Leakage associated with urinary catheter usage: a design challenge.

Indwelling bladder catheter-associated leakage, or catheter bypassing, is a frequently experienced problem, necessitating a carefully planned intervention. Once a bladder catheter is in place, urine may flow intermittently between the catheter shaft and the urethra mucosa, or from around the catheter when inserted suprapubically. A review of the literature identified several reasons for this leakage, including catheter size and anatomical abnormalities. Based on clinical experience, the authors posit that indwelling catheter leakage may also occur as a result of a catheter design flaw. This article provides the theoretical rationale for this hypothesis and a potential solution; formal, rigorous, and appropriate research should be performed to test the hypothesis.

Internal reporting system to improve a pharmacy's medication distribution process.

PURPOSE: The current pharmacy occurrence-reporting system in an institution was reviewed, and an internal procedure that would provide data to improve the medication-use process was developed. SUMMARY: In a rural, 353-bed, tertiary care academic center, the effectiveness of a departmental occurrence-reporting system was determined over a nine-month period to increase occurrence reporting within the pharmacy and allow administrators to identify specific areas for improvement within the medication distribution process. These events were identified according to the number and type of near misses documented by pharmacy staff. The pharmacy staff was asked to complete a survey about the department's current reporting process and what the staff desired in a new occurrence-reporting system. The staff was also surveyed on which steps of the pharmacy's medication distribution process could contribute to the most errors. Initially, a paper-based error-reporting form was developed for all steps of the pharmacy distribution process except pharmacist order entry. Once the paper-based error-reporting form was introduced, the pharmacist order-entry phase of the project was begun. During the evaluation period, 203 pharmacy-dispensing errors were reported to the hospital's error-reporting system. In contrast, 1385 total pharmacy events were documented using the pharmacy's internal occurrence-reporting system. At least 204 of those reported events involved high-alert medications according to the institution's high-alert medications policy. CONCLUSION: A pharmacy internal occurrence-reporting system increased staff reporting and identified areas for improvement within the medication distribution process that may not have been recorded by a hospital-based reporting system.

Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest.

STUDY OBJECTIVE: This study evaluates inter-rater reliability and comfort of BLS providers with the application of an out-of-hospital Basic Life Support Termination of Resuscitation (BLS TOR) clinical prediction rule. This rule suggests that continued BLS cardiac resuscitation is futile and can be terminated in the field if the following three conditions are met: (1) no return of spontaneous circulation; (2) no shock given prior to transport; (3) cardiac arrest not witnessed by EMS personnel. METHODS: Providers hypothetically applied the rule and rated their comfort level on a five-point Likert-type scale, from "very comfortable" to "very uncomfortable" during the prospective validation of a BLS TOR clinical prediction rule in out-of-hospital cardiac arrest conducted in 12 rural and urban communities [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. New Engl J Med 2006;355(5):478-87]. A Kappa score measured agreement between providers and compared to the correct interpretation of the rule. RESULTS: We compared mean comfort levels of providers who interpreted the rule correctly versus incorrectly. Of 1240 enrolled cases, 1184 (95.5%) had paramedic attendant forms and 1211 (97.7%) had driver forms and 1175 (94.7%) had both. Kappa for interpretation agreement between driver and attendant was 0.90 (95% CI, 0.87-0.92); between attendant and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91); between driver and correct interpretation of the BLS TOR clinical prediction rule, 0.88 (95% CI, 0.85-0.91). For instances in which both providers applied the rule correctly (607/635 [95.6%]), the providers were significantly more comfortable (chi(2)(4)=30.5, p<0.0001) than those instances in which they did not (28/635 [4.4%]. CONCLUSIONS: The vast majority of providers were able to apply the BLS TOR clinical prediction rule correctly and were comfortable doing so. This suggests that both reliability and comfort will remain high during routine application of the rule when paramedics are well trained as users of the rule.