mean ± S.D. warfarin dose attempted when the nurse received an alert was 4.10 ± 2.48 mg. The majority of doses with alerts (70%) were for patients who had an active order for warfarin. CONCLUSION: Of the large number of medication-error alerts generated through a BCMA system, only a small proportion were considered clinically significant. This indicated that the rate of false-positive alerts was unexpectedly high, increasing the risk of alert fatigue.

Experience of monitoring beaches for radioactive particles.

This paper discusses some of the theoretical and practical problems that are encountered in monitoring beaches for hot particles. The experience is from operating a near-continuous monitoring program, for a period of eight years, on beaches near the Dounreay site. The reliability and failure mechanisms of the monitoring systems used will be discussed, together with remedial actions employed. The viability and performance of several types and configurations of radiation detectors will be described, along with methods by which particles might be detected, given their response to buried particles. When large areas are being monitored at high spatial resolution, which is required for efficient particle detection, the volume of data recorded for audit purposes can be very large. The use and abuse of Geographical Information Systems for this work is described. Other practical aspects of performing surveys are also discussed, including understanding health-and-safety requirements; constraints imposed by weather, tides and tidal speed; the logistics of making vehicles available to perform the work; and how a particle should be recovered once detected.