Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

PubMed

Abdel-Qader, Derar H; Harper, Lindsay; Cantrill, Judith A; Tully, Mary P

2010-11-01

Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data. There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.

Development and validation of a survey instrument for assessing prescribers' perception of computerized drug-drug interaction alerts.

PubMed

Zheng, Kai; Fear, Kathleen; Chaffee, Bruce W; Zimmerman, Christopher R; Karls, Edward M; Gatwood, Justin D; Stevenson, James G; Pearlman, Mark D

2011-12-01

To develop a theoretically informed and empirically validated survey instrument for assessing prescribers' perception of computerized drug-drug interaction (DDI) alerts. The survey is grounded in the unified theory of acceptance and use of technology and an adapted accident causation model. Development of the instrument was also informed by a review of the extant literature on prescribers' attitude toward computerized medication safety alerts and common prescriber-provided reasons for overriding. To refine and validate the survey, we conducted a two-stage empirical validation study consisting of a pretest with a panel of domain experts followed by a field test among all eligible prescribers at our institution. The resulting survey instrument contains 28 questionnaire items assessing six theoretical dimensions: performance expectancy, effort expectancy, social influence, facilitating conditions, perceived fatigue, and perceived use behavior. Satisfactory results were obtained from the field validation; however, a few potential issues were also identified. We analyzed these issues accordingly and the results led to the final survey instrument as well as usage recommendations. High override rates of computerized medication safety alerts have been a prevalent problem. They are usually caused by, or manifested in, issues of poor end user acceptance. However, standardized research tools for assessing and understanding end users' perception are currently lacking, which inhibits knowledge accumulation and consequently forgoes improvement opportunities. The survey instrument presented in this paper may help fill this methodological gap. We developed and empirically validated a survey instrument that may be useful for future research on DDI alerts and other types of computerized medication safety alerts more generally.

Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system

PubMed Central

Coleman, Jamie J; Hodson, James; Thomas, Sarah K; Brooks, Hannah L; Ferner, Robin E

2015-01-01

Background A computerized physician order entry (CPOE) system with embedded clinical decision support can reduce medication errors in hospitals, but might increase the time taken to generate orders. Aims We aimed to quantify the effects of temporal (month, day of week, hour of shift) and other factors (grade of doctor, prior experience with the system, alert characteristics, and shift type) on the time taken to generate a prescription order. Setting A large university teaching hospital using a locally developed CPOE system with an extensive audit database. Design We retrospectively analyzed prescription orders from the audit database between August 2011 and July 2012. Results The geometric mean time taken to generate a prescription order within the CPOE system was 11.75 s (95% CI 11.72 to 11.78). Time to prescribe was most affected by the display of high-level (24.59 s (24.43 to 24.76); p<0.001) or previously unseen (18.87 s (18.78 to 18.96); p<0.001) alerts. Prescribers took significantly less time at weekends (11.29 s (11.23 to 11.35)) than on weekdays (11.88 s (11.84 to 11.91); p<0.001), in the first (11.25 s (11.16 to 11.34); p<0.001) and final (11.56 s (11.47 to 11.66); p<0.001) hour of their shifts, and after the first month of using the system. Conclusions The display of alerts, prescribing experience, system familiarity, and environment all affect the time taken to generate a prescription order. Our study reinforces the need for appropriate alerts to be presented to individuals at an appropriate place in the workflow, in order to improve prescribing efficiency. PMID:25074989

Cognitive Analysis of Decision Support for Antibiotic Prescribing at the Point of Ordering in a Neonatal Intensive Care Unit

PubMed Central

Sheehan, Barbara; Kaufman, David; Stetson, Peter; Currie, Leanne M.

2009-01-01

Computerized decision support systems have been used to help ensure safe medication prescribing. However, the acceptance of these types of decision support has been reported to be low. It has been suggested that decreased acceptance may be due to lack of clinical relevance. Additionally, cognitive fit between the user interface and clinical task may impact the response of clinicians as they interact with the system. In order to better understand clinician responses to such decision support, we used cognitive task analysis methods to evaluate clinical alerts for antibiotic prescribing in a neonatal intensive care unit. Two methods were used: 1) a cognitive walkthrough; and 2) usability testing with a ‘think-aloud’ protocol. Data were analyzed for impact on cognitive effort according to categories of cognitive distance. We found that responses to alerts may be context specific and that lack of screen cues often increases cognitive effort required to use a system. PMID:20351922

Computerized Orders with Standardized Concentrations Decrease Dispensing Errors of Continuous Infusion Medications for Pediatrics

PubMed Central

Sowan, Azizeh K.; Vaidya, Vinay U.; Soeken, Karen L.; Hilmas, Elora

2010-01-01

OBJECTIVES The use of continuous infusion medications with individualized concentrations may increase the risk for errors in pediatric patients. The objective of this study was to evaluate the effect of computerized prescriber order entry (CPOE) for continuous infusions with standardized concentrations on frequency of pharmacy processing errors. In addition, time to process handwritten versus computerized infusion orders was evaluated and user satisfaction with CPOE as compared to handwritten orders was measured. METHODS Using a crossover design, 10 pharmacists in the pediatric satellite within a university teaching hospital were given test scenarios of handwritten and CPOE order sheets and asked to process infusion orders using the pharmacy system in order to generate infusion labels. Participants were given three groups of orders: five correct handwritten orders, four handwritten orders written with deliberate errors, and five correct CPOE orders. Label errors were analyzed and time to complete the task was recorded. RESULTS Using CPOE orders, participants required less processing time per infusion order (2 min, 5 sec ± 58 sec) compared with time per infusion order in the first handwritten order sheet group (3 min, 7 sec ± 1 min, 20 sec) and the second handwritten order sheet group (3 min, 26 sec ± 1 min, 8 sec), (p<0.01). CPOE eliminated all error types except wrong concentration. With CPOE, 4% of infusions processed contained errors, compared with 26% of the first group of handwritten orders and 45% of the second group of handwritten orders (p<0.03). Pharmacists were more satisfied with CPOE orders when compared with the handwritten method (p=0.0001). CONCLUSIONS CPOE orders saved pharmacists' time and greatly improved the safety of processing continuous infusions, although not all errors were eliminated. pharmacists were overwhelmingly satisfied with the CPOE orders PMID:22477811

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system.

PubMed

Chung, Clement; Patel, Shital; Lee, Rosetta; Fu, Lily; Reilly, Sean; Ho, Tuyet; Lionetti, Jason; George, Michael D; Taylor, Pam

2018-03-15

The development of a computerized prescriber order-entry (CPOE) system for chemotherapy in a multisite safety-net health system and the challenges to its successful implementation are described. Before CPOE for chemotherapy was first implemented and embedded in the electronic medical record system of Harris Health System (HHS), pharmacy personnel relied on regimen-specific preprinted order sets. However, due to differences in practice styles and workflow logistics, the paper orders across the 3 facilities were mostly site specific, with varying clinical content. Many of these order sets had not been approved by the oncology subcommittee. In addition, disparities in clinical knowledge and lack of communication contributed to inconsistencies in order set development. Led by medical directors from medical oncology departments at the 3 facilities, pharmacy administrators, and information technology representatives, HHS committed resources to supporting the adoption and use of a CPOE system for chemotherapy. Five practical lessons of broad applicability have been learned: engagement of interprofessional stakeholders, optimization of workflow before CPOE implementation, requirement of verification tool for CPOE, consolidation of protocols, and commitment to ongoing training and support. Evaluation of the CPOE system demonstrated a systemwide reduction in medication errors by 75% ( p < 0.05). Satisfaction with the CPOE system varied among sites and was unchanged institutionwide 6 months after the CPOE implementation. The development and implementation of CPOE for chemotherapy at a multisite safety-net health system created opportunities to optimize patient care and reduce variations through interprofessional collaborations. Initial evaluation suggested that CPOE reduced the medication-order error rate and improved user satisfaction in 1 of 3 facilities. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events?

PubMed

Charles, Krista; Cannon, Margaret; Hall, Robert; Coustasse, Alberto

2014-01-01

Computerized provider order entry (CPOE) systems allow physicians to prescribe patient services electronically. In hospitals, CPOE essentially eliminates the need for handwritten paper orders and achieves cost savings through increased efficiency. The purpose of this research study was to examine the benefits of and barriers to CPOE adoption in hospitals to determine the effects on medical errors and adverse drug events (ADEs) and examine cost and savings associated with the implementation of this newly mandated technology. This study followed a methodology using the basic principles of a systematic review and referenced 50 sources. CPOE systems in hospitals were found to be capable of reducing medical errors and ADEs, especially when CPOE systems are bundled with clinical decision support systems designed to alert physicians and other healthcare providers of pending lab or medical errors. However, CPOE systems face major barriers associated with adoption in a hospital system, mainly high implementation costs and physicians' resistance to change.

Electronic prescribing in ambulatory practice: promises, pitfalls, and potential solutions.

PubMed

Papshev, D; Peterson, A M

2001-07-01

To examine advantages of and obstacles to electronic prescribing in the ambulatory care environment. MEDLINE and International Pharmaceutical Abstract searches were conducted for the period from January 1980 to September 2000. Key words were electronic prescribing, computerized physician order entry, prior authorization, drug utilization review, and consumer satisfaction. In September 2000, a public search engine (www.google.com) was used to find additional technical information. In addition, pertinent articles were cross-referenced to identify other resources. Articles, symposia proceedings, and organizational position statements published in the United States on electronic prescribing and automation in healthcare are cited. Electronic prescribing can eliminate the time gap between point of care and point of service, reduce medication errors, improve quality of care, and increase patient satisfaction. Considerable funding requirements, segmentation of healthcare markets, lack of technology standardization, providers' resistance to change, and regulatory indecisiveness create boundaries to the widespread use of automated prescribing. The potential solutions include establishing a standardizing warehouse or a router and gaining stakeholder support in implementation of the technology. Electronic prescribing can provide immense benefits to healthcare providers, patients, and managed care. Resolution of several obstacles that limit feasibility of this technology will determine its future.

Residents' numeric inputting error in computerized physician order entry prescription.

PubMed

Wu, Xue; Wu, Changxu; Zhang, Kan; Wei, Dong

2016-04-01

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention. This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors. Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations. The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety. Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed.

PubMed

Hsu, Chia-Chen; Chou, Chia-Lin; Chen, Tzeng-Ji; Ho, Chin-Chin; Lee, Chung-Yuan; Chou, Yueh-Ching

2015-05-01

Clinical care has become increasingly dependent on computerized physician order entry (CPOE) systems. No study has reported the adverse effect of CPOE on physicians' ability to handwrite prescriptions. This study took advantage of an extensive crash of the CPOE system at a large hospital to assess the completeness, legibility, and accuracy of physicians' handwritten prescriptions. The CPOE system had operated at the outpatient department of an academic medical center in Taiwan since 1993. During an unintentional shutdown that lasted 3.5 hours in 2010, physicians were forced to write prescriptions manually. These handwritten prescriptions, together with clinical medical records, were later audited by clinical pharmacists with respect to 16 fields of the patient's, prescriber's, and drug data. A total of 1418 prescriptions with 3805 drug items were handwritten by 114 to 1369 patients. Not a single prescription had all necessary fields filled in. Although the field of age was most frequently omitted (1282 [90.4%] of 1418 prescriptions) among the patient's data, the field of dosage form was most frequently omitted (3480 [91.5%] of 3805 items) among the drug data. In contrast, the scale of illegibility was rather small. The highest percentage reached only 1.5% (n = 57) in the field of drug frequency. Inaccuracies of strength, dose, and drug name were observed in 745 (19.6%), 517 (13.6%), and 435 (11.4%) prescribed drug items, respectively. The unintentional shutdown of a long-running CPOE system revealed that physicians fail to handwrite flawless prescriptions in the digital era. The contingency plans for computer disasters at health care facilities might include preparation of stand-alone e-prescribing software so that the service delay could be kept to the minimum. However, guidance on prescribing should remain an essential part of medical education. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.

Computerized pharmacy surveillance and alert system for drug-related problems.

PubMed

Ferrández, O; Urbina, O; Grau, S; Mateu-de-Antonio, J; Marin-Casino, M; Portabella, J; Mojal, S; Riu, M; Salas, E

2017-04-01

Because of the impact of drug-related problems (DRPs) on morbidity and mortality, there is a need for computerized strategies to increase drug safety. The detection and identification of the causes of potential DRPs can be facilitated by the incorporation of a pharmacy warning system (PWS) in the computerized prescriber order entry (CPOE) and its application in the routine validation of inpatient drug therapy. A limited number of studies have evaluated a clinical decision support system to monitor drug treatment. Most of these applications have utilized a small range of drugs with alerts and/or types of alert. The objective of this study was to describe the implementation of a PWS integrated in the electronic medical record (EMR). The PWS was developed in 2003-2004. Pharmacological information to generate drug alerts was entered on demographic data, drug dosage, laboratory tests related to the prescribed drug and drug combinations (interactions, duplications and necessary combinations). The PWS was applied in the prescription reviews conducted in patients admitted to the hospital in 2012. Information on 83% of the drugs included in the pharmacopeia was introduced into the PWS, allowing detection of 2808 potential DRPs, representing 79·1% of all potential DRPs detected during the study period. Twenty per cent of PWS DRPs were clinically relevant, requiring pharmacist intervention. The PWS detected most potential DRPs, thus increasing inpatient safety. The detection ability of the PWS was higher than that reported for other tools described in the literature. © 2017 John Wiley & Sons Ltd.

Systematic Review of Medical Informatics-Supported Medication Decision Making.

PubMed

Melton, Brittany L

2017-01-01

This systematic review sought to assess the applications and implications of current medical informatics-based decision support systems related to medication prescribing and use. Studies published between January 2006 and July 2016 which were indexed in PubMed and written in English were reviewed, and 39 studies were ultimately included. Most of the studies looked at computerized provider order entry or clinical decision support systems. Most studies examined decision support systems as a means of reducing errors or risk, particularly associated with medication prescribing, whereas a few studies evaluated the impact medical informatics-based decision support systems have on workflow or operations efficiency. Most studies identified benefits associated with decision support systems, but some indicate there is room for improvement.

Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients.

PubMed

Vermeulen, K M; van Doormaal, J E; Zaal, R J; Mol, P G M; Lenderink, A W; Haaijer-Ruskamp, F M; Kosterink, J G W; van den Bemt, P M L A

2014-08-01

Prescribing medication is an important aspect of almost all in-hospital treatment regimes. Besides their obviously beneficial effects, medicines can also cause adverse drug events (ADE), which increase morbidity, mortality and health care costs. Partially, these ADEs arise from medication errors, e.g. at the prescribing stage. ADEs caused by medication errors are preventable ADEs. Until now, medication ordering was primarily a paper-based process and consequently, it was error prone. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) is considered to enhance patient safety. Limited information is available on the balance between the health gains and the costs that need to be invested in order to achieve these positive effects. Aim of this study was to study the balance between the effects and costs of CPOE/CDSS compared to the traditional paper-based medication ordering. The economic evaluation was performed alongside a clinical study (interrupted time series design) on the effectiveness of CPOE/CDSS, including a cost minimization and a cost-effectiveness analysis. Data collection took place between 2005 and 2008. Analyses were performed from a hospital perspective. The study was performed in a general teaching hospital and a University Medical Centre on general internal medicine, gastroenterology and geriatric wards. Computerized Physician Order Entry, combined with basic Clinical Decision Support System (CPOE/CDSS) was compared to a traditional paper based system. All costs of both medication ordering systems are based on resources used and time invested. Prices were expressed in Euros (price level 2009). Effectiveness outcomes were medication errors and preventable adverse drug events. During the paper-based prescribing period 592 patients were included, and during the CPOE/CDSS period 603. Total costs of the paper-based system and CPOE/CDSS amounted to €12.37 and €14.91 per patient/day respectively. The Incremental Cost-Effectiveness Ratio (ICER) for medication errors was 3.54 and for preventable adverse drug events 322.70, indicating the extra amount (€) that has to be invested in order to prevent one medication error or one pADE. CPOE with basic CDSS contributes to a decreased risk of preventable harm. Overall, the extra costs of CPOE/CDSS needed to prevent one ME or one pADE seem to be acceptable. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two ‘early adopter’ hospitals

PubMed Central

Cresswell, Kathrin M; Bates, David W; Williams, Robin; Morrison, Zoe; Slee, Ann; Coleman, Jamie; Robertson, Ann; Sheikh, Aziz

2014-01-01

Objective To understand the medium-term consequences of implementing commercially procured computerized physician order entry (CPOE) and clinical decision support (CDS) systems in ‘early adopter’ hospitals. Materials and methods In-depth, qualitative case study in two hospitals using a CPOE or a CDS system for at least 2 years. Both hospitals had implemented commercially available systems. Hospital A had implemented a CPOE system (with basic decision support), whereas hospital B invested additional resources in a CDS system that facilitated order entry but which was integrated with electronic health records and offered more advanced CDS. We used a combination of documentary analysis of the implementation plans, audiorecorded semistructured interviews with system users, and observations of strategic meetings and systems usage. Results We collected 11 documents, conducted 43 interviews, and conducted a total of 21.5 h of observations. We identified three major themes: (1) impacts on individual users, including greater legibility of prescriptions, but also some accounts of increased workloads; (2) the introduction of perceived new safety risks related to accessibility and usability of hardware and software, with users expressing concerns that some problems such as duplicate prescribing were more likely to occur; and (3) realizing organizational benefits through secondary uses of data. Conclusions We identified little difference in the medium-term consequences of a CPOE and a CDS system. It is important that future studies investigate the medium- and longer-term consequences of CPOE and CDS systems in a wider range of hospitals. PMID:24431334

Incorporating medication indications into the prescribing process.

PubMed

Kron, Kevin; Myers, Sara; Volk, Lynn; Nathan, Aaron; Neri, Pamela; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Karmiy, Sam; McCord, Sarah; Seoane-Vazquez, Enrique; Eguale, Tewodros; Rodriguez-Monguio, Rosa; Bates, David W; Schiff, Gordon

2018-04-19

The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, including avoiding look-alike/sound-alike errors, facilitating selection of drugs of choice, aiding in communication among the healthcare team, bolstering patient understanding and adherence, and organizing medication lists to facilitate medication reconciliation. Although strongly supported by pharmacists, multiple prior attempts to encourage prescribers to include the indication on prescriptions have not been successful. We convened 6 expert panels to consult high-level stakeholders on system design considerations and requirements necessary for building and implementing an indications-based computerized prescriber order-entry (CPOE) system. We summarize our findings from the 6 expert stakeholder panels, including rationale, literature findings, potential benefits, and challenges of incorporating indications into the prescribing process. Based on this stakeholder input, design requirements for a new CPOE interface and workflow have been identified. The emergence of universal electronic prescribing and content knowledge vendors has laid the groundwork for incorporating indications into the CPOE prescribing process. As medication prescribing moves in the direction of inclusion of the indication, it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Evaluation and implementation of chemotherapy regimen validation in an electronic health record.

PubMed

Diaz, Amber H; Bubalo, Joseph S

2014-12-01

Computerized provider order entry of chemotherapy regimens is quickly becoming the standard for prescribing chemotherapy in both inpatient and ambulatory settings. One of the difficulties with implementation of chemotherapy regimen computerized provider order entry lies in verifying the accuracy and completeness of all regimens built in the system library. Our goal was to develop, implement, and evaluate a process for validating chemotherapy regimens in an electronic health record. We describe our experience developing and implementing a process for validating chemotherapy regimens in the setting of a standard, commercially available computerized provider order entry system. The pilot project focused on validating chemotherapy regimens in the adult inpatient oncology setting and adult ambulatory hematologic malignancy setting. A chemotherapy regimen validation process was defined as a result of the pilot project. Over a 27-week pilot period, 32 chemotherapy regimens were validated using the process we developed. Results of the study suggest that by validating chemotherapy regimens, the amount of time spent by pharmacists in daily chemotherapy review was decreased. In addition, the number of pharmacist modifications required to make regimens complete and accurate were decreased. Both physician and pharmacy disciplines showed improved satisfaction and confidence levels with chemotherapy regimens after implementation of the validation system. Chemotherapy regimen validation required a considerable amount of planning and time but resulted in increased pharmacist efficiency and improved provider confidence and satisfaction. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Design and Evaluation of an Electronic Override Mechanism for Medication Alerts to Facilitate Communication Between Prescribers and Pharmacists.

PubMed

Russ, Alissa L; Chen, Siying; Melton, Brittany L; Saleem, Jason J; Weiner, Michael; Spina, Jeffrey R; Daggy, Joanne K; Zillich, Alan J

2015-07-01

Computerized medication alerts can often be bypassed by entering an override rationale, but prescribers' override reasons are frequently ambiguous to pharmacists who review orders. To develop and evaluate a new override mechanism for adverse reaction and drug-drug interaction alerts. We hypothesized that the new mechanism would improve usability for prescribers and increase the clinical appropriateness of override reasons. A counterbalanced, crossover study was conducted with 20 prescribers in a simulated prescribing environment. We modified the override mechanism timing, navigation, and text entry. Instead of free-text entry, the new mechanism presented prescribers with a predefined set of override reasons. We assessed usability (learnability, perceived efficiency, and usability errors) and used a priori criteria to evaluate the clinical appropriateness of override reasons entered. Prescribers rated the new mechanism as more efficient (Wilcoxon signed-rank test, P = 0.032). When first using the new design, 5 prescribers had difficulty finding the new mechanism, and 3 interpreted the navigation to mean that the alert could not be overridden. The number of appropriate override reasons significantly increased with the new mechanism compared with the original mechanism (median change of 3.0; interquartile range = 3.0; P < 0.0001). When prescribers were given a menu-based choice for override reasons, clinical appropriateness of these reasons significantly improved. Further enhancements are necessary, but this study is an important first step toward a more standardized menu of override choices. Findings may be used to improve communication through e-prescribing systems between prescribers and pharmacists. © The Author(s) 2015.

Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study.

PubMed

Zucker, Jason; Mittal, Jaimie; Jen, Shin-Pung; Cheng, Lucy; Cennimo, David

2016-03-01

There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART. This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study. Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention. Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact. © 2016 Pharmacotherapy Publications, Inc.

Usability evaluation of pharmacogenomics clinical decision support aids and clinical knowledge resources in a computerized provider order entry system: a mixed methods approach.

PubMed

Devine, Emily Beth; Lee, Chia-Ju; Overby, Casey L; Abernethy, Neil; McCune, Jeannine; Smith, Joe W; Tarczy-Hornoch, Peter

2014-07-01

Pharmacogenomics (PGx) is positioned to have a widespread impact on the practice of medicine, yet physician acceptance is low. The presentation of context-specific PGx information, in the form of clinical decision support (CDS) alerts embedded in a computerized provider order entry (CPOE) system, can aid uptake. Usability evaluations can inform optimal design, which, in turn, can spur adoption. The study objectives were to: (1) evaluate an early prototype, commercial CPOE system with PGx-CDS alerts in a simulated environment, (2) identify potential improvements to the system user interface, and (3) understand the contexts under which PGx knowledge embedded in an electronic health record is useful to prescribers. Using a mixed methods approach, we presented seven cardiologists and three oncologists with five hypothetical clinical case scenarios. Each scenario featured a drug for which a gene encoding drug metabolizing enzyme required consideration of dosage adjustment. We used Morae(®) to capture comments and on-screen movements as participants prescribed each drug. In addition to PGx-CDS alerts, 'Infobutton(®)' and 'Evidence' icons provided participants with clinical knowledge resources to aid decision-making. Nine themes emerged. Five suggested minor improvements to the CPOE user interface; two suggested presenting PGx information through PGx-CDS alerts using an 'Infobutton' or 'Evidence' icon. The remaining themes were strong recommendations to provide succinct, relevant guidelines and dosing recommendations of phenotypic information from credible and trustworthy sources; any more information was overwhelming. Participants' median rating of PGx-CDS system usability was 2 on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree). Usability evaluation results suggest that participants considered PGx information important for improving prescribing decisions; and that they would incorporate PGx-CDS when information is presented in relevant and useful ways. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Longitudinal Prescribing Patterns for Psychoactive Medications in Community-Based Individuals with Developmental Disabilities: Utilization of Pharmacy Records

ERIC Educational Resources Information Center

Lott, I. T.; McGregor, M.; Engelman, L.; Touchette, P.; Tournay, A.; Sandman, C.; Fernandez, G.; Plon, L.; Walsh, D.

2004-01-01

Little is known about longitudinal prescribing practices for psychoactive medications for individuals with intellectual disabilities and developmental disabilities (IDDD) who are living in community settings. Computerized pharmacy records were accessed for 2344 community-based individuals with IDDD for whom a total of 3421 prescriptions were…

Managing drugs safely.

PubMed

van den Anker, John N

2005-02-01

There is hard data to show that newborn infants are more likely than adults to experience adverse reactions to drugs. Paradoxically, drug-related legislation to ensure safe and effective drug use in humans neglected neonates until 2002, when the Best Pharmaceuticals Act for Children was signed into law in the USA. The situation for neonates should now catch up with that for adults and neonates will be prescribed more licensed drugs in the near future. If we are to be able to analyze the underlying system errors to improve the safe use of drugs in the studied patient population, reporting of adverse drug events and reactions needs to happen in a blame free environment. In addition, computerized physician order entry will certainly further improve the current situation by preventing errors in ordering, transcribing, verifying, and transmitting medication orders.

The evolution of the market for commercial computerized physician order entry and computerized decision support systems for prescribing.

PubMed

Mozaffar, Hajar; Williams, Robin; Cresswell, Kathrin; Morrison, Zoe; Bates, David W; Sheikh, Aziz

2016-03-01

To understand the evolving market of commercial off-the-shelf Computerized Physician Order Entry (CPOE) and Computerized Decision Support (CDS) applications and its effects on their uptake and implementation in English hospitals. Although CPOE and CDS vendors have been quick to enter the English market, uptake has been slow and uneven. To investigate this, the authors undertook qualitative ethnography of vendors and adopters of hospital CPOE/CDS systems in England. The authors collected data from semi-structured interviews with 11 individuals from 4 vendors, including the 2 most entrenched suppliers, and 6 adopter hospitals, and 21 h of ethnographic observation of 2 user groups, and 1 vendor event. The research and analysis was informed by insights from studies of the evolution of technology fields and the emergence of generic COTS enterprise solutions. Four key themes emerged: (1) adoption of systems that had been developed outside of England, (2) vendors' configuration and customization strategies, (3) localized adopter practices vs generic systems, and (4) unrealistic adopter demands. Evidence for our over-arching finding concerning the current immaturity of the market was derived from vendors' strategies, adopters' reactions to the technology, and policy makers' incomplete insights. The CPOE/CDS market in England is still in an emergent phase. The rapid entrance of diverse products, triggered by federal policy initiatives, has resulted in premature adoption of systems that do not yet adequately meet the needs of hospitals. Vendors and adopters lacked understanding of how to design and implement generic solutions to meet diverse user needs. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Electronic information and clinical decision support for prescribing: state of play in Australian general practice

PubMed Central

Robertson, Jane; Moxey, Annette J; Newby, David A; Gillies, Malcolm B; Williamson, Margaret; Pearson, Sallie-Anne

2011-01-01

Background. Investments in eHealth worldwide have been mirrored in Australia, with >90% of general practices computerized. Recent eHealth incentives promote the use of up to date electronic information sources relevant to general practice with flexibility in mode of access. Objective. To determine GPs’ access to and use of electronic information sources and computerized clinical decision support systems (CDSSs) for prescribing. Methods. Semi-structured interviews were conducted with 18 experienced GPs and nine GP trainees in New South Wales, Australia in 2008. A thematic analysis of interview transcripts was undertaken. Results. Information needs varied with clinical experience, and people resources (specialists, GP peers and supervisors for trainees) were often preferred over written formats. Experienced GPs used a small number of electronic resources and accessed them infrequently. Familiarity from training and early clinical practice and easy access were dominant influences on resource use. Practice time constraints meant relevant information needed to be readily accessible during consultations, requiring integration or direct access from prescribing software. Quality of electronic resource content was assumed and cost a barrier for some GPs. Conclusions. The current Australian practice incentives do not prescribe which information resources GPs should use. Without integration into practice computing systems, uptake and routine use seem unlikely. CDSS developments must recognize the time pressures of practice, preference for integration and cost concerns. Minimum standards are required to ensure that high-quality information resources are integrated and regularly updated. Without standards, the anticipated benefits of computerization on patient safety and health outcomes will be uncertain. PMID:21109619

E-Prescribing: History, Issues, and Potentials

PubMed Central

Salmon, J. Warren; Jiang, Ruixuan

2012-01-01

Electronic-Prescribing, Computerized Prescribing, or E-RX has increased dramatically of late in the American health care system, a long overdue alternative to the written form for the almost five billion drug treatments annually. This paper examines the history and selected issues in the rise of E-RX by a review of salient literature, interviews, and field observations in Pharmacy. Pharmacies were early adopters of computerization for a variety of factors. The profession in its new corporate forms of chain drug stores and pharmacy benefits firms has sought efficiencies, profit enhancements, and clinical improvements through managed care strategies that rely upon data automation. E-RX seems to be a leading factor in overall physician acceptance of Electronic Medical Records (EMRs), although the Centers for Medicare and Medicaid (CMS) incentives seem to be the propelling force in acceptance. We conclude that greater research should be conducted by public health professionals to focus on resolutions to pharmaceutical use, safety, and cost escalation, which persist and remain dire following health reform. PMID:23569654

Optimizing radiologist e-prescribing of CT oral contrast agent using a protocoling portal.

PubMed

Wasser, Elliot J; Galante, Nicholas J; Andriole, Katherine P; Farkas, Cameron; Khorasani, Ramin

2013-12-01

The purpose of this study is to quantify the time expenditure associated with radiologist ordering of CT oral contrast media when using an integrated protocoling portal and to determine radiologists' perceptions of the ordering process. This prospective study was performed at a large academic tertiary care facility. Detailed timing information for CT inpatient oral contrast orders placed via the computerized physician order entry (CPOE) system was gathered over a 14-day period. Analyses evaluated the amount of physician time required for each component of the ordering process. Radiologists' perceptions of the ordering process were assessed by survey. Descriptive statistics and chi-square analysis were performed. A total of 96 oral contrast agent orders were placed by 13 radiologists during the study period. The average time necessary to create a protocol for each case was 40.4 seconds (average range by subject, 20.0-130.0 seconds; SD, 37.1 seconds), and the average total time to create and sign each contrast agent order was 27.2 seconds (range, 10.0-50.0 seconds; SD, 22.4 seconds). Overall, 52.5% (21/40) of survey respondents indicated that radiologist entry of oral contrast agent orders improved patient safety. A minority of respondents (15% [6/40]) indicated that contrast agent order entry was either very or extremely disruptive to workflow. Radiologist e-prescribing of CT oral contrast agents using CPOE can be embedded in a protocol workflow. Integration of health IT tools can help to optimize user acceptance and adoption.

Assessment of Pharmacy Information System Performance in Three Hospitals in Eastern Province, Saudi Arabia

PubMed Central

El.Mahalli, Azza; El-Khafif, Sahar H.; Yamani, Wid

2016-01-01

The pharmacy information system is one of the central pillars of a hospital information system. This research evaluated a pharmacy information system according to six aspects of the medication process in three hospitals in Eastern Province, Saudi Arabia. System administrators were interviewed to determine availability of functionalities. Then, system users within the hospital were targeted to evaluate their level of usage of these functionalities. The study was cross-sectional. Two structured surveys were designed. The overall response rate of hospital users was 31.7 percent. In all three hospitals studied, the electronic health record is hybrid, implementation has been completed and the system is running, and the systems have computerized provider order entry and clinical decision support. Also, the pharmacy information systems are integrated with the electronic health record, and computerized provider order entry and almost all prescribing and transcription functionalities are available; however, drug dispensing is a mostly manual process. However, the study hospitals do not use barcode-assisted medication administration systems to verify patient identity and electronically check dose administration, and none of them have computerized adverse drug event monitoring that uses the electronic health record. The numbers of users who used different functionalities most or all of the time was generally low. The highest frequency of utilization was for patient administration records (56.8 percent), and the lowest was for linkage of the pharmacy information system to pharmacy stock (9.1 percent). Encouraging users to use different functionalities was highly recommended. PMID:26903780

Assessment of Pharmacy Information System Performance in Three Hospitals in Eastern Province, Saudi Arabia.

