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2.
Jt Comm J Qual Patient Saf ; 44(11): 683-694, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30064953

RESUMO

BACKGROUND: Blood glucose (BG) testing is the most widely performed point-of-care (POC) test in a hospital setting. Multiple adverse events reported to the Food and Drug Administration (FDA) revealed that treatment decisions may be affected by information displayed on the POC glucometer's results screen. A randomized, crossover simulation study was conducted to compare two results screen configurations for ACCU-CHEK Inform II, a POC glucometer. METHODS: Prior to the study, a heuristic evaluation of the results screen configurations and a pilot study were conducted to select the two results screen configurations for comparison. At two multicampus medical centers, 66 nurse participants experienced two computer-based simulation scenarios that asked them to interpret glucometer readings and make treatment decisions for simulated patients with 32 mg/dL BG levels and subtle symptoms of hypoglycemia. One scenario displayed a numeric value ("32 mg/dL"), and the other displayed a range abbreviation, such as "RR LO" (out of reportable range; low). Treatment errors were recorded when the participant did not treat the hypoglycemic patient with glucose or when they administered insulin. RESULTS: When ACCU-CHEK Inform II displayed an "RR LO" reading, 10.6% of participants made a treatment error, including 6.7% of participants with prior training on the meaning of an "RR LO" reading. None of the participants made a treatment error when ACCU-CHEK Inform II displayed a "32 mg/dL" reading. CONCLUSION: Displaying a numeric BG reading eliminated potentially life-threating treatment errors caused by confusing range abbreviations. Manufacturers should consider these findings during future research and development of POC glucometers.


Assuntos
Análise Química do Sangue/instrumentação , Glicemia/análise , Erros de Medicação/prevenção & controle , Sistemas Automatizados de Assistência Junto ao Leito , Análise Química do Sangue/economia , Simulação por Computador , Estudos Cross-Over , Humanos , Hiperglicemia/tratamento farmacológico , Hipoglicemia/induzido quimicamente , Insulina/administração & dosagem , Insulina/efeitos adversos
3.
AORN J ; 107(1): 72-82, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29341077

RESUMO

Medical device use errors, such as instrument connection errors made with electrosurgical units (ESUs), can lead to adverse events. Current device acquisition processes at health care facilities do not typically include a proactive evaluation of use-error risk before device purchase. We conducted an evaluation to identify ESU user interface design features that can help prevent or mitigate instrument connection errors during clinical care. Thirty-six current ESU users participated in the evaluation. We used a randomized crossover design in which each participant used two ESU models in a simulated OR scenario. We compared participants' instrument connection accuracy, efficiency, and subjective feedback regarding the user interface design across the two ESU models. Overall, we found that the ESU model that incorporated more user interface design principles resulted in better performance and increased acceptance from users. Based on the results, we designed a decision-support tool to assess the risk of instrument connection errors before ESU purchase.


Assuntos
Eletrocirurgia/efeitos adversos , Eletrocirurgia/instrumentação , Desenho de Equipamento , Equipamentos e Provisões/efeitos adversos , Erros Médicos , Humanos , Competência Profissional
4.
Infect Control Hosp Epidemiol ; 38(9): 1103-1106, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28693623

RESUMO

We evaluated the isolation of postoperative nontuberculous mycobacteria (NTM) associated with heater-cooler devices (HCDs) used during cardiopulmonary bypass (CPB) surgery in the Veterans Health Administration from January 1, 2010, to December 31, 2016. In more than 38,000 CPB procedures, NTM was isolated in 111 patients; 1 Mycobacterium chimaera mediastinitis case and 1 respiratory isolate were found. Infect Control Hosp Epidemiol 2017;38:1103-1106.


Assuntos
Ponte Cardiopulmonar/efeitos adversos , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Infecções por Mycobacterium não Tuberculosas/epidemiologia , Micobactérias não Tuberculosas/isolamento & purificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Contaminação de Equipamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/microbiologia , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Saúde dos Veteranos
5.
Nature ; 546(7656): 137-140, 2017 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-28514440

RESUMO

Temperature and fluid pressure conditions control rock deformation and mineralization on geological faults, and hence the distribution of earthquakes. Typical intraplate continental crust has hydrostatic fluid pressure and a near-surface thermal gradient of 31 ± 15 degrees Celsius per kilometre. At temperatures above 300-450 degrees Celsius, usually found at depths greater than 10-15 kilometres, the intra-crystalline plasticity of quartz and feldspar relieves stress by aseismic creep and earthquakes are infrequent. Hydrothermal conditions control the stability of mineral phases and hence frictional-mechanical processes associated with earthquake rupture cycles, but there are few temperature and fluid pressure data from active plate-bounding faults. Here we report results from a borehole drilled into the upper part of the Alpine Fault, which is late in its cycle of stress accumulation and expected to rupture in a magnitude 8 earthquake in the coming decades. The borehole (depth 893 metres) revealed a pore fluid pressure gradient exceeding 9 ± 1 per cent above hydrostatic levels and an average geothermal gradient of 125 ± 55 degrees Celsius per kilometre within the hanging wall of the fault. These extreme hydrothermal conditions result from rapid fault movement, which transports rock and heat from depth, and topographically driven fluid movement that concentrates heat into valleys. Shear heating may occur within the fault but is not required to explain our observations. Our data and models show that highly anomalous fluid pressure and temperature gradients in the upper part of the seismogenic zone can be created by positive feedbacks between processes of fault slip, rock fracturing and alteration, and landscape development at plate-bounding faults.

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