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Biomedical subjects

David W Bates

Publications and source records attributed to David W Bates.

At least 145 records · Page 8Linked to original sources
PubMed2003

Use of chart and record reviews to detect medication errors in a state psychiatric hospital.

OBJECTIVE: This study compared the effectiveness of using a review team and the usual self-reporting method in detecting different types of medication errors in a state psychiatric hospital. METHODS: Medication errors were defined by using widely accepted criteria. Rates of prescription, transcription, administration, and dispensing errors were determined, and the risk of harm from each error was rated as high, moderate, or low. A review team was assigned to retrospectively review 31 patient records for prescription, transcription, and administration errors for a total of 1,448 patient-days. Dispensing errors, which can only be determined concurrently, were reported for an equivalent number of patient-days. The error rate was compared with the rate that was determined by the usual method of self-reports from all nursing and medical staff. RESULTS: In the 31 charts retrospectively reviewed and the dispensing events concurrently reviewed, the team detected a total of 2,194 medication errors, whereas a total of nine errors were self-reported for the same patient group. Administration errors accounted for more than half of the total (66 percent), followed by transcription errors (23 percent), prescription errors (11 percent), and dispensing errors (less than 1 percent). Nineteen percent of errors were rated as having a low risk of harm, 23 percent as having a moderate risk, and 58 percent as having a high risk. CONCLUSIONS: Use of a review team should be considered as a method for detecting and reporting medication errors.

Hospitals, Psychiatric↗
PubMed2003

A computer-based intervention for improving the appropriateness of antiepileptic drug level monitoring.

We designed and implemented 2 automated, computerized screens for use at the time of antiepileptic drug (AED) test order entry to improve appropriateness by reminding physicians when a potentially redundant test was ordered and providing common indications for monitoring and pharmacokinetics of the specific AED. All computerized orders for inpatient serum AED levels during two 3-month periods were included in the study. During the 3-month period after implementation of the automated intervention, 13% of all AED tests ordered were canceled following computerized reminders. For orders appearing redundant, the cancellation rate was 27%. For nonredundant orders, 4% were canceled when information on specific AED monitoring and pharmacokinetics was provided. The cancellation rate was sustained after 4 years. There has been a 19.5% decrease in total AED testing volume since implementation of this intervention, despite a 19.3% increase in overall chemistry test volume. Inappropriateness owing to repeated testing before pharmacologic steady state was reached decreased from 54% of all AED orders to 14.6%. A simple, automated, activity-based intervention targeting a specific test-ordering behavior effectively reduced inappropriate laboratory testing. The sustained benefit supports the idea that computerized interventions may durably affect physician behavior. Computerized delivery of such evidence-based boundary guidelines can help narrow the gap between evidence and practice.

Algorithms↗
PubMed2003

Clinical impact of drug-drug interactions with systemic azole antifungals.

The number of drug-drug interactions is remarkably high among hospitalized patients receiving systemic azole antifungal agents. Recent estimates suggest that as many as 95% of hospitalized patients treated with azole antifungals may receive medications capable of producing a major or moderate pharmacokinetic interaction. The antifungal properties of the azoles stem from their propensity to inhibit fungal cytochrome P-450 enzymes. In humans, however, azole antifungals also interfere with several hepatic and intestinal cytochrome P-450 isoenzymes responsible for the metabolism of numerous drugs. As a result, the azole antifungals have drug-drug interactions with a plethora of drug classes, including H(1)-antihistamines, antineoplastics, steroids, antimicrobials, antiretrovirals, opioids, long acting barbiturates, cardiovascular agents, psychotropics and oral contraceptives. These interactions are so numerous that it is extremely difficult to remember them all and would be even harder to prospectively predict their consequences in an individual patient. In fact, any drug that shares the same cytochrome P-450 isoenzymes for metabolism may potentially to give rise to drug-drug interactions in vivo. Patients with specific polymorphisms are probably at especially high risk. Certain drug combinations with azoles should be absolutely avoided, while other combinations may be prescribed provided monitoring of drug levels is undertaken, dosage reduction of one or more of the drugs is made (as appropriate) and/or careful monitoring of clinical parameters is performed.