PubMed

El Mahalli, Azza; El-Khafif, Sahar H; Yamani, Wid

2016-01-01

The pharmacy information system is one of the central pillars of a hospital information system. This research evaluated a pharmacy information system according to six aspects of the medication process in three hospitals in Eastern Province, Saudi Arabia. System administrators were interviewed to determine availability of functionalities. Then, system users within the hospital were targeted to evaluate their level of usage of these functionalities. The study was cross-sectional. Two structured surveys were designed. The overall response rate of hospital users was 31.7 percent. In all three hospitals studied, the electronic health record is hybrid, implementation has been completed and the system is running, and the systems have computerized provider order entry and clinical decision support. Also, the pharmacy information systems are integrated with the electronic health record, and computerized provider order entry and almost all prescribing and transcription functionalities are available; however, drug dispensing is a mostly manual process. However, the study hospitals do not use barcode-assisted medication administration systems to verify patient identity and electronically check dose administration, and none of them have computerized adverse drug event monitoring that uses the electronic health record. The numbers of users who used different functionalities most or all of the time was generally low. The highest frequency of utilization was for patient administration records (56.8 percent), and the lowest was for linkage of the pharmacy information system to pharmacy stock (9.1 percent). Encouraging users to use different functionalities was highly recommended.

The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis.

PubMed

Bayoumi, Imaan; Al Balas, Mosab; Handler, Steven M; Dolovich, Lisa; Hutchison, Brian; Holbrook, Anne

2014-06-01

Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable. To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes. Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013. Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility. A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains. Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert. There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions). Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Privacy considerations in the context of an Australian observational database.

PubMed

Duszynski, K M; Beilby, J J; Marley, J E; Walker, D C; Pratt, N L

2001-12-01

Observational databases are increasingly acknowledged for their value in clinical investigation. Australian general practice in particular presents an exciting opportunity to examine treatment in a natural setting. The paper explores issues such as privacy and confidentiality--foremost considerations when conducting this form of pharmacoepidemiological research. Australian legislation is currently addressing these exact issues in order to establish clear directives regarding ethical concerns. The development of a pharmacoepidemiological database arising from the integration of computerized Australian general practice records is described in addition, to the challenges associated with creating a database which considers patient privacy. The database known as 'Medic-GP', presently contains more than 950,000 clinical notes (including consultations, pathology, diagnostic imaging and adverse reactions) over a 5-year time period and relates to 55,000 patients. The paper then details a retrospective study which utilized the database to examine the interaction between antibiotic prescribing and patient outcomes from a community perspective, following a policy intervention. This study illustrates the application of computerized general practice records in research.

Implementation of a simple electronic transfusion alert system decreases inappropriate ordering of packed red blood cells and plasma in a multi-hospital health care system.

PubMed

Smith, Matthew; Triulzi, Darrell J; Yazer, Mark H; Rollins-Raval, Marian A; Waters, Jonathan H; Raval, Jay S

2014-12-01

Prescriber adherence to institutional blood component ordering guidelines can be low. The goal of this study was to decrease red blood cell (RBC) and plasma orders that did not meet institutional transfusion guidelines by using data within the laboratory information system to trigger alerts in the computerized order entry (CPOE) system at the time of order entry. At 10 hospitals within a regional health care system, discernment rules were created for RBC and plasma orders utilizing transfusion triggers of hemoglobin <8 gm/dl and INR >1.6, respectively, with subsequent alert generation that appears within the CPOE system when a prescriber attempts to order RBCs or plasma on a patient whose antecedent laboratory values do not suggest that a transfusion is indicated. Orders and subsequent alerts were tracked for RBCs and plasma over evaluation periods of 15 and 10 months, respectively, along with the hospital credentials of the ordering health care providers (physician or nurse). Alerts triggered which were heeded remained steady and averaged 11.3% for RBCs and 19.6% for plasma over the evaluation periods. Overall, nurses and physicians canceled statistically identical percentages of alerted RBC (10.9% vs. 11.5%; p = 0.78) and plasma (21.3% vs. 18.7%; p = 0.22) orders. Implementing a simple evidence-based transfusion alert system at the time of order entry decreased non-evidence based transfusion orders by both nurse and physician providers. Copyright © 2014 Elsevier Ltd. All rights reserved.

Unsurfaced Road Maintenance Management

DOT National Transportation Integrated Search

1992-12-01

This draft manual describes an unsurfaced road maintenance management system for use on military installations. This system is available in either a manual or computerized mode (Micro PAVER). The maintenance standards prescribed should protect Govern...

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a Pediatric Intensive Care Unit.

PubMed

Balasuriya, Lilanthi; Vyles, David; Bakerman, Paul; Holton, Vanessa; Vaidya, Vinay; Garcia-Filion, Pamela; Westdorp, Joan; Sanchez, Christine; Kurz, Rhonda

2017-09-01

An enhanced dose range checking (DRC) system was developed to evaluate prescription error rates in the pediatric intensive care unit and the pediatric cardiovascular intensive care unit. An enhanced DRC system incorporating "soft" and "hard" alerts was designed and implemented. Practitioner responses to alerts for patients admitted to the pediatric intensive care unit and the pediatric cardiovascular intensive care unit were retrospectively reviewed. Alert rates increased from 0.3% to 3.4% after "go-live" (P < 0.001). Before go-live, all alerts were soft alerts. In the period after go-live, 68% of alerts were soft alerts and 32% were hard alerts. Before go-live, providers reduced doses only 1 time for every 10 dose alerts. After implementation of the enhanced computerized physician order entry system, the practitioners responded to soft alerts by reducing doses to more appropriate levels in 24.7% of orders (70/283), compared with 10% (3/30) before go-live (P = 0.0701). The practitioners deleted orders in 9.5% of cases (27/283) after implementation of the enhanced DRC system, as compared with no cancelled orders before go-live (P = 0.0774). Medication orders that triggered a soft alert were submitted unmodified in 65.7% (186/283) as compared with 90% (27/30) of orders before go-live (P = 0.0067). After go-live, 28.7% of hard alerts resulted in a reduced dose, 64% resulted in a cancelled order, and 7.4% were submitted as written. Before go-live, alerts were often clinically irrelevant. After go-live, there was a statistically significant decrease in orders that were submitted unmodified and an increase in the number of orders that were reduced or cancelled.

Pilot evaluation of a method to assess prescribers' information processing of medication alerts.

PubMed

Russ, Alissa L; Melton, Brittany L; Daggy, Joanne K; Saleem, Jason J

2017-02-01

Prescribers commonly receive alerts during medication ordering. Prescribers work in a complex, time-pressured environment; to enhance the effectiveness of safety alerts, the effort needed to cognitively process these alerts should be minimized. Methods to evaluate the extent to which computerized alerts support prescribers' information processing are lacking. To develop a methodological protocol to assess the extent to which alerts support prescribers' information processing at-a-glance; specifically, the incorporation of information into their working memory. We hypothesized that the method would be feasible and that we would be able to detect a significant difference in prescribers' information processing with a revised alert display that incorporates warning design guidelines compared to the original alert display. A counterbalanced, within-subject study was conducted with 20 prescribers in a human-computer interaction laboratory. We tested a single alert that was displayed in two different ways. Prescribers were informed that an alert would appear for 10s. After the alert was shown, a white screen was displayed, and prescribers were asked to verbally describe what they saw; indicate how many total warnings; and describe anything else they remembered about the alert. We measured information processing via the accuracy of prescribers' free recall and their ability to identify that three warning messages were present. Two analysts independently evaluated participants' responses against a comprehensive catalog of alert elements and then discussed discrepancies until reaching consensus. This feasibility study demonstrated that the method seemed to be effective for evaluating prescribers' information processing of medication alert displays. With this method, we were able to detect significant differences in prescribers' recall of alert information. The proportion of total data elements that prescribers were able to accurately recall was significantly greater for the revised versus original alert display (p=0.006). With the revised display, more prescribers accurately reported that three warnings were shown (p=0.002). The methodological protocol was feasible for evaluating the alert display and yielded important findings on prescribers' information processing. Study methods supplement traditional usability evaluation methods and may be useful for evaluating information processing of other healthcare technologies. Published by Elsevier Inc.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.

PubMed

Page, N; Baysari, M T; Westbrook, J I

2017-09-01

To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems. PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness. Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits. The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system. Copyright © 2017 Elsevier B.V. All rights reserved.

Impact of computerized pre-authorization of broad spectrum antibiotics in Pseudomonas aeruginosa at a children's hospital in Japan.

PubMed

Horikoshi, Yuho; Higuchi, Hiroshi; Suwa, Junichi; Isogai, Mihoko; Shoji, Takayo; Ito, Kenta

2016-08-01

The spread of antimicrobial-resistant organisms is a global concern. To stem this tide, an antimicrobial stewardship program at hospitals is essential to optimize the prescription of broad spectrum antibiotics. In this study we examined the impact of computerized pre-authorization for broad spectrum antibiotics for Pseudomonas aeruginosa at a children's hospital. An antimicrobial stewardship program at Tokyo Metropolitan Children's Medical Center was assessed between March 2010 and March 2015. A paper-based post-prescription audit was switched to computerized pre-authorization for broad antipseudomonal agents in October 2011. The prescriber was required to obtain approval from physicians in the pediatric infectious diseases division before prescribing restricted antimicrobial agents. Approved prescriptions were processed and logged electronically. We evaluated days of therapy per 1000 patient-days, the cost of antibiotics, and the susceptibility of P. aeruginosa to piperacillin, ceftazidime, cefepime, piperacillin/tazobactam, carbapenems, and ciprofloxacin. Also, the average length of admission and infection-related mortality at 30 days were compared pre- and post-intervention. Administration of carbapenems, piperacillin/tazobactam, and ceftazidime decreased significantly after the introduction of computerized pre-authorization. Antibiotic costs were reduced by JPY2.86 million (USD 26,000) annually. None of the antipseudomonal agents showed decreased sensitivity. The average length of admission was shorter in post-intervention. Infection-related mortality at 30 days showed no difference between the pre- and post-intervention periods. An antimicrobial stewardship program using computerized pre-authorization decreased the use and cost of broad spectrum antibiotics without significant difference in infection-related mortality at 30 days, although our study did not improve susceptibilities of P. aeruginosa. Copyright © 2016 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Computerized clinical decision support for prescribing: provision does not guarantee uptake

PubMed Central

Moxey, Annette; Robertson, Jane; Newby, David; Hains, Isla; Williamson, Margaret; Pearson, Sallie-Anne

2010-01-01

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990–2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved. PMID:20064798

Clinical Decision Support Improves Initial Dosing and Monitoring of Tobramycin and Amikacin

PubMed Central

Cox, Zachary L.; Nelsen, Cori L.; Waitman, Lemuel R.; McCoy, Jacob A.; Peterson, Josh F.

2010-01-01

Purpose Clinical decision support (CDS) systems could be valuable tools in reducing aminoglycoside prescribing errors. We evaluated the impact of CDS on initial dosing, interval, and pharmacokinetic outcomes of amikacin and tobramycin therapy. Methods A complex CDS advisor to provide guidance on initial dosing and monitoring, using both traditional and extended interval dosing strategies, was integrated into computerized provider order entry (CPOE) and compared to a control group which featured close pharmacy monitoring of all aminoglycoside orders. A random sample of 118 patients from an academic, tertiary care medical center prescribed amikacin and tobramycin prior to advisor implementation was compared to 98 patients admitted following advisor implementation. Primary outcome was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes were a guideline-adherent interval, trough and peak concentrations in goal range, and incidence of nephrotoxicity. Results Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The primary outcome of initial dosing consistent with guideline-based care increased from 40% in the pre-advisor arm to 80% in the post-advisor arm (p<0.001), with a number needed to treat of 3 patients to prevent one incorrect dose. Correct initial interval based on renal function also increased from 63% to 87% (p<0.001). The changes in initial dosing and interval resulted in an increase of trough concentrations in the goal range from 59% pre-advisor to 89% post-advisor implementation (p=0.0004). There was no significant difference in peak concentrations in goal range or incidence of nephrotoxicity (25% vs. 17%, p=0.2). Conclusion An advisor for aminoglycoside dosing and monitoring integrated into CPOE significantly improves initial dosing, selection of interval, and trough concentrations at goal compared to unassisted physician dosing. PMID:21411805

Interventions to Improve Suboptimal Prescribing in Nursing Homes: A Narrative Review

PubMed Central

Marcum, Zachary A.; Handler, Steven M.; Wright, Rollin; Hanlon, Joseph T.

2010-01-01

Background Appropriate medication prescribing for nursing home residents remains a challenge. Objective The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. Methods The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors’ files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. Results Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention’s impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in ≥1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. Conclusions Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature. PMID:20624609

Overdosed prescription of paracetamol (acetaminophen) in a teaching hospital.

PubMed

Charpiat, B; Henry, A; Leboucher, G; Tod, M; Allenet, B

2012-07-01

Paracetamol is the most commonly used analgesic and antipyretic. Reviews of hospital use of paracetamol are scarce. Little is known about the appropriateness of the dose of paracetamol prescribed for hospitalized adults. The aim of this study was to report on the nature and the frequency of the overdosed prescription of paracetamol observed in adult patients over a 4.5-year period in a teaching hospital. Prescription analysis by pharmacists was performed once a week in six medical and three surgical departments and daily in a post-emergency unit. In cases of prescription error, the pharmacist notified the physician through an electronic alert when a computerized prescription order entry system was available or otherwise by face-to-face discussion. For each drug-related problem detected, the pharmacists recorded relevant details in a database. From October 2006 to April 2011, 44,404 prescriptions were reviewed and 480 alerts related to the overdosed prescription of paracetamol were made (1% of analyzed prescriptions). The extent of errors of dosage was within the intervals [90-120 mg/kg/d] and greater than 120 mg/kg/d for 87 and 11 patients respectively, who were prescribed a single non-combination paracetamol containing product. Sixty alerts concerned co-prescription of at least two paracetamol containing products with similar frequency for computerized (1.4/1000) or handwritten (1.2/1000) prescriptions. Prescriptions of paracetamol for hospitalized adults frequently exceed the recommended dosage. These results highlight the need for increased awareness of unintentional paracetamol overdose and support the initiation of an educational program aimed at physicians and nurses. Copyright © 2012. Published by Elsevier Masson SAS.

Mixed results in the safety performance of computerized physician order entry.

PubMed

Metzger, Jane; Welebob, Emily; Bates, David W; Lipsitz, Stuart; Classen, David C

2010-04-01

Computerized physician order entry is a required feature for hospitals seeking to demonstrate meaningful use of electronic medical record systems and qualify for federal financial incentives. A national sample of sixty-two hospitals voluntarily used a simulation tool designed to assess how well safety decision support worked when applied to medication orders in computerized order entry. The simulation detected only 53 percent of the medication orders that would have resulted in fatalities and 10-82 percent of the test orders that would have caused serious adverse drug events. It is important to ascertain whether actual implementations of computerized physician order entry are achieving goals such as improved patient safety.

Improving adherence to the Epic Beacon ambulatory workflow.

PubMed

Chackunkal, Ellen; Dhanapal Vogel, Vishnuprabha; Grycki, Meredith; Kostoff, Diana

2017-06-01

Computerized physician order entry has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Epic's Beacon Oncology Information System of computerized physician order entry and electronic medication administration was implemented in Henry Ford Health System's ambulatory oncology infusion centers on 9 November 2013. Since that time, compliance to the infusion workflow had not been assessed. The objective of this study was to optimize the current workflow and improve the compliance to this workflow in the ambulatory oncology setting. This study was a retrospective, quasi-experimental study which analyzed the composite workflow compliance rate of patient encounters from 9 to 23 November 2014. Based on this analysis, an intervention was identified and implemented in February 2015 to improve workflow compliance. The primary endpoint was to compare the composite compliance rate to the Beacon workflow before and after a pharmacy-initiated intervention. The intervention, which was education of infusion center staff, was initiated by ambulatory-based, oncology pharmacists and implemented by a multi-disciplinary team of pharmacists and nurses. The composite compliance rate was then reassessed for patient encounters from 2 to 13 March 2015 in order to analyze the effects of the determined intervention on compliance. The initial analysis in November 2014 revealed a composite compliance rate of 38%, and data analysis after the intervention revealed a statistically significant increase in the composite compliance rate to 83% ( p < 0.001). This study supports a pharmacist-initiated educational intervention can improve compliance to an ambulatory, oncology infusion workflow.

Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial

PubMed Central

Sequist, Thomas D.; Ayanian, John Z.; Shaykevich, Shimon; Fairchild, David G.; Orav, E. John; Bates, David W.

2008-01-01

BACKGROUND We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients. METHODS We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group. We assessed prescribing of guideline-recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients’ race/ethnicity using interaction terms. MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42% at baseline and 46% at the outcome visit with no significant differences between groups. After adjustment for patients’ demographic and clinical characteristics, number of prior visits, and levels of baseline blood pressure control, there were no differences between intervention groups in the odds of outcome blood pressure control. The use of CDS to providers significantly improved Joint National Committee (JNC) guideline adherent medication prescribing compared to usual care (7% versus 5%, P < 0.001); the effects of the intervention remained after multivariable adjustment (odds ratio [OR] 1.39 [CI, 1.13–1.72]) and the effects of the intervention did not differ by patients’ race and ethnicity. CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control. Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed. PMID:18373141

[Is the ICU staff satisfied with the computerized physician order entry? A cross-sectional survey study].

PubMed

Fumis, Renata Rego Lins; Costa, Eduardo Leite Vieira; Martins, Paulo Sergio; Pizzo, Vladimir; Souza, Ivens Augusto; Schettino, Guilherme de Paula Pinto

2014-01-01

To evaluate the satisfaction of the intensive care unit staff with a computerized physician order entry and to compare the concept of the computerized physician order entry relevance among intensive care unit healthcare workers. We performed a cross-sectional survey to assess the satisfaction of the intensive care unit staff with the computerized physician order entry in a 30-bed medical/surgical adult intensive care unit using a self-administered questionnaire. The questions used for grading satisfaction levels were answered according to a numerical scale that ranged from 1 point (low satisfaction) to 10 points (high satisfaction). The majority of the respondents (n=250) were female (66%) between the ages of 30 and 35 years of age (69%). The overall satisfaction with the computerized physician order entry scored 5.74±2.14 points. The satisfaction was lower among physicians (n=42) than among nurses, nurse technicians, respiratory therapists, clinical pharmacists and diet specialists (4.62±1.79 versus 5.97±2.14, p<0.001); satisfaction decreased with age (p<0.001). Physicians scored lower concerning the potential of the computerized physician order entry for improving patient safety (5.45±2.20 versus 8.09±2.21, p<0.001) and the ease of using the computerized physician order entry (3.83±1.88 versus 6.44±2.31, p<0.001). The characteristics independently associated with satisfaction were the system's user-friendliness, accuracy, capacity to provide clear information, and fast response time. Six months after its implementation, healthcare workers were satisfied, albeit not entirely, with the computerized physician order entry. The overall users' satisfaction with computerized physician order entry was lower among physicians compared to other healthcare professionals. The factors associated with satisfaction included the belief that digitalization decreased the workload and contributed to the intensive care unit quality with a user-friendly and accurate system and that digitalization provided concise information within a reasonable time frame.

Utilizing VA Information Technology to Develop Psychiatric Resident Prescription Profiles

ERIC Educational Resources Information Center

Rohrbaugh, Robert; Federman, Daniel G.; Borysiuk, Lydia; Sernyak, Michael

2009-01-01

Objectives: Feedback about resident prescription practices allows psychiatry educators to ensure that residents have broad prescribing experience and can facilitate practice-based learning initiatives. The authors report on a procedure utilizing U.S. Department of Veterans Affairs' computerized pharmacy records to efficiently construct…

Safe and successful implementation of CPOE for chemotherapy at a children's cancer center.

PubMed

Hoffman, James M; Baker, Donald K; Howard, Scott C; Laver, Joseph H; Shenep, Jerry L

2011-02-01

Computerized prescriber order entry (CPOE) for medications has been implemented in only approximately 1 in 6 United States hospitals, with CPOE for chemotherapy lagging behind that for nonchemotherapy medications. The high risks associated with chemotherapy combined with other aspects of cancer care present unique challenges for the safe and appropriate use of CPOE. This article describes the process for safe and successful implementation of CPOE for chemotherapy at a children's cancer center. A core principle throughout the development and implementation of this system was that it must be as safe (and eventually safer) as existing paper systems and processes. The history of requiring standardized, regimen-specific, preprinted paper order forms served as the foundation for safe implementation of CPOE for chemotherapy. Extensive use of electronic order sets with advanced functionality; formal process redesign and system analysis; automated clinical decision support; and a phased implementation approach were essential strategies for safe implementation of CPOE. With careful planning and adequate resources, CPOE for chemotherapy can be safely implemented.

A framework for considering business models.

PubMed

Anderson, James G

2003-01-01

Information technology (IT) such as computerized physician order entry, computer-based decision support and alerting systems, and electronic prescribing can reduce medical errors and improve the quality of health care. However, the business value of these systems is frequently questioned. At present a number of barriers exist to realizing the potential of IT to improve quality of care. Some of these barriers are: the ineffectiveness of existing error reporting systems, low investment in IT infrastructure, legal impediments to reforms, and the difficulty in demonstrating a sufficient return on investment to justify expenditures for quality improvement. This paper provides an overview of these issues, a framework for considering business models, and examples of successful implementations of IT to improve quality of patient care.

Comparison of Centralized-Manual, Centralized-Computerized, and Decentralized-Computerized Order and Management Information Models for the Turkish Air Force Logistics System.

DTIC Science & Technology

1986-09-01

differentiation between the systems. This study will investigate an appropriate Order Processing and Management Information System (OP&MIS) to link base-level...methodology: 1. Reviewed the current order processing and information model of the TUAF Logistics System. (centralized-manual model) 2. Described the...RDS program’s order processing and information system. (centralized-computerized model) 3. Described the order irocessing and information system of

Exercise Prescribing: Computer Application in Older Adults

ERIC Educational Resources Information Center

Kressig, Reto W.; Echt, Katharina V.

2002-01-01

Purpose: The purpose of this study was to determine if older adults are capable and willing to interact with a computerized exercise promotion interface and to determine to what extent they accept computer-generated exercise recommendations. Design and Methods: Time and requests for assistance were recorded while 34 college-educated volunteers,…

Renal Drug Dosing

PubMed Central

Vogel, Erin A.; Billups, Sarah J.; Herner, Sheryl J.

2016-01-01

Summary Objective The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists. Methods This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient’s renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period. Results During the pharmacist- and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist- and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall). Conclusions Prescriber- and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS. PMID:27466041

Prescribing Control in Mixed Conifer Stands Affected by Annosus Root Disease

Treesearch

Gary Petersen

1989-01-01

Tree mortality caused by root diseases constitutes a major drain on Forest productivity of mixed-conifer stands. Factors such as changes in species composition, selective harvesting, unfavorable economic climate, and optimizing of short-term benefits have contributed to current stand conditions. Computer simulation models, such as the "RRMOD Computerized Root...

The Fire Effects Information System

Treesearch

William C. Fischer

1987-01-01

Lack of information regarding fire effects is perceived by many fire and resource managers as a barrier to the effective application of prescribed fire. This lack of information, in many instances, is the result of poor diffusion of existing knowledge rather than lack of knowledge. A computerized Fire Effects Information System can make existing fire effects knowledge...

A Pilot Study of a Computerized Decision Support System to Detect Invasive Fungal Infection in Pediatric Hematology/Oncology Patients.

PubMed

Bartlett, Adam; Goeman, Emma; Vedi, Aditi; Mostaghim, Mona; Trahair, Toby; O'Brien, Tracey A; Palasanthiran, Pamela; McMullan, Brendan

2015-11-01

Computerized decision support systems (CDSSs) can provide indication-specific antimicrobial recommendations and approvals as part of hospital antimicrobial stewardship (AMS) programs. The aim of this study was to assess the performance of a CDSS for surveillance of invasive fungal infections (IFIs) in an inpatient hematology/oncology cohort. Between November 1, 2012, and October 31, 2013, pediatric hematology/oncology inpatients diagnosed with an IFI were identified through an audit of the CDSS and confirmed by medical record review. The results were compared to hospital diagnostic-related group (DRG) coding for IFI throughout the same period. A total of 83 patients were prescribed systemic antifungals according to the CDSS for the 12-month period. The CDSS correctly identified 19 patients with IFI on medical record review, compared with 10 patients identified by DRG coding, of whom 9 were confirmed to have IFI on medical record review. CDSS was superior to diagnostic coding in detecting IFI in an inpatient pediatric hematology/oncology cohort. The functionality of CDSS lends itself to inpatient infectious diseases surveillance but depends on prescriber adherence.

Designing Computerized Provider Order Entry Software in Iran: The Nurses' and Physicians' Viewpoints.

PubMed

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Keshtkaran, Ali; Barati, Omid

2016-09-01

This study aimed to identify the functional requirements of computerized provider order entry software and design this software in Iran. This study was conducted using review documentation, interview, and focus group discussions in Shiraz University of Medical Sciences, as the medical pole in Iran, in 2013-2015. The study sample consisted of physicians (n = 12) and nurses (n = 2) in the largest hospital in the southern part of Iran and information technology experts (n = 5) in Shiraz University of Medical Sciences. Functional requirements of the computerized provider order entry system were examined in three phases. Finally, the functional requirements were distributed in four levels, and accordingly, the computerized provider order entry software was designed. The software had seven main dimensions: (1) data entry, (2) drug interaction management system, (3) warning system, (4) treatment services, (5) ability to write in software, (6) reporting from all sections of the software, and (7) technical capabilities of the software. The nurses and physicians emphasized quick access to the computerized provider order entry software, order prescription section, and applicability of the software. The software had some items that had not been mentioned in other studies. Ultimately, the software was designed by a company specializing in hospital information systems in Iran. This study was the first specific investigation of computerized provider order entry software design in Iran. Based on the results, it is suggested that this software be implemented in hospitals.

Computerized N-acetylcysteine physician order entry by template protocol for acetaminophen toxicity.

PubMed

Thompson, Trevonne M; Lu, Jenny J; Blackwood, Louisa; Leikin, Jerrold B

2011-01-01

Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in treating acetaminophen poisoning. An 18-month retrospective review of computerized inpatient pharmacy records for NAC use was performed. All patients who received NAC for the treatment of acetaminophen poisoning were included. Each record was analyzed to determine the form of NAC given and whether an administration error occurred. In the 82 cases of acetaminophen poisoning in which NAC was given, no medication administration errors were identified. Oral NAC was given in 31 (38%) cases; intravenous NAC was given in 51 (62%) cases. In this retrospective analysis of N-acetylcysteine administration using computerized physician order entry and order sets, no medication administration errors occurred. CPOE is an effective tool in safely executing complicated protocols in an inpatient setting.

Patient and physician predictors of patient receipt of therapies recommended by a computerized decision support system when initially prescribed broad-spectrum antibiotics: a cohort study

PubMed Central

Lye, David C.; Arah, Onyebuchi A

2016-01-01

Objective Antibiotic computerized decision support systems (CDSSs) were developed to guide antibiotic decisions, yet prescriptions of CDSS-recommended antibiotics have remained low. Our aim was to identify predictors of patients' receipt of empiric antibiotic therapies recommended by a CDSS when the prescribing physician had an initial preference for using broad-spectrum antibiotics. Methods We conducted a prospective cohort study in a 1 500-bed tertiary-care hospital in Singapore. We included all patients admitted from October 1, 2011 through September 30, 2012, who were prescribed piperacillin-tazobactam or carbapenem for empiric therapy and auto-triggered to receive antibiotic recommendations by the in-house antibiotic CDSS. Relevant data on the patient, prescribing and attending physicians were collected via electronic linkages of medical records and administrative databases. To account for clustering, we used multilevel logistic regression models to explore factors associated with receipt of CDSS-recommended antibiotic therapy. Results One-quarter of the 1 886 patients received CDSS-recommended antibiotics. More patients treated for pneumonia (33.2%) than sepsis (12.1%) and urinary tract infections (7.1%) received CDSS-recommended antibiotic therapies. The prescribing physician – but not the attending physician or clinical specialty – accounted for some (13.3%) of the variation. Prior hospitalization (odds ratio [OR] 1.32, 95% CI, 1.01-1.71), presumed pneumonia (OR 6.77, 95% CI, 3.28-13.99), intensive care unit (ICU) admission (OR 0.38, 95% CI, 0.21-0.66), and renal impairment (OR 0.70, 95% CI, 0.52-0.93) were factors associated with patients’ receipt of CDSS-recommended antibiotic therapies. Conclusions We observed that ICU admission and renal impairment were negative predictors of patients’ receipt of CDSS-recommended antibiotic therapies. Patients admitted to ICU and those with renal impairment might have more complex clinical conditions that require a physician's assessment in addition to antibiotic CDSS. PMID:26342216

Hospital pharmacy practice in Saudi Arabia: Prescribing and transcribing in the Riyadh region

PubMed Central

Alsultan, Mohammed S.; Khurshid, Fowad; Salamah, Heba J.; Mayet, Ahmed Y.; Al-jedai, Ahmed H.

2011-01-01

Purpose The purpose of this survey is to outline pharmacy services in hospitals on a regional level in the Kingdom of Saudi Arabia. Methods A modified-American Society of Health-System Pharmacists (ASHP) survey questionnaire as pertinent to Saudi Arabia was used to conduct a national survey. After discussing with the pharmacy directors of 48 hospitals in the Riyadh region over the phone on the survey’s purpose, the questionnaires were personally delivered and collected upon completion. The hospital lists were drawn from the Ministry of Health hospital database. Results Twenty-nine hospitals participated in the survey giving a response rate of 60.4%. Approximately 60% of the hospitals which participated in the survey required prior approval for the use of non-formulary medications. About 83.3% of hospitals reviewed compliance with clinical practice guidelines and 72.7% hospitals reported that pharmacists are also actively involved in these activities. Pharmacists in more than 95% of hospitals provided consultations on drug information. A staff pharmacist routinely answering questions was the most frequently cited (74.1%) method by which objective drug information was provided to prescribers. Electronic drug information resources were available in 77.7% of hospitals, although internet use is not widely available to hospital pharmacists, with only 58.6% of hospitals providing pharmacist access to the internet. About, 34.5% of hospitals had computerized prescriber order entry (CPOE) systems with clinical decision-support systems (CDSSs) and 51.9% of the hospitals had electronic medical record (EMR) system. Conclusion Hospital pharmacists are increasingly using electronic technologies to improve prescribing and transcribing of medications in Saudi Arabia. PMID:23960794

Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence.

PubMed

Stein, Bradley D; Kogan, Jane N; Mihalyo, Mark J; Schuster, James; Deegan, Patricia E; Sorbero, Mark J; Drake, Robert E

2013-04-01

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants.

PubMed

Horri, J; Cransac, A; Quantin, C; Abrahamowicz, M; Ferdynus, C; Sgro, C; Robillard, P-Y; Iacobelli, S; Gouyon, J-B

2014-12-01

The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE) + manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA < 33 weeks) in a mixed prescription system. The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose. The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P = 0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR = 3·3; 95% CI: 1·6-7·0, P < 0·001). The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units. © 2014 John Wiley & Sons Ltd.

Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients.

PubMed

Fischer, Michael A; Solomon, Daniel H; Teich, Jonathan M; Avorn, Jerry

2003-11-24

Many hospitalized patients continue to receive intravenous medications longer than necessary. Earlier conversion from the intravenous to the oral route could increase patient safety and comfort, reduce costs, and facilitate earlier discharge from the hospital without compromising clinical care. We examined the effect of a computer-based intervention to prompt physicians to switch appropriate patients from intravenous to oral medications. This study was performed at Brigham and Women's Hospital, an academic tertiary care hospital at which all medications are ordered online. We targeted 5 medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. We used the hospital's computerized order entry system to prompt physicians to convert appropriate intravenous medications to the oral route. We measured the total use of the targeted medications via each route in the 4 months before and after the implementation of the intervention. We also measured the rate at which physicians responded to the intervention when prompted. The average intravenous defined daily dose declined by 11.1% (P =.002) from the preintervention to the postintervention period, while the average oral defined daily dose increased by 3.7% (P =.002). Length of stay, case-mix index, and total drug use at the hospital increased during the study period. The average total monthly use of the intravenous preparation of all of the targeted medications declined in the 4 months after the intervention began, compared with the 4 months before. In 35.6% of 1045 orders for which a prompt was generated, the physician either made a conversion from the intravenous to the oral version or canceled the order altogether. Computer-generated reminders can produce a substantial reduction in excessive use of targeted intravenous medications. As online prescribing becomes more common, this approach can be used to reduce excess use of intravenous medications, with potential benefits in patient comfort, safety, and cost.

An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions.

PubMed

George, Jessica A; Park, Paul S; Hunsberger, Joanne; Shay, Joanne E; Lehmann, Christoph U; White, Elizabeth D; Lee, Benjamin H; Yaster, Myron

2016-03-01

Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge. We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

Increasing pregnancy-related use of prescribed opioid analgesics

PubMed Central

Epstein, Richard A.; Bobo, William V.; Martin, Peter R.; Morrow, James A.; Wang, Wei; Chandrasekhar, Rameela; Cooper, William O.

