Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome.

OBJECTIVE: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. DESIGN: Retrospective cross-sectional study. SETTING: One academic and three community hospitals in the Chicago region. PATIENTS: A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. MEASUREMENTS AND MAIN RESULTS: Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight. CONCLUSIONS: More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.

Counting matters: lessons from the root cause analysis of a retained surgical item.

BACKGROUND: Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. The retained sponge was removed with no further complications. ROOT CAUSE ANALYSIS: The fundamental error involved the obstetric team's failure to perform the standard protocol of counting sponges before, as well as after, the procedure. This was attributed to a lack of reminders to perform the count, relatively recent implementation of the sponge-count policy, and a breakdown in teamwork and communication between physicians and nurses. CORRECTIVE ACTIONS: The corrective actions focused on systems improvement, as opposed to the human error of the memory lapse. The sponge-counting process was reinforced by incorporating a sign-out at the end of obstetric procedures to ensure that the counts have been done and any discrepancies addressed. A specialized delivery note with mandatory field to document sponge count was implemented in the electronic health record as an additional reminder. All staff participated in a teamwork and communication training program. TRACKING COMPLIANCE: Since the incident's occurrence in 2010, the staff has demonstrated 100% compliance with the corrective actions, and a retained surgical item complication has not recurred. CONCLUSION: Individual accountability must be balanced with systems improvement, given that most medical errors are a result of fallible humans working in chaotic, unpredictable, and complex clinical environment.

Barcode medication. Administration implementation in an acute care hospital and lessons learned.

Bar code medication administration (BCMA) systems ensure the five "rights" during medication administration: right patient, drug, dose, route and time. Implementing BCMA is a vital component of a medication safety strategy. Implementing BCMA is a complex project that involves many disciplines, each with unique workflow implications. For example, nursing has interface configuration and hardware reliability concerns, whereas pharmacy considers efficiency maximization and inventory management of unit-dosed bar coded medications as the main priorities. Suboptimal planning or ineffective project methodology may lead to poor adoption or to nurses implementing BCMA workarounds that can negate potential benefits or lead to new errors. This paper describes our experience in successfully implementing a BCMA system at a 630-bed acute tertiary care public hospital. We will describe the BCMA system and project methodology, discuss important considerations related to pharmacy, technology, admitting, nursing adoption and service area considerations, and share lessons learned.

Medication errors: problems and recommendations from a consensus meeting.

Here we discuss 15 recommendations for reducing the risks of medication errors: 1. Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. 2. Provision of opportunities for students to practise skills that help to reduce errors. 3. Education of students about common types of medication errors and how to avoid them. 4. Education of prescribers in taking accurate drug histories. 5. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. 6. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. 7. Comprehensive assessment of elderly patients for declining function. 8. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. 9. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. 10. More involvement of pharmacists in clinical practice. 11. Introduction of integrated prescription forms and national implementation in individual countries. 12. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. 13. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. 14. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. 15. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

Medication errors: prevention using information technology systems.

1. Given the high frequency of medication errors with resultant patient harm and cost, their prevention is a worldwide priority for health systems. 2. Systems that use information technology (IT), such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records, are vital components of strategies to prevent medication errors, and a growing body of evidence calls for their widespread implementation. 3. However, important barriers, such as the high costs of such systems, must be addressed through economic incentives and government policies. 4. This paper provides a review of the current state of IT systems in preventing medication errors.

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system.

BACKGROUND: Medication reconciliation (MedRecon) has been a Joint Commission National Patient Safety Goal since 2006. However, there is scant literature on the evaluation of electronic MedRecon systems in reducing medication errors and on improving reliability of the MedRecon process. METHODS: An electronic MedRecon system was designed and implemented in an acute inpatient care facility. Two analyses were performed: (1) one based on a 2-week pilot evaluation of the system based on 120 MedRecon events, and (2) a more comprehensive 17-month evaluation of the system, based on 19,356 MedRecon events. RESULTS: The unintended discrepancy rate between a patient's home medications and admission medication orders was reduced from 20% during the pilot phase to 1.4%. The omission of a home medication was the most common type of discrepancy. Nighttime admission (8 P.M.-8 A.M.), total home medications > four, patient age > 65 years, and resident physician performing the medication reconciliation were found to have a significant positive correlation (p < .05) with the discrepancy rate. Using computerized alerts improved compliance with the MedRecon process from 34% to 98%-100%. DISCUSSION: Using a multidisciplinary process based on an electronic system substantially reduced medication errors on admission, suggesting that an electronic MedRecon system can be an important tool in improving patient safety. The use of an interactive reminder alert in the MedRecon system improved systems reliability by ensuring physician compliance with MedRecon performance. Although computerized physician order entry (CPOE) decision support tools are an important component of medication error prevention strategies, they alone are not sufficient to prevent errors of prescribing.