Antifungal Agents↗
PubMed2003

Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients.

OBJECTIVES: Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them. METHODS: A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors. RESULTS: Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; kappa: 0.82). CONCLUSIONS: Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.

Adult↗
PubMed2003

Creating an enterprise-wide allergy repository at Partners HealthCare System.

A significant fraction of medication errors and preventable adverse drug events are related to drug-allergy interactions (DAIs). Computerized prescribing can help prevent DAIs, but an accurate record of the patient's allergies is required. At Partners HealthCare System in Boston, the patient's allergy list is distributed across several applications including computer physician order entry (CPOE), the outpatient medical record, pharmacy applications, and nurse charting applications. Currently, each application has access only to its own allergy data. This paper presents details of a project designed to integrate the various allergy repositories at Partners. We present data documenting that patients have allergy data stored in multiple repositories. We give detail about issues we are encountering such as which applications should participate in the repository, whether "NKA" or "NKDA" should be used to document known absence of allergies, and which personnel should be allowed to enter allergies. The issues described in this paper may well be faced by other initiatives intended to create comprehensive allergy repositories.

Boston↗
PubMed2003

Primary care clinician attitudes towards electronic clinical reminders and clinical practice guidelines.

Compliance with outpatient practice guidelines is low and clinical reminders have had variable success in improving adherence rates. We surveyed primary care physicians (PCPs) regarding practice guidelines and the perceived utility of electronic reminders for both routine health maintenance (HM) items and chronic disease management. Most PCPs preferred receiving reminders in an electronic format rather than a paper format. Electronic reminders were felt to be more useful for HM items than for diabetes management. The majority of clinicians felt that electronic reminders significantly improved overall health care quality.

Attitude of Health Personnel↗
PubMed2003

Defining the priorities and challenges for the adoption of Information Technology in HealthCare: opinions from an expert panel.

The Harvard Interfaculty Initiative developed a tool to assess the level of Information Technology adoption at healthcare organizations and asked an expert panel to rate the clinical functions where IT-based solutions can impact quality of care. The experts were asked to identify high priority areas where IT might impact quality, and to rate the difficulty in implementation associated with that solution. While scores from the expert panel varied widely in assessing difficulties in implementation of IT, there was broad consensus on high priority areas.

Delivery of Health Care↗
PubMed2003

KnowledgeLink update: just-in-time context-sensitive information retrieval.

Medical knowledge expands at a pace that makes it impossible for the individual clinician to keep up, especially for medications. Medication-related queries are the most common type of query that typically go unanswered during the course of providing care.1 Unanswered questions may result in errors, as found in one study evaluating systems failures associated with adverse drug events. This study found that better information might have prevented half of serious medication errors, and that lack of drug-specific knowledge accounted for the single largest proportion of these events (29%).2 While this information was available somewhere (either on paper or electronically), it was not at the providers' fingertips. Information technology should anticipate clinicians' needs, and bring the information they require to the point of care. For this purpose, we developed an application extender called KnowledgeLink, which provides "just-in-time" context-sensitive information retrieval for drug-related queries.

Drug Therapy, Computer-Assisted↗
PubMed2003

Physicians' perceptions toward electronic communication with patients.

Despite the widespread use of email, electronic communication between physicians and patients is not part of the standard physician-patient relationship in the United States. Increased use of email may improve physician-patient communication, which is associated with improved patient satisfaction and health status. Evaluating email communication in this context is vital to minimizing potential risks and maximizing benefit to physicians and patients. We evaluated email use between physicians and patients, and physicians perceptions of the value and issues surrounding this form of communication in order to identify issues that would facilitate and improve electronic communication.

Attitude of Health Personnel↗
PubMed2003

Overcoming the barriers to the implementing computerized physician order entry systems in US hospitals: perspectives from senior management.