2013-01-01

Purpose To quantify the prevalence of prescribed opioid analgesics among pregnant women enrolled in Tennessee Medicaid from 1995 to 2009. Methods Retrospective cohort study of 277,555 pregnancies identified from birth and fetal death certificates, and linked to previously-validated computerized pharmacy records. Poisson regression was used to estimate trends over time, rate ratios and 95% confidence intervals. Results During the study period, 29% of pregnant women filled a prescription for an opioid analgesic. From 1995 to 2009, any pregnancy-related use increased 1.90-fold (95% CI = 1.83, 1.98), first trimester use increased 2.27-fold (95% CI = 2.14, 2.41), and second or third trimester use increased 2.02-fold (95% CI = 1.93, 2.12), after adjusting for maternal characteristics. Any pregnancy-related, first trimester, and second or third trimester use were each more likely among mothers who were at least 21 years old, white, non-Hispanic, prima gravid, resided in non-urban areas, enrolled in Medicaid due to disability, and who had less than a high school education. Conclusions Opioid analgesic use by Tennessee Medicaid-insured pregnant women increased nearly 2-fold from 1995 to 2009. Additional study is warranted in order to understand the implications of this increased use. PMID:23889859

The Reality, Direction, and Future of Computerized Publications

ERIC Educational Resources Information Center

Levenstein, Nicholas

2012-01-01

Sharing information in digital form by using a computer is a growing phenomenon. Many universities are making their applications available on computer. More than one hundred and thirty-six universities have developed computerized applications on their own or through a commercial vendor. Universities developed computerized applications in order to…

Economic impact of electronic prescribing in the hospital setting: A systematic review.

PubMed

Ahmed, Zamzam; Barber, Nick; Jani, Yogini; Garfield, Sara; Franklin, Bryony Dean

2016-04-01

To examine evidence on the economic impact of electronic prescribing (EP) systems in the hospital setting. We conducted a systematic search of MEDLINE, EMBASE, PsycINFO, International Pharmaceutical Abstracts, the NHS Economic Evaluation Database, the European Network of Health Economic Evaluation Database and Web of Science from inception to October 2013. Full and partial economic evaluations of EP or computerized provider order entry were included. We excluded studies assessing prescribing packages for specific drugs, and monetary outcomes that were not related to medicines. A checklist was used to evaluate risk of bias and evidence quality. The search yielded 1160 articles of which three met the inclusion criteria. Two were full economic evaluations and one a partial economic evaluation. A meta-analysis was not appropriate as studies were heterogeneous in design, economic evaluation method, interventions and outcome measures. Two studies investigated the financial impact of reducing preventable adverse drug events. The third measured savings related to various aspects of the system including those related to medication. Two studies reported positive financial effects. However the overall quality of the economic evidence was low and key details often not reported. There seems to be some evidence of financial benefits of EP in the hospital setting. However, it is not clear if evidence is transferable to other settings. Research is scarce and limited in quality, and reported methods are not always transparent. Further robust, high quality research is required to establish if hospital EP is cost effective and thus inform policy makers' decisions. Copyright © 2016. Published by Elsevier Ireland Ltd.

Immediate financial impact of computerized clinical decision support for long-term care residents with renal insufficiency: a case study.

PubMed

Subramanian, Sujha; Hoover, Sonja; Wagner, Joann L; Donovan, Jennifer L; Kanaan, Abir O; Rochon, Paula A; Gurwitz, Jerry H; Field, Terry S

2012-01-01

In a randomized trial of a clinical decision support system for drug prescribing for residents with renal insufficiency in a large long-term care facility, analyses were conducted to estimate the system's immediate, direct financial impact. We determined the costs that would have been incurred if drug orders that triggered the alert system had actually been completed compared to the costs of the final submitted orders and then compared intervention units to control units. The costs incurred by additional laboratory testing that resulted from alerts were also estimated. Drug orders were conservatively assigned a duration of 30 days of use for a chronic drug and 10 days for antibiotics. It was determined that there were modest reductions in drug costs, partially offset by an increase in laboratory-related costs. Overall, there was a reduction in direct costs (US$1391.43, net 7.6% reduction). However, sensitivity analyses based on alternative estimates of duration of drug use suggested a reduction as high as US$7998.33 if orders for non-antibiotic drugs were assumed to be continued for 180 days. The authors conclude that the immediate and direct financial impact of a clinical decision support system for medication ordering for residents with renal insufficiency is modest and that the primary motivation for such efforts must be to improve the quality and safety of medication ordering.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: methods of a decision-maker-researcher partnership systematic review.

PubMed

Haynes, R Brian; Wilczynski, Nancy L

2010-02-05

Computerized clinical decision support systems are information technology-based systems designed to improve clinical decision-making. As with any healthcare intervention with claims to improve process of care or patient outcomes, decision support systems should be rigorously evaluated before widespread dissemination into clinical practice. Engaging healthcare providers and managers in the review process may facilitate knowledge translation and uptake. The objective of this research was to form a partnership of healthcare providers, managers, and researchers to review randomized controlled trials assessing the effects of computerized decision support for six clinical application areas: primary preventive care, therapeutic drug monitoring and dosing, drug prescribing, chronic disease management, diagnostic test ordering and interpretation, and acute care management; and to identify study characteristics that predict benefit. The review was undertaken by the Health Information Research Unit, McMaster University, in partnership with Hamilton Health Sciences, the Hamilton, Niagara, Haldimand, and Brant Local Health Integration Network, and pertinent healthcare service teams. Following agreement on information needs and interests with decision-makers, our earlier systematic review was updated by searching Medline, EMBASE, EBM Review databases, and Inspec, and reviewing reference lists through 6 January 2010. Data extraction items were expanded according to input from decision-makers. Authors of primary studies were contacted to confirm data and to provide additional information. Eligible trials were organized according to clinical area of application. We included randomized controlled trials that evaluated the effect on practitioner performance or patient outcomes of patient care provided with a computerized clinical decision support system compared with patient care without such a system. Data will be summarized using descriptive summary measures, including proportions for categorical variables and means for continuous variables. Univariable and multivariable logistic regression models will be used to investigate associations between outcomes of interest and study specific covariates. When reporting results from individual studies, we will cite the measures of association and p-values reported in the studies. If appropriate for groups of studies with similar features, we will conduct meta-analyses. A decision-maker-researcher partnership provides a model for systematic reviews that may foster knowledge translation and uptake.

The Evaluation of SISMAKOM (Computerized SDI Project).

ERIC Educational Resources Information Center

University of Science, Penang (Malaysia).

A survey of 88 users of SISMAKOM, a computerized selective dissemination of information (SDI) and document delivery service provided by the Universiti Sains Malaysia and four other Malaysian universities, was conducted in August 1982 in order to collect data about SISMAKOM and to assess the value of a computerized SDI service in a developing…

Computerized physician order entry from a chief information officer perspective.

PubMed

Cotter, Carole M

2004-12-01

Designing and implementing a computerized physician order entry system in the critical care units of a large urban hospital system is an enormous undertaking. With their significant potential to improve health care and significantly reduce errors, the time for computerized physician order entry or physician order management systems is past due. Careful integrated planning is the key to success, requiring multidisciplinary teams at all levels of clinical and administrative management to work together. Articulated from the viewpoint of the Chief Information Officer of Lifespan, a not-for-profit hospital system in Rhode Island, the vision and strategy preceding the information technology plan, understanding the system's current state, the gap analysis between current and future state, and finally, building and implementing the information technology plan are described.

A Computer Prescribing Order Entry-Clinical Decision Support system designed for neonatal care: results of the 'preselected prescription' concept at the bedside.

PubMed

Gouyon, B; Iacobelli, S; Saliba, E; Quantin, C; Pignolet, A; Jacqz-Aigrain, E; Gouyon, J B

2017-02-01

The neonatal intensive care units (NICUs) are at the highest risk of drug dose error of all hospital wards. NICUs also have the most complicated prescription modalities. The computerization of the prescription process is currently recommended to decrease the risk of preventable adverse drug effects (pADEs) in NICUs. However, Computer Prescribing Order Entry-Clinical Decision Support (C.P.O.E./C.D.S.) systems have been poorly studied in NICUs, and their technical compatibility with neonatal specificities has been limited. We set up a performance study of the preselected prescription of drugs for neonates, which limited the role of the prescriber to choosing the drugs and their indications. A single 29 bed neonatal ward used this neonatal C.P.O.E./C.D.S. system for all prescriptions of all hospitalized newborns over an 18-month period. The preselected prescription of drugs was based on the indication, gestational age, body weight and post-natal age. The therapeutic protocols were provided by a formulary reference (330 drugs) that had been specifically designed for newborns. The preselected prescription also gave complete information about preparation and administration of drugs by nurses. The prescriber was allowed to modify the preselected prescription but alarms provided warning when the prescription was outside the recommended range. The main clinical characteristics and all items of each line of prescription were stored in a data warehouse, thus enabling this study to take place. Seven hundred and sixty successive newborns (from 24 to 42 weeks' gestation) were prescribed 52 392 lines of prescription corresponding to 65 drugs; About 30·4% of neonates had at least one out of licensed prescription; A prescription out of the recommended range for daily dose was recorded for 1·0% of all drug prescriptions. WHAT IS NEW?: The C.P.O.E./C.D.S. systems can currently provide a complete preselected prescription in NICUs according to dose rules, which are specific to newborns and also comply with local specificities (therapeutic protocols and formulation of drugs). The role of the prescriber is limited to the choice of drugs and their indications. The prescriber still retains the possibility of modifying each item of the prescription, with all other prescription items being calculated by the C.P.O.E. system. In these conditions, the prescribers rarely modified the preselected prescription and the rate of out of range prescription was low. A multicentric study is required to confirm and extend these observations. This study showed the feasibility of preselected prescription in NICUs and a low rate of out of range prescriptions. The preselected prescription could play a key role in lowering the dose error rate in NICUs. © 2016 John Wiley & Sons Ltd.

A Real Time Interface Between a Computerized Physician Order Entry System and the Computerized ICU Medication Administration Record

PubMed Central

Chen, Jeannie; Shabot, M. Michael; LoBue, Mark

2003-01-01

Prior attempts to interface ICU Clinical Information Systems (CIS) to Pharmacy systems have been less than successful. The major problem is that in ICUs, medications frequently have to be administered and charted in the CIS Medication Administration Record (MAR) before pharmacists can enter them into the Pharmacy system. When the Pharmacy system belatedly sends medication orders to the CIS MAR, this may create duplicate entries for medications that ICU nurses have had to enter manually to chart doses actually given. The authors have implemented a real time interface between a Computerized Physician Order Entry (CPOE) system and a CIS operating in ten ICUs that solves this problem. The interface transfers new medication orders including order details and alerts directly to the CIS Medication Administration Record (MAR), where they are immediately available for nurse charting. PMID:14728315

Effect of closed-loop order processing on the time to initial antimicrobial therapy.

PubMed

Panosh, Nicole; Rew, Richardd; Sharpe, Michelle

2012-08-15

The results of a study comparing the average time to initiation of i.v. antimicrobial therapy with closed-versus open-loop order entry and processing are reported. A retrospective cohort study was performed to compare order-to-administration times for initial doses of i.v. antimicrobials before and after a closed-loop order-processing system including computerized prescriber order entry (CPOE) was implemented at a large medical center. A total of 741 i.v. antimicrobial administrations to adult patients during designated five-month preimplementation and postimplementation study periods were assessed. Drug-use reports generated by the pharmacy database were used to identify order-entry times, and medication administration records were reviewed to determine times of i.v. antimicrobial administration. The mean ± S.D. order-to-administration times before and after the implementation of the CPOE system and closed-loop order processing were 3.18 ± 2.60 and 2.00 ± 1.89 hours, respectively, a reduction of 1.18 hours (p < 0.0001). Closed-loop order processing was associated with significant reductions in the average time to initiation of i.v. therapy in all patient care areas evaluated (cardiology, general medicine, and oncology). The study results suggest that CPOE-based closed-loop order processing can play an important role in achieving compliance with current practice guidelines calling for increased efforts to ensure the prompt initiation of i.v. antimicrobials for severe infections (e.g., sepsis, meningitis). Implementation of a closed-loop order-processing system resulted in a significant decrease in order-to-administration times for i.v. antimicrobial therapy.

Computerized Provider Order Entry and Health Care Quality on Hospital Level among Pediatric Patients during 2006-2009

ERIC Educational Resources Information Center

Wang, Liya

2016-01-01

This study examined the association between Computerized Physician Order Entry (CPOE) application and healthcare quality in pediatric patients at hospital level. This was a retrospective study among 1,428 hospitals with pediatric setting in Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) and Health Information and…

Significant reduction in red blood cell transfusions in a general hospital after successful implementation of a restrictive transfusion policy supported by prospective computerized order auditing.

PubMed

Yerrabothala, Swaroopa; Desrosiers, Kevin P; Szczepiorkowski, Zbigniew M; Dunbar, Nancy M

2014-10-01

Our hospital transfusion policy was recently revised to recommend single-unit red blood cell transfusion (RBC TXN) for nonbleeding inpatients when the hemoglobin (Hb) level is not more than 7 g/dL. Our computerized provider order entry system was reconfigured to provide real-time decision support using prospective computerized order auditing based on the most recent Hb level and to remove the single-click ordering option for 2-unit RBC TXNs to enhance compliance. This study was undertaken to assess the impact of these changes on hospital transfusion practice. This study analyzed the total number of transfusion events, proportion of single and 2-unit transfusions and the Hb transfusion trigger in the preimplementation period (October 2011-March 2012) compared to the postimplementation period (October 2012-March 2013). In the postimplementation period the total number of RBC units transfused/1000 patient-days decreased from 60.8 to 44.2 (p < 0.0001). The proportion of 2-unit TXNs decreased from 47% to 15% (p < 0.0001). We also observed significant decreases in pretransfusion Hb triggers. Implementation of restrictive transfusion policy supported by prospective computerized order auditing has resulted in significantly decreased RBC utilization at our institution. © 2014 AABB.

Computerized optimization of multiple isocentres in stereotactic convergent beam irradiation

NASA Astrophysics Data System (ADS)

Treuer, U.; Treuer, H.; Hoevels, M.; Müller, R. P.; Sturm, V.

1998-01-01

A method for the fully computerized determination and optimization of positions of target points and collimator sizes in convergent beam irradiation is presented. In conventional interactive trial and error methods, which are very time consuming, the treatment parameters are chosen according to the operator's experience and improved successively. This time is reduced significantly by the use of a computerized procedure. After the definition of target volume and organs at risk in the CT or MR scans, an initial configuration is created automatically. In the next step the target point positions and collimator diameters are optimized by the program. The aim of the optimization is to find a configuration for which a prescribed dose at the target surface is approximated as close as possible. At the same time dose peaks inside the target volume are minimized and organs at risk and tissue surrounding the target are spared. To enhance the speed of the optimization a fast method for approximate dose calculation in convergent beam irradiation is used. A possible application of the method for calculating the leaf positions when irradiating with a micromultileaf collimator is briefly discussed. The success of the procedure has been demonstrated for several clinical cases with up to six target points.

Designing an architectural style for dynamic medical Cross-Organizational Workflow management system: an approach based on agents and web services.

PubMed

Bouzguenda, Lotfi; Turki, Manel

2014-04-01

This paper shows how the combined use of agent and web services technologies can help to design an architectural style for dynamic medical Cross-Organizational Workflow (COW) management system. Medical COW aims at supporting the collaboration between several autonomous and possibly heterogeneous medical processes, distributed over different organizations (Hospitals, Clinic or laboratories). Dynamic medical COW refers to occasional cooperation between these health organizations, free of structural constraints, where the medical partners involved and their number are not pre-defined. More precisely, this paper proposes a new architecture style based on agents and web services technologies to deal with two key coordination issues of dynamic COW: medical partners finding and negotiation between them. It also proposes how the proposed architecture for dynamic medical COW management system can connect to a multi-agent system coupling the Clinical Decision Support System (CDSS) with Computerized Prescriber Order Entry (CPOE). The idea is to assist the health professionals such as doctors, nurses and pharmacists with decision making tasks, as determining diagnosis or patient data analysis without stopping their clinical processes in order to act in a coherent way and to give care to the patient.

The Effects of Computerized Auditory Feedback on Electronic Article Surveillance Tag Placement in an Auto-Parts Distribution Center

ERIC Educational Resources Information Center

Goomas, David T.

2008-01-01

In this report from the field, computerized auditory feedback was used to inform order selectors and order selector auditors in a distribution center to add an electronic article surveillance (EAS) adhesive tag. This was done by programming handheld computers to emit a loud beep for high-priced items upon scanning the item's bar-coded Universal…

Paediatric homoeopathy in general practice: where, when and why?

PubMed Central

Ekins-Daukes, Suzie; Helms, Peter J; Taylor, Michael W; Simpson, Colin R; McLay, James S

2005-01-01

Aims To investigate the extent of homoeopathic prescribing in primary care for childhood diseases and assess GP attitudes towards the use of homoeopathy in children. Methods Homoeopathic prescribing in primary care was assessed in 167 865 children aged 0–16 years for the year 1999–2000. Computerized prescribing data were retrieved from 161 representative general practices in Scotland. Medical attitudes towards homoeopathic prescribing to children were also assessed via a questionnaire survey. Results During the year 1999–2000 22% (36) of general practices prescribed homoeopathic medicines to 190 (1.1/1000 registered) children. The majority of such prescriptions were issued to children under 1 year of age (8.0/1000 registered children). The most frequently prescribed medicines were for common self-limiting infantile conditions such as colic, cuts and bruises, and teething. A total of 259 completed questionnaires were returned by GPs, giving a response rate of 75%. GPs who frequently prescribed homoeopathic medicines to children (more than 1 per month) were more likely to claim an interest in homoeopathy, have had a formal training and keep up to date in the discipline, and refer on to a homoeopath (P < 0.001 for all variables) than those GPs who prescribed less than once a month or never. The majority of GPs who prescribed homoeopathic medicines did so when conventional treatments had apparently failed (76%), while 94% also perceived homoeopathy to be safe. Frequent prescribers reported a more positive attitude towards homoeopathic medicines than those who prescribed less frequently. Non-prescribers reported a lack of proven efficacy and lack of training as the main reasons for not prescribing homoeopathic medicines (55% and 79%, respectively). However non-prescribers from within homoeopathic prescribing practices reported a more favourable attitude in general towards homoeopathy and less resistance towards prescribing in the future than non-prescribers from practices where none of the partners practiced homoeopathy. Conclusions In primary care paediatric prescribing of homoeopathic medicines most commonly occurs for self-limiting conditions in infants less than 1 year of age. Although the current level of homoeopathic prescribing is low, the widespread use in the community suggests that at least some knowledge of the main indications for homoeopathy and the preparations used would be of benefit to registered medical practitioners. PMID:15948942

Implementing computerized physician order entry: the importance of special people.

PubMed

Ash, Joan S; Stavri, P Zoë; Dykstra, Richard; Fournier, Lara

2003-03-01

To articulate important lessons learned during a study to identify success factors for implementing computerized physician order entry (CPOE) in inpatient and outpatient settings. Qualitative study by a multidisciplinary team using data from observation, focus groups, and both formal and informal interviews. Data were analyzed using a grounded approach to develop a taxonomy of patterns and themes from the transcripts and field notes. The theme we call Special People is explored here in detail. A taxonomy of types of Special People includes administrative leaders, clinical leaders (champions, opinion leaders, and curmudgeons), and bridgers or support staff who interface directly with users. The recognition and nurturing of Special People should be among the highest priorities of those implementing computerized physician order entry. Their education and training must be a goal of teaching programs in health administration and medical informatics.

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation

PubMed Central

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade

2018-01-01

Background A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan. Objective This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. Methods A CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter. Results The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians’ responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. Conclusions The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient’s medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required. PMID:29351893

Anticholinergics and Central Nervous System Effects: Are We Confused?

PubMed Central

Staskin, David R; Zoltan, Edward

2007-01-01

The central nervous system (CNS) effects of anticholinergic agents have been documented in various patient populations and to varying degrees in case reports, brain-activity surrogates, and computerized cognitive testing. The older patient population with overactive bladder represents a group at increased risk of cognitive impairment and other CNS side effects associated with antimuscarinic agents. The complexity of the effect of anticholinergic agents on CNS function requires an increased level of careful investigation. Studies need to be performed in the at-risk population with multiple, validated tests at clinically prescribed doses in acute and chronic situations. These studies need to take into account the effect of commonly prescribed dosing regimens, with doses selected to represent with equivalent bladder potency. The alterations in the serum levels and parent/metabolite effects contributed by metabolic issues or drug delivery systems require special attention. PMID:18231615

The VA Computerized Patient Record — A First Look

PubMed Central

Anderson, Curtis L.; Meldrum, Kevin C.

1994-01-01

In support of its in-house DHCP Physician Order Entry/Results Reporting application, the VA is developing the first edition of a Computerized Patient Record. The system will feature a physician-oriented interface with real time, expert system-based order checking, a controlled vocabulary, a longitudinal repository of patient data, HL7 messaging support, a clinical reminder and warning system, and full integration with existing VA applications including lab, pharmacy, A/D/T, radiology, dietetics, surgery, vitals, allergy tracking, discharge summary, problem list, progress notes, consults, and online physician order entry. PMID:7949886

Computerizing Maintenance Management Improves School Processes.

ERIC Educational Resources Information Center

Conroy, Pat

2002-01-01

Describes how a Computerized Maintenance Management System (CMMS), a centralized maintenance operations database that facilitates work order procedures and staff directives, can help individual school campuses and school districts to manage maintenance. Presents the benefits of CMMS and things to consider in CMMS selection. (EV)

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

PubMed

Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M

2002-01-01

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Clinical evaluation of the WOMAC 3.0 OA Index in numeric rating scale format using a computerized touch screen version.

PubMed

Theiler, R; Spielberger, J; Bischoff, H A; Bellamy, N; Huber, J; Kroesen, S

2002-06-01

The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index is a previously described self-administered questionnaire covering three domains: pain, stiffness and function. It has been validated in patients with osteoarthritis (OA) of the hip or knee in a paper-based format. To validate the WOMAC 3.0 using a numerical rating scale in a computerized touch screen format allowing immediate evaluation of the questionnaire. In the computed version cartoons, written and audio instruments were included in order facilitate application. Fifty patients, demographically balanced, with radiographically proven primary hip or knee OA completed the classical paper and the new computerized WOMAC version. Subjects were randomized either to paper format or computerized format first to balance possible order effects. The intra-class correlation coefficients for pain, stiffness and function values were 0.915, 0.745 and 0.940, respectively. The Spearman correlation coefficients for pain, stiffness and function were 0.88, 0.77 and 0.87, respectively. These data indicate that the computerized WOMAC OA index 3.0 is comparable to the paper WOMAC in all three dimensions. The computerized version would allow physicians to get an immediate result and if present a direct comparison with a previous exam. Copyright 2002 OsteoArthritis Research Society International. Published by Elsevier Science Ltd. All rights reserved.

Using EHR Data to Detect Prescribing Errors in Rapidly Discontinued Medication Orders.

PubMed

Burlison, Jonathan D; McDaniel, Robert B; Baker, Donald K; Hasan, Murad; Robertson, Jennifer J; Howard, Scott C; Hoffman, James M

2018-01-01

Previous research developed a new method for locating prescribing errors in rapidly discontinued electronic medication orders. Although effective, the prospective design of that research hinders its feasibility for regular use. Our objectives were to assess a method to retrospectively detect prescribing errors, to characterize the identified errors, and to identify potential improvement opportunities. Electronically submitted medication orders from 28 randomly selected days that were discontinued within 120 minutes of submission were reviewed and categorized as most likely errors, nonerrors, or not enough information to determine status. Identified errors were evaluated by amount of time elapsed from original submission to discontinuation, error type, staff position, and potential clinical significance. Pearson's chi-square test was used to compare rates of errors across prescriber types. In all, 147 errors were identified in 305 medication orders. The method was most effective for orders that were discontinued within 90 minutes. Duplicate orders were most common; physicians in training had the highest error rate ( p  < 0.001), and 24 errors were potentially clinically significant. None of the errors were voluntarily reported. It is possible to identify prescribing errors in rapidly discontinued medication orders by using retrospective methods that do not require interrupting prescribers to discuss order details. Future research could validate our methods in different clinical settings. Regular use of this measure could help determine the causes of prescribing errors, track performance, and identify and evaluate interventions to improve prescribing systems and processes. Schattauer GmbH Stuttgart.

Impact of a clinical decision support system for drug dosage in patients with renal failure.

PubMed

Desmedt, Sophie; Spinewine, Anne; Jadoul, Michel; Henrard, Séverine; Wouters, Dominique; Dalleur, Olivia

2018-05-21

Background A clinical decision support system (CDSS) linked to the computerized physician order entry may help improve prescription appropriateness in inpatients with renal insufficiency. Objective To evaluate the impact on prescription appropriateness of a CDSS prescriber alert for 85 drugs in renal failure patients. Setting Before-after study in a 975-bed academic hospital. Method Prescriptions of patients with renal failure were reviewed during two comparable periods of 6 days each, before and after the implementation of the CDSS (September 2009 and 2010). Main outcome measure The proportion of inappropriate dosages of 85 drugs included in the CDSS was compared in the pre- and post-implementation group. Results Six hundred and fifteen patients were included in the study (301 in pre- and 314 in post-implementation periods). In the pre- and post-implementation period, respectively 2882 and 3485 prescriptions were evaluated, of which 14.9 and 16.6% triggered an alert. Among these, the dosage was inappropriate in respectively 25.4 and 24.6% of prescriptions in the pre- and post-implementation periods (OR 0.97; 95% CI 0.72-1.29). The most frequently involved drugs were paracetamol, perindopril, tramadol and allopurinol. Conclusion The implementation of a CDSS did not significantly reduce the proportion of inappropriate drug dosages in patients with renal failure. Further research is required to investigate the reasons why prescribers override alerts. Collaboration with clinical pharmacists might improve compliance with the CDSS recommendations.

Development of an inpatient operational pharmacy productivity model.

PubMed

Naseman, Ryan W; Lopez, Ben R; Forrey, Ryan A; Weber, Robert J; Kipp, Kris M

2015-02-01

An innovative model for measuring the operational productivity of medication order management in inpatient settings is described. Order verification within a computerized prescriber order-entry system was chosen as the pharmacy workload driver. To account for inherent variability in the tasks involved in processing different types of orders, pharmaceutical products were grouped by class, and each class was assigned a time standard, or "medication complexity weight" reflecting the intensity of pharmacist and technician activities (verification of drug indication, verification of appropriate dosing, adverse-event prevention and monitoring, medication preparation, product checking, product delivery, returns processing, nurse/provider education, and problem-order resolution). The resulting "weighted verifications" (WV) model allows productivity monitoring by job function (pharmacist versus technician) to guide hiring and staffing decisions. A 9-month historical sample of verified medication orders was analyzed using the WV model, and the calculations were compared with values derived from two established models—one based on the Case Mix Index (CMI) and the other based on the proprietary Pharmacy Intensity Score (PIS). Evaluation of Pearson correlation coefficients indicated that values calculated using the WV model were highly correlated with those derived from the CMI-and PIS-based models (r = 0.845 and 0.886, respectively). Relative to the comparator models, the WV model offered the advantage of less period-to-period variability. The WV model yielded productivity data that correlated closely with values calculated using two validated workload management models. The model may be used as an alternative measure of pharmacy operational productivity. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

[Obligatory vaccination reporting in Saxony-Anhalt. Possibilities and limitations of establishing a computerized vaccination registry].

PubMed

Oppermann, H; Wahl, G; Borrmann, M; Fleischer, J

2009-11-01

Vaccination registries are databases intended to assess and manage complete vaccination data of as many individuals as possible in a population under survey. The task of these registries is to identify low vaccination rates on the individual and population level, to enable systems of reminding individuals, to focus vaccination campaigns and to maximize overall vaccination coverage. Saxony-Anhalt is the only federal state of Germany to have a law that prescribes the reporting of vaccinations. Vaccinations of children up to the age of 7 are reported to the regional public health services. However, as the law provides no regulations as to how the data should be registered and processed, the development of a vaccination registry depends entirely on the initiative and cooperation of the "players in vaccination". The key players in vaccination in Saxony-Anhalt have recently created a Vaccination-Committee, which set out to develop the theoretical standards and a software prototype for the establishment of a computerized vaccination registry. Recent developments in the public health reporting system of Saxony-Anhalt (which strives to modernize its computerized assessment of child and adolescent health) are now opening the possibility to integrate the vaccination registry into the commercially available child health software.

Electronic Chemotherapy Order Entry: A Major Cancer Center's Implementation

PubMed Central

Sklarin, Nancy T.; Granovsky, Svetlana; O'Reilly, Eileen M.; Zelenetz, Andrew D.

2011-01-01

Implementation of a computerized provider order entry system for complex chemotherapy regimens at a large cancer center required intense effort from a multidisciplinary team of clinical and systems experts with experience in all facets of the chemotherapy process. The online tools had to resemble the paper forms used at the time and parallel the successful established process as well as add new functionality. Close collaboration between the institution and the vendor was necessary. This article summarizes the institutional efforts, challenges, and collaborative processes that facilitated universal chemotherapy computerized electronic order entry across multiple sites during a period of several years. PMID:22043182

Electronic Chemotherapy Order Entry: A Major Cancer Center's Implementation.

PubMed

Sklarin, Nancy T; Granovsky, Svetlana; O'Reilly, Eileen M; Zelenetz, Andrew D

2011-07-01

Implementation of a computerized provider order entry system for complex chemotherapy regimens at a large cancer center required intense effort from a multidisciplinary team of clinical and systems experts with experience in all facets of the chemotherapy process. The online tools had to resemble the paper forms used at the time and parallel the successful established process as well as add new functionality. Close collaboration between the institution and the vendor was necessary. This article summarizes the institutional efforts, challenges, and collaborative processes that facilitated universal chemotherapy computerized electronic order entry across multiple sites during a period of several years.

45 CFR 307.11 - Functional requirements for computerized support enforcement systems in operation by October 1...

Code of Federal Regulations, 2011 CFR

2011-10-01

... violence or child abuse); (xi) Indication of an order; (xii) Locate request type (optional); (xiii) Locate... to Public Welfare OFFICE OF CHILD SUPPORT ENFORCEMENT (CHILD SUPPORT ENFORCEMENT PROGRAM), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES COMPUTERIZED SUPPORT...

45 CFR 307.11 - Functional requirements for computerized support enforcement systems in operation by October 1...

Code of Federal Regulations, 2013 CFR

2013-10-01

... violence or child abuse); (xi) Indication of an order; (xii) Locate request type (optional); (xiii) Locate... to Public Welfare OFFICE OF CHILD SUPPORT ENFORCEMENT (CHILD SUPPORT ENFORCEMENT PROGRAM), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES COMPUTERIZED SUPPORT...

45 CFR 307.11 - Functional requirements for computerized support enforcement systems in operation by October 1...

Code of Federal Regulations, 2012 CFR

2012-10-01

... violence or child abuse); (xi) Indication of an order; (xii) Locate request type (optional); (xiii) Locate... to Public Welfare OFFICE OF CHILD SUPPORT ENFORCEMENT (CHILD SUPPORT ENFORCEMENT PROGRAM), ADMINISTRATION FOR CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES COMPUTERIZED SUPPORT...

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion.

PubMed

Patel, Vijay M; Rains, Anna W; Clark, Christopher T

2016-01-01

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

Computerized provider order entry in the clinical laboratory

PubMed Central

Baron, Jason M.; Dighe, Anand S.

2011-01-01

Clinicians have traditionally ordered laboratory tests using paper-based orders and requisitions. However, paper orders are becoming increasingly incompatible with the complexities, challenges, and resource constraints of our modern healthcare systems and are being replaced by electronic order entry systems. Electronic systems that allow direct provider input of diagnostic testing or medication orders into a computer system are known as Computerized Provider Order Entry (CPOE) systems. Adoption of laboratory CPOE systems may offer institutions many benefits, including reduced test turnaround time, improved test utilization, and better adherence to practice guidelines. In this review, we outline the functionality of various CPOE implementations, review the reported benefits, and discuss strategies for using CPOE to improve the test ordering process. Further, we discuss barriers to the implementation of CPOE systems that have prevented their more widespread adoption. PMID:21886891

Optimization of the sources in local hyperthermia using a combined finite element-genetic algorithm method.

PubMed

Siauve, N; Nicolas, L; Vollaire, C; Marchal, C

2004-12-01

This article describes an optimization process specially designed for local and regional hyperthermia in order to achieve the desired specific absorption rate in the patient. It is based on a genetic algorithm coupled to a finite element formulation. The optimization method is applied to real human organs meshes assembled from computerized tomography scans. A 3D finite element formulation is used to calculate the electromagnetic field in the patient, achieved by radiofrequency or microwave sources. Space discretization is performed using incomplete first order edge elements. The sparse complex symmetric matrix equation is solved using a conjugate gradient solver with potential projection pre-conditionning. The formulation is validated by comparison of calculated specific absorption rate distributions in a phantom to temperature measurements. A genetic algorithm is used to optimize the specific absorption rate distribution to predict the phases and amplitudes of the sources leading to the best focalization. The objective function is defined as the specific absorption rate ratio in the tumour and healthy tissues. Several constraints, regarding the specific absorption rate in tumour and the total power in the patient, may be prescribed. Results obtained with two types of applicators (waveguides and annular phased array) are presented and show the faculties of the developed optimization process.