Evaluation of an electronic medication reconciliation system in inpatient setting in an acute care hospital.

BACKGROUND: Medication reconciliation (MedRecon) is being implemented in many healthcare facilities as a means to reduce medication errors. However, there is scant literature on the evaluation of electronic MedRecon systems. OBJECTIVE: To evaluate the rate and type of discrepancies between a patient's home medication history and admission orders and to analyze factors affecting their occurrence using an electronic MedRecon system. DESIGN/METHODS: We analyzed 3,426 consecutive inpatient admission MedRecon events from August to October 2006 in an acute care hospital using a recently implemented electronic MedRecon system. RESULTS: Overall, discrepancy rate was 3.12% (n=107) with omission of a home medication being the most common type (56.52%, n=65) of discrepancy. Admission time(8 PM to 8 AM), and total home medications>4 were found to have a significant positive correlation with discrepancy rate. CONCLUSION: Using multidisciplinary MedRecon process based on an electronic system, we found a low discrepancy rate between patient's home medication history and admission orders compared with the rate in the literature, implying that an electronic MedRecon system is an important tool for improving patient safety.

Factors associated with improved completion of computerized clinical reminders across a large healthcare system.

OBJECTIVE: To analyze the relationship of completion rates for a standardized set of computerized clinical reminders across a large healthcare system to practice and provider characteristics. METHODS: The relationship between completion rate for 13 standardized reminders at 49 primary care practices in the VA New England Healthcare System for a 30-day period and practice characteristics, provider demographics and, via survey, provider attitudes was analyzed. RESULTS: There was no difference in clinical reminder completion rate between staff physicians versus nurse practitioners/physician assistants (87.6% versus 88.1%) but both were better than residents (76.6%, p<0.0001). With residents excluded, there were no differences between hospital and community-based clinics or between teaching and non-teaching sites. Clinical reminder completion rate was lower for sites that did not fully utilize support staff in completion process versus sites that did (82.4% versus 88.1%, p<0.0001). Analysis of survey results showed no correlation of completion rate with provider demographics or attitudes towards reminders. However there was significant correlation with frequency of receiving individual feedback on reminder completion (r=0.288, p=0.004). CONCLUSION: Completion of computerized clinical reminders was not affected by a variety of provider characteristics, including professional training, demographics and provider attitude, although was lower among residents than staff providers. However incorporation of support staff into clinic processes and individualized feedback to providers were strongly associated with improved completion. These findings demonstrate the importance of considering practice and provider factors and not just technical elements when implementing informatics tools.

Literature based discovery of gene clusters using phylogenetic methods.

Biomedical literature can offer valuable information for organizing genes associated with the etiology and pathogenesis of disease. In this study, we demonstrate the utility of existing phylogenetic methods for organizing 375 genes associated with Breast Cancer using the MeSH annotations from over 35,000 Medline articles. Specifically, we compare the clustering (using the Colless Imbalance Index, Ic) of distance-based methods, which are used by popular phylogenetic clustering algorithms, and a character- based method (Maximum Parsimony) that is commonly used for phylogenetic studies. Focusing on genes that cluster around BRCA1 and BRCA2, we examine the relevance of the clustered genes proposed by the different clustering methods based on the number of exclusive MeSH terms. Our results indicate that existing phylogenetic methods and associated metrics can be used for organizing genes according to annotated knowledge in biomedical literature.

Adherence to computerized clinical reminders in a large healthcare delivery network.

OBJECTIVE: To evaluate clinicians' adherence with clinical reminders (CRs) across multiple ambulatory practice settings in an integrated health care network. MATERIALS AND METHODS: Adherence rate to 15 CRs, integrated into a computerized patient record system, was evaluated for 451 clinicians in 49 clinics from eight Veterans Affairs (VA) medical centers. RESULTS: Overall, mean rate of adherence to CRs for all clinics was 86.2%, with a range of 66.59% to 97.08% (P<.001). The hepatitis C risk assessment reminder was found to have the highest overall adherence rate (95.9%) and the tobacco use cessation had the lowest adherence rate (62.9%). Mean adherence rate for all reminders was 80.34% (P<.001). Mean adherence rate for individual clinicians was 82.6%, with a range of 29% to 100%. CONCLUSION: While overall adherence to CRs was high, there is significant variation by clinic, individual clinician and individual CR. Understanding this variation is critical in directing future efforts to improve the contribution of computerized CRs to quality and cost-effectiveness of care, and to decrease undesirable variation in clinical practice. Further research is needed to systematically evaluate clinician, reminder and systems related factors that influence adherence to CRs.

