A real-time assessment of factors influencing medication events.

Reducing medical error is critical to improving the safety and quality of healthcare. Physician stress, fatigue, and excessive workload are performance-shaping factors (PSFs) that may influence medical events (actual administration errors and near misses), but direct relationships between these factors and patient safety have not been clearly defined. This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. During an 18-month study period, 185 physician participants working at four university-affiliated teaching hospitals reported medication events using a confidential reporting application on handheld computers. Emotional stress scores, perceived workload, patient case volume, clinical experience, total sleep, and demographic variables were also captured via the handheld computers. Medication event reports (n = 11) were then correlated with these demographic and PSFs. Medication events were associated with 36.1% higher perceived workload (p < .05), 38.6% higher inpatient caseloads (p < .01), and 55.9% higher emotional stress scores (p < .01). There was a trend for reported events to also be associated with less sleep (p = .10). These results confirm the effect of factors influencing medication events, and support attention to both provider and hospital environmental characteristics for improving patient safety.

A real-time assessment of work stress in physicians and nurses.

OBJECTIVE: This study adapted ecological momentary assessment methods to: (a) examine differences in work stress between nurses and physicians, and (b) to study relationships between work stress, work activity patterns, and sleep. DESIGN: A total of 185 physicians and 119 nurses (206 women, 98 men) working in four teaching hospitals participated in an observational study of work stress. MAIN OUTCOME MEASURES: Participants carried handheld computers that randomly prompted them for work activity, patient load, and work stress information. RESULTS: Participants completed more than 9,500 random interval surveys during the study (an average of 30.8 surveys per person-week). Approximately 85% of all surveys were completed in full (73.3%) or partially (11.6%). Emotional stress scores among physicians were nearly 50% higher (26.9[19.0]) than those of nurses (18.1[14.9], r[302] = .37, p < .001). Direct and indirect care activities were associated with higher stress reports by both clinician groups (rs[159] = .14-.26, ps < .01). Sleep quality and quantity were predictors of work stress scores (ps < .05). Finally, higher work stress and lower sleep quality were also associated with poorer memory performance (r[302] = -.12, .17, ps < 05). CONCLUSIONS: The findings identify patterns of work stress in relationship to work activities, sleep habits, and provider differences that may be used to assist ongoing hospital work reform efforts.

Intern to attending: assessing stress among physicians.

PURPOSE: Organizations have raised concerns regarding stress in the medical work environment and effects on health care worker performance. This study's objective was to assess workplace stress among interns, residents, and attending physicians using Ecological Momentary Assessment technology, the gold-standard method for real-time measurement of psychological characteristics. METHOD: The authors deployed handheld computers with customized software to 185 physicians on the medicine and pediatric wards of four major teaching hospitals. The physicians contemporaneously recorded multiple dimensions of physician work (e.g., type of call day), emotional stress (e.g., worry, stress, fatigue), and perceived workload (e.g., patient volume). The authors performed descriptive statistics and t test and linear regression analyses. RESULTS: Participants completed 5,673 prompts during an 18-month period from 2004 to 2005. Parameters associated with higher emotional stress in linear regression models included male gender (t = -2.5, P = .01), total patient load (t = 4.2, P < .001), and sleep quality (t = -2.8, P = .006). Stress levels reported by attendings (t = -3.3, P = .001) were lower than levels reported by residents (t = -2.6, P = .009), and emotional stress levels of attendings and residents were both lower compared with interns. CONCLUSIONS: On inpatient wards, after recent resident duty hours changes, physician trainees continue to show wide-ranging evidence of workplace stress and poor sleep quality. This is among the first studies of medical workplace stress in real time. These results can help residency programs target education in stress and sleep and readdress workload distribution by training level. Further research is needed to clarify behavioral factors underlying variability in housestaff stress responses.

Management of chronic hepatitis C in veterans: the potential of integrated care models.

The prevalence of hepatitis C virus (HCV) infection is higher among veterans than nonveterans, but only about 14% of all identified infected veterans have ever received antiviral therapy. High rates of comorbid psychiatric and substance use disorders are major barriers to receiving antiviral treatment for veterans, and characteristics associated with poor virologic response are more common in this population. However, accumulating evidence indicates that patients with psychiatric and substance use disorders can successfully receive interferon-based antiviral therapies in an integrated or multidisciplinary health-care setting. The broad aims of integrated care models include reducing fragmentation and improving continuity and coordination of care. Although, to date, there are no randomized controlled trials of specific care models for patients with HCV, studies of integrated care for other chronic diseases suggest several strategies for optimizing outcomes for patients with HCV. Components of an HCV clinic incorporating these principles have been tested in a nonrandomized setting and include routine screening of all patients for psychiatric and substance use disorder risk factors, collaboration with mental health providers within the HCV clinic, following a defined integrated medical/psychiatric clinical protocol, provision of ongoing integrated support during antiviral treatment or retreatment, and educating patients on principles of chronic disease self-management.

Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians.

OBJECTIVE: To determine the feasibility of capturing self-reported medication events using a handheld computer-based Medication Event Reporting Tool (MERT). DESIGN AND PARTICIPANTS: Handheld computers operating the MERT software application were deployed among volunteer physician (n = 185) and nurse (n = 119) participants on the medical wards of four university-affiliated teaching hospitals. Participants were encouraged to complete confidential reports on the handheld computers for medication events observed during the study period. MEASUREMENTS AND MAIN RESULTS: Demographic variables including age, gender, education level, and clinical experience were recorded for all participants. Each MERT report included details on the provider, location, timing and type of medication event recorded. Over the course of 2,311 days of clinician participation, 76 events were reported; the median time for report completion was 231 seconds. The average event reporting rate for all participants was 0.033 reports per clinician shift. Nurses had a significantly higher reporting rate compared to physicians (0.045 vs 0.026 reports/shift, p = .02). Subgroup analysis revealed that attending physicians reported events more frequently than resident physicians (0.042 vs 0.021 reports/shift, p = .03), and at a rate similar to that of nurses (p = .80). Only 5% of MERT medication events were reported to require increased monitoring or treatment. CONCLUSIONS: A handheld-based event reporting tool is a feasible method to record medication events in inpatient hospital care units. Handheld reporting tools may hold promise to augment existing hospital reporting systems.

Psychiatric comorbidity does not predict interferon treatment completion rates in hepatitis C seropositive veterans.

GOALS: The aim of this study was to evaluate the impact of common psychiatric disorders on treatment completion of antiviral therapy prescribed to a series of hepatitis C virus (HCV) positive US veterans. BACKGROUND: Clinical experience suggests that preexisting psychiatric conditions may adversely affect the ability to tolerate combination antiviral therapy in patients with HCV infection. STUDY: We performed a retrospective chart review of 130 HCV positive veterans treated with combination antiviral therapy [interferon (IFN)/ribavirin] at VA San Diego from 2000 to 2004. We examined baseline psychiatric and substance use diagnoses, as well as demographic and comorbid medical disease variables for all patients started on treatment. RESULTS: Thirteen percent of patients in our cohort required treatment discontinuation for neuropsychiatric adverse effects. There was no association between treatment completion and any specific psychiatric diagnosis, baseline use of antidepressants, history of substance abuse/dependence, or combined psychiatric and substance use diagnoses for patient groups receiving either standard or pegylated IFN plus ribavirin therapies. Psychiatric and substance use disorders were not associated with dropout due to neuropsychiatric adverse effects. Baseline comorbid medical disorders also did not predict treatment completion. However, higher body weight did predict likelihood of treatment completion, especially for those > or =100 kg compared with thinner subjects (odds ratio=2.90; P=0.037). CONCLUSIONS: In this cohort of veterans, prior psychiatric or substance use history did not predict completion of recommended IFN/ribavirin treatment. These findings suggest that a larger pool of veterans with psychiatric or substance use disorders may be considered candidates for antiviral therapy when provided with multidisciplinary support.

Lithium toxicity after switch from fosinopril to lisinopril.

There is a small body of literature on the interactions between lithium and angiotensin-converting enzyme inhibitors (ACEIs), but little data documenting the differences between these agents in their impact on serum lithium levels. We present the case of a 46-year-old male who sustained a five-fold increase in his serum lithium level after switching from fosinopril to lisinopril, with a peak serum lithium level of 3.4 meq/l. There was also an increase in serum creatinine from 1.1 on fosinopril to 1.4 after switching to lisinopril. The patient was hospitalized, and intravenously hydrated with 0.5 normal saline, with a reduction of the serum lithium level to 0.7 meq/l by 72 h after admission. The hospital course was marked by two episodes of bradycardia, but was otherwise uneventful, and the patient was discharged without any neurological sequelae. This case demonstrates that ACEIs may have differential effects on renal function, and the potential for significant alterations in lithium clearance that may not be clinically evident for several weeks. Lithium-treated patients who have a change in ACEI, especially those who are older or have below average renal function, must have diligent monitoring for the first 4-6 weeks after switching to detect potentially serious changes in serum lithium levels.