Guided medication dosing for elderly emergency patients using real-time, computerized decision support.

PubMed

Griffey, Richard T; Lo, Helen G; Burdick, Elisabeth; Keohane, Carol; Bates, David W

2012-01-01

To evaluate the impact of a real-time computerized decision support tool in the emergency department that guides medication dosing for the elderly on physician ordering behavior and on adverse drug events (ADEs). A prospective controlled trial was conducted over 26 weeks. The status of the decision support tool alternated OFF (7/17/06-8/29/06), ON (8/29/06-10/10/06), OFF (10/10/06-11/28/06), and ON (11/28/06-1/16/07) in consecutive blocks during the study period. In patients ≥65 who were ordered certain benzodiazepines, opiates, non-steroidals, or sedative-hypnotics, the computer application either adjusted the dosing or suggested a different medication. Physicians could accept or reject recommendations. The primary outcome compared medication ordering consistent with recommendations during ON versus OFF periods. Secondary outcomes included the admission rate, emergency department length of stay for discharged patients, 10-fold dosing orders, use of a second drug to reverse the original medication, and rate of ADEs using previously validated explicit chart review. 2398 orders were placed for 1407 patients over 1548 visits. The majority (49/53; 92.5%) of recommendations for alternate medications were declined. More orders were consistent with dosing recommendations during ON (403/1283; 31.4%) than OFF (256/1115; 23%) periods (p≤0.0001). 673 (43%) visits were reviewed for ADEs. The rate of ADEs was lower during ON (8/237; 3.4%) compared with OFF (31/436; 7.1%) periods (p=0.02). The remaining secondary outcomes showed no difference. Single institution study, retrospective chart review for ADEs. Though overall agreement with recommendations was low, real-time computerized decision support resulted in greater acceptance of medication recommendations. Fewer ADEs were observed when computerized decision support was active.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]--study protocol and baseline practice and provider characteristics.

PubMed

Persell, Stephen D; Friedberg, Mark W; Meeker, Daniella; Linder, Jeffrey A; Fox, Craig R; Goldstein, Noah J; Shah, Parth D; Knight, Tara K; Doctor, Jason N

2013-06-27

Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. ClinicalTrials.gov: NCT01454947.

Evaluation of a medication order writing standards policy in a regional health authority.

PubMed

Raymond, Colette B; Sproll, Barbara; Coates, Jan; Woloschuk, Donna M M

2013-09-01

The Winnipeg Regional Health Authority (WRHA) implemented a medication order writing standards (MOWS) policy (including banned abbreviations) to improve patient safety. Widespread educational campaigns and direct prescriber feedback were implemented. We audited orders within the WRHA from 2005 to 2009 and surveyed all WRHA staff in 2011 about the policy and suggestions for improving education and compliance. Overall, orders containing banned abbreviations, acronyms or symbols numbered 2261/8565 (26.4%) preimplementation. After WRHA-wide didactic education, the proportion declined to 1358/5461 (24.9%) (p = 0.043) and then, with targeted prescriber feedback, to 1186/6198 (19.1%) (p < 0.0001). A survey of 723 employees showed frequent violations of the MOWS, despite widespread knowledge of the policy. Respondents supported ongoing efforts to enforce the policy within the WRHA. Nonprescribers were significantly more likely than prescribers to agree with statements regarding enhancing compliance by defining prescriber/transcriber responsibilities and placing sanctions on noncompliant prescribers. Education, raising general awareness and targeted feedback to prescribers alone are insufficient to ensure compliance with MOWS policies. WRHA staff supported ongoing communication, improved tools such as compliant preprinted orders and reporting and feedback about medication incidents. A surprising number of respondents supported placing sanctions on noncompliant prescribers. Serial audits and targeted interventions such as direct prescriber feedback improve prescription quality in inpatient hospital settings. Education plus direct prescriber feedback had a greater impact than education alone on improving compliance with a MOWS policy. Future efforts at the WRHA to improve compliance will require an expanded focus on incentives, resources and development of action plans that involve all affected staff, not just prescribers. Plans include continued advertising, MOWS summaries in all charts, all-staff education, reminders and exploration of sustainable interventions for targeted feedback for prescribers.

Acute drug prescribing to children on chronic antiepilepsy therapy and the potential for adverse drug interactions in primary care

PubMed Central

Novak, Philipp H; Ekins-Daukes, Suzie; Simpson, Colin R; Milne, Robert M; Helms, Peter; McLay, James S

2005-01-01

Aims To investigate the extent of acute coprescribing in primary care to children on chronic antiepileptic therapy, which could give rise to potentially harmful drug–drug interactions. Design Acute coprescribing to children on chronic antiepileptic drug therapy in primary care was assessed in 178 324 children aged 0–17 years for the year 1 November 1999 to 31 October 2000. Computerized prescribing data were retrieved from 161 representative general practices in Scotland. Setting One hundred and sixty-one general practices throughout Scotland. Results During the study year 723 (0.41%) children chronically prescribed antiepileptic therapy were identified. Fourteen antiepileptic agents were prescribed, with carbamazepine, sodium valproate and lamotrigine accounting for 80% of the total. During the year children on chronic antiepileptic therapy were prescribed 4895 acute coprescriptions for 269 different medicines. The average number of acute coprescriptions for non-epileptic drug therapy were eight, 11, six, and six for the 0–1, 2–4, 5–11, and 12–17-year-olds, respectively. Of these acute coprescriptions 72 (1.5%) prescribed to 22 (3.0%) children were identified as a potential source of clinically serious interactions. The age-adjusted prevalence rates for potentially serious coprescribing were 86, 26, 22, and 33/1000 children chronically prescribed antiepileptic therapy in the 0–1, 2–4, 5–11, and 12–17-year-old age groups, respectively. The drugs most commonly coprescribed which could give rise to such interactions were antacids, erythromycin, ciprofloxacin, theophylline and the low-dose oral contraceptive. For 10 (45.5%0 of the 20 children identified at risk of a potentially clinically serious adverse drug interaction, the acute coprescription was prescribed off label because of age or specific contraindication/warning. Conclusions In primary care, 3.0% of children on chronic antiepileptic therapy are coprescribed therapeutic agents, which could give rise to clinically serious drug–drug interactions. PMID:15948936

The Development of COBOL and RPG Instructional Modules to Audit Computerized Accounting Systems.

ERIC Educational Resources Information Center

Skudrna, Vincent J.

1982-01-01

Details steps involved (as found in the literature) in the systems approach to design and develop instruction in order to provide a rationale for the development of instructional modules in COBOL and RPG to teach accounting students how to audit computerized accounting systems. Outlines of two modules are appended. (EAO)

Computerized tomography versus magnetic resonance imaging: a comparative study in hypothalamic-pituitary and parasellar pathology.

PubMed

Webb, S M; Ruscalleda, J; Schwarzstein, D; Calaf-Alsina, J; Rovira, A; Matos, G; Puig-Domingo, M; de Leiva, A

1992-05-01

We wished to analyse the relative value of computerized tomography and magnetic resonance in patients referred for evaluation of pituitary and parasellar lesions. We performed a separate evaluation by two independent neuroradiologists of computerized tomography and magnetic resonance images ordered numerically and anonymously, with no clinical data available. We studied 40 patients submitted for hypothalamic-pituitary study; 31 were carried out preoperatively, of which histological confirmation later became available in 14. The remaining nine patients were evaluated postoperatively. Over 40 parameters relating to the bony margins, cavernous sinuses, carotid arteries, optic chiasm, suprasellar cisterns, pituitary, pituitary stalk and extension of the lesion were evaluated. These reports were compared with the initial ones offered when the scans were ordered, and with the final diagnosis. Concordance between initial computerized tomography and magnetic resonance was observed in 27 cases (67.5%); among the discordant cases computerized tomography showed the lesion in two, magnetic resonance in 10, while in the remaining case reported to harbour a microadenoma on computerized tomography the differential diagnosis between a true TSH-secreting microadenoma and pituitary resistance to thyroid hormones is still unclear. Both neuroradiologists coincided in their reports in 32 patients (80%); when the initial report was compared with those of the neuroradiologists, concordance was observed with at least one of them in 34 instances (85%). Discordant results were observed principally in microadenomas secreting ACTH or PRL and in delayed puberty. In the eight patients with Cushing's disease (histologically confirmed in six) magnetic resonance was positive in five and computerized tomography in two; the abnormal image correctly identified the side of the lesion at surgery. In patients referred for evaluation of Cushing's syndrome or hyperprolactinaemia (due to microadenomas) or after surgery, magnetic resonance is clearly preferable to computerized tomography. In macroadenomas both scans are equally diagnostic but magnetic resonance offers more information on pituitary morphology and neighbouring structures. Nevertheless, there are cases in which the results of computerized tomography and magnetic resonance will complement each other, since different parameters are analysed with each examination and discordant results are encountered.

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

PubMed

Hickman, Thu-Trang T; Quist, Arbor Jessica Lauren; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Volk, Lynn A; Bates, David W; Schiff, Gordon

2018-04-01

Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous. To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous. During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason 'Error (erroneous entry)." Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders. From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error. Drugs are not infrequently discontinued 'in error.' Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

PubMed

Yang, Cheng-Yi; Lo, Yu-Sheng; Chen, Ray-Jade; Liu, Chien-Tsai

2018-01-19

A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients' integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients' medication records prescribed by different health care facilities across Taiwan. This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters. A CDS engine was developed that can download patients' up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians' responses to handling the alerts for each encounter. The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians' responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled. The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient's medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required. ©Cheng-Yi Yang, Yu-Sheng Lo, Ray-Jade Chen, Chien-Tsai Liu. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 19.01.2018.

Evaluation of a Computerized Decision Support Intervention to Decrease Use of Anti-Pseudomonal Carbapenems in Penicillin Allergic Patients

PubMed Central

Caplinger, Christina; Smith, Garret; Remington, Richard; Madaras-Kelly, Karl

2016-01-01

Allergies to β-lactam antibiotics are commonly documented in hospitalized patients; however, true allergy is uncommon. Cross-reactivity rates for advanced generation cephalosporins and carbapenems are low; particularly for patients without a history of symptoms consistent with type 1 hypersensitivity. We observed that providers preferentially prescribed antipseudomonal carbapenems (APC) over advanced generation cephalosporins for patients with β-lactam allergy history, including those with low risk for antimicrobial-resistant infections. Information was inserted into the computerized decision support system (CDSS) to aid clinicians in assessing β-lactam cross-reactivity risk and selecting appropriate therapy. A retrospective evaluation was conducted in a small hospital to assess the impact of the CDSS changes in APC prescribing. Inpatients (n = 68) who received at least one APC dose during hospitalization over a 13 month pre-intervention period were compared to inpatients who received an APC during the 15 month post-intervention period (n = 59) for documented APC indications and β-lactam allergy history. APC initiations were measured and corrected per 1000 patient-days; interrupted time-series analysis was performed to assess changes in use before and after implementation. Aggregate monthly APC initiations decreased from 7.01 to 6.14 per 1000 patient-days after the implementation (p = 0.03). Post-intervention APC initiations for patients with low-risk β-lactam histories decreased from 92% to 83% (p = 0.17). No adverse events were observed in patients with low-risk β-lactam histories. The intervention was associated with a reduction in APC initiations. PMID:27025522

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding.

PubMed

MacKay, Mark; Anderson, Collin; Boehme, Sabrina; Cash, Jared; Zobell, Jeffery

2016-04-01

The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors. © 2015 American Society for Parenteral and Enteral Nutrition.

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration--2011.

PubMed

Pedersen, Craig A; Schneider, Philip J; Scheckelhoff, Douglas J

2012-05-01

Results of the 2011 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented. A stratified random sample of pharmacy directors at 1401 general and children's medical-surgical hospitals in the United States were surveyed by mail. In this national probability sample survey, the response rate was 40.1%. Decentralization of the medication-use system continues, with 40% of hospitals using a decentralized system and 58% of hospitals planning to use a decentralized model in the future. Automated dispensing cabinets were used by 89% of hospitals, robots were used by 11%, carousels were used in 18%, and machine-readable coding was used in 34% of hospitals to verify doses before dispensing. Overall, 65% of hospitals had a United States Pharmacopeia chapter 797 compliant cleanroom for compounding sterile preparations. Medication administration records (MARs) have become increasingly computerized, with 67% of hospitals using electronic MARs. Bar-code-assisted medication administration was used in 50% of hospitals, and 68% of hospitals had smart infusion pumps. Health information is becoming more electronic, with 67% of hospitals having partially or completely implemented an electronic health record and 34% of hospitals having computerized prescriber order entry. The use of these technologies has substantially increased over the past year. The average number of full-time equivalent staff per 100 occupied beds averaged 17.5 for pharmacists and 15.0 for technicians. Directors of pharmacy reported declining vacancy rates for pharmacists. Pharmacists continue to improve medication use at the dispensing and administration steps of the medication-use system. The adoption of new technology is changing the philosophy of medication distribution, and health information is rapidly becoming electronic.

Electronic prescribing: criteria for evaluating handheld prescribing systems and an evaluation of a new, handheld, wireless wide area network (WWAN) prescribing system.

PubMed

Goldblum, O M

2001-02-01

The objectives of this study were: 1) to establish criteria for evaluating handheld computerized prescribing systems; and 2) to evaluate out-of-box performance and features of a new, Palm Operating System (OS)-based, handheld, wireless wide area network (WWAN) prescribing system. The system consisted of a Palm Vx handheld organizer, a Novatel Minstrel V wireless modem, OmniSky wireless internet access and ePhysician ePad 1.1, the Palm OS electronic prescribing software program. A dermatologist familiar with healthcare information technology conducted an evaluation of the performance and features of a new, handheld, WWAN electronic prescribing system in an office practice during a three-month period in 2000. System performance, defined as transmission success rate, was determined from data collected during the three-month trial. Evaluation criteria consisted of an analysis of features found in electronic prescribing systems. All prescriptions written for all patients seen during a three-month period (August - November, 2000) were eligible for inclusion. Prescriptions written for patients who intended to fill them at pharmacies without known facsimile receiving capabilities were excluded from the study. The performance of the system was evaluated using data collected during the study. Criteria for evaluating features of electronic prescribing systems were developed and used to analyze the system employed in this study. During this three-month trial, 200 electronic prescriptions were generated for 132 patients included in the study. Of these prescriptions, 92.5 percent were successfully transmitted to pharmacies. Transmission failures resulted from incorrect facsimile numbers and non-functioning facsimile machines. Criteria established for evaluation of electronic prescribing systems included System (Hardware & Software), Costs, System Features, Printing & Transmission, Formulary & Insurance, Customization, Drug Safety and Security. This study is the first effort to establish comprehensive criteria for evaluating handheld prescribing systems and to evaluate the performance and features of a handheld, electronic prescribing system. The results demonstrated that the evaluated system: 1) was simple to install; 2) successfully interfaced with a commonly used practice management system; 3) was user-friendly and easy to operate; 4) offered a robust variety of standard features; and, 5) resulted in a high rate of success for transmitting electronic prescriptions. The criteria established for the evaluation of features of an electronic prescribing system can be used to critically evaluate the performance and features of other handheld and personal computer-based electronic prescribing systems.

Supporting Patient Care in the Emergency Department with a Computerized Whiteboard System

PubMed Central

Aronsky, Dominik; Jones, Ian; Lanaghan, Kevin; Slovis, Corey M.

2008-01-01

Efficient information management and communication within the emergency department (ED) is essential to providing timely and high-quality patient care. The ED whiteboard (census board) usually serves as an ED’s central access point for operational and patient-related information. This article describes the design, functionality, and experiences with a computerized ED whiteboard, which has the ability to display relevant operational and patient-related information in real time. Embedded functionality, additional whiteboard views, and the integration with ED and institutional information system components, such as the computerized patient record or the provider order entry system, provide rapid access to more detailed information. As an information center, the computerized whiteboard supports our ED environment not only for providing patient care, but also for operational, educational, and research activities. PMID:18096913

An Integrated Computerized Triage System in the Emergency Department

PubMed Central

Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

2008-01-01

Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >290,000 pediatric and adult patients. PMID:18999190

The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan.

PubMed

Long, An-Jim; Chang, Polun

2012-09-01

There is an evidence that pregnant women have been prescribed a significant number of improper medications that could lead to potential damage for a developing fetus due to discontinuity of care. The safety of pregnant women raises public concern and there is a need to identify ways to prevent potential adverse events to the pregnant woman. This study used a health smart card with a clinical reminder system to keep continuous records of general outpatient visits of pregnant women to protect them from potential adverse events caused by improper prescription. The health smart card, issued to all 23 million citizens in Taiwan, was used to work with a Computerized Physician Order Entry (CPOE) implemented at a 700-bed teaching medical center in Taipei to provide the outpatient information of pregnant women. FDA pregnancy risk classification was used to categorize the risk of pregnant women. The log file, combined with the physicians' and patients' profiles, were statistically examined using the Mantel-Haenszel technique to evaluate the impact of system in changing physician's prescription behavior. A total of 441 patients ranged in age from 15 to 50 years with 1114 prescriptions involved in FDA pregnancy risk classification C, D, and X during the study period. 144 reminders (13.1%) were accepted by physicians for further assessment and 100 (69.4%) of them were modified. Non-obstetric physicians in non-emergency setting were more intended to accept reminders (27.8%, 4.9 folds than obstetricians). Reminders triggered on patients in second trimester (15.5%) were accepted by all physicians more than third trimester (OR 1.52, p<0.05). A health smart card armed with CPOE reminder system and well-defined criteria had the potential to decrease harmful medication prescribed to pregnant patients. The results show better conformance for non-obstetric physicians (26%) and when physicians accepted the alerts they are more likely to went back and review their orders (69%). In sum, reminder criteria of FDA pregnancy risk classification C for obstetricians and reminder based on different trimesters is suggested to be refined to improve system acceptability and to decrease improper prescription. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Is there a link between the hospital-acquired injurious fall rates in US acute care hospitals and these institutions' implementation levels of computerized systems?

PubMed

Tzeng, Huey-Ming; Hu, Hsou Mei; Yin, Chang-Yi

2011-12-01

Medicare no longer reimburses acute care hospitals for the costs of additional care required due to hospital-acquired injuries. Consequently, this study explored the effective computerized systems to inform practice for better interventions to reduce fall risk. It provided a correlation between type of computerized system and hospital-acquired injurious fall rates at acute care hospitals in California, Florida, and New York. It used multiple publicly available data sets, with the hospital as the unit of analysis. Descriptive and Pearson correlation analyses were used. The analysis included 462 hospitals. Significant correlations could be categorized into two groups: (1) meaningful computerized systems that were associated with lower injurious fall rates: the decision support systems for drug allergy alerts, drug-drug interaction alerts, and drug-laboratory interaction alerts; and (2) computerized systems that were associated with higher injurious fall rates: the decision support system for drug-drug interaction alerts and the computerized provider order entry system for radiology tests. Future research may include additional states, multiple years of data, and patient-level data to validate this study's findings. This effort may further inform policy makers and the public about effective clinical computerized systems provided to clinicians to improve their practice decisions and care outcomes.

Computerized Physician Order Entry: Reluctance of Physician Adoption of Technology Linked to Improving Health Care

ERIC Educational Resources Information Center

Ulinski, Don

2013-01-01

Physicians are the influential force in the complex field of patient care delivery. Physicians determine when and where patient healthcare is delivered and affect 80% of the money spent on it. Computerized systems used in the delivery of healthcare information have become an integral part that physicians use to provide patient care. This study…

g--Acceleration of Gravity: Its Measurement from the Shape of Water by Using a Computerized Rotational System

ERIC Educational Resources Information Center

Pintao, Carlos A. F.; de Souza Filho, Moacir P.

2007-01-01

This paper proposes a different experimental setup compared with the traditional ones, in order to determine the acceleration of gravity, which is carried out by using a fluid at a constant rotation. A computerized rotational system--by using a data acquisition system with specific software, a power amplifier and a rotary motion sensor--is…

Modeling of outpatient prescribing process in iran: a gateway toward electronic prescribing system.

PubMed

Ahmadi, Maryam; Samadbeik, Mahnaz; Sadoughi, Farahnaz

2014-01-01

Implementation of electronic prescribing system can overcome many problems of the paper prescribing system, and provide numerous opportunities of more effective and advantageous prescribing. Successful implementation of such a system requires complete and deep understanding of work content, human force, and workflow of paper prescribing. The current study was designed in order to model the current business process of outpatient prescribing in Iran and clarify different actions during this process. In order to describe the prescribing process and the system features in Iran, the methodology of business process modeling and analysis was used in the present study. The results of the process documentation were analyzed using a conceptual model of workflow elements and the technique of modeling "As-Is" business processes. Analysis of the current (as-is) prescribing process demonstrated that Iran stood at the first levels of sophistication in graduated levels of electronic prescribing, namely electronic prescription reference, and that there were problematic areas including bottlenecks, redundant and duplicated work, concentration of decision nodes, and communicative weaknesses among stakeholders of the process. Using information technology in some activities of medication prescription in Iran has not eliminated the dependence of the stakeholders on paper-based documents and prescriptions. Therefore, it is necessary to implement proper system programming in order to support change management and solve the problems in the existing prescribing process. To this end, a suitable basis should be provided for reorganization and improvement of the prescribing process for the future electronic systems.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01] - study protocol and baseline practice and provider characteristics

PubMed Central

2013-01-01

Background Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. Methods/design The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. Discussion The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. Trials registration ClinicalTrials.gov: NCT01454947 PMID:23806017

Nurses' role in medication safety.

PubMed

Choo, Janet; Hutchinson, Alison; Bucknall, Tracey

2010-10-01

To explore the nurse's role in the process of medication management and identify the challenges associated with safe medication management in contemporary clinical practice. Medication errors have been a long-standing factor affecting consumer safety. The nursing profession has been identified as essential to the promotion of patient safety. A review of literature on medication errors and the use of electronic prescribing in medication errors. Medication management requires a multidisciplinary approach and interdisciplinary communication is essential to reduce medication errors. Information technologies can help to reduce some medication errors through eradication of transcription and dosing errors. Nurses must play a major role in the design of computerized medication systems to ensure a smooth transition to such as system. The nurses' roles in medication management cannot be over-emphasized. This is particularly true when designing a computerized medication system. The adoption of safety measures during decision making that parallel those of the aviation industry safety procedures can provide some strategies to prevent medication error. Innovations in information technology offer potential mechanisms to avert adverse events in medication management for nurses. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.

Medication-related clinical decision support in computerized provider order entry systems: a review.

PubMed

Kuperman, Gilad J; Bobb, Anne; Payne, Thomas H; Avery, Anthony J; Gandhi, Tejal K; Burns, Gerard; Classen, David C; Bates, David W

2007-01-01

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Computerized urea kinetic modeling to prescribe and monitor delivered Kt/V (pKt/V, dKt/V) in peritoneal dialysis. Fresenius Randomized Dialysis Prescriptions and Clinical Outcome Study (RDP/CO).

PubMed

Gotch, F A; Lipps, B J; Keen, M L; Panlilio, F

1996-01-01

A computerized urea kinetic model of peritoneal urea transport (PACK-PD) has been developed and used to calculate prescription parameters which would result in the prescribed weekly peritoneal urea clearance (pKpt/V) required to achieve levels of weekly summed renal + peritoneal urea clearance (pKprt/ V) targeted at 1.75 and 2.16. Baseline kinetic data were obtained and analyzed with PACK-PD on 88 patients, and the program then used these data to calculate the required pKpt/V and subsequently the delivered Kpt/V (dKpt/V) from the dialysate collections. A total of 108 prescriptions were written and compared to dKpt/V measured over one to 24 months in the 88 patients. Both continuous ambulatory peritoneal dialysis and automated peritoneal dialysis (APD) were studied (APD consisted of PD+ with one or two diurnal and two to four nocturnal cycler exchanges). The correlation of dKpt/V to pKpt/V showed r = 0.93 with 95% confidence limits (CL) on agreement of +/-20% over a range of pKpt/V 0.52-2.55. The 95% CL on (dKpt/V-pKpt/V) were +/-0.30. We concluded: (1) that the prescription can be modeled as reliably in peritoneal dialysis as in hemodialysis (HD) where dKt/V and pKt/V agree to +/-25%, (2) that any individual weekly dKpt/V may vary as much as 0.3-0.4 from pKpt/V, and (3) that frequent measurement of dKpt/V and adjustment of pKpt/V as needed are required (as in HD) to control mean dKpt/V to within +/-10% of mean pKpt/V.

Computer programming: quality and safety for neonatal parenteral nutrition orders.

PubMed

Huston, Robert K; Markell, Andrea M; McCulley, Elizabeth A; Marcus, Matthew J; Cohen, Howard S

2013-08-01

Computerized software programs reduce errors and increase consistency when ordering parenteral nutrition (PN). The purpose of this study was to evaluate the effectiveness of our computerized neonatal PN calculator ordering program in reducing errors and optimizing nutrient intake. This was a retrospective study of infants requiring PN during the first 2-3 weeks of life. Caloric, protein, calcium, and phosphorus intakes; days above and below amino acid (AA) goals; and PN ordering errors were recorded. Infants were divided into 3 groups by birth weight for analysis: ≤1000 g, 1001-1500 g, and >1500 g. Intakes and outcomes of infants before (2007) vs after (2009) implementation of the calculator for each group were compared. There were no differences in caloric, protein, or phosphorus intakes in 2007 vs 2009 in any group. Mean protein intakes were 97%-99% of goal for ≤1000-g and 1001- to 1500-g infants in 2009 vs 87% of goal for each group in 2007. In 2007, 7.6 per 100 orders were above and 11.5 per 100 were below recommended AA intakes. Calcium intakes were higher in 2009 vs 2007 in ≤1000-g (46.6 ± 6.1 vs 39.5 ± 8.0 mg/kg/d, P < .001) and >1500-g infants (50.6 ± 7.4 vs 39.9 ± 8.3 mg/kg/d, P < .001). Ordering errors were reduced from 4.6 per 100 in 2007 to 0.1 per 100 in 2009. Our study reaffirms that computerized ordering systems can increase the quality and safety of neonatal PN orders. Calcium and AA intakes were optimized and ordering errors were minimized using the computer-based ordering program.

Effect of a Computerized Provider Order Entry (CPOE) System on Medication Orders at a Community Hospital and University Hospital

PubMed Central

Wess, Mark L.; Embi, Peter J.; Besier, James L.; Lowry, Chad H.; Anderson, Paul F.; Besier, James C.; Thelen, Geriann; Hegner, Catherine

2007-01-01

Computerized Provider Order Entry (CPOE) has been demonstrated to improve the medication ordering process, but most published studies have been performed at academic hospitals. Little is known about the effects of CPOE at community hospitals. With a pre-post study design, we assessed the effects of a CPOE system on the medication ordering process at both a community and university hospital. The time from provider ordering to pharmacist verification decreased by two hours with CPOE at the community hospital (p<0.0001) and by one hour at the university hospital (p<0.0001). The rate of medication clarifications requiring signature was 2.80 percent pre-CPOE and 0.40 percent with CPOE (p<0.0001) at the community hospital. The university hospital was 2.76 percent pre-CPOE and 0.46 percent with CPOE (p<0.0001). CPOE improved medication order processing at both community and university hospitals. These findings add to the limited literature on CPOE in community hospitals. PMID:18693946

A case study on the impacts of computerized provider order entry (CPOE) system on hospital clinical workflow.

PubMed

Mominah, Maher; Yunus, Faisel; Househ, Mowafa S

2013-01-01

Computerized provider order entry (CPOE) is a health informatics system that helps health care providers create and manage orders for medications and other health care services. Through the automation of the ordering process, CPOE has improved the overall efficiency of hospital processes and workflow. In Saudi Arabia, CPOE has been used for years, with only a few studies evaluating the impacts of CPOE on clinical workflow. In this paper, we discuss the experience of a local hospital with the use of CPOE and its impacts on clinical workflow. Results show that there are many issues related to the implementation and use of CPOE within Saudi Arabia that must be addressed, including design, training, medication errors, alert fatigue, and system dep Recommendations for improving CPOE use within Saudi Arabia are also discussed.

17 CFR 201.141 - Orders and decisions: Service of orders instituting proceedings and other orders and decisions.

Code of Federal Regulations, 2010 CFR

2010-04-01

.... (3) Record of service. The Secretary shall maintain a record of service on parties (in hard copy or computerized format), identifying the party given notice, the method of service, the date of service, the...

Computerized Alerts Improve Outpatient Laboratory Monitoring of Transplant Patients

PubMed Central

Staes, Catherine J.; Evans, R. Scott; Rocha, Beatriz H.S.C.; Sorensen, John B.; Huff, Stanley M.; Arata, Joan; Narus, Scott P.

2008-01-01

Authors evaluated the impact of computerized alerts on the quality of outpatient laboratory monitoring for transplant patients. For 356 outpatient liver transplant patients managed at LDS Hospital, Salt Lake City, this observational study compared traditional laboratory result reporting, using faxes and printouts, to computerized alerts implemented in 2004. Study alerts within the electronic health record notified clinicians of new results and overdue new orders for creatinine tests and immunosuppression drug levels. After implementing alerts, completeness of reporting increased from 66 to >99 %, as did positive predictive value that a report included new information (from 46 to >99 %). Timeliness of reporting and clinicians' responses improved after implementing alerts (p <0.001): median times for clinicians to receive and complete actions decreased to 9 hours from 33 hours using the prior traditional reporting system. Computerized alerts led to more efficient, complete, and timely management of laboratory information. PMID:18308982

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

PubMed

Weir, Charlene R; Nebeker, Jonathan J R; Hicken, Bret L; Campo, Rebecca; Drews, Frank; Lebar, Beth

2007-01-01

Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system.

A systematic review of opioid use after extremity trauma in orthopedic surgery.

PubMed

Koehler, Rikki M; Okoroafor, Ugochi C; Cannada, Lisa K

2018-06-01

The United States is in a prescription opioid crisis. Orthopedic surgeons prescribe more opioid narcotics than any other surgical specialty. The purpose of this study was to evaluate the state of opioid use after extremity trauma in orthopedic surgery. A computerized literature search of PubMed/MEDLINE was conducted to evaluate the status of opioids after extremity fractures. Six articles were identified and included in the review. Patients who consume more opioids communicate greater pain intensity and less satisfaction with pain control. Intraoperative multimodal drug injection and nerve blockade are viable alternatives for postoperative pain control and can help decrease systemic opioid use. Orthopedic surgeons are overprescribing opioids. Compared to other countries, the United States consumes more opioids with no better satisfaction with pain control. Orthopedic trauma surgeons should tailor their postoperative opioid prescriptions to the individual patient and utilize alternative options in order to control postoperative pain. Patients should be counseled regarding narcotic addiction and dependence. Patients unable to manage pain postoperatively should be followed closely and receive the proper chronic pain management, mental and social health services referrals. Copyright © 2018 Elsevier Ltd. All rights reserved.

Is Metabolic Syndrome On the Radar? Improving Real-Time Detection of Metabolic Syndrome and Physician Response by Computerized Scan of the Electronic Medical Record

PubMed Central

Lui, Kingwai; Randhawa, Gagandeep; Totten, Vicken; Smith, Adam E.; Raese, Joachim

2016-01-01

Objective: Metabolic syndrome is a common underdiagnosed condition among psychiatric patients exacerbated by second-generation antipsychotics, with the exception of aripiprazole and ziprasidone. This study evaluated the prescribing and treating behavior with regard to antipsychotics and metabolic syndrome of psychiatrists before and after implementation of a mandatory admission order set and electronic notification of results. Method: Baseline data from 9,100 consecutive psychiatric admissions to a mental health hospital (July 2013–July 2014) were compared to postintervention data (July 2014–January 2015), which included 1,499 consecutive patient records. The intervention initiated standardized admission testing with electronic notification to psychiatrists when patients met metabolic syndrome criteria (according to Axis III of the DSM-IV). Charts were examined for inclusion of this diagnosis at discharge and for treatment changes. Results: At baseline, only 2.4% of patients (n = 214) were evaluated for metabolic syndrome. Of these, 34.5% (0.8% of the total sample) met metabolic syndrome criteria. Only 15 patients (0.16%) were comprehensively treated. No chart listed metabolic syndrome under Axis III of the DSM-IV. After the intervention, the diagnosis of patients meeting the criteria for metabolic syndrome increased from 0% to 29.3%. Less than 3% of patients were switched to drugs with a more benign metabolic profile. All patients who continued on second-generation antipsychotics had metabolic retesting. Thirty-eight experienced a significant and rapid increase in triglyceride levels after only 3 to 17 days. Conclusions: Mandatory intake testing increases the number of patients evaluated for metabolic syndrome. Electronic alerts increase the inclusion of metabolic syndrome among discharge diagnoses but rarely affect prescribing practices. PMID:27247842

Experimental Investigation of Fibre Reinforced Composite Materials Under Impact Load

NASA Astrophysics Data System (ADS)

Koppula, Sravani; Kaviti, Ajay kumar; Namala, Kiran kumar

2018-03-01

Composite materials are extensively used in various engineering applications. They have very high flexibility design which allows prescribe tailoring of material properties by lamination of composite fibres with reinforcement of resin to it. Complex failure condition prevail in the composite materials under the action of impact loads, major modes of failure in composite may include matrix cracking, fibre matrix, fibre breakage, de-bonding or de- lamination between composite plies. This paper describes the mechanical properties of glass fibre reinforced composite material under impact loading conditions through experimental setup. Experimental tests are performed according to ASTM standards using impact testing machines like Charpy test, computerized universal testing machine.