We sought to identify the barriers to CPOE implementation and the strategies for overcoming them. By analyzing 57 transcripts of interviews with management officials at 25 US hospitals, we identified costs and physician resistance as the two most significant barriers. Hospitals often overcome the high cost of CPOE implementation by placing patient safety at the top of their agenda. Other hospitals manage physician resistance by leveraging strong leadership, external influence, vendor commitment and the presence of house staff and hospitalists. Efforts to promote the adoption of CPOE should therefore focus on these strategies.

Costs and Cost Analysis↗
PubMed2003

Intelligent intravenous infusion pumps to improve medication administration safety.

Intravenous (IV) medications are vital in the management of hospitalized patients. Inpatients frequently receive several IV medications concurrently, and these are commonly delivered with infusion pump systems. In particular, critically ill patients receive potent "high-alert" IV drugs, many with narrow safety margins requiring careful nursing titration. However, while intravenous medications have important benefits, errors associated with IV medication administration can result in severe or life-threatening adverse drug events (ADEs). Although errors in prescribing are often intercepted, administration errors do not get caught with most current systems While several safety improvements in IV infusion pump design have reduced mechanical complications, errors with IV drug administration such as incorrect programming persist. Intelligent IV infusion pumps have integrated software to provide point of care decision support (DS). This software includes drug library profiles configured for specific patient care units and includes programming of safety limits for drug/dose calculations.

Decision Making, Computer-Assisted↗
PubMed2003

Supporting patient care beyond the clinical encounter: three informatics innovations from partners health care.

As the focus of medicine moves from acute episodic care in the hospital to chronic disease management in outpatients, the primary care physician will play an increasingly important role in the coordination of patient care activities. Traditional outpatient informatics systems have largely focused on the workflow during the clinical encounter. Many tasks, including management of test results,coordination of subspecialty referrals and communication between patients and the practice,remain unsupported. When these tasks are not performed well, quality of care, patient safety and satisfaction may suffer. To address these issues ,Partners Healthcare in Boston, MA has recently developed several applications to address these issues. This demonstration will showcase 3 of these new applications: i) Results Manager, ii) Referrals Manager and iii) Patient Gateway. All interoperate with a browser-based electronic medical record already used by over 500 primary care physicians at Partners Healthcare.

Ambulatory Care↗
PubMed2002

Analysis of medication-related malpractice claims: causes, preventability, and costs.

BACKGROUND: Adverse drug events (ADEs) may lead to serious injury and may result in malpractice claims. While ADEs resulting in claims are not representative of all ADEs, such data provide a useful resource for studying ADEs. Therefore, we conducted a review of medication-related malpractice claims to study their frequency, nature, and costs and to assess the human factor failures associated with preventable ADEs. We also assessed the potential benefits of proved effective ADE prevention strategies on ADE claims prevention. METHODS: We conducted a retrospective analysis of a New England malpractice insurance company claims records from January 1, 1990, to December 31, 1999. Cases were electronically screened for possible ADEs and followed up by independent review of abstracts by 2 physician reviewers (T.K.G. and R.K.). Additional in-depth claims file reviews identified potential human factor failures associated with ADEs. RESULTS: Adverse drug events represented 6.3% (129/2040) of claims. Adverse drug events were judged preventable in 73% (n = 94) of the cases and were nearly evenly divided between outpatient and inpatient settings. The most frequently involved medication classes were antibiotics, antidepressants or antipsychotics, cardiovascular drugs, and anticoagulants. Among these ADEs, 46% were life threatening or fatal. System deficiencies and performance errors were the most frequent cause of preventable ADEs. The mean costs of defending malpractice claims due to ADEs were comparable for nonpreventable inpatient and outpatient ADEs and preventable outpatient ADEs (mean, $64,700-74,200), but costs were considerably greater for preventable inpatient ADEs (mean, $376,500). CONCLUSIONS: Adverse drug events associated with malpractice claims were often severe, costly, and preventable, and about half occurred in outpatients. Many interventions could potentially have prevented ADEs, with error proofing and process standardization covering the greatest proportion of events.

