Technology alone does not achieve error reduction - a study of handwritten, tick-sheet, ink stamp and electronic medical prescriptions.

BACKGROUND: Technology in the form of electronic record systems and prescriptions have been touted as a potential solution to human error. In South Africa, a middle-income country where health facilities have large variations in technological capacity, prescription errors can be complex and varied. We evaluated different prescribing methods to find if the increased use of technology in prescriptions will assist in reducing error rates. METHODS: A retrospective, non-randomised study compared prescriptions, error rates and types in four hospitals with different prescribing methods: these were handwritten, ink stamp, tick-sheet and electronic prescriptions. A modern human error theory data collection tool was designed which included patient complexity. Cataract surgery was chosen as the single common procedure. RESULTS: One thousand six hundred and sixty-one individual scripts had 1 307 prescription errors. Increasing patient complexity was not an indicator of error rate. Handwritten and tick-sheet prescriptions had the fewest errors (49% and 51%, respectively). Electronic (96%) and ink stamp scripts (101%) had almost twice as many errors as handwritten scripts (p < 0.001) mainly due to systemic inbuilt errors. CONCLUSION: The application of increasing degrees of technological complexity does not automatically reduce error rate. This is especially apparent when technology is not integrated into human factors engineering and persistent critical assessment.

Striking a balance between usability and quality control in electronic health records.

BACKGROUND: This project is the first formal usability review of the hybrid electronic medical registry (HEMR) since its implementation in 2012. METHODS: A synchronous usability evaluation by novice operators was followed by a survey of veteran users. The usability evaluation was done by moderated think-aloud interview while completing tasks for a mock patient. The veteran survey was paper-based and focused on satisfaction of the system. RESULTS: A total of 141 comments on system errors were identified by the novice doctors. These consisted of 123 unique problems, of which three were hardware faults and were thus excluded. The identified issues were categorised into errors of control (27%), minimalist (21%), error (17%), match (13%), flexibility, visibility and consistency (9% each), and history (4%). Every unique usability violation was evaluated by the three experts who agreed that 82 of the 141 errors (58%) were valid and applicable. The other 59 items were rejected, not only because of the inability to reproduce some errors or programme shortcomings, but also because a series of "hurdles" were purposely included in the software to decrease cognitive dissonance and reduce error by the users. The survey of veteran users showed high levels of contentment with the system with regards to efficiency, satisfaction and preference. CONCLUSION: Despite many usability complaints by novices, almost half of them were rejected. Although usability in electronic health systems is important, it can often be sacrificed for more imperative aims such as safety, error filtering and clinical decision support.

Significance of HbA1c levels in diabetic retinopathy extremes in South Africa.

BACKGROUND: Diabetic retinopathy (DR) is one of the leading causes of blindness in sub-Saharan Africa and globally, placing a huge disease burden on patients and the public health system. DR varies in severity from non-proliferative to proliferative DR (PDR). OBJECTIVES: Using a monitor of medium- to long-term blood glucose control, to determine the association between glycated haemoglobin (HbA1c) levels in patients with PDR and those with no DR. METHODS: A prospective, cross-sectional study was conducted at McCord Provincial Eye Hospital in Durban, South Africa. We studied only patients diagnosed with diabetes mellitus (DM) for >1 year who had either PDR or no DR, and compared their HbA1c levels. Patients with non-proliferative DR were not included. RESULTS: Patients with PDR had significantly higher HbA1c levels than those with no DR. Patients with type 1 DM had higher HbA1c levels than patients with type 2 DM in both the PDR and no-DR groups. Older patients (>70 years) had lower HbA1c levels than younger patients. Gender, race and duration of diabetes had no influence on HbA1c levels. CONCLUSIONS: PDR was associated with higher HbA1c in type 2 DM in all races and age groups and was independent of duration of disease. The trend was the same for type 1 DM, but significance could not be reached, probably because of small numbers in this subset of patients.

Synthesis and evaluation of multisubstrate inhibitors of an oncogene-encoded tyrosine-specific protein kinase. 1.

The synthesis and testing of potential multisubstrate inhibitors of tyrosine-specific protein kinases are described. One of the substrates, ATP, was mimicked by the known kinase inhibitor 5'-[4-(fluorosulfonyl)benzoyl]adenosine, which was covalently linked via the sulfonyl moiety to tyrosine mimics. The resulting multisubstrate inhibitors were tested for their ability to inhibit the transfer of phosphate from ATP to a protein acceptor by p60v-abl, the tyrosine kinase encoded by the transforming gene (v-abl) of the Abelson murine leukemia virus (A-MuLV). Although the series of inhibitors displayed moderately potent activity (IC50 values as low as 19 microM), the absence of large effects produced by modification of the tyrosine mimic suggests that they do not behave as multisubstrate inhibitors but bind primarily through the adenosine moiety common to all the inhibitors. This interpretation is strengthened by the finding that the inhibitors lack specificity, inhibiting a serine kinase at comparable concentrations.

Synthesis and evaluation of multisubstrate inhibitors of an oncogene-encoded tyrosine-specific protein kinase. 2.

Tyrosine-specific protein kinases that transfer the terminal phosphate from ATP to protein acceptors are associated with certain transforming viruses and cell surface growth factor receptors. Here we describe the synthesis and testing of potential multisubstrate inhibitors of this class of enzymes. The inhibitors were prepared by covalent attachment of the terminal phosphate of ATP or its tetraphosphate analogue to tyrosine mimics. Testing against p60v-abl, the tyrosine kinase from the Abelson murine leukemia virus, showed that the series of inhibitors was moderately potent (IC50 values as low as 13 microM). However, structural modification of the tyrosine mimic, including replacement with a serine-like moiety, had little effect on potency. It is therefore concluded that the ATP moiety is largely responsible for binding and that the enzyme requires additional structural features for recognition of the tyrosine-containing substrate.

Imidodisulfamides. 2. Substituted 1,2,3,4-tetrahydroisoquinolinylsulfonic imides as antagonists of slow-reacting substance of anaphylaxis.

As part of a study of the influence of structural modifications of N',N'-bis(aralkyl)imidodisulfamides on their ability to selectively antagonize SRS-A activity, a few conformationally constrained structures were examined. Among these derivatives having a conformationally restricted alkylene side chain, substituted 1,2,3,4-tetrahydroisoquinolinylsulfonic imides produced optimum SRS-A antagonist activity and selectivity. These compounds were tested for antagonism of partially purified SRS-A induced contractions of isolated guinea pig ileum. In this series of tetrahydroisoquinolines, the effect of aromatic ring substitution, as well as substitution and variation of the size of the heterocyclic ring on SRS-A antagonist activity and selectivity, was studied.

Imidodisulfamides. 1. A novel class of antagonists of slow-reacting substance of anaphylaxis.

A series of N',N"-bis(aryl)- and N',N"-(aralkyl)imidodisulfamides was prepared and evaluated as antagonists of slow-reacting substance of anaphylaxis (SRS-A) induced contractions of isolated guinea pig ileum. Some of these compounds, notably N',N"-bis(4-phenylbutyl)-, N',N"-bis[2-(4-chlorophenyl)ethyl]-, and N',N"-bis[2-(4-bromophenyl)ethyl]imidodisulfamides (16, 22, and 26), were moderately potent and selective antagonists of SRS-A. The influence of lipophilic (pi) and electronic (sigma) factors on SRS-A antagonist activity appears to be of considerable importance to the derivation of potent and selective SRS-A antagonists.