Computerized method for detection of vertebral fractures on lateral chest radiographs based on morphometric data

NASA Astrophysics Data System (ADS)

Kasai, Satoshi; Li, Feng; Shiraishi, Junji; Li, Qiang; Straus, Christopher; Vokes, Tamara; MacMahon, Heber; Doi, Kunio

2007-03-01

Vertebral fractures are the most common osteoporosis-related fractures. It is important to detect vertebral fractures, because they are associated with increased risk of subsequent fractures, and because pharmacologic therapy can reduce the risk of subsequent fractures. Although vertebral fractures are often not clinically recognized, they can be visualized on lateral chest radiographs taken for other purposes. However, only 15-60% of vertebral fractures found on lateral chest radiographs are mentioned in radiology reports. The purpose of this study was to develop a computerized method for detection of vertebral fractures on lateral chest radiographs in order to assist radiologists' image interpretation. Our computerized method is based on the automated identification of upper and lower vertebral edges. In order to develop the scheme, radiologists provided morphometric data for each identifiable vertebra, which consisted of six points for each vertebra, for 25 normals and 20 cases with severe fractures. Anatomical information was obtained from morphometric data of normal cases in terms of vertebral heights, heights of vertebral disk spaces, and vertebral centerline. Computerized detection of vertebral fractures was based on the reduction in the heights of fractured vertebrae compared to adjacent vertebrae and normal reference data. Vertebral heights from morphometric data on normal cases were used as reference. On 138 chest radiographs (20 with fractures) the sensitivity of our method for detection of fracture cases was 95% (19/20) with 0.93 (110/118) false-positives per image. In conclusion, the computerized method would be useful for detection of potentially overlooked vertebral fractures on lateral chest radiographs.

Exploiting Semantic Web Technologies to Develop OWL-Based Clinical Practice Guideline Execution Engines.

PubMed

Jafarpour, Borna; Abidi, Samina Raza; Abidi, Syed Sibte Raza

2016-01-01

Computerizing paper-based CPG and then executing them can provide evidence-informed decision support to physicians at the point of care. Semantic web technologies especially web ontology language (OWL) ontologies have been profusely used to represent computerized CPG. Using semantic web reasoning capabilities to execute OWL-based computerized CPG unties them from a specific custom-built CPG execution engine and increases their shareability as any OWL reasoner and triple store can be utilized for CPG execution. However, existing semantic web reasoning-based CPG execution engines suffer from lack of ability to execute CPG with high levels of expressivity, high cognitive load of computerization of paper-based CPG and updating their computerized versions. In order to address these limitations, we have developed three CPG execution engines based on OWL 1 DL, OWL 2 DL and OWL 2 DL + semantic web rule language (SWRL). OWL 1 DL serves as the base execution engine capable of executing a wide range of CPG constructs, however for executing highly complex CPG the OWL 2 DL and OWL 2 DL + SWRL offer additional executional capabilities. We evaluated the technical performance and medical correctness of our execution engines using a range of CPG. Technical evaluations show the efficiency of our CPG execution engines in terms of CPU time and validity of the generated recommendation in comparison to existing CPG execution engines. Medical evaluations by domain experts show the validity of the CPG-mediated therapy plans in terms of relevance, safety, and ordering for a wide range of patient scenarios.

Health technology assessment review: Computerized glucose regulation in the intensive care unit - how to create artificial control

PubMed Central

2009-01-01

Current care guidelines recommend glucose control (GC) in critically ill patients. To achieve GC, many ICUs have implemented a (nurse-based) protocol on paper. However, such protocols are often complex, time-consuming, and can cause iatrogenic hypoglycemia. Computerized glucose regulation protocols may improve patient safety, efficiency, and nurse compliance. Such computerized clinical decision support systems (Cuss) use more complex logic to provide an insulin infusion rate based on previous blood glucose levels and other parameters. A computerized CDSS for glucose control has the potential to reduce overall workload, reduce the chance of human cognitive failure, and improve glucose control. Several computer-assisted glucose regulation programs have been published recently. In order of increasing complexity, the three main types of algorithms used are computerized flowcharts, Proportional-Integral-Derivative (PID), and Model Predictive Control (MPC). PID is essentially a closed-loop feedback system, whereas MPC models the behavior of glucose and insulin in ICU patients. Although the best approach has not yet been determined, it should be noted that PID controllers are generally thought to be more robust than MPC systems. The computerized Cuss that are most likely to emerge are those that are fully a part of the routine workflow, use patient-specific characteristics and apply variable sampling intervals. PMID:19849827

Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use.

PubMed

Vandenberg, Ann E; Vaughan, Camille P; Stevens, Melissa; Hastings, Susan N; Powers, James; Markland, Alayne; Hwang, Ula; Hung, William; Echt, Katharina V

2017-02-01

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'. Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

A New Observatory for Eastern College: A Dream Realized

NASA Astrophysics Data System (ADS)

Bradstreet, D. H.

1996-12-01

The Eastern College Observatory began as a rooftop observing deck with one Celestron 8 telescope in 1976 as the workhorse instrument of the observational astronomy lab within the core curriculum. For 20 years the observing deck served as the crude observatory, being augmented through the years by other computerized Celestron 8's and a 17.5" diameter Dobsonian with computerized setting circles. The lab consisted primarily of visual observations and astrophotography. In 1987 plans were set into motion to raise money to build a permanent Observatory on the roof of the main classroom building. Fundraising efforts included three Jog-A-Thons (raising more than $40,000) and many donations from individuals and foundations. The fundraising was completed in 1996 and a two telescope observatory was constructed in the summer of 1996 complete with warm room, CCD cameras, computers, spectrograph, video network, and computerized single channel photometer. The telescopes are computerized 16" diameter Meade LX200 Schmidt-Cassegrains, each coupled to Gateway Pentium Pro 200 MHz computers. SBIG ST-8 CCD cameras were also secured for each telescope and an Optec SSP-7 photometer and Optomechanics Research 10C Spectrograph were also purchased. A Daystar H-alpha solar filter and Thousand Oaks visual light solar filter have expanded the Observatory's functionality to daytime observing as well. This is especially useful for the thousands of school children who frequent the Planetarium each year. The Observatory primarily serves the core astronomy lab where students must observe and photograph a prescribed number of celestial objects in a semester. Advanced students can take directed studies where they conduct photometry on eclipsing binaries or other variable stars or search for new asteroids. In addition, the Observatory and Planetarium are open to the public. Interested members of the community can reserve time on the telescopes and receive training and supervision from lab assistants. The lessons learned from building the Observatory as well as structural plans, equipment and curriculum development will be discussed in this poster.

Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis.

PubMed

Gong, Cynthia L; Zangwill, Kenneth M; Hay, Joel W; Meeker, Daniella; Doctor, Jason N

2018-05-08

Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs). To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs. Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data. Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider. (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues. Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events. Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

Using 'nudge' principles for order set design: a before and after evaluation of an electronic prescribing template in critical care.

PubMed

Bourdeaux, Christopher P; Davies, Keith J; Thomas, Matthew J C; Bewley, Jeremy S; Gould, Timothy H

2014-05-01

Computerised order sets have the potential to reduce clinical variation and improve patient safety but the effect is variable. We sought to evaluate the impact of changes to the design of an order set on the delivery of chlorhexidine mouthwash and hydroxyethyl starch (HES) to patients in the intensive care unit. The study was conducted at University Hospitals Bristol NHS Foundation Trust, UK. Our intensive care unit uses a clinical information system (CIS). All drugs and fluids are prescribed with the CIS and drug and fluid charts are stored within a database. Chlorhexidine mouthwash was added as a default prescription to the prescribing template in January 2010. HES was removed from the prescribing template in April 2009. Both interventions were available to prescribe manually throughout the study period. We conducted a database review of all patients eligible for each intervention before and after changes to the configuration of choices within the prescribing system. 2231 ventilated patients were identified as appropriate for treatment with chlorhexidine, 591 before the intervention and 1640 after. 55.3% were prescribed chlorhexidine before the change and 90.4% after (p<0.001). 6199 patients were considered in the HES intervention, 2177 before the intervention and 4022 after. The mean volume of HES infused per patient fell from 630 mL to 20 mL after the change (p<0.001) and the percentage of patients receiving HES fell from 54.1% to 3.1% (p<0.001). These results were well sustained with time. The presentation of choices within an electronic prescribing system influenced the delivery of evidence-based interventions in a predictable way and the effect was well sustained. This approach has the potential to enhance the effectiveness of computerised order sets.

A Cognitive Task Analysis of Information Management Strategies in a Computerized Provider Order Entry Environment

PubMed Central

Weir, Charlene R.; Nebeker, Jonathan J.R.; Hicken, Bret L.; Campo, Rebecca; Drews, Frank; LeBar, Beth

2007-01-01

Objective Computerized Provider Order Entry (CPOE) with electronic documentation, and computerized decision support dramatically changes the information environment of the practicing clinician. Prior work patterns based on paper, verbal exchange, and manual methods are replaced with automated, computerized, and potentially less flexible systems. The objective of this study is to explore the information management strategies that clinicians use in the process of adapting to a CPOE system using cognitive task analysis techniques. Design Observation and semi-structured interviews were conducted with 88 primary-care clinicians at 10 Veterans Administration Medical Centers. Measurements Interviews were taped, transcribed, and extensively analyzed to identify key information management goals, strategies, and tasks. Tasks were aggregated into groups, common components across tasks were clarified, and underlying goals and strategies identified. Results Nearly half of the identified tasks were not fully supported by the available technology. Six core components of tasks were identified. Four meta-cognitive information management goals emerged: 1) Relevance Screening; 2) Ensuring Accuracy; 3) Minimizing memory load; and 4) Negotiating Responsibility. Strategies used to support these goals are presented. Conclusion Users develop a wide array of information management strategies that allow them to successfully adapt to new technology. Supporting the ability of users to develop adaptive strategies to support meta-cognitive goals is a key component of a successful system. PMID:17068345

Computerized implementation of higher-order electron-correlation methods and their linear-scaling divide-and-conquer extensions.

PubMed

Nakano, Masahiko; Yoshikawa, Takeshi; Hirata, So; Seino, Junji; Nakai, Hiromi

2017-11-05

We have implemented a linear-scaling divide-and-conquer (DC)-based higher-order coupled-cluster (CC) and Møller-Plesset perturbation theories (MPPT) as well as their combinations automatically by means of the tensor contraction engine, which is a computerized symbolic algebra system. The DC-based energy expressions of the standard CC and MPPT methods and the CC methods augmented with a perturbation correction were proposed for up to high excitation orders [e.g., CCSDTQ, MP4, and CCSD(2) TQ ]. The numerical assessment for hydrogen halide chains, polyene chains, and first coordination sphere (C1) model of photoactive yellow protein has revealed that the DC-based correlation methods provide reliable correlation energies with significantly less computational cost than that of the conventional implementations. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

[Computerized acquisition and elaboration of clinical data in Rheumatology during ten years: state of art and prospectives

PubMed

Troise Rioda, W.; Nervetti, A.

2001-01-01

The well known complexity to collect the clinical data of patients and in particular in the area of rheumatology push us to develop a computerized clinical chart in order to facilitate the classification, evaluation and monitoring of these patients. The proposed computerized clinical chart is easy to use but at the same time is a very potent tool that allow the clinicians to organize the classic rheumatological pathologies as well as the more complexes or even rare. The proposed clinical chart is based on a relational database (FileMaker Pro 5.0v1) available for both the actual operative systems implemented on personal computers (Windows and Macintosh); this allow the full compatibility among the two systems, the possibility of exchanging data without any loss of information. The computerized clinical chart is structured on modules for specific pathologies and for homogeneous groups of illnesses. Basically the modules are defined correlated files of data for a specific pathology but that can be used also as a common pool for different pathologies. Our experience, based on ten years of use, indicates in the computerized rheumatological clinical chart an indispensable tool for rheumatologists with a real friendly use.

Diagnostic Yield of Transbronchial Biopsy in Comparison to High Resolution Computerized Tomography in Sarcoidosis Cases

PubMed

Akten, H Serpil; Kilic, Hatice; Celik, Bulent; Erbas, Gonca; Isikdogan, Zeynep; Turktas, Haluk; Kokturk, Nurdan

2018-04-25

This study aimed to evaluate the diagnostic yield of fiberoptic bronchoscopic (FOB) transbronchial biopsy and its relation with quantitative findings of high resolution computerized tomography (HRCT). A total of 83 patients, 19 males and 64 females with a mean age of 45.1 years diagnosed with sarcoidosis with complete records of high resolution computerized tomography were retrospectively recruited during the time period from Feb 2005 to Jan 2015. High resolution computerized tomography scans were retrospectively assessed in random order by an experienced observer without knowledge of the bronchoscopic results or lung function tests. According to the radiological staging with HRCT, 2.4% of the patients (n=2) were stage 0, 19.3% (n=16) were stage 1, 72.3% (n=60) were stage 2 and 6.0% (n=5) were stage 3. This study showed that transbronchial lung biopsy showed positive results in 39.7% of the stage I or II sarcoidosis patients who were diagnosed by bronchoscopy. Different high resolution computerized tomography patterns and different scores of involvement did make a difference in the diagnostic accuracy of transbronchial biopsy (p=0.007). Creative Commons Attribution License

What can paper-based clinical information systems tell us about the design of computerized clinical information systems (CIS) in the ICU?

PubMed

Miller, A; Pilcher, D; Mercaldo, N; Leong, T; Scheinkestel, C; Schildcrout, J

2010-08-01

Screen designs in computerized clinical information systems (CIS) have been modeled on their paper predecessors. However, limited understanding about how paper forms support clinical work means that we risk repeating old mistakes and creating new opportunities for error and inefficiency as illustrated by problems associated with computerized provider order entry systems. This study was designed to elucidate principles underlying a successful ICU paper-based CIS. The research was guided by two exploratory hypotheses: (1) paper-based artefacts (charts, notes, equipment, order forms) are used differently by nurses, doctors and other healthcare professionals in different (formal and informal) conversation contexts and (2) different artefacts support different decision processes that are distributed across role-based conversations. All conversations undertaken at the bedsides of five patients were recorded with any supporting artefacts for five days per patient. Data was coded according to conversational role-holders, clinical decision process, conversational context and artefacts. 2133 data points were analyzed using Poisson logistic regression analyses. Results show significant interactions between artefacts used during different professional conversations in different contexts (chi(2)((df=16))=55.8, p<0.0001). The interaction between artefacts used during different professional conversations for different clinical decision processes was not statistically significant although all two-way interactions were statistically significant. Paper-based CIS have evolved to support complex interdisciplinary decision processes. The translation of two design principles - support interdisciplinary perspectives and integrate decision processes - from paper to computerized CIS may minimize the risks associated with computerization. 2010 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Multitasking capacities in persons diagnosed with schizophrenia: a preliminary examination of their neurocognitive underpinnings and ability to predict real world functioning.

PubMed

Laloyaux, Julien; Van der Linden, Martial; Levaux, Marie-Noëlle; Mourad, Haitham; Pirri, Anthony; Bertrand, Hervé; Domken, Marc-André; Adam, Stéphane; Larøi, Frank

2014-07-30

Difficulties in everyday life activities are core features of persons diagnosed with schizophrenia and in particular during multitasking activities. However, at present, patients׳ multitasking capacities have not been adequately examined in the literature due to the absence of suitable assessment strategies. We thus recently developed a computerized real-life activity task designed to take into account the complex and multitasking nature of certain everyday life activities where participants are required to prepare a room for a meeting. Twenty-one individuals diagnosed with schizophrenia and 20 matched healthy controls completed the computerized task. Patients were also evaluated with a cognitive battery, measures of symptomatology and real world functioning. To examine the ecological validity, 14 other patients were recruited and were given the computerized version and a real version of the meeting preparation task. Results showed that performance on the computerized task was significantly correlated with executive functioning, pointing to the major implication of these cognitive processes in multitasking situations. Performance on the computerized task also significantly predicted up to 50% of real world functioning. Moreover, the computerized task demonstrated good ecological validity. These findings suggest the importance of evaluating multitasking capacities in patients diagnosed with schizophrenia in order to predict real world functioning. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

E-learning to improve the drug prescribing in the hospitalized elderly patients: the ELICADHE feasibility pilot study.

PubMed

Franchi, C; Mari, D; Tettamanti, M; Pasina, L; Djade, C D; Mannucci, P M; Onder, G; Bernabei, R; Gussoni, G; Bonassi, S; Nobili, A

2014-08-01

E-learning is an efficient and cost-effective educational method. This study aimed at evaluating the feasibility of an educational e-learning intervention, focused on teaching geriatric pharmacology and notions of comprehensive geriatric assessment, to improve drug prescribing to hospitalized elderly patients. Eight geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control. Clinicians of the two groups had to complete a specific per group e-learning program in 30 days. Then, ten patients (aged ≥75 years) had to be consecutively enrolled collecting clinical data at hospital admission, discharge, and 3 months later. The quality of prescription was evaluated comparing the prevalence of potentially inappropriate medications through Beer's criteria and of potential drug-drug interactions through a specific computerized database. The study feasibility was confirmed by the high percentage (90 %) of clinicians who completed the e-learning program, the recruitment, and follow-up of all planned patients. The intervention was well accepted by all participating clinicians who judged positively (a mean score of >3 points on a scale of 5 points: 0 = useless; 5 = most useful) the specific contents, the methodology applied, the clinical relevance and utility of e-learning contents and tools for the evaluation of the appropriateness of drug prescribing. The pilot study met all the requested goals. The main study is currently ongoing and is planned to finish on July 2015.

Evaluation of causes and frequency of medication errors during information technology downtime.

PubMed

Hanuscak, Tara L; Szeinbach, Sheryl L; Seoane-Vazquez, Enrique; Reichert, Brendan J; McCluskey, Charles F

2009-06-15

The causes and frequency of medication errors occurring during information technology downtime were evaluated. Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated. Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors. Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.

Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting.

PubMed

Sinha Gregory, Naina; Seley, Jane Jeffrie; Gerber, Linda M; Tang, Chin; Brillon, David

2016-12-01

More than one-third of hospitalized patients have hyperglycemia. Despite evidence that improving glycemic control leads to better outcomes, achieving recognized targets remains a challenge. The objective of this study was to evaluate the implementation of a computerized insulin order set and titration algorithm on rates of hypoglycemia and overall inpatient glycemic control. A prospective observational study evaluating the impact of a glycemic order set and titration algorithm in an academic medical center in non-critical care medical and surgical inpatients. The initial intervention was hospital-wide implementation of a comprehensive insulin order set. The secondary intervention was initiation of an insulin titration algorithm in two pilot medicine inpatient units. Point of care testing blood glucose reports were analyzed. These reports included rates of hypoglycemia (BG < 70 mg/dL) and hyperglycemia (BG >200 mg/dL in phase 1, BG > 180 mg/dL in phase 2). In the first phase of the study, implementation of the insulin order set was associated with decreased rates of hypoglycemia (1.92% vs 1.61%; p < 0.001) and increased rates of hyperglycemia (24.02% vs 27.27%; p < 0.001) from 2010 to 2011. In the second phase, addition of a titration algorithm was associated with decreased rates of hypoglycemia (2.57% vs 1.82%; p = 0.039) and increased rates of hyperglycemia (31.76% vs 41.33%; p < 0.001) from 2012 to 2013. A comprehensive computerized insulin order set and titration algorithm significantly decreased rates of hypoglycemia. This significant reduction in hypoglycemia was associated with increased rates of hyperglycemia. Hardwiring the algorithm into the electronic medical record may foster adoption.

The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.

PubMed

Franklin, Bryony Dean; O'Grady, Kara; Donyai, Parastou; Jacklin, Ann; Barber, Nick

2007-08-01

To assess the impact of a closed-loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Before-and-after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Closed-loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Prescribing errors were identified in 3.8% of 2450 medication orders pre-intervention and 2.0% of 2353 orders afterwards (p<0.001; chi(2) test). MAEs occurred in 7.0% of 1473 non-intravenous doses pre-intervention and 4.3% of 1139 afterwards (p = 0.005; chi(2) test). Patient identity was not checked for 82.6% of 1344 doses pre-intervention and 18.9% of 1291 afterwards (p<0.001; chi(2) test). Medical staff required 15 s to prescribe a regular inpatient drug pre-intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre-intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; chi(2) test). A closed-loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication-related tasks increased.

Reduction in chemotherapy order errors with computerized physician order entry.

PubMed

Meisenberg, Barry R; Wright, Robert R; Brady-Copertino, Catherine J

2014-01-01

To measure the number and type of errors associated with chemotherapy order composition associated with three sequential methods of ordering: handwritten orders, preprinted orders, and computerized physician order entry (CPOE) embedded in the electronic health record. From 2008 to 2012, a sample of completed chemotherapy orders were reviewed by a pharmacist for the number and type of errors as part of routine performance improvement monitoring. Error frequencies for each of the three distinct methods of composing chemotherapy orders were compared using statistical methods. The rate of problematic order sets-those requiring significant rework for clarification-was reduced from 30.6% with handwritten orders to 12.6% with preprinted orders (preprinted v handwritten, P < .001) to 2.2% with CPOE (preprinted v CPOE, P < .001). The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders (preprinted v handwritten, P < .001) to 0.1% with CPOE (CPOE v preprinted, P < .001). The number of problem- and error-containing chemotherapy orders was reduced sequentially by preprinted order sets and then by CPOE. CPOE is associated with low error rates, but it did not eliminate all errors, and the technology can introduce novel types of errors not seen with traditional handwritten or preprinted orders. Vigilance even with CPOE is still required to avoid patient harm.

39 CFR 955.1 - Jurisdiction, procedure, service of documents.

Code of Federal Regulations, 2011 CFR

2011-07-01

.... These time limitations are similarly eligible for extension in appropriate circumstances. (ii) Except as otherwise provided by law, in computing any period of time prescribed by these rules or by any order of the... in these rules or an applicable order, prescribed periods of time are measured in calendar days...

Expectations for antibiotics increase their prescribing: Causal evidence about localized impact.

PubMed

Sirota, Miroslav; Round, Thomas; Samaranayaka, Shyamalee; Kostopoulou, Olga

2017-04-01

Clinically irrelevant but psychologically important factors such as patients' expectations for antibiotics encourage overprescribing. We aimed to (a) provide missing causal evidence of this effect, (b) identify whether the expectations distort the perceived probability of a bacterial infection either in a pre- or postdecisional distortions pathway, and (c) detect possible moderators of this effect. Family physicians expressed their willingness to prescribe antibiotics (Experiment 1, n₁ = 305) or their decision to prescribe (Experiment 2, n₂ = 131) and assessed the probability of a bacterial infection in hypothetical patients with infections either with low or high expectations for antibiotics. Response order of prescribing/probability was manipulated in Experiment 1. Overall, the expectations for antibiotics increased intention to prescribe (Experiment 1, F(1, 301) = 25.32, p < .001, η p ² = .08, regardless of the response order; Experiment 2, odds ratio [OR] = 2.31, and OR = 0.75, Vignettes 1 and 2, respectively). Expectations for antibiotics did not change the perceived probability of a bacterial infection (Experiment 1, F(1, 301) = 1.86, p = .173, η p ² = .01, regardless of the response order; Experiment 2, d = -0.03, and d = +0.25, Vignettes 1 and 2, respectively). Physicians' experience was positively associated with prescribing, but it did not moderate the expectations effect on prescribing. Patients' and their parents' expectations increase antibiotics prescribing, but their effect is localized-it does not leak into the perceived probability of a bacterial infection. Interventions reducing the overprescribing of antibiotics should target also psychological factors. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Improving the appropriateness of antimicrobial use in primary care after implementation of a local antimicrobial guide in both levels of care.

PubMed

Fernández Urrusuno, Rocío; Flores Dorado, Macarena; Vilches Arenas, Angel; Serrano Martino, Carmen; Corral Baena, Susana; Montero Balosa, Ma Carmen

2014-08-01

This study aims to assess the effectiveness of multiple interventions carried out during the implementation of a guide, on the improvement of the appropriateness of antimicrobial prescribing in primary care. This is a cross-sectional before/after study carried out in Aljarafe Health Care Area (Andalusia, Spain), with a population of 368,728 inhabitants assisted in 37 health centers. Subjects include patients with antibiotic prescriptions during 2009 (pre-intervention phase) or 2012 (postintervention phase) selected by simple random sampling (confidence level, 95%; accuracy, 5%), with infections registered in the electronic clinical history. This study involve training sessions in primary care centers and hospital services, incorporation of the electronic guide to the Health Care Service Websites, and incorporation of the guide to the Digital Health History as a tool to support decision making. Difference on appropriate antibiotic prescribing before and after interventions resulted from the study. Other variables also include age, gender, type of pharmacy, antibiotic prescribed, number of treatments per year, infection site, and main comorbidities In addition, this study uses computerized pharmacy records of reimbursed and dispensed drugs and electronic medical histories. The percentage of appropriate antibiotic prescribing increased from 36% in 2009 to 57% in 2012 (p < 0.001) is shown. The improvement was observed in all age patients of any sex and was higher among working-age patients and patients with comorbidities. The best results were observed in the group of beta-lactams and in the treatment of respiratory and skin infections. The realization of multifactorial interventions involving professionals from both levels of care could be an effective strategy to improve the use of antimicrobials in primary care.

Effects of an e-Prescribing interface redesign on rates of generic drug prescribing: exploiting default options.

PubMed

Malhotra, Sameer; Cheriff, Adam D; Gossey, J Travis; Cole, Curtis L; Kaushal, Rainu; Ancker, Jessica S

2016-09-01

Increasing the use of generic medications could help control medical costs. However, educational interventions have limited impact on prescriber behavior, and e-prescribing alerts are associated with high override rates and alert fatigue. Our objective was to evaluate the effect of a less intrusive intervention, a redesign of an e-prescribing interface that provides default options intended to "nudge" prescribers towards prescribing generic drugs. This retrospective cohort study in an academic ambulatory multispecialty practice assessed the effects of customizing an e-prescribing interface to substitute generic equivalents for brand-name medications during order entry and allow a one-click override to order the brand-name medication. Among drugs with generic equivalents, the proportion of generic drugs prescribed more than doubled after the interface redesign, rising abruptly from 39.7% to 95.9% (a 56.2% increase; 95% confidence interval, 56.0-56.4%; P < .001). Before the redesign, generic drug prescribing rates varied by therapeutic class, with rates as low as 8.6% for genitourinary products and 15.7% for neuromuscular drugs. After the redesign, generic drug prescribing rates for all but four therapeutic classes were above 90%: endocrine drugs, neuromuscular drugs, nutritional products, and miscellaneous products. Changing the default option in an e-prescribing interface in an ambulatory care setting was followed by large and sustained increases in the proportion of generic drugs prescribed at the practice. Default options in health information technology exert a powerful effect on user behavior, an effect that can be leveraged to optimize decision making. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

The process of development of a prioritization tool for a clinical decision support build within a computerized provider order entry system: Experiences from St Luke's Health System.

PubMed

Wolf, Matthew; Miller, Suzanne; DeJong, Doug; House, John A; Dirks, Carl; Beasley, Brent

2016-09-01

To establish a process for the development of a prioritization tool for a clinical decision support build within a computerized provider order entry system and concurrently to prioritize alerts for Saint Luke's Health System. The process of prioritizing clinical decision support alerts included (a) consensus sessions to establish a prioritization process and identify clinical decision support alerts through a modified Delphi process and (b) a clinical decision support survey to validate the results. All members of our health system's physician quality organization, Saint Luke's Care as well as clinicians, administrators, and pharmacy staff throughout Saint Luke's Health System, were invited to participate in this confidential survey. The consensus sessions yielded a prioritization process through alert contextualization and associated Likert-type scales. Utilizing this process, the clinical decision support survey polled the opinions of 850 clinicians with a 64.7 percent response rate. Three of the top rated alerts were approved for the pre-implementation build at Saint Luke's Health System: Acute Myocardial Infarction Core Measure Sets, Deep Vein Thrombosis Prophylaxis within 4 h, and Criteria for Sepsis. This study establishes a process for developing a prioritization tool for a clinical decision support build within a computerized provider order entry system that may be applicable to similar institutions. © The Author(s) 2015.

Using intranet-based order sets to standardize clinical care and prepare for computerized physician order entry.

PubMed

Heffner, John E; Brower, Kathleen; Ellis, Rosemary; Brown, Shirley

2004-07-01

The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE's benefits and offer opportunities to acculturate physicians toward standardized care. INTRANET CLINICIAN ORDER FORMS (COF): The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources. Work on COF began in March 2000 with transfer of 25 MUSC paper-based order set forms to an intranet site. Physician groups developed additional order sets, which number more than 200. Web traffic increased progressively during a 24-month period, peaking at more than 6,400 hits per month to COF. Decision support tools improved compliance with Centers for Medicare & Medicaid Services core indicators. Clinicians demonstrated a willingness to develop and use order sets and decision support tools posted on the COF site. COF provides a low-cost method for preparing caregivers and institutions to adopt CPOE and standardization of care. The educational resources, relevant links to external resources, and communication alerts will all link to CPOE, thereby providing a head start in CPOE implementation.

Provincial Comparison of Pharmacist Prescribing in Canada Using Alberta’s Model as the Reference Point

PubMed Central

Bhatia, Surya; Simpson, Scot H; Bungard, Tammy

2017-01-01

Background In the past decade, pharmacist practice has evolved tremendously in Canada, but the scope of practice varies substantially from one province to another. Objective To describe pharmacists’ scopes of practice relevant to prescribing within various jurisdictions of Canada, using the prescribing model in Alberta (authors’ province) as the reference point. Methods This cross-sectional survey consisted of clinical scenarios for emergency prescribing, adapting or renewing a prescription, and initial-access prescribing for a chronic disease. Pharmacists were asked about their ability to administer injections and to order or access the results of laboratory tests, as well as certification and training requirements and reimbursement models. Results Thirteen pharmacists representing Canadian provinces other than Alberta were surveyed in late 2015, for comparison with Alberta. With specific reference to the scenarios presented, pharmacists were able to prescribe in an emergency in 9 of the 10 provinces, renew prescriptions in all provinces, and adapt prescriptions in 6 provinces. Three provinces required that pharmacists have collaborative practice agreements identifying a specific practice area in order to initiate a prescription for a chronic disease (with 6–12 pharmacists per province having such agreements). Alberta required pharmacists to have authorization, based on a detailed application, in order to initiate any provincially regulated drug (with about 1150 pharmacists having this authorization). Pharmacists were allowed to administer vaccines in 9 provinces, and 5 provinces allowed pharmacists to administer drugs by injection. Three provinces had systems in place for pharmacists to access laboratory test results, and 2 allowed pharmacists to order laboratory tests. Five provinces had government-reimbursed programs in place for select prescribing services; however, all 9 provinces with public vaccination programs reimbursed pharmacists for this service. Conclusions Pharmacist prescribing differs among Canadian provinces. Although most provinces allow emergency prescribing and renewal or adaptation of prescriptions by pharmacists, only 4 provinces allow prescription initiation, with variable criteria and scope. Despite some progress to enhance patient flow through the health care system (e.g., by allowing pharmacists to extend prescriptions), further work should be pursued to harmonize clinical practices across Canada and to enable pharmacists to initiate and manage drug therapy. PMID:29109578

Computerization of guidelines: a knowledge specification method to convert text to detailed decision tree for electronic implementation.

PubMed

Aguirre-Junco, Angel-Ricardo; Colombet, Isabelle; Zunino, Sylvain; Jaulent, Marie-Christine; Leneveut, Laurence; Chatellier, Gilles

2004-01-01

The initial step for the computerization of guidelines is the knowledge specification from the prose text of guidelines. We describe a method of knowledge specification based on a structured and systematic analysis of text allowing detailed specification of a decision tree. We use decision tables to validate the decision algorithm and decision trees to specify and represent this algorithm, along with elementary messages of recommendation. Edition tools are also necessary to facilitate the process of validation and workflow between expert physicians who will validate the specified knowledge and computer scientist who will encode the specified knowledge in a guide-line model. Applied to eleven different guidelines issued by an official agency, the method allows a quick and valid computerization and integration in a larger decision support system called EsPeR (Personalized Estimate of Risks). The quality of the text guidelines is however still to be developed further. The method used for computerization could help to define a framework usable at the initial step of guideline development in order to produce guidelines ready for electronic implementation.