A systematic critique of diabetes on the world wide web for patients and their physicians.

PURPOSE: The web, a widely accessed medium for patients to obtain health information, has special relevance for patients with diabetes. This paper critiques the publicly available web sites for diabetes, and it establishes criteria for excellence in these sites. METHODS: A web search for diabetes mellitus based on Google, Yahoo, and the directory Mendosa provided the basis for the study. We defined and evaluated three major categories for each site: usability, content, and reliability. Usability was defined by design, ease of navigation, interactivity, and internal search capability. Content was based on the quality of general information about diabetes, discussions about monitoring blood glucose, meal planning, exercise, complications, medications, alternative therapies, resources, and support systems. Reliability was defined by the presence of the HON code, identification of an author, and the availability of experts. RESULTS: The focused Mendosa search produced 47 web sites. The majority were published by commercial organizations. Five sites were found to have the best usability. Other sites were cluttered or inundated with distracting information from advertisements. Content was generally excellent but limited by an absence of specific advice and information about controlling associated risk factors for cardiovascular disease. Only 17% of sites met all criteria for reliability. The sites that best met the criteria for quality were the American Diabetes Association (www.diabetes.org) and the Joslin Diabetes Center (www.joslin.org). CONCLUSIONS: Despite the large numbers of publicly available web sites for diabetes, only a few met criteria for quality. The physician's input and ongoing evaluation of these quality measures are essential to assure that patients get meaningful and relevant information from the web about managing diabetes.

Information and communication technology in cardiovascular disease prevention in developing countries: hype and hope. Report of the International Collaboration on Information Use in Cardiovascular Health Promotion in Developing Countries.

Information can be an important tool in promoting a prevention strategy to address the emerging epidemic of cardiovascular disease in developing countries. Advances in information and communication technology offer new promises for global access to information and for global mobilization to prevent and control cardiovascular disease. This is especially true for health professionals, whose needs in areas such as networking, exchange of expertise and access to relevant advances remain unfulfilled. Information technology can also sensitize the lay public to the magnitude of cardiovascular diseases, creating awareness about risk states, and highlighting preventive strategies. Effective application mandates that the technology be relevant to local needs. Cost, feasibility, and relevance of information need to be considered before wide adoption is advocated. Several initiatives, such as ProCOR, Global Cardiovascular Infobase, Heartfile, and the Virtual Congress of Cardiology, have successfully utilized information technology to promote cardiovascular prevention. The experience of these initiatives suggests that, while information technology holds great potential, there are many potential perils, such as the widening global information gap, inequitable access, and irrelevant information. For now, information technology must be viewed as part of a broader strategy, which includes conventional communication media, to address the unmet information needs for cardiovascular prevention globally. Enlightened policies can exploit the energies of the recent information boom for promoting cardiovascular prevention, taking into account the considered limitations.

Return on investment analysis for a computer-based patient record in the outpatient clinic setting.

While the computer-based patient record (CPR) is considered essential technology for improving efficiency and quality of health care, the high cost of CPR implementation has been a major barrier to widespread acceptance of these systems. This paper describes a framework to evaluate the costs and benefits of implementing CPR systems in outpatient clinical settings. Return on investment (ROI), a measurement of the difference between the costs of and benefits from an investment, is one method to evaluate the economic implications of CPR. The major costs in acquiring a CPR system include the costs of hardware, software, networking, ongoing maintenance, installation and training, and opportunity costs. Benefits of CPR systems include improved productivity by reducing resource utilization or improving revenues; improved quality by providing convenient access to information at the point of care, computerized physician-order entry and decision support systems; and intangible benefits that can not be simply quantified in monetary terms, such as enhanced data capture and access, enhanced business management and improved legal and regulatory compliance. We believe that understanding the ROI framework will enable physicians to make informed strategic decisions regarding purchase and implementation of CPR systems in their practices.