Health Care Costs↗
PubMed2002

The quality case for information technology in healthcare.

BACKGROUND: As described in the Institute of Medicine's Crossing the Quality Chasm report, the quality of health care in the U.S. today leaves much to be desired. DISCUSSION: One major opportunity for improving quality relates to increasing the use of information technology, or IT. Health care organizations currently invest less in IT than in any other information-intensive industry, and not surprisingly current systems are relatively primitive, compared with industries such as banking or aviation. Nonetheless, a number of organizations have demonstrated that quality can be substantially improved in a variety of ways if IT use is increased in ways that improve care. Specifically, computerization of processes that are error-prone and computerized decision support may substantially improve both efficiency and quality, as well as dramatically facilitate quality measurement. This report discusses the current levels of IT and quality in health care, how quality improvement and management are currently done, the evidence that more IT might be helpful, a vision of the future, and the barriers to getting there. SUMMARY: This report suggests that there are five key policy domains that need to be addressed: standards, incentives, security and confidentiality, professional involvement, and research, with financial incentives representing the single most important lever.

Decision Support Techniques↗
PubMed2002

Clinical use of bone densitometry: clinical applications.

Osteoporosis represents a difficult problem for physicians because, although many diagnostic tests are available, interpreting their results is not straightforward. As a result, many patients, even those with clear indications such as long-term steroid therapy or vertebral fractures on radiography, do not get screened or treated. Current evidence-based guidelines recommend screening for all white women older than 65 years and not already receiving an osteoporosis treatment and for many nonwhite women. For postmenopausal women who are younger than 65 years and have strong risk factors for osteoporosis, screening may also be beneficial. The optimal testing strategy depends on what is available locally. The best role for follow-up testing is still being defined, and interpretation of such testing is tricky. Reports of results can be hard to understand; a randomized controlled trial of clearer reports increased testing and decreased confusion about the meaning of test results. Densitometry might be more effectively used in practice if strategies such as having patients fill out a short questionnaire to assess for risk factors or creating a nurse-based system were used to identify patients. Clinicians need better approaches for identifying patients most likely to benefit from screening, systems that facilitate their application, and test results that are easy to interpret.

Absorptiometry, Photon↗
PubMed2002

Medication errors observed in 36 health care facilities.

BACKGROUND: Medication errors are a national concern. OBJECTIVE: To identify the prevalence of medication errors (doses administered differently than ordered). DESIGN: A prospective cohort study. SETTING: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. PARTICIPANTS: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. METHODS: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. MAIN OUTCOME MEASURE: Medication errors reaching patients. RESULTS: In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04) CONCLUSIONS: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.

Accreditation↗
PubMed2002

Unexpected hypoglycemia in a critically ill patient.

Administration of the wrong medication is a serious and understudied problem. Because physicians are not directly involved in the drug administration process, they tend to overlook the possibility of adverse drug events and medication errors in their differential diagnoses of patient illnesses or acute deterioration. This article analyzes the case of a patient with iatrogenic hypoglycemia due to administration of the wrong medication: Insulin instead of heparin was used to flush the patient's arterial line. In addition to assessing the results of the institution's "root-cause analysis" of the factors contributing to this particular adverse event and the institution's response, this article reviews the literature on preventing medication errors. Key strategies that might have been helpful in this case include using checklists for common emergency conditions (such as altered level of consciousness) and automated paging for "panic laboratory values," as well as instituting protocols for medication administration. Changing the system of administering medications by bar coding drugs, with checks of the medication, patient, and provider, could have prevented this accident. Finally, organizations need to strive for a "culture of safety" by providing opportunities to discuss errors and adverse events in constructive, supportive environments and by resisting pressure to find a scapegoat.

Aged↗