Exploring the possibility of modeling a genetic counseling guideline using agile methodology.

PubMed

Choi, Jeeyae

2013-01-01

Increased demand of genetic counseling services heightened the necessity of a computerized genetic counseling decision support system. In order to develop an effective and efficient computerized system, modeling of genetic counseling guideline is an essential step. Throughout this pilot study, Agile methodology with United Modeling Language (UML) was utilized to model a guideline. 13 tasks and 14 associated elements were extracted. Successfully constructed conceptual class and activity diagrams revealed that Agile methodology with UML was a suitable tool to modeling a genetic counseling guideline.

Bone Scan

MedlinePlus

... your doctor might order additional imaging called single-photon emission computerized tomography (SPECT). This imaging can help ... radioactivity from the tracers is usually completely eliminated two days after the scan. Results A doctor who ...

Do final‐year medical students have sufficient prescribing competencies? A systematic literature review

PubMed Central

Tichelaar, Jelle; Graaf, Sanne; Otten, René H. J.; Richir, Milan C.; van Agtmael, Michiel A.

2018-01-01

Aims Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate. Methods PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included. Results Twenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies. Conclusions There is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors. PMID:29315721

Do final-year medical students have sufficient prescribing competencies? A systematic literature review.

PubMed

Brinkman, David J; Tichelaar, Jelle; Graaf, Sanne; Otten, René H J; Richir, Milan C; van Agtmael, Michiel A

2018-04-01

Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final-year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate. PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms 'prescribing', 'competence' and 'medical students' in combination. Articles describing or evaluating essential prescribing competencies of final-year medical students were included. Twenty-five articles describing, and 47 articles evaluating, the prescribing competencies of final-year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self-confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies. There is considerable evidence that final-year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors. © 2018 VU University Medical Centre. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.

Evaluation of prescriber responses to pharmacogenomics clinical decision support for thiopurine S-methyltransferase testing.

PubMed

Ubanyionwu, Samuel; Formea, Christine M; Anderson, Benjamin; Wix, Kelly; Dierkhising, Ross; Caraballo, Pedro J

2018-02-15

Results of a study of prescribers' responses to a pharmacogenomics-based clinical decision support (CDS) alert designed to prompt thiopurine S -methyltransferase (TPMT) status testing are reported. A single-center, retrospective, chart review-based study was conducted to evaluate prescriber compliance with a pretest CDS alert that warned of potential thiopurine drug toxicity resulting from deficient TPMT activity due to TPMT gene polymorphism. The CDS alert was triggered when prescribers ordered thiopurine drugs for patients whose records did not indicate TPMT status or when historical thiopurine use was documented in the electronic health record. The alert pop-up also provided a link to online educational resources to guide thiopurine dosing calculations. During the 9-month study period, 500 CDS alerts were generated: in 101 cases (20%), TPMT phenotyping or TPMT genotyping was ordered; in 399 cases (80%), testing was not ordered. Multivariable regression analysis indicated that documentation of historical thiopurine use was the only independent predictor of test ordering. Among the 99 patients tested subsequent to CDS alerts, 70 (71%) had normal TPMT activity, 29 (29%) had intermediate activity, and none had deficient activity. The online resources provided thiopurine dosing recommendations applicable to 24 patients, but only 3 were prescribed guideline-supported doses after CDS alerts. The pretest CDS rule resulted in a large proportion of neglected alerts due to poor alerting accuracy and consequent alert fatigue. Prescriber usage of online thiopurine dosing resources was low. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

The impact of a closed‐loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before‐and‐after study

PubMed Central

Franklin, Bryony Dean; O'Grady, Kara; Donyai, Parastou; Jacklin, Ann; Barber, Nick

2007-01-01

Objectives To assess the impact of a closed‐loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Design, setting and participants Before‐and‐after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Intervention Closed‐loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Main outcome measures Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Results Prescribing errors were identified in 3.8% of 2450 medication orders pre‐intervention and 2.0% of 2353 orders afterwards (p<0.001; χ2 test). MAEs occurred in 7.0% of 1473 non‐intravenous doses pre‐intervention and 4.3% of 1139 afterwards (p = 0.005; χ2 test). Patient identity was not checked for 82.6% of 1344 doses pre‐intervention and 18.9% of 1291 afterwards (p<0.001; χ2 test). Medical staff required 15 s to prescribe a regular inpatient drug pre‐intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre‐intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; χ2 test). Conclusions A closed‐loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication‐related tasks increased. PMID:17693676

Herniation of unruptured tuberculous lung abscess into chest wall without pleural or bronchial spillage

PubMed Central

Magazine, Rahul; Mohapatra, Aswini K.; Manu, Mohan K.; Srivastava, Rajendra K.

2011-01-01

A 22-year-old unmarried man presented to the chest outpatient department with a history of productive cough of two-month duration. He also complained of pain and swelling on the anterior aspect of right side of chest of one-month duration. Imaging studies of the thorax, including chest roentgenography and computerized tomography, revealed an unruptured lung abscess which had herniated into the chest wall. Culture of pus aspirated from the chest wall swelling grew Mycobacterium tuberculosis. He was diagnosed to have a tuberculous lung abscess which had extended into the chest wall, without spillage into the pleural cavity or the bronchial tree. Antituberculosis drugs were prescribed, and he responded to the treatment with complete resolution of the lesion. PMID:22084547

Brachytherapy of prostate cancer after colectomy for colorectal cancer: pilot experience.

PubMed

Koutrouvelis, Panos G; Theodorescu, Dan; Katz, Stuart; Lailas, Niko; Hendricks, Fred

2005-01-01

We present a method of brachytherapy for prostate cancer using a 3-dimensional stereotactic system and computerized tomography guidance in patients without a rectum due to previous treatment for colorectal cancer. From June 1994 to November 2003 a cohort of 800 patients were treated with brachytherapy for prostate cancer. Four patients had previously been treated for colorectal cancer with 4,500 cGy external beam radiation therapy, abdominoperineal resection and chemotherapy, while 1 underwent abdominoperineal resection alone for ulcerative colitis. Because of previous radiation therapy, these patients were not candidates for salvage external beam radiation therapy or radical prostatectomy and they had no rectum for transrectal ultrasound guided transperineal brachytherapy or cryotherapy. A previously described, 3-dimensional stereotactic system was used for brachytherapy in these patients. The prescribed radiation dose was 120 to 144 Gy with iodine seeds in rapid strand format. Patient followup included clinical examination and serum prostate specific antigen measurement. Average followup was 18.6 months. Four patients had excellent biochemical control, while 1 had biochemical failure. Patients did not experience any gastrointestinal morbidity. One patient had a stricture of the distal ureter, requiring a stent. Three-dimensional computerized tomography guided brachytherapy for prostate cancer in patients with a history of colorectal cancer who have no rectum is a feasible method of treatment.

A computerized education module improves patient knowledge and attitudes about appropriate antibiotic use for acute respiratory tract infections.

PubMed

Price, Erika Leemann; Mackenzie, Thomas D; Metlay, Joshua P; Camargo, Carlos A; Gonzales, Ralph

2011-12-01

Over-use of antibiotics for acute respiratory infections (ARIs) increases antimicrobial resistance, treatment costs, and side effects. Patient desire for antibiotics contributes to over-use. To explore whether a point-of-care interactive computerized education module increases patient knowledge and decreases desire for antibiotics. Bilingual (English/Spanish) interactive kiosks were available in 8 emergency departments as part of a multidimensional intervention to reduce antibiotic prescribing for ARIs. The symptom-tailored module included assessment of symptoms, knowledge about ARIs (3 items), and desire for antibiotics on a 10-point visual analog scale. Multivariable analysis assessed predictors of change in desire for antibiotics. Of 686 adults with ARI symptoms, 63% initially thought antibiotics might help. The proportion of patients with low (1-3 on the scale) desire for antibiotics increased from 22% pre-module to 49% post-module (p<.001). Self-report of "learning something new" was associated with decreased desire for antibiotics, after adjusting for baseline characteristics (p=.001). An interactive educational kiosk improved knowledge about antibiotics and ARIs. Learning correlated with changes in personal desire for antibiotics. By reducing desire for antibiotics, point-of-care interactive educational computer technology may help decrease inappropriate use for antibiotics for ARIs. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility.

PubMed

Elliott, Rohan A; Lee, Cik Yin; Hussainy, Safeera Y

2016-06-01

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study.

PubMed

Charpiat, B; Goutelle, S; Schoeffler, M; Aubrun, F; Viale, J-P; Ducerf, C; Leboucher, G; Allenet, B

2012-09-01

Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug-drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.

A Pharmacy Blueprint for Electronic Medical Record Implementation Success

PubMed Central

Bach, David S.; Risko, Kenneth R.; Farber, Margo S.; Polk, Gregory J.

2015-01-01

Objective: Implementation of an integrated, electronic medical record (EMR) has been promoted as a means of improving patient safety and quality. While there are a few reports of such processes that incorporate computerized prescriber order entry, pharmacy verification, an electronic medication administration record (eMAR), point-of-care barcode scanning, and clinical decision support, there are no published reports on how a pharmacy department can best participate in implementing such a process across a multihospital health care system. Method: This article relates the experience of the design, build, deployment, and maintenance of an integrated EMR solution from the pharmacy perspective. It describes a 9-month planning and build phase and the subsequent rollout at 8 hospitals over the following 13 months. Results: Key components to success are identified, as well as a set of guiding principles that proved invaluable in decision making and dispute resolution. Labor/personnel requirements for the various stages of the process are discussed, as are issues involving medication workflow analysis, drug database considerations, the development of clinical order sets, and incorporation of bar-code scanning of medications. Recommended implementation and maintenance strategies are presented, and the impact of EMR implementation on the pharmacy practice model and revenue analysis are examined. Conclusion: Adherence to the principles and practices outlined in this article can assist pharmacy administrators and clinicians during all medication-related phases of the development, implementation, and maintenance of an EMR solution. Furthermore, review and incorporation of some or all of practices presented may help ease the process and ensure its success. PMID:26405340

Variable-Length Computerized Adaptive Testing Using the Higher Order DINA Model

ERIC Educational Resources Information Center

Hsu, Chia-Ling; Wang, Wen-Chung

2015-01-01

Cognitive diagnosis models provide profile information about a set of latent binary attributes, whereas item response models yield a summary report on a latent continuous trait. To utilize the advantages of both models, higher order cognitive diagnosis models were developed in which information about both latent binary attributes and latent…

E-waste Management and Refurbishment Prediction (EMARP) Model for Refurbishment Industries.

PubMed

Resmi, N G; Fasila, K A

2017-10-01

This paper proposes a novel algorithm for establishing a standard methodology to manage and refurbish e-waste called E-waste Management And Refurbishment Prediction (EMARP), which can be adapted by refurbishing industries in order to improve their performance. Waste management, particularly, e-waste management is a serious issue nowadays. Computerization has been into waste management in different ways. Much of the computerization has happened in planning the waste collection, recycling and disposal process and also managing documents and reports related to waste management. This paper proposes a computerized model to make predictions for e-waste refurbishment. All possibilities for reusing the common components among the collected e-waste samples are predicted, thus minimizing the wastage. Simulation of the model has been done to analyse the accuracy in the predictions made by the system. The model can be scaled to accommodate the real-world scenario. Copyright © 2017 Elsevier Ltd. All rights reserved.

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

PubMed

Sethuraman, Usha; Kannikeswaran, Nirupama; Murray, Kyle P; Zidan, Marwan A; Chamberlain, James M

2015-06-01

Prescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates. © 2015 by the Society for Academic Emergency Medicine.

Computerized Physician Order Entry

PubMed Central

Khanna, Raman; Yen, Tony

2014-01-01

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks. PMID:24381708

Twelve-month drug cost savings related to use of an electronic prescribing system with integrated decision support in primary care.

PubMed

McMullin, S Troy; Lonergan, Thomas P; Rynearson, Charles S

2005-05-01

We reported previously the results of a 6-month controlled trial in which the use of a commercially available electronic prescribing system with integrated clinical decision support and evidence-based message capability was associated with significantly lower primary care drug costs. The original study focused on new prescriptions, defined as claims for a medication that the patient had not received in the previous 12 months. The main objectives of this follow-up report were to (a) determine if the 6-month savings on new prescriptions were sustained during 12 months of follow-up, (b) evaluate the impact of the computerized decision support system (CDSS) on all pharmacy claims and per-member-per-month (PMPM) expenditures, and (c) evaluate the prescribing behaviors within 8 high-cost therapeutic categories that were frequently targeted by the electronic messages to prescribers to help verify that the drug cost savings were due to the recommendations in the electronic prescribing system. Two database queries were performed to identify additional pharmacy claims data for all Network Health Plan patients who were cared for by the 38 primary care clinicians (32 physicians, 4 nurse practitioners, and 2 physician assistants) included in our original 6-month study. This follow-up analysis (a) identified all new prescription claims for the 2 groups of clinicians throughout the 12-month follow-up period (June 2002 through May 2003) and (b) assessed all pharmacy claims during the same 12-month period to provide more complete savings estimates and to examine between-group differences in PMPM expenditures. During 12 months of follow-up, clinicians using the electronic prescribing system continued to have lower prescription costs than the controls. Clinicians using the electronic prescribing system had average costs for 26,674 new prescriptions that were dollar 4.12 lower (95% confidence interval, dollar 1.53-dollar 6.71; P=0.003) and PMPM expenditures that were dollar 0.57 lower than expected based on the changes observed for 24,507 new prescriptions written by clinicians in the control group. The average drug cost savings on new prescriptions were dollar 482 per prescriber per month (PPPM), based upon prescription cost and dollar 465 PPPM based upon PMPM analysis. When all pharmacy claims (156,429) were analyzed, the intervention group.s average prescription cost was dollar 2.57 lower and their PMPM expenditures were dollar 1.07 lower than expected based on the changes observed in the control group. The average drug cost savings on all pharmacy claims were dollar 863 PPPM based on average prescription cost and dollar 873 PPPM based on PMPM analysis. The proportion of prescriptions for highcost drugs that were the target of the CDSS messages to prescribers was a relative 17.5% lower among the intervention group (35.8%) compared with the control group (43.4%; P=0.03). An electronic prescribing system with integrated decision support shifted prescribing behavior away from high-cost therapies and significantly lowered prescription drug costs. The savings associated with altered prescribing behavior offset the monthly subscription cost of the system.

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients

PubMed Central

Chen, Ying; Zhu, Ling-Ling; Zhou, Quan

2014-01-01

Background Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls. Materials and methods Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed. Results Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer’s agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug–drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk. Conclusion Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient’s medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls. PMID:24966681

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients.

PubMed

Chen, Ying; Zhu, Ling-Ling; Zhou, Quan

2014-01-01

Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls. Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed. Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer's agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug-drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk. Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient's medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls.

[Survey on computerized immunization registries in Italy].

PubMed

Alfonsi, V; D'Ancona, F; Ciofi degli Atti, M L

2008-01-01

Computerized immunization registries are essential for conducting and monitoring vaccination programs. In fact, they enable to improve vaccine offering to target population, generating needed-immunization lists and assessing levels of vaccination coverage. In 2007, a national survey on immunization registries was conducted in Italy. In February 2007, all the 21 Regional Health Authorities (RHAs) completed and returned an ad hoc questionnaire. In June 2007, RHAs were further contacted by telephone in order to verify and update the information provided in questionnaires. In 9 Italian Regions (42.8%), vaccination registries are computerized in all Local Health Units (LHUs). In five of these Regions, all LHUs use the same software, while in the remaining four Regions, different softwares are in use. In six additional Regions (28.6%), only some LHUs use computerized immunization registries (range 61.5%-95%). In the remaining 6 Regions (28.6%), which are all in Southern Italy, there are no computerised immunization registries at all. In total, computerised immunization registries cover 126/180 Italian LHUs (70%); in 76/126 (60%) of these LUHs, immunization registries are linked with population registries. This survey shows the need to improve the implementation of computerised immunization registries in Italy, especially in Southern Regions.

Preliminary evaluation of a micro-based repeated measures testing system

NASA Technical Reports Server (NTRS)

Kennedy, Robert S.; Wilkes, Robert L.; Lane, Norman E.

1985-01-01

A need exists for an automated performance test system to study the effects of various treatments which are of interest to the aerospace medical community, i.e., the effects of drugs and environmental stress. The ethics and pragmatics of such assessment demand that repeated measures in small groups of subjects be the customary research paradigm. Test stability, reliability-efficiency and factor structure take on extreme significance; in a program of study by the U.S. Navy, 80 percent of 150 tests failed to meet minimum metric requirements. The best is being programmed on a portable microprocessor and administered along with tests in their original formats in order to examine their metric properties in the computerized mode. Twenty subjects have been tested over four replications on a 6.0 minute computerized battery (six tests) and which compared with five paper and pencil marker tests. All tests achieved stability within the four test sessions, reliability-efficiencies were high (r greater than .707 for three minutes testing), and the computerized tests were largely comparable to the paper and pencil version from which they were derived. This computerized performance test system is portable, inexpensive and rugged.

A Quality, Benefit, Cost, and Financial Framework for Health Information Technology, E-Prescribing: A Delphi Study.

PubMed

DeMuro, Paul R; Ash, Joan; Middleton, Blackford; Fletcher, Justin; Madison, Cecelia J

2017-01-01

Little research has been conducted about the quality, benefits, costs, and financial considerations associated with health information technology (HIT), particularly informatics technologies, such as e-prescribing, from the perspective of all its stakeholders. This research effort sought to identify the stakeholders involved in e-prescribing and to identify and rank-order the positives and the negatives from the perspective of the stakeholders to create a framework to assist in the development of incentives and payment mechanisms which result in better managed care. The Delphi method was employed by enlisting a panel of experts. They were presented with the results of initial research in an online survey of questions which sought to prioritize the quality, benefit, cost, and financial effects of e-prescribing from the perspective of each stakeholder. From the results of this study, a framework was presented to framework experts. The experts added stakeholders and positives and negatives to the initial lists and rank-ordered the positives and negatives of e-prescribing from the perspective of each stakeholder. The aggregate results were summarized by category of stakeholder. The framework experts evaluated the framework. Positives and negatives can be rank-ordered from the perspective of each stakeholder. A useful framework was created.

Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety.

PubMed

Abend, Rany; Dan, Orrie; Maoz, Keren; Raz, Sivan; Bar-Haim, Yair

2014-12-01

Assessment of state anxiety is frequently required in clinical and research settings, but its measurement using standard multi-item inventories entails practical challenges. Such inventories are increasingly complemented by paper-and-pencil, single-item visual analog scales measuring state anxiety (VAS-A), which allow rapid assessment of current anxiety states. Computerized versions of VAS-A offer additional advantages, including facilitated and accurate data collection and analysis, and applicability to computer-based protocols. Here, we establish the psychometric properties of a computerized VAS-A. Experiment 1 assessed the reliability, convergent validity, and discriminant validity of the computerized VAS-A in a non-selected sample. Experiment 2 assessed its sensitivity to increase in state anxiety following social stress induction, in participants with high levels of social anxiety. Experiment 1 demonstrated the computerized VAS-A's test-retest reliability (r = .44, p < .001); convergent validity with the State-Trait Anxiety Inventory's state subscale (STAI-State; r = .60, p < .001); and discriminant validity as indicated by significantly lower correlations between VAS-A and different psychological measures relative to the correlation between VAS-A and STAI-State. Experiment 2 demonstrated the VAS-A's sensitivity to changes in state anxiety via a significant pre- to during-stressor rise in VAS-A scores (F(1,48) = 25.13, p < .001). Set-order administration of measures, absence of clinically-anxious population, and gender-unbalanced samples. The adequate psychometric characteristics, combined with simple and rapid administration, make the computerized VAS-A a valuable self-rating tool for state anxiety. It may prove particularly useful for clinical and research settings where multi-item inventories are less applicable, including computer-based treatment and assessment protocols. The VAS-A is freely available: http://people.socsci.tau.ac.il/mu/anxietytrauma/visual-analog-scale/. Copyright © 2014 Elsevier Ltd. All rights reserved.

Introducing Physician Order Entry at a Major Academic Medical Center: I. Impact on Organizational Culture and Behavior.

ERIC Educational Resources Information Center

Massaro, Thomas A.

1993-01-01

Implementation of the University of Virginia Medical Center's computerized system for mandatory recordkeeping of physician orders is discussed, focusing on administrative issues: delays, costs, disruption of work routine and behavior, and the need to bring in a senior management team. Recommendations are made for institutions with similar…

Air Pollution Episodes Associated with Prescribed Burns

NASA Astrophysics Data System (ADS)

Hart, M.; Di Virgilio, G.; Jiang, N.

2017-12-01

Air pollution events associated with wildfires have been associated with extreme health impacts. Prescribed burns are an important tool to reduce the severity of wildfires. However, if undertaken during unfavourable meteorological conditions, they too have the capacity to trigger extreme air pollution events. The Australian state of New South Wales has increased the annual average area treated by prescribed burn activities by 45%, in order to limit wildfire activity. Prescribed burns need to be undertaken during meteorological conditions that allow the fuel load to burn, while still allowing the burn to remain under control. These conditions are similar to those that inhibit atmospheric dispersion, resulting in a fine balance between managing fire risk and managing ambient air pollution. During prescribed burns, the Sydney air shed can experience elevated particulate matter concentrations, especially fine particulates (PM2.5) that occasionally exceed national air quality standards. Using pollutant and meteorological data from sixteen monitoring stations in Sydney we used generalized additive model and CART analyses to profile the meteorological conditions influencing air quality during planned burns. The insights gained from this study will help improve prescribed burn scheduling in order to reduce the pollution risk to the community, while allowing fire agencies to conduct this important work.

Weigh-in-Motion systems evaluation : final report.

DOT National Transportation Integrated Search

1976-04-01

This relatively short-term project was initiated in order to perfect installation, operation, and maintenance practices necessary for continued accurate and reliable operation of a computerized Weigh-in-Motion system which will be used to gather truc...

77 FR 25710 - Agency Information Collection Extension

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-01

... Accident/Incident Reporting System (CAIRS); Occurrence Reporting and Processing System (ORPS); Noncompliance Tracking System (NTS); Radiation Exposure Monitoring System (REMS); Annual Fire Protection Summary... following additional authorities: Computerized Accident/Incident Reporting System (CAIRS): DOE Order 231.1B...

Principles for a Successful Computerized Physician Order Entry Implementation

PubMed Central

Ash, Joan S.; Fournier, Lara; Stavri, P. Zoë; Dykstra, Richard

2003-01-01

To identify success factors for implementing computerized physician order entry (CPOE), our research team took both a top-down and bottom-up approach and reconciled the results to develop twelve overarching principles to guide implementation. A consensus panel of experts produced ten Considerations with nearly 150 sub-considerations, and a three year project using qualitative methods at multiple successful sites for a grounded theory approach yielded ten general themes with 24 sub-themes. After reconciliation using a meta-matrix approach, twelve Principles, which cluster into groups forming the mnemonic CPOE emerged. Computer technology principles include: temporal concerns; technology and meeting information needs; multidimensional integration; and costs. Personal principles are: value to users and tradeoffs; essential people; and training and support. Organizational principles include: foundational underpinnings; collaborative project management; terms, concepts and connotations; and improvement through evaluation and learning. Finally, Environmental issues include the motivation and context for implementing such systems. PMID:14728129

Computerized physician order entry: promise, perils, and experience.

PubMed

Khanna, Raman; Yen, Tony

2014-01-01

Computerized physician order entry (CPOE) has been promoted as an important component of patient safety, quality improvement, and modernization of medical practice. In practice, however, CPOE affects health care delivery in complex ways, with benefits as well as risks. Every implementation of CPOE is associated with both generally recognized and unique local factors that can facilitate or confound its rollout, and neurohospitalists will often be at the forefront of such rollouts. In this article, we review the literature on CPOE, beginning with definitions and proceeding to comparisons to the standard of care. We then proceed to discuss clinical decision support systems, negative aspects of CPOE, and cultural context of CPOE implementation. Before concluding, we follow the experiences of a Chief Medical Information Officer and neurohospitalist who rolled out a CPOE system at his own health care organization and managed the resulting workflow changes and setbacks.

Computerized provider order entry systems.

PubMed

2001-01-01

Computerized provider order entry (CPOE) systems are designed to replace a hospital's paper-based ordering system. They allow users to electronically write the full range of orders, maintain an online medication administration record, and review changes made to an order by successive personnel. They also offer safety alerts that are triggered when an unsafe order (such as for a duplicate drug therapy) is entered, as well as clinical decision support to guide caregivers to less expensive alternatives or to choices that better fit established hospital protocols. CPOE systems can, when correctly configured, markedly increase efficiency and improve patient safety and patient care. However, facilities need to recognize that currently available CPOE systems require a tremendous amount of time and effort to be spent in customization before their safety and clinical support features can be effectively implemented. What's more, even after they've been customized, the systems may still allow certain unsafe orders to be entered. Thus, CPOE systems are not currently a quick or easy remedy for medical errors. ECRI's Evaluation of CPOE systems--conducted in collaboration with the Institute for Safe Medication Practices (ISMP)--discusses these and other related issues. It also examines and compares CPOE systems from three suppliers: Eclipsys Corp., IDX Systems Corp., and Siemens Medical Solutions Health Services Corp. Our testing focuses primarily on the systems' interfacing capabilities, patient safeguards, and ease of use.

Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients.

PubMed

Gertz, Zachary M; O'Donnell, William; Raina, Amresh; Balderston, Jessica R; Litwack, Andrew J; Goldberg, Lee R

2016-10-15

The rising use of imaging cardiac stress tests has led to potentially unnecessary testing. Interventions designed to reduce inappropriate stress testing have focused on the ambulatory setting. We developed a computerized order entry tool intended to reduce the use of imaging cardiac stress tests and improve appropriate use in hospitalized patients. The tool was evaluated using preimplementation and postimplementation cohorts at a single urban academic teaching hospital. All hospitalized patients referred for testing were included. The co-primary outcomes were the use of imaging stress tests as a percentage of all stress tests and the percentage of inappropriate tests, compared between the 2 cohorts. There were 478 patients in the precohort and 463 in the postcohort. The indication was chest pain in 66% and preoperative in 18% and was not significantly different between groups. The use of nonimaging stress tests increased from 4% in the pregroup to 15% in the postgroup (p <0.001). Among very low-risk chest pain patients, the use of nonimaging stress tests increased from 7% to 25% (p <0.001). Inappropriate testing did not change significantly between groups (12% vs 11%). Inappropriate tests were most often preoperative evaluations (83%). In conclusion, our computerized ordering tool significantly increased the use of nonimaging cardiac stress tests and reduced the use of imaging tests yet was not able to reduce inappropriate use. Our study highlights the differences in cardiac stress testing between hospitalized and ambulatory patients. Copyright © 2016 Elsevier Inc. All rights reserved.

An Analysis of the External Environmental and Internal Organizational Factors Associated with Adoption of the Electronic Health Record

ERIC Educational Resources Information Center

Kruse, Clemens Scott

2013-01-01

Despite a Presidential Order in 2004 that launched national incentives for the use of health information technology, specifically the Electronic Health Record (EHR), adoption of the EHR has been slow. This study attempts to quantify factors associated with adoption of the EHR and Computerized Provider Order Entry (CPOE) by combining multiple…

Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units.

PubMed

Hoonakker, Peter L T; Carayon, Pascale; Brown, Roger L; Cartmill, Randi S; Wetterneck, Tosha B; Walker, James M

2013-01-01

Implementation of Computerized Provider Order Entry (CPOE) has many potential advantages. Despite the potential benefits of CPOE, several attempts to implement CPOE systems have failed or met with high levels of user resistance. Implementation of CPOE can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes required by CPOE. User satisfaction is a critical factor in information technology implementation. Little is known about how end-user satisfaction with CPOE changes over time. To examine ordering provider and nurse satisfaction with CPOE implementation over time. We conducted a repeated cross-sectional questionnaire survey in four intensive care units of a large hospital. We analyzed the questionnaire data as well as the responses to two open-ended questions about advantages and disadvantages of CPOE. Users were moderately satisfied with CPOE and there were interesting differences between user groups: ordering providers and nurses. User satisfaction with CPOE did not change over time for providers, but it did improve significantly for nurses. Results also show that nurses and providers are satisfied with different aspects of CPOE.

A survey of attitudes, practices, and knowledge regarding drug-drug interactions among medical residents in Iran.

PubMed

Nabovati, Ehsan; Vakili-Arki, Hasan; Taherzadeh, Zhila; Saberi, Mohammad Reza; Abu-Hanna, Ameen; Eslami, Saeid

2017-06-01

Background When prescribing medications, physicians should recognize clinically relevant potential drug-drug interactions (DDIs). To improve medication safety, it is important to understand prescribers' knowledge and opinions pertaining to DDIs. Objective To determine the current DDI information sources used by medical residents, their knowledge of DDIs, their opinions about performance feedback on co-prescription of interacting drugs. Setting Academic hospitals of Mashhad University of Medical Sciences (MUMS) in Iran. Methods A questionnaire containing questions regarding demographic and practice characteristics, DDI information sources, ability to recognize DDIs, and opinions about performance feedback was distributed to medical residents of 22 specialties in eight academic hospitals in Iran. We analyzed their perception pertaining to DDIs, their performance on classifying drug pairs, and we used a linear regression model to assess the association of potential determinants on their DDI knowledge. Main Outcome Measure prescribers' knowledge and opinions pertaining to DDIs. Results The overall response rate and completion rate for 315 distributed questionnaires were 90% (n = 295) and 86% (n = 281), respectively. Among DDI information sources, books, software on mobile phone or tablet, and Internet were the most commonly-used references. Residents could correctly classify only 41% (5.7/14) of the drug pairs. The regression model showed no significant association between residents' characteristics and their DDI knowledge. An overwhelming majority of the respondents (n = 268, 95.4%) wished to receive performance feedback on co-prescription of interacting drugs in their prescriptions. They mostly selected information technology-based tools (i.e. short text message and email) as their preferred method of receiving feedback. Conclusion Our findings indicate that prescribers may have poor ability to prevent clinically relevant potential DDI occurrence, and they perceive the need for performance feedback. These findings underline the importance of well-designed computerized alerting systems and delivering performance feedback to improve patient safety.

Views of general practitioners on the use of STOPP&START in primary care: a qualitative study.

PubMed

Dalleur, O; Feron, J-M; Spinewine, A

2014-08-01

STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria aim at detecting potentially inappropriate prescribing in older people. The objective was to explore general practitioners' (GPs) perceptions regarding the use of the STOPP&START tool in their practice. We conducted three focus groups which were conveniently sampled. Vignettes with clinical cases were provided for discussion as well as a full version of the STOPP&START tool. Knowledge, strengths and weaknesses of the tool and its implementation were discussed. Two researchers independently performed content analysis, classifying quotes and creating new categories for emerging themes. Discussions highlighted incentives (e.g. systematic procedure for medication review) and barriers (e.g. time-consuming application) influencing the use of STOPP&START in primary care. Usefulness, comprehensiveness, and relevance of the tool were also questioned. Another important category emerging from the content analysis was the projected use of the tool. The GPs imagined key elements for the implementation in daily practice: computerized clinical decision support system, education, and multidisciplinary collaborations, especially at care transitions and in nursing homes. Despite variables views on the usefulness, comprehensiveness, and relevance of STOPP&START, GPs suggest the implementation of this tool in primary care within computerized clinical decision support systems, through education, and used as part of multidisciplinary collaborations.

The impact of pharmacy services on opioid prescribing in dental practice.

PubMed

Stewart, Autumn; Zborovancik, Kelsey J; Stiely, Kara L

To compare rates of dental opioid prescribing between periods of full and partial integration of pharmacy services and periods of no integration. This observational study used a retrospective chart review of opioid prescriptions written by dental providers practicing in a free dental clinic for the medically underserved over a period of 74 months. Pharmacy services were fully integrated into the practice model for 48 of the 74 months under study. During this time frame, all dental opioid orders required review by the pharmacy department before prescribing. Outcomes related to prescribing rates and errors were compared between groups, which were defined by the level of integrated pharmacy services. Demographic and prescription-specific data (drug name, dose, quantity, directions, professional designation of individual entering order) and clinic appointment data were collected and analyzed with the use of descriptive and inferential statistics. A total of 102 opioids were prescribed to 89 patients; hydrocodone-acetaminophen combination products were the most frequently used. Opioid prescribing rates were 5 times greater when pharmacy services were not integrated (P <0.001); and dentists were 81% less likely to prescribe opioids when pharmacy was fully integrated (odds ratio 0.19, 95% confidence interval 0.124-0.293; P <0.001). Frequency of hydrocodone use compared with other opioids did not decrease after the rescheduling of hydrocodone to a Schedule II controlled substance. The frequency of prescribing errors was not statistically different between groups, although there were numerically fewer errors with integrated pharmacy services. The literature reports that dentists are the third most frequent prescribers of opioids. The findings from this study suggest that collaboration between pharmacists and dentists has the potential to decrease opioid utilization in primary dental practice. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Effective Heart Disease Detection Based on Quantitative Computerized Traditional Chinese Medicine Using Representation Based Classifiers.

PubMed

Shu, Ting; Zhang, Bob; Tang, Yuan Yan

2017-01-01

At present, heart disease is the number one cause of death worldwide. Traditionally, heart disease is commonly detected using blood tests, electrocardiogram, cardiac computerized tomography scan, cardiac magnetic resonance imaging, and so on. However, these traditional diagnostic methods are time consuming and/or invasive. In this paper, we propose an effective noninvasive computerized method based on facial images to quantitatively detect heart disease. Specifically, facial key block color features are extracted from facial images and analyzed using the Probabilistic Collaborative Representation Based Classifier. The idea of facial key block color analysis is founded in Traditional Chinese Medicine. A new dataset consisting of 581 heart disease and 581 healthy samples was experimented by the proposed method. In order to optimize the Probabilistic Collaborative Representation Based Classifier, an analysis of its parameters was performed. According to the experimental results, the proposed method obtains the highest accuracy compared with other classifiers and is proven to be effective at heart disease detection.

Transfusion audit of fresh-frozen plasma in southern Taiwan.

PubMed

Yeh, C-J; Wu, C-F; Hsu, W-T; Hsieh, L-L; Lin, S-F; Liu, T-C

2006-10-01

The demand for transfusions has increased rapidly in southern Taiwan. Between 1993 and 2003, requests for fresh-frozen plasma (FFP) in particular rose dramatically at Kaohsiung Medical University Hospital (KMUH). Transfusion orders were not tightly regulated, and inappropriate use of blood products was common. We carried out a prospective analysis of transfusion requests from October 2003 to January 2004 at KMUH, and then repeated the audit for another 3-month period after the clinical faculty had undergone five sessions of education on transfusion guidelines. Later, our consultant haematologist applied computerized guidelines to periodic audits. A 5.2% decrease in inappropriate FFP usage followed the educational programme and a further 30% reduction took place after the application of computerized transfusion guidelines. With the guidelines and periodic audits, FFP transfusions decreased by 74.6% and inappropriate requests from 65.2% to 30%. Hospital policy, computerized transfusion guidelines and periodic audits greatly reduced inappropriate FFP transfusions. An educational campaign had a more limited effect.

Comparison of warfarin therapy clinical outcomes following implementation of an automated mobile phone-based critical laboratory value text alert system.

PubMed

Lin, Shu-Wen; Kang, Wen-Yi; Lin, Dong-Tsamn; Lee, James; Wu, Fe-Lin; Chen, Chuen-Liang; Tseng, Yufeng J

2014-01-01

Computerized alert and reminder systems have been widely accepted and applied to various patient care settings, with increasing numbers of clinical laboratories communicating critical laboratory test values to professionals via either manual notification or automated alerting systems/computerized reminders. Warfarin, an oral anticoagulant, exhibits narrow therapeutic range between treatment response and adverse events. It requires close monitoring of prothrombin time (PT)/international normalized ratio (INR) to ensure patient safety. This study was aimed to evaluate clinical outcomes of patients on warfarin therapy following implementation of a Personal Handy-phone System-based (PHS) alert system capable of generating and delivering text messages to communicate critical PT/INR laboratory results to practitioners' mobile phones in a large tertiary teaching hospital. A retrospective analysis was performed comparing patient clinical outcomes and physician prescribing behavior following conversion from a manual laboratory result alert system to an automated system. Clinical outcomes and practitioner responses to both alert systems were compared. Complications to warfarin therapy, warfarin utilization, and PT/INR results were evaluated for both systems, as well as clinician time to read alert messages, time to warfarin therapy modification, and monitoring frequency. No significant differences were detected in major hemorrhage and thromboembolism, warfarin prescribing patterns, PT/INR results, warfarin therapy modification, or monitoring frequency following implementation of the PHS text alert system. In both study periods, approximately 80% of critical results led to warfarin discontinuation or dose reduction. Senior physicians' follow-up response time to critical results was significantly decreased in the PHS alert study period (46.3% responded within 1 day) compared to the manual notification study period (24.7%; P = 0.015). No difference in follow-up response time was detected for junior physicians. Implementation of an automated PHS-based text alert system did not adversely impact clinical or safety outcomes of patients on warfarin therapy. Approximately 80% immediate recognition of text alerts was achieved. The potential benefits of an automated PHS alert for senior physicians were demonstrated.

Implementation of a Computerized Decision Support System to Improve the Appropriateness of Antibiotic Therapy Using Local Microbiologic Data

PubMed Central

Rodriguez-Maresca, Manuel; Sorlozano, Antonio; Grau, Magnolia; Rodriguez-Castaño, Rocio; Ruiz-Valverde, Andres; Gutierrez-Fernandez, Jose

2014-01-01

A prospective quasi-experimental study was undertaken in 218 patients with suspicion of nosocomial infection hospitalized in a polyvalent ICU where a new electronic device (GERB) has been designed for antibiotic prescriptions. Two GERB-based applications were developed to provide local resistance maps (LRMs) and preliminary microbiological reports with therapeutic recommendation (PMRTRs). Both applications used the data in the Laboratory Information System of the Microbiology Department to report on the optimal empiric therapeutic option, based on the most likely susceptibility profile of the microorganisms potentially responsible for infection in patients and taking into account the local epidemiology of the hospital department/unit. LRMs were used for antibiotic prescription in 20.2% of the patients and PMRTRs in 78.2%, and active antibiotics against the finally identified bacteria were prescribed in 80.0% of the former group and 82.4% of the latter. When neither LMRs nor PMRTRs were considered for empiric treatment prescription, only around 40% of the antibiotics prescribed were active. Hence, the percentage appropriateness of the empiric antibiotic treatments was significantly higher when LRM or PMRTR guidelines were followed rather than other criteria. LRMs and PMRTRs applications are dynamic, highly accessible, and readily interpreted instruments that contribute to the appropriateness of empiric antibiotic treatments. PMID:25197643

Knowledge Translation of the PERC Rule for Suspected Pulmonary Embolism: A Blueprint for Reducing the Number of CT Pulmonary Angiograms.

PubMed

Drescher, Michael J; Fried, Jeremy; Brass, Ryan; Medoro, Amanda; Murphy, Timothy; Delgado, João

2017-10-01

Computerized decision support decreases the number of computed tomography pulmonary angiograms (CTPA) for pulmonary embolism (PE) ordered in emergency departments, but it is not always well accepted by emergency physicians. We studied a department-endorsed, evidence-based clinical protocol that included the PE rule-out criteria (PERC) rule, multi-modal education using principles of knowledge translation (KT), and clinical decision support embedded in our order entry system, to decrease the number of unnecessary CTPA ordered. We performed a historically controlled observational before-after study for one year pre- and post-implementation of a departmentally-endorsed protocol. We included patients > 18 in whom providers suspected PE and who did not have a contraindication to CTPA. Providers entered clinical information into a diagnostic pathway via computerized order entry. Prior to protocol implementation, we provided education to ordering providers. The primary outcome measure was the number of CTPA ordered per 1,000 visits one year before vs. after implementation. CTPA declined from 1,033 scans for 98,028 annual visits (10.53 per 1,000 patient visits (95% CI [9.9-11.2]) to 892 scans for 101,172 annual visits (8.81 per 1,000 patient visits (95% CI [8.3-9.4]) p<0.001. The absolute reduction in PACT ordered was 1.72 per 1,000 visits (a 16% reduction). Patient characteristics were similar for both periods. Knowledge translation clinical decision support using the PERC rule significantly reduced the number of CTPA ordered.

3D multimodal cardiac data reconstruction using angiography and computerized tomographic angiography registration.

PubMed

Moosavi Tayebi, Rohollah; Wirza, Rahmita; Sulaiman, Puteri S B; Dimon, Mohd Zamrin; Khalid, Fatimah; Al-Surmi, Aqeel; Mazaheri, Samaneh

2015-04-22

Computerized tomographic angiography (3D data representing the coronary arteries) and X-ray angiography (2D X-ray image sequences providing information about coronary arteries and their stenosis) are standard and popular assessment tools utilized for medical diagnosis of coronary artery diseases. At present, the results of both modalities are individually analyzed by specialists and it is difficult for them to mentally connect the details of these two techniques. The aim of this work is to assist medical diagnosis by providing specialists with the relationship between computerized tomographic angiography and X-ray angiography. In this study, coronary arteries from two modalities are registered in order to create a 3D reconstruction of the stenosis position. The proposed method starts with coronary artery segmentation and labeling for both modalities. Then, stenosis and relevant labeled artery in X-ray angiography image are marked by a specialist. Proper control points for the marked artery in both modalities are automatically detected and normalized. Then, a geometrical transformation function is computed using these control points. Finally, this function is utilized to register the marked artery from the X-ray angiography image on the computerized tomographic angiography and get the 3D position of the stenosis lesion. The result is a 3D informative model consisting of stenosis and coronary arteries' information from the X-ray angiography and computerized tomographic angiography modalities. The results of the proposed method for coronary artery segmentation, labeling and 3D reconstruction are evaluated and validated on the dataset containing both modalities. The advantage of this method is to aid specialists to determine a visual relationship between the correspondent coronary arteries from two modalities and also set up a connection between stenosis points from an X-ray angiography along with their 3D positions on the coronary arteries from computerized tomographic angiography. Moreover, another benefit of this work is that the medical acquisition standards remain unchanged, which means that no calibration in the acquisition devices is required. It can be applied on most computerized tomographic angiography and angiography devices.

Usability Evaluation at the Point-of-Care: A Method to Identify User Information Needs in CPOE Applications

PubMed Central

Washburn, Jeff; Fiol, Guilherme Del; Rocha, Roberto A.

2006-01-01

Point of care usability evaluation may help identify information needs that occur during the process of providing care. We describe the process of using usability-specific recording software to record Computerized Physician Order Entry (CPOE) ordering sessions on admitted adult and pediatric patients at two urban tertiary hospitals in the Intermountain Healthcare system of hospitals. PMID:17238756

Teaching Prescribing: Just What the Doctor Ordered? A Thematic Analysis of the Views of Newly Qualified Doctors

PubMed Central

Hansen, Christina R.; Walsh, Elaine K.; Bradley, Colin P.; Sahm, Laura J.

2017-01-01

Undergraduate medical education has been criticised for failing to adequately prepare doctors for the task of prescribing. Pharmacists have been shown to improve medication use in hospitals. This study aims to elicit the views of intern doctors on the challenges of prescribing, and to suggest changes in education to enhance prescribing practice and potential role of the pharmacist. Semi-structured, qualitative interviews were conducted with intern doctors in their first year post qualification in an Irish hospital. Data collection was conducted until no new themes emerged and thematic analysis was performed. Thirteen interviews took place. Interns described training in practical prescribing as limited and felt the curriculum failed to convey the reality of actual prescribing. Pharmacists were perceived to be a useful, but underutilised, information source in the prescribing process. They requested an earlier introduction, and repeated exposure, to prescribing, and suggested the involvement of peers and pharmacists in this teaching. Intern doctors reported difficulties in applying knowledge gained in medical school to clinical practice. New strategies are needed to enhance the clinical relevance of the medical curriculum by rethinking the learning outcomes regarding prescribing practice and the involvement of pharmacists in prescribing education. PMID:28970444

Lessons from a Successful Implementation of a Computerized Provider Order Entry System

PubMed Central

Jacobs, Brian R.; Hallstrom, Craig K.; Hart, Kim Ward; Mahoney, Daniela; Lykowski, Gayle

2007-01-01

OBJECTIVES The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success. PMID:23055847

75 FR 6391 - Agency Information Collection Activities: Existing Collection; Emergency Extension

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-09

... Commission prescribes by regulation or order. Accordingly, the EEOC issued regulations prescribing the EEO-1... accordance with the Paperwork Reduction Act, the Equal Employment Opportunity Commission (EEOC or Commission... (202) 663-7063 (TTY). SUPPLEMENTARY INFORMATION: The EEOC has collected information from certain...

27 CFR 555.217 - Lighting.

Code of Federal Regulations, 2012 CFR

2012-04-01

...) Electric lighting used in any explosives storage magazine must meet the standards prescribed by the “National Electrical Code,” (National Fire Protection Association, NFPA 70-81), for the conditions present... also meet the standards prescribed by the National Electrical Code. (c) Copies of invoices, work orders...

27 CFR 555.217 - Lighting.

Code of Federal Regulations, 2010 CFR

2010-04-01

...) Electric lighting used in any explosives storage magazine must meet the standards prescribed by the “National Electrical Code,” (National Fire Protection Association, NFPA 70-81), for the conditions present... also meet the standards prescribed by the National Electrical Code. (c) Copies of invoices, work orders...

27 CFR 555.217 - Lighting.

Code of Federal Regulations, 2011 CFR

2011-04-01

...) Electric lighting used in any explosives storage magazine must meet the standards prescribed by the “National Electrical Code,” (National Fire Protection Association, NFPA 70-81), for the conditions present... also meet the standards prescribed by the National Electrical Code. (c) Copies of invoices, work orders...

27 CFR 555.217 - Lighting.

Code of Federal Regulations, 2014 CFR

2014-04-01

...) Electric lighting used in any explosives storage magazine must meet the standards prescribed by the “National Electrical Code,” (National Fire Protection Association, NFPA 70-81), for the conditions present... also meet the standards prescribed by the National Electrical Code. (c) Copies of invoices, work orders...

27 CFR 555.217 - Lighting.

Code of Federal Regulations, 2013 CFR

2013-04-01

...) Electric lighting used in any explosives storage magazine must meet the standards prescribed by the “National Electrical Code,” (National Fire Protection Association, NFPA 70-81), for the conditions present... also meet the standards prescribed by the National Electrical Code. (c) Copies of invoices, work orders...

Decision Support Alerts for Medication Ordering in a Computerized Provider Order Entry (CPOE) System

PubMed Central

Beccaro, M. A. Del; Villanueva, R.; Knudson, K. M.; Harvey, E. M.; Langle, J. M.; Paul, W.

2010-01-01

Objective We sought to determine the frequency and type of decision support alerts by location and ordering provider role during Computerized Provider Order Entry (CPOE) medication ordering. Using these data we adjusted the decision support tools to reduce the number of alerts. Design Retrospective analyses were performed of dose range checks (DRC), drug-drug interaction and drug-allergy alerts from our electronic medical record. During seven sampling periods (each two weeks long) between April 2006 and October 2008 all alerts in these categories were analyzed. Another audit was performed of all DRC alerts by ordering provider role from November 2008 through January 2009. Medication ordering error counts were obtained from a voluntary error reporting system. Measurement/Results Between April 2006 and October 2008 the percent of medication orders that triggered a dose range alert decreased from 23.9% to 7.4%. The relative risk (RR) for getting an alert was higher at the start of the interventions versus later (RR= 2.40, 95% CI 2.28-2.52; p< 0.0001). The percentage of medication orders that triggered alerts for drug-drug interactions also decreased from 13.5% to 4.8%. The RR for getting a drug interaction alert at the start was 1.63, 95% CI 1.60-1.66; p< 0.0001. Alerts decreased in all clinical areas without an increase in reported medication errors. Conclusion We reduced the quantity of decision support alerts in CPOE using a systematic approach without an increase in reported medication errors PMID:23616845

Non-steroidal anti-inflammatory drug prescribing patterns in general practice: comparison of a general practitioner-based survey and a pharmacy-based survey in France.

PubMed

Clinard, F; Sgro, C; Bardou, M; Dumas, M; Hillon, P; Bonithon-Kopp, C

2001-01-01

In order to assess biases occurring in primary care prescription studies, we compared non-steroidal anti-inflammatory drug (NSAID) prescribing patterns reported by general practitioners directly (GP-based survey) and from a pharmacy-based survey of general practitioner prescribing (pharmacy-based survey). Volunteer GPs of the administrative area of Côte d'Or (France) returned a mailed questionnaire on NSAID prescribing patterns for consecutive patients seen during a 2-month period. In order to obtain a reference basis, pharmacies of the same administrative area provided all prescriptions that included NSAIDs during a 1-week period originating in general practice. The rate of participation was 25% for the GPs and 40% for the pharmacies. Participant GPs were representative of GPs of the area with regard to sex, year of graduation and practice area but pharmacies from rural areas were over-represented. The GP-based survey and the pharmacy-based survey provided respectively 770 and 1050 prescriptions. There were no differences between either survey in the type of NSAIDs prescribed and in the most frequently associated drugs. GPs who volunteered in the GP survey prescribed NSAIDs more frequently orally and at higher doses than GPs involved in the pharmacy-based survey. They also prescribed more gastroprotective drugs, especially in the elderly. None of these results could be explained by differences in patient characteristics and GP practice areas. GPs who actively participate in prescription surveys exhibit prescribing patterns that fit better with official recommendations than the average. Although selection biases cannot be ruled out, it is suggested that some changes in GP prescription habits may have been induced by the survey itself.

Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example.

PubMed

Lau, Brandyn D; Haider, Adil H; Streiff, Michael B; Lehmann, Christoph U; Kraus, Peggy S; Hobson, Deborah B; Kraenzlin, Franca S; Zeidan, Amer M; Pronovost, Peter J; Haut, Elliott R

2015-01-01

All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. This was a retrospective cohort study of a quality improvement intervention. The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.

Effects of electronic prescribing on formulary compliance and generic drug utilization in the ambulatory care setting: a retrospective analysis of administrative claims data.

PubMed

Ross, S Michael; Papshev, Diana; Murphy, Erin L; Sternberg, David J; Taylor, Jeffrey; Barg, Ronald

2005-06-01

Electronic prescribing (e-prescribing) provides formulary information at the point of care. The objective of this study was to assess the effects of e-prescribing on formulary compliance and generic utilization. This was a retrospective analysis of pharmacy claims data from a large national managed care organization. A sample of 95 providers using predominantly e-prescribing was randomly selected (e-prescriber group). A matched sample of 95 traditional prescribers was selected (traditional prescriber group), matched to the e-prescriber group by zip code and medical specialty. A total of 110,975 paid pharmacy claims, for the 12 months from August 1, 2001, through July 31, 2002, were analyzed to assess the effect of e-prescribing on formulary compliance and generic utilization. All paid pharmacy claims were examined for each group; for the e-prescriber group, this included all claims, not just those prescribed using an e-prescribing device. A written qualitative survey was distributed to physicians and office managers to assess e-prescribing usage, sources of formulary information, and effects of e-prescribing on office resources. Both predominantly e-prescribers and traditional prescribers demonstrated high levels of formulary compliance, 83.2% versus 82.8%, respectively (P=0.32). Formulary compliance for these groups did not differ from the overall prescriber population (82.0%). There was not a difference in generic drug utilization rates between e-prescribers and traditional prescribers (absolute rates 37.3% versus 36.9%, P=0.18). Qualitative survey responses supported previously reported research indicating reductions in calls both to and from pharmacies for prescription orders. An examination of paid pharmacy claims from a large, national managed care organization demonstrated no differences between predominantly e-prescribers and traditional prescribers in measures of formulary compliance or generic drug utilization. Future studies should examine keystroke data at the point of care to observe more detail about drug selection methods.

Impact of Computerized Provider Order Entry on Pharmacist Productivity

PubMed Central

Hatfield, Mark D.; Cox, Rodney; Mhatre, Shivani K.; Flowers, W. Perry

2014-01-01

Abstract Purpose: To examine the impact of computerized provider order entry (CPOE) implementation on average time spent on medication order entry and the number of order actions processed. Methods: An observational time and motion study was conducted from March 1 to March 17, 2011. Two similar community hospital pharmacies were compared: one without CPOE implementation and the other with CPOE implementation. Pharmacists in the central pharmacy department of both hospitals were observed in blocks of 1 hour, with 24 hours of observation in each facility. Time spent by pharmacists on distributive, administrative, clinical, and miscellaneous activities associated with order entry were recorded using time and motion instrument documentation. Information on medication order actions and order entry/verifications was obtained using the pharmacy network system. Results: The mean ± SD time spent by pharmacists per hour in the CPOE pharmacy was significantly less than the non-CPOE pharmacy for distributive activities (43.37 ± 7.75 vs 48.07 ± 8.61) and significantly greater than the non-CPOE pharmacy for administrative (8.58 ± 5.59 vs 5.72 ± 6.99) and clinical (7.38 ± 4.27 vs 4.22 ± 3.26) activities. The CPOE pharmacy was associated with a significantly higher number of order actions per hour (191.00 ± 82.52 vs 111.63 ± 25.66) and significantly less time spent (in minutes per hour) on order entry and order verification combined (28.30 ± 9.25 vs 36.56 ± 9.14) than the non-CPOE pharmacy. Conclusion: The implementation of CPOE facilitated pharmacists to allocate more time to clinical and administrative functions and increased the number of order actions processed per hour, thus enhancing workflow efficiency and productivity of the pharmacy department. PMID:24958959

Information Retrieval Performance of Probabilistically Generated, Problem-Specific Computerized Provider Order Entry Pick-Lists: A Pilot Study

PubMed Central

Rothschild, Adam S.; Lehmann, Harold P.

2005-01-01

Objective: The aim of this study was to preliminarily determine the feasibility of probabilistically generating problem-specific computerized provider order entry (CPOE) pick-lists from a database of explicitly linked orders and problems from actual clinical cases. Design: In a pilot retrospective validation, physicians reviewed internal medicine cases consisting of the admission history and physical examination and orders placed using CPOE during the first 24 hours after admission. They created coded problem lists and linked orders from individual cases to the problem for which they were most indicated. Problem-specific order pick-lists were generated by including a given order in a pick-list if the probability of linkage of order and problem (PLOP) equaled or exceeded a specified threshold. PLOP for a given linked order-problem pair was computed as its prevalence among the other cases in the experiment with the given problem. The orders that the reviewer linked to a given problem instance served as the reference standard to evaluate its system-generated pick-list. Measurements: Recall, precision, and length of the pick-lists. Results: Average recall reached a maximum of .67 with a precision of .17 and pick-list length of 31.22 at a PLOP threshold of 0. Average precision reached a maximum of .73 with a recall of .09 and pick-list length of .42 at a PLOP threshold of .9. Recall varied inversely with precision in classic information retrieval behavior. Conclusion: We preliminarily conclude that it is feasible to generate problem-specific CPOE pick-lists probabilistically from a database of explicitly linked orders and problems. Further research is necessary to determine the usefulness of this approach in real-world settings. PMID:15684134

Provision of continued professional development for non-medical prescribers within a South of England Strategic Health Authority: a report on a training needs analysis.

PubMed

Green, Anita; Westwood, Olwyn; Smith, Pam; Peniston-Bird, Fiona; Holloway, David

2009-07-01

This paper reports on a Training Needs Analysis for Non-Medical Prescribers commissioned by a south of England Strategic Health Authority. The aim of the TNA was to inform future policy, educational provision and practice development and provide nurse managers with significant information on the perceived Continuing Professional Development (CPD) needs of the non-medical prescribers. Data were collected from a sample of 270 non-medical prescribers using an in-depth questionnaire, and telephone interviews with a purposive sample of 11 key stakeholders. The findings report: * The qualifications that non-medical prescribers possess. * The level of confidence described by the non-medical prescribers in their role. * What non-medical prescribers identify as their present and future CPD requirements in relation to prescribing. * What education and training provision non-medical prescribers have attended in relation to their prescribing role since qualifying. The findings suggest, first that short courses that were specific to the non-medical prescribers role were considered to be the most popular and useful. However, courses needed to be advertised well in advance. Second, training gaps were identified. Pharmacology and prescribing are rapidly changing and require regular CPD in order to keep up to date with the latest developments. Non-medical prescribing is a comparatively new innovation to the NHS, therefore those who are not medically qualified need mentorship from experienced prescribers, as well as the encouragement from nurse managers to be confident prescribers themselves and enhance patient care.

A survey of medical informatics in Belgium.

PubMed

Roger, F H; Behets, M; Andre, J; de Moor, G; Sevens, C; Willems, J L

1987-01-01

The Belgian Society for Medical Informatics (MIM) organized a survey in 1986 in order to assess the present state of development of medical informatics in Belgium. Questionnaires were sent to hospitals, laboratories, private practitioners and pharmacists, as well as to social security organizations and software industries. The response rate was higher in hospitals (93%) than in any other category. Results showed a large number of computerized hospitals (93% of general acute care hospitals and 91% of psychiatric hospitals). There has been a sharp increase (+ 15%) in computerization of the admission, accounting and billing procedures since 1985, most likely in relation with administrative rules issued by the Belgian Government. The same trend (+ 20%) has been observed for computer applications in clinical laboratories, between 1984 and 1985. There is almost one computer terminal for ten beds in the hospitals with more than 200 beds in 1986. This figure exemplifies the present trend to on-line access to data. Computerized instrumental aids to medicine such as text processing, imaging or computerized interpretation of signals have known a rapid extension during recent years, although less comprehensive than administrative applications in hospitals and in social security organizations. The present state of other applications in medicine (general practice, pharmacy, etc.) was more difficult to assess as those information systems remain more pinpointed. In all medical fields, there appears to be a new rise in computer programs offered by software companies.

A methodological protocol for selecting and quantifying low-value prescribing practices in routinely collected data: an Australian case study.

PubMed

Brett, Jonathan; Elshaug, Adam G; Bhatia, R Sacha; Chalmers, Kelsey; Badgery-Parker, Tim; Pearson, Sallie-Anne

2017-05-03

Growing imperatives for safety, quality and responsible resource allocation have prompted renewed efforts to identify and quantify harmful or wasteful (low-value) medical practices such as test ordering, procedures and prescribing. Quantifying these practices at a population level using routinely collected health data allows us to understand the scale of low-value medical practices, measure practice change following specific interventions and prioritise policy decisions. To date, almost all research examining health care through the low-value lens has focused on medical services (tests and procedures) rather than on prescribing. The protocol described herein outlines a program of research funded by Australia's National Health and Medical Research Council to select and quantify low-value prescribing practices within Australian routinely collected health data. We start by describing our process for identifying and cataloguing international low-value prescribing practices. We then outline our approach to translate these prescribing practices into indicators that can be applied to Australian routinely collected health data. Next, we detail methods of using Australian health data to quantify these prescribing practices (e.g. prevalence of low-value prescribing and related costs) and their downstream health consequences. We have approval from the necessary Australian state and commonwealth human research ethics and data access committees to undertake this work. The lack of systematic and transparent approaches to quantification of low-value practices in routinely collected data has been noted in recent reviews. Here, we present a methodology applied in the Australian context with the aim of demonstrating principles that can be applied across jurisdictions in order to harmonise international efforts to measure low-value prescribing. The outcomes of this research will be submitted to international peer-reviewed journals. Results will also be presented at national and international pharmacoepidemiology and health policy forums such that other jurisdictions have guidance to adapt this methodology.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

PubMed Central

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-01-01

Introduction Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. Methods and analysis The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics and dissemination Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. PMID:26463224

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

PubMed

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-10-13

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

77 FR 39238 - Agency Information Collection Activities: Existing Collection; Emergency Extension

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-02

... prescribes by regulation or order. Accordingly, the EEOC issued regulations prescribing the reporting... Employment Opportunity Commission (EEOC or Commission) announces that it submitted to the Office of... Information Report (EEO-5) to be effective after the current June 30, 2012 expiration date. EEOC is requesting...

75 FR 6391 - Agency Information Collection Activities: Existing Collection; Emergency Extension

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-09

... Commission prescribes by regulation or order. Accordingly, the EEOC issued regulations prescribing the... Commission (EEOC or Commission) announces that it submitted to the Office of Management and Budget (OMB) a..., Washington, DC 20507; (202) 663-4958 (voice) or (202) 663-7063 (TTY). SUPPLEMENTARY INFORMATION: The EEOC has...

Canadian adaptation of the Newest Vital Sign©, a health literacy assessment tool.

PubMed

Mansfield, Elizabeth D; Wahba, Rana; Gillis, Doris E; Weiss, Barry D; L'Abbé, Mary

2018-04-25

The Newest Vital Sign© (NVS) was developed in the USA to measure patient health literacy in clinical settings. We adapted the NVS for use in Canada, in English and French, and created a computerized version. Our objective was to evaluate the reliability of the Canadian NVS as a self-administered computerized tool. We used a randomized crossover design with a washout period of 3-4 weeks to compare health literacy scores obtained using the computerized version with scores obtained using the standard interviewer-administered NVS. ANOVA models and McNemar's tests assessed differences in outcomes assessed with each version of the NVS and order effects of the testing. Participants were recruited from multicultural catchment areas in Ontario and Nova Scotia. English- and French-speaking adults aged 18 years or older. A total of 180 (81 %) of the 222 adults (112 English/110 French) initially recruited completed both the interviewer-NVS and computer-NVS. Scores for those who completed both assessments ranged from 0 to 6 with a mean of 3·63 (sd 2·11) for the computerized NVS and 3·41 (sd 2·21) for the interview-administered NVS. Few (n 18; seven English, eleven French) participants' health literacy assessments differed between the two versions. Overall, the computerized Canadian NVS performed as well as the interviewer-administered version for assessing health literacy levels of English- and French-speaking participants. This Canadian adaptation of the NVS provides Canadian researchers and public health practitioners with an easily administered health literacy assessment tool that can be used to address the needs of Canadians across health literacy levels and ultimately improve health outcomes.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

PubMed Central

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, , Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals. PMID:29445698

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran.

PubMed

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

Indication-Based Ordering: A New Paradigm for Glycemic Control in Hospitalized Inpatients

PubMed Central

Lee, Joshua; Clay, Brian; Zelazny, Ziband; Maynard, Gregory

2008-01-01

Background Inpatient glycemic control is a constant challenge. Institutional insulin management protocols and structured order sets are commonly advocated but poorly studied. Effective and validated methods to integrate algorithmic protocol guidance into the insulin ordering process are needed. Methods We introduced a basic structured set of computerized insulin orders (Version 1), and later introduced a paper insulin management protocol, to assist users with the order set. Metrics were devised to assess the impact of the protocol on insulin use, glycemic control, and hypoglycemia using pharmacy data and point of care glucose tests. When incremental improvement was seen (as described in the results), Version 2 of the insulin orders was created to further streamline the process. Results The percentage of regimens containing basal insulin improved with Version 1. The percentage of patient days with hypoglycemia improved from 3.68% at baseline to 2.59% with Version 1 plus the paper insulin management protocol, representing a relative risk for hypoglycemic day of 0.70 [confidence interval (CI) 0.62, 0.80]. The relative risk of an uncontrolled (mean glucose over 180 mg/dl) patient stay was reduced to 0.84 (CI 0.77, 0.91) with Version 1 and was reduced further to 0.73 (CI 0.66, 0.81) with the paper protocol. Version 2 used clinician-entered patient parameters to guide protocol-based insulin ordering and simultaneously improved the flexibility and ease of ordering over Version 1. Conclusion Patient parameter and protocol-based clinical decision support, added to computerized provider order entry, has a track record of improving glycemic control indices. This justifies the incorporation of these algorithms into online order management. PMID:19885198

Reduction in unnecessary red blood cell folate testing by restricting computerized physician order entry in the electronic health record.

PubMed

MacMillan, Thomas E; Gudgeon, Patrick; Yip, Paul M; Cavalcanti, Rodrigo B

2018-05-02

Red blood cell folate is a laboratory test with limited clinical utility. Previous attempts to reduce physician ordering of unnecessary laboratory tests, including folate, have resulted in only modest success. The objective of this study was to assess the effectiveness and impacts of restricting red blood cell folate ordering in the electronic health record. This was a retrospective observational study from January 2010 to December 2016 at a large academic healthcare network in Toronto, Canada. All inpatients and outpatients who underwent at least 1 red blood cell folate or vitamin B12 test during the study period were included. Red blood cell folate ordering was restricted to clincians in gastroenterology and hematology and was removed from other physicians' computerized order entry screen in the electronic health record in June 2013. Red blood cell folate testing decreased by 94.4% during the study, from a mean of 493.0 (SD 48.0) tests/month before intervention to 27.6 (SD 10.3) tests/month after intervention (P<.001). Restricting red blood cell folate ordering in the electronic health record resulted in a large and sustained reduction in red blood cell folate testing. Significant cost savings estimated at over a quarter-million dollars (CAD) over three years were achieved. There was no significant clinical impact of the intervention on the diagnosis of folate deficiency. Copyright © 2018. Published by Elsevier Inc.

El Camino Hospital: using health information technology to promote patient safety.

PubMed

Bukunt, Susan; Hunter, Christine; Perkins, Sharon; Russell, Diana; Domanico, Lee

2005-10-01

El Camino Hospital is a leader in the use of health information technology to promote patient safety, including bar coding, computerized order entry, electronic medical records, and wireless communications. Each year, El Camino Hospital's board of directors sets performance expectations for the chief executive officer, which are tied to achievement of local, regional, and national safety and quality standards, including the six Institute of Medicine quality dimensions. He then determines a set of explicit quality goals and measurable actions, which serve as guidelines for the overall hospital. The goals and progress reports are widely shared with employees, medical staff, patients and families, and the public. For safety, for example, the medication error reduction team tracks and reviews medication error rates. The hospital has virtually eliminated transcription errors through its 100% use of computerized physician order entry. Clinical pathways and standard order sets have reduced practice variation, providing a safer environment. Many projects focused on timeliness, such as emergency department wait time, lab turnaround time, and pneumonia time to initial antibiotic. Results have been mixed, with projects most successful when a link was established with patient outcomes, such as in reducing time to percutaneous transluminal coronary angioplasty for patients with acute myocardial infarction.

Computerized detection of unruptured aneurysms in MRA images: reduction of false positives using anatomical location features

NASA Astrophysics Data System (ADS)

Uchiyama, Yoshikazu; Gao, Xin; Hara, Takeshi; Fujita, Hiroshi; Ando, Hiromichi; Yamakawa, Hiroyasu; Asano, Takahiko; Kato, Hiroki; Iwama, Toru; Kanematsu, Masayuki; Hoshi, Hiroaki

2008-03-01

The detection of unruptured aneurysms is a major subject in magnetic resonance angiography (MRA). However, their accurate detection is often difficult because of the overlapping between the aneurysm and the adjacent vessels on maximum intensity projection images. The purpose of this study is to develop a computerized method for the detection of unruptured aneurysms in order to assist radiologists in image interpretation. The vessel regions were first segmented using gray-level thresholding and a region growing technique. The gradient concentration (GC) filter was then employed for the enhancement of the aneurysms. The initial candidates were identified in the GC image using a gray-level threshold. For the elimination of false positives (FPs), we determined shape features and an anatomical location feature. Finally, rule-based schemes and quadratic discriminant analysis were employed along with these features for distinguishing between the aneurysms and the FPs. The sensitivity for the detection of unruptured aneurysms was 90.0% with 1.52 FPs per patient. Our computerized scheme can be useful in assisting the radiologists in the detection of unruptured aneurysms in MRA images.

Use of Order Sets in Inpatient Computerized Provider Order Entry Systems: A Comparative Analysis of Usage Patterns at Seven Sites

PubMed Central

Wright, Adam; Feblowitz, Joshua C.; Pang, Justine E.; Carpenter, James D.; Krall, Michael A.; Middleton, Blackford; Sittig, Dean F.

2012-01-01

Background Many computerized provider order entry (CPOE) systems include the ability to create electronic order sets: collections of clinically-related orders grouped by purpose. Order sets promise to make CPOE systems more efficient, improve care quality and increase adherence to evidence-based guidelines. However, the development and implementation of order sets can be expensive and time-consuming and limited literature exists about their utilization. Methods Based on analysis of order set usage logs from a diverse purposive sample of seven sites with commercially- and internally-developed inpatient CPOE systems, we developed an original order set classification system. Order sets were categorized across seven non-mutually exclusive axes: admission/discharge/transfer (ADT), perioperative, condition-specific, task-specific, service-specific, convenience, and personal. In addition, 731 unique subtypes were identified within five axes: four in ADT (S=4), three in perioperative, 144 in condition-specific, 513 in task-specific, and 67 in service-specific. Results Order sets (n=1,914) were used a total of 676,142 times at the participating sites during a one-year period. ADT and perioperative order sets accounted for 27.6% and 24.2% of usage respectively. Peripartum/labor, chest pain/Acute Coronary Syndrome/Myocardial Infarction and diabetes order sets accounted for 51.6% of condition-specific usage. Insulin, angiography/angioplasty and arthroplasty order sets accounted for 19.4% of task-specific usage. Emergency/trauma, Obstetrics/Gynecology/Labor Delivery and anesthesia accounted for 32.4% of service-specific usage. Overall, the top 20% of order sets accounted for 90.1% of all usage. Additional salient patterns are identified and described. Conclusion We observed recurrent patterns in order set usage across multiple sites as well as meaningful variations between sites. Vendors and institutional developers should identify high-value order set types through concrete data analysis in order to optimize the resources devoted to development and implementation. PMID:22819199

Reducing nurses'. Workload using a computerized nursing support system linked to the hospital information system.

PubMed

Ito, C; Satoh, I; Michiya, H; Kitayama, Y; Miyazaki, K; Ota, S; Satoh, H; Sakurai, T; Shirato, H; Miyasaka, K

1997-01-01

A computerised nursing support system (CNSS) linked to the hospital information system (HIS) was developed and has been in use for one year, in order to reduce the workload of nurses. CNSS consists of (1) a hand held computer for each nurse (2) desk-top computers in the nurses' station and doctors' rooms (3) a data server (4) an interface with the main hospital information system. Nurses enter vital signs, food intake and other information about the patients into the hand held computer at the bed-side. The information is then sent automatically to the CNSS data server, which also receives patients' details (prescribed medicines etc.) from the HIS. Nurses and doctors can see all the information on the desk-top and hand held computers. This system was introduced in May 1995 into a university hospital ward with 40 beds. A questionnaire was completed by 23 nurses before and after the introduction of CNSS. The mean time required to post vital data was significantly reduced from 121 seconds to 54 seconds (p < 0.01). After three months 30% of nurses felt CNSS had reduced their workload, while 30% felt it had complicated their work; after five months 70% noted a reduction and 0% reported that CNSS had made their work more complex. The study therefore concludes that the interface between a computerised nursing support system and the hospital information system reduced the workload of nurses.

Air Traffic ControL : FAA Order 7110.65K

DOT National Transportation Integrated Search

1997-07-17

This order prescribes air traffic control procedures and phraseology for use by : personnel providing air traffic control services. Controllers are required to : be familiar with the provisions of this order that pertain to their operational : respon...

7 CFR 1209.51 - Assessments.

Code of Federal Regulations, 2011 CFR

2011-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER Mushroom Promotion, Research, and Consumer Information Order Expenses and... current of commerce, mushrooms produced in the United States shall, in the manner as prescribed by the...

7 CFR 1209.51 - Assessments.

Code of Federal Regulations, 2013 CFR

2013-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER Mushroom Promotion, Research, and Consumer Information Order Expenses and... current of commerce, mushrooms produced in the United States shall, in the manner as prescribed by the...

7 CFR 1209.51 - Assessments.

Code of Federal Regulations, 2012 CFR

2012-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER Mushroom Promotion, Research, and Consumer Information Order Expenses and... current of commerce, mushrooms produced in the United States shall, in the manner as prescribed by the...

7 CFR 1209.51 - Assessments.

Code of Federal Regulations, 2014 CFR

2014-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER Mushroom Promotion, Research, and Consumer Information Order Expenses and... current of commerce, mushrooms produced in the United States shall, in the manner as prescribed by the...

7 CFR 1209.51 - Assessments.

Code of Federal Regulations, 2010 CFR

2010-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE MUSHROOM PROMOTION, RESEARCH, AND CONSUMER INFORMATION ORDER Mushroom Promotion, Research, and Consumer Information Order Expenses and... current of commerce, mushrooms produced in the United States shall, in the manner as prescribed by the...

7 CFR 1216.41 - Nominations.

Code of Federal Regulations, 2011 CFR

2011-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE PEANUT PROMOTION, RESEARCH, AND INFORMATION ORDER Peanut Promotion, Research, and Information Order National Peanut Board § 1216.41... Secretary shall prescribe. Eligible peanut producer organizations within each state as certified pursuant to...

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

PubMed Central

Shah, Priya; Wyatt, Jeremy C; Makubate, Boikanyo; Cross, Frank W

2011-01-01

Objective Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems. Design A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task. Measurements The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems. Results Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04). Conclusions Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. PMID:21836158

An electronic safety screening process during inpatient computerized physician order entry improves the efficiency of magnetic resonance imaging exams.

PubMed

Schneider, Erika; Ruggieri, Paul; Fromwiller, Lauren; Underwood, Reginald; Gurland, Brooke; Yurkschatt, Cynthia; Kubiak, Kevin; Obuchowski, Nancy A

2013-12-01

Delays between order and magnetic resonance (MR) exam often result when using the conventional paper-based MR safety screening process. The impact of an electronic MR safety screening process imbedded in a computerized physician order entry (CPOE) system was evaluated. Retrospective chart review of 4 months of inpatient MR exam orders and reports was performed before and after implementation of electronic MR safety documentation. Time from order to MR exam completion, time from MR exam completion to final radiology report, and time from first order to final report were analyzed by exam anatomy. Length of stay (LOS) and date of service within the admission were also analyzed. We evaluated 1947 individual MR orders in 1549 patients under an institutional review board exemption and a waiver of informed consent. Implementation of the electronic safety screening process resulted in a significant decrease of 1.1 hours (95% confidence interval 1.0-1.3 hours) in the mean time between first order to final report and a nonsignificant decrease of 0.8 hour in the median time from first order to exam end. There was a 1-day reduction (P = .697) in the time from admission to the MR exam compared to the paper process. No significant change in LOS was found except in neurological intensive care patients imaged within the first 24 hours of their admission, where a mean 0.9-day decrease was found. Benefits of an electronic process for MR safety screening include enabling inpatients to have decreased time to MR exams, thus enabling earlier diagnosis and treatment and reduced LOS. Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.

Computerization and its contribution to care quality improvement: the nurses' perspective.

PubMed

Kagan, Ilya; Fish, Miri; Farkash-Fink, Naomi; Barnoy, Sivia

2014-12-01

Despite the widely held belief that the computerization of hospital medical systems contributes to improved patient care management, especially in the context of ordering medications and record keeping, extensive study of the attitudes of medical staff to computerization has found them to be negative. The views of nursing staff have been barely studied and so are unclear. The study reported here investigated the association between nurses' current computer use and skills, the extent of their involvement in quality control and improvement activities on the ward and their perception of the contribution of computerization to improving nursing care. The study was made in the context of a Joint Commission International Accreditation (JCIA) in a large tertiary medical center in Israel. The perception of the role of leadership commitment in the success of a quality initiative was also tested for. Two convenience samples were drawn from 33 clinical wards and units of the medical center. They were questioned at two time points, one before the JCIA and a second after JCIA completion. Of all nurses (N=489), 89 were paired to allow analysis of the study data in a before-and-after design. Thus, this study built three data sets: a pre-JCIA set, a post-JCIA set and a paired sample who completed the questionnaire both before and after JCIA. Data were collected by structured self-administered anonymous questionnaire. After the JCIA the participants ranked the role of leadership in quality improvement, the extent of their own quality control activity, and the contribution of computers to quality improvement higher than before the JCIA. Significant Pearson correlations were found showing that the higher the rating given to quality improvement leadership the more nurses reported quality improvement activities undertaken by them and the higher nurses rated the impact of computerization on the quality of care. In a regression analysis quality improvement leadership and computer use/skills accounted for 30% of the variance in the perceived contribution of computerization to quality improvement. (a) The present study is the first to show a relationship between organizational leadership and computer use by nurses for the purpose of improving clinical care. (b) The nurses' appreciation of the contribution computerization can make to data management and to clinical care quality improvement were both increased by the JCI accreditation process. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 8 2010-10-01 2010-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY PROCEDURE TO BE... NSA ORDER NO. 47 Section 1 What this order does. This order prescribes procedures for the preparation...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 8 2013-10-01 2013-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY PROCEDURE TO BE... NSA ORDER NO. 47 Section 1 What this order does. This order prescribes procedures for the preparation...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 8 2014-10-01 2014-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY PROCEDURE TO BE... NSA ORDER NO. 47 Section 1 What this order does. This order prescribes procedures for the preparation...

A Nurse Prescribing Programme Incorporating e-Learning

ERIC Educational Resources Information Center

Burgess, Joan

2007-01-01

In order to become a UK Nurse Prescriber, a First Level Registered Nurse must undergo an approved University based educational programme, which consists of theory, and a period of practice supervised by doctors. The Nursing and Midwifery Council (NMC) requires nurses undertaking this programme to have some formal university attendance and to be…

1:1 Technology and Computerized State Assessments

ERIC Educational Resources Information Center

Medlin, Shane A.

2016-01-01

American students in the 21st century are growing up with Internet accessible technology available at their fingertips. Considering this and the continued pressure to compete in a global society, The United States' Department of Education's National Education Technology Plan (NETP) (2010) calls for educators to leverage technology in order to…

In-Process Items on LCS.

ERIC Educational Resources Information Center

Russell, Thyra K.

Morris Library at Southern Illinois University computerized its technical processes using the Library Computer System (LCS), which was implemented in the library to streamline order processing by: (1) providing up-to-date online files to track in-process items; (2) encouraging quick, efficient accessing of information; (3) reducing manual files;…

Pedagogical Strategies for Human and Computer Tutoring.

ERIC Educational Resources Information Center

Reiser, Brian J.

The pedagogical strategies of human tutors in problem solving domains are described and the possibility of incorporating these techniques into computerized tutors is examined. GIL (Graphical Instruction in LISP), an intelligent tutoring system for LISP programming, is compared to human tutors teaching the same material in order to identify how the…

The Development of Two Self-Assessment Work Value Instruments.

ERIC Educational Resources Information Center

Boyle, John R.

In response to input from the employment and training community, the Department of Labor's Assessment and Research Development Program (ARDP) and its state partners have developed two self-assessment work value instruments to be incorporated into career exploration and counseling programs. Computerized multiple rank-order and paper-and-pencil…

Developmental Changes in Face Processing Skills.

ERIC Educational Resources Information Center

Mondloch, Catherine J.; Geldart, Sybil; Maurer, Daphne; Le Grand, Richard

2003-01-01

Two experiments examined the impact of slow development of processing differences among faces in the spacing among facial features (second-order relations). Computerized tasks involving various face-processing skills were used. Results of experiment with 6-, 8-, and 10-year-olds and with adults indicated that slow development of sensitivity to…

An automated library financial management system

NASA Technical Reports Server (NTRS)

Dueker, S.; Gustafson, L.

1977-01-01

A computerized library acquisition system developed for control of informational materials acquired at NASA Ames Research Center is described. The system monitors the acquisition of both library and individual researchers' orders and supplies detailed financial, statistical, and bibliographical information. Applicability for other libraries and the future availability of the program is discussed.

How Stakeholder Assessment of E-Prescribing Can Help Determine Incentives to Facilitate Management of Care: A Delphi Study.

PubMed

DeMuro, Paul R; Ash, Joan; Middleton, Blackford; Fletcher, Justin; Madison, Cecelia J

2017-11-01

Little research has been conducted on the quality, benefits, costs, and financial considerations associated with health information technology (HIT), particularly informatics technologies such as e-prescribing, from the perspective of all of its stakeholders. To (a) identify the stakeholders involved in e-prescribing and (b) identify and rank order the positives and negatives of e-prescribing from the perspective of stakeholders in order to create a framework for payers, integrated delivery systems, policymakers and legislators, and those who influence public policy to assist them in the development of incentives and payment mechanisms that result in the better management of care. The Delphi method was used to enlist a panel of experts in e-prescribing, informatics, and/or HIT who have published in the field. This panel was presented with the results of initial research and an online survey of questions that sought to prioritize the quality, benefit, cost, and financial effects of e-prescribing from the perspective of each stakeholder. Eleven experts completed the first survey, which contained a list of stakeholders and positives and negatives associated with e-prescribing. Nine of the 11 experts completed the second survey, and 7 experts completed the final survey. From the results of these 3 surveys, a framework was presented to 5 framework experts, who were representatives from payers, integrated delivery systems, policymakers and legislators, and those who influence public policy. These framework experts were interviewed regarding the usefulness of the framework from their perspectives. The experts added stakeholders and many positives and negatives to the initial list and rank ordered the positives and negatives of e-prescribing from the perspective of each stakeholder. The aggregate results were summarized by stakeholder category. The positives and negatives were categorized as health, finance, effort, time, management, or data concerns. The framework experts evaluated the framework and found it useful. Positives and negatives associated with e-prescribing in the areas of quality, benefits, costs, and financial considerations can be rank ordered from the perspective of each stakeholder. The experts agreed on some points but disagreed on others. For example, they agreed that the main negative of e-prescribing from the perspective of pharmacists and pharmacies was its implementation costs but differed on the importance of providing faster information transfer. A framework was created that could be successfully used by payers, integrated delivery systems, policymakers and legislators, and those who influence public policy for the development of incentives and payment mechanisms. This research was supported by the National Library of Medicine of the National Institutes of Health under Award Number T15LM007088. The authors declare no conflicts of interest in the research. Study concept and design were contributed by DeMuro, Ash, Middleton, and Fletcher. DeMuro took the lead in data collection, along with Ash, and data interpretation was performed by DeMuro, Ash, Madison, Middleton, and Fletcher. The manuscript was written primarily by DeMuro, along with Ash and Middleton, and revised by DeMuro, Madison, and Ash, along with Middleton and Fletcher.

Prototype simulates remote sensing spectral measurements on fruits and vegetables

NASA Astrophysics Data System (ADS)

Hahn, Federico

1998-09-01

A prototype was designed to simulate spectral packinghouse measurements in order to simplify fruit and vegetable damage assessment. A computerized spectrometer is used together with lenses and an externally controlled illumination in order to have a remote sensing simulator. A laser is introduced between the spectrometer and the lenses in order to mark the zone where the measurement is being taken. This facilitates further correlation work and can assure that the physical and remote sensing measurements are taken in the same place. Tomato ripening and mango anthracnose spectral signatures are shown.

Enabling medication management through health information technology (Health IT).

PubMed

McKibbon, K Ann; Lokker, Cynthia; Handler, Steve M; Dolovich, Lisa R; Holbrook, Anne M; O'Reilly, Daria; Tamblyn, Robyn; J Hemens, Brian; Basu, Runki; Troyan, Sue; Roshanov, Pavel S; Archer, Norman P; Raina, Parminder

2011-04-01

The objective of the report was to review the evidence on the impact of health information technology (IT) on all phases of the medication management process (prescribing and ordering, order communication, dispensing, administration and monitoring as well as education and reconciliation), to identify the gaps in the literature and to make recommendations for future research. We searched peer-reviewed electronic databases, grey literature, and performed hand searches. Databases searched included MEDLINE®, Embase, CINAHL (Cumulated Index to Nursing and Allied Health Literature), Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts, Compendex, Inspec (which includes IEEE Xplore), Library and Information Science Abstracts, E-Prints in Library and Information Science, PsycINFO, Sociological Abstracts, and Business Source Complete. Grey literature searching involved Internet searching, reviewing relevant Web sites, and searching electronic databases of grey literatures. AHRQ also provided all references in their e-Prescribing, bar coding, and CPOE knowledge libraries. Paired reviewers looked at citations to identify studies on a range of health IT used to assist in the medication management process (MMIT) during multiple levels of screening (titles and abstracts, full text and final review for assignment of questions and data abstrction). Randomized controlled trials and cohort, case-control, and case series studies were independently assessed for quality. All data were abstracted by one reviewer and examined by one of two different reviewers with content and methods expertise. 40,582 articles were retrieved. After duplicates were removed, 32,785 articles were screened at the title and abstract phase. 4,578 full text articles were assessed and 789 articles were included in the final report. Of these, 361 met only content criteria and were listed without further abstraction. The final report included data from 428 articles across the seven key questions. Study quality varied according to phase of medication management. Substantially more studies, and studies with stronger comparative methods, evaluated prescribing and monitoring. Clinical decision support systems (CDSS) and computerized provider order entry (CPOE) systems were studied more than any other application of MMIT. Physicians were more often the subject of evaluation than other participants. Other health care professionals, patients, and families are important but not studied as thoroughly as physicians. These nonphysicians groups often value different aspects of MMIT, have diverse needs, and use systems differently. Hospitals and ambulatory clinics were well-represented in the literature with less emphasis placed on long-term care facilities, communities, homes, and nonhospital pharmacies. Most studies evaluated changes in process and outcomes of use, usability, and knowledge, skills, and attitudes. Most showed moderate to substantial improvement with implementation of MMIT. Economics studies and those with clinical outcomes were less frequently studied. Those articles that did address economics and clinical outcomes often showed equivocal findings on the effectiveness and cost-effectiveness of MMIT systems. Qualitative studies provided evidence of strong perceptions, both positive and negative, of the effects of MMIT and unintended consequences. We found little data on the effects of forms of medications, conformity, standards, and open source status. Much descriptive literature discusses implementation issues but little strong evidence exists. Interest is strong in MMIT and more groups and institutions will implement systems in the next decades, especially with the Federal Government's push toward more health IT to support better and more cost-effective health care. MMIT is well-studied, although on closer examination of the literature the evidence is not uniform across phases of medication management, groups of people involved, or types of MMIT. MMIT holds the promise of improved processes; clinical and economics studies and the understanding of sustainability issues are lacking.

7 CFR 1216.46 - Procedure.

Code of Federal Regulations, 2010 CFR

2010-01-01

... AND ORDERS; MISCELLANEOUS COMMODITIES), DEPARTMENT OF AGRICULTURE PEANUT PROMOTION, RESEARCH, AND INFORMATION ORDER Peanut Promotion, Research, and Information Order National Peanut Board § 1216.46 Procedure... prescribed in this section by mail, facsimile, telephone, or any telecommunication method appropriate for the...

Management of acute gastroenteritis in healthy children in Lebanon - A national survey.

PubMed

Alameddine, Aouni; Mourad, Sawsan; Rifai, Nahida

2010-11-01

Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis. The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system. The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated. A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents. Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals.

PubMed

Chaves, N J; Cheng, A C; Runnegar, N; Kirschner, J; Lee, T; Buising, K

2014-06-01

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals. We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors. Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines. The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices. A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Patient, Physician and Organizational Influences on Variation in Antipsychotic Prescribing Behavior.

PubMed

Tang, Yan; Chang, Chung-Chou H; Lave, Judith R; Gellad, Walid F; Huskamp, Haiden A; Donohue, Julie M

2016-03-01

Physicians face the choice of multiple ingredients when prescribing drugs in many therapeutic categories. For conditions with considerable patient heterogeneity in treatment response, customizing treatment to individual patient needs and preferences may improve outcomes. To assess variation in the diversity of antipsychotic prescribing for mental health conditions, a necessary although not sufficient condition for personalizing treatment. To identify patient caseload, physician, and organizational factors associated with the diversity of antipsychotic prescribing. Using 2011 data from Pennsylvania's Medicaid program, IMS Health's HCOSTM database, and the AMA Masterfile, we identified 764 psychiatrists who prescribed antipsychotics to 10 patients. We constructed three physician-level measures of diversity/concentration of antipsychotic prescribing: number of ingredients prescribed, share of prescriptions for most preferred ingredient, and Herfindahl-Hirschman index (HHI). We used multiple membership linear mixed models to examine patient caseload, physician, and healthcare organizational predictors of physician concentration of antipsychotic prescribing. There was substantial variability in antipsychotic prescribing concentration among psychiatrists, with number of ingredients ranging from 2-17, share for most preferred ingredient from 16%-85%, and HHI from 1,088-7,270. On average, psychiatrist prescribing behavior was relatively diversified; however, 11% of psychiatrists wrote an average of 55% of their prescriptions for their most preferred ingredient. Female prescribers and those with smaller shares of disabled or serious mental illness patients had more concentrated prescribing behavior on average. Antipsychotic prescribing by individual psychiatrists in a large state Medicaid program varied substantially across psychiatrists. Our findings illustrate the importance of understanding physicians' prescribing behavior and indicate that even among specialties regularly prescribing a therapeutic category, some physicians rely heavily on a small number of agents. Health systems may need to offer educational interventions to clinicians in order to improve their ability to tailor treatment decisions to the needs of individual patients. Future studies should examine the impact of the diversity of antipsychotic prescribing to determine whether more diversified prescribing improves patient adherence and outcomes.

Hospital prescribing errors: epidemiological assessment of predictors

PubMed Central

Fijn, R; Van den Bemt, P M L A; Chow, M; De Blaey, C J; De Jong-Van den Berg, L T W; Brouwers, J R B J

2002-01-01

Aims To demonstrate an epidemiological method to assess predictors of prescribing errors. Methods A retrospective case-control study, comparing prescriptions with and without errors. Results Only prescriber and drug characteristics were associated with errors. Prescriber characteristics were medical specialty (e.g. orthopaedics: OR: 3.4, 95% CI 2.1, 5.4) and prescriber status (e.g. verbal orders transcribed by nursing staff: OR: 2.5, 95% CI 1.8, 3.6). Drug characteristics were dosage form (e.g. inhalation devices: OR: 4.1, 95% CI 2.6, 6.6), therapeutic area (e.g. gastrointestinal tract: OR: 1.7, 95% CI 1.2, 2.4) and continuation of preadmission treatment (Yes: OR: 1.7, 95% CI 1.3, 2.3). Conclusions Other hospitals could use our epidemiological framework to identify their own error predictors. Our findings suggest a focus on specific prescribers, dosage forms and therapeutic areas. We also found that prescriptions originating from general practitioners involved errors and therefore, these should be checked when patients are hospitalized. PMID:11874397

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 8 2014-10-01 2014-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY LAUNCH SERVICES Section 1 What this order does. This order prescribes the circumstances under which launch hire will be...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 8 2010-10-01 2010-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY LAUNCH SERVICES Section 1 What this order does. This order prescribes the circumstances under which launch hire will be...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 8 2013-10-01 2013-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY LAUNCH SERVICES Section 1 What this order does. This order prescribes the circumstances under which launch hire will be...

Online detection of potential duplicate medications and changes of physician behavior for outpatients visiting multiple hospitals using national health insurance smart cards in Taiwan.

PubMed

Hsu, Min-Huei; Yeh, Yu-Ting; Chen, Chien-Yuan; Liu, Chien-Hsiang; Liu, Chien-Tsai

2011-03-01

Doctor shopping (or hospital shopping), which means changing doctors (or hospitals) without professional referral for the same or similar illness conditions, is common in Hong Kong, Taiwan and Japan. Due to the lack of infrastructure for sharing health information and medication history among hospitals, doctor-shopping patients are more likely to receive duplicate medications and suffer adverse drug reactions. The Bureau of National Health Insurance (BNHI) adopted smart cards (or NHI-IC cards) as health cards in Taiwan. With their NHI-IC cards, patients can freely access different medical institutions. Because an NHI-IC card carries information about a patient's prescribed medications received from different hospitals nationwide, we used this system to address the problem of duplicate medications for outpatients visiting multiple hospitals. A computerized physician order entry (CPOE) system was enhanced with the capability of accessing NHI-IC cards and providing alerts to physicians when the system detects potential duplicate medications at the time of prescribing. Physician responses to the alerts were also collected to analyze changes in physicians' behavior. Chi-square tests and two-sided z-tests with Bonferroni adjustments for multiple comparisons were used to assess statistical significance of differences in actions taken by physicians over the three months. The enhanced CPOE system for outpatient services was implemented and installed at the Pediatric and Urology Departments of Taipei Medical University Wan-Fang Hospital in March 2007. The "Change Log" that recorded physician behavior was activated during a 3-month study period from April to June 2007. In 67.93% of patient visits, the physicians read patient NHI-IC cards, and in 16.76% of the reads, the NHI-IC card contained at least one prescribed medication that was taken by the patient. Among the prescriptions issued by physicians, on average, there were 2.36% prescriptions containing at least one medication that might be duplicative to the prior prescriptions stored in NHI-IC cards. The rate of potential duplicate medication alerts for the Pediatric Department was higher than that for the Urology Department (2.78% versus 1.67%). However, the rate of revisions to prescriptions was higher in the Urology Department than the Pediatric Department. Overall, the rate of physicians reviewing and revising their prescriptions was 29.25%; the rate of physicians reviewing without revising their prescriptions was 43.62%; the rate of physicians turning off the alert screens right after the screens popped up (overridden) was 27.13%. Thus, physicians accepted alerts to review their prescriptions with patients in most situations (72.87%). Moreover, over the study period, the rate of total revisions made to prescriptions increased and the "overridden" rate decreased. Our approach enhances the capability of CPOE systems using NHI-IC cards as a nationwide infrastructure to provide more complete patient health information and medication history sharing among hospitals in Taiwan. Thus, our system can provide a better prescribing tool to help physicians detect potential duplicate medications for frequent doctor-shopping patients and hence enhance patient safety across hospital boundaries. However, the effectiveness of detecting duplicate medications with our approach is very much dependent on the completeness of NHI-IC cards, which in turn primarily depends on physician use of the cards when prescribing. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Effectiveness of a computerized alert system based on re-testing intervals for limiting the inappropriateness of laboratory test requests.

PubMed

Lippi, Giuseppe; Brambilla, Marco; Bonelli, Patrizia; Aloe, Rosalia; Balestrino, Antonio; Nardelli, Anna; Ceda, Gian Paolo; Fabi, Massimo

2015-11-01

There is consolidated evidence that the burden of inappropriate laboratory test requests is very high, up to 70%. We describe here the function of a computerized alert system linked to the order entry, designed to limit the number of potentially inappropriate laboratory test requests. A computerized alert system based on re-testing intervals and entailing the generation of pop-up alerts when preset criteria of appropriateness for 15 laboratory tests were violated was implemented in two clinical wards of the University Hospital of Parma. The effectiveness of the system for limiting potentially inappropriate tests was monitored for 6months. Overall, 765/3539 (22%) test requests violated the preset criteria of appropriateness and generated the appearance of electronic alert. After alert appearance, 591 requests were annulled (17% of total tests requested and 77% of tests alerted, respectively). The total number of test requests violating the preset criteria of inappropriateness constantly decreased over time (26% in the first three months of implementation versus 17% in the following period; p<0.001). The total financial saving of test withdrawn was 3387 Euros (12.8% of the total test cost) throughout the study period. The results of this study suggest that a computerized alert system may be effective to limit the inappropriateness of laboratory test requests, generating significant economic saving and educating physicians to a more efficient use of laboratory resources. Copyright © 2015 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Development of helicopter attitude axes controlled hover flight without pilot assistance and vehicle crashes

NASA Astrophysics Data System (ADS)

Simon, Miguel

In this work, we show how to computerize a helicopter to fly attitude axes controlled hover flight without the assistance of a pilot and without ever crashing. We start by developing a helicopter research test bed system including all hardware, software, and means for testing and training the helicopter to fly by computer. We select a Remote Controlled helicopter with a 5 ft. diameter rotor and 2.2 hp engine. We equip the helicopter with a payload of sensors, computers, navigation and telemetry equipment, and batteries. We develop a differential GPS system with cm accuracy and a ground computerized navigation system for six degrees of freedom (6-DoF) free flight while tracking navigation commands. We design feedback control loops with yet-to-be-determined gains for the five control "knobs" available to a flying radio-controlled (RC) miniature helicopter: engine throttle, main rotor collective pitch, longitudinal cyclic pitch, lateral cyclic pitch, and tail rotor collective pitch. We develop helicopter flight equations using fundamental dynamics, helicopter momentum theory and blade element theory. The helicopter flight equations include helicopter rotor equations of motions, helicopter rotor forces and moments, helicopter trim equations, helicopter stability derivatives, and a coupled fuselage-rotor helicopter 6-DoF model. The helicopter simulation also includes helicopter engine control equations, a helicopter aerodynamic model, and finally helicopter stability and control equations. The derivation of a set of non-linear equations of motion for the main rotor is a contribution of this thesis work. We design and build two special test stands for training and testing the helicopter to fly attitude axes controlled hover flight, starting with one axis at a time and progressing to multiple axes. The first test stand is built for teaching and testing controlled flight of elevation and yaw (i.e., directional control). The second test stand is built for teaching and testing any one or combination of the following attitude axes controlled flight: (1) pitch, (2) roll and (3) yaw. The subsequent development of a novel method to decouple, stabilize and teach the helicopter hover flight is a primary contribution of this thesis. The novel method included the development of a non-linear modeling technique for linearizing the RPM state equation dynamics so that a simple but accurate transfer function is derivable between the "available torque of the engine" and RPM. Specifically, the main rotor and tail rotor torques are modeled accurately with a bias term plus a nonlinear term involving the product of RPM squared times the main rotor blade pitch angle raised to the three-halves power. Application of this non-linear modeling technique resulted in a simple, representative and accurate transfer function model of the open-loop plant for the entire helicopter system so that all the feedback control laws for autonomous flight purposes could be derived easily using classical control theory. This is one of the contributions of this dissertation work. After discussing the integration of hardware and software elements of our helicopter research test bed system, we perform a number of experiments and tests using the two specially built test stands. Feedback gains are derived for controlling the following: (1) engine throttle to maintain prescribed main rotor angular speed, (2) main rotor collective pitch to maintain constant elevation, (3) longitudinal cyclic pitch to maintain prescribed pitch angle, (4) lateral cyclic pitch to maintain prescribed roll angle, and (5) yaw axis to maintain prescribed compass direction. (Abstract shortened by UMI.)

Technical standing order : airborne supplemental navigation equipment using the global positioning system (GPS)

DOT National Transportation Integrated Search

2001-01-01

This technical standard order (TSO) prescribes the minimum performance standard that airborne supplemental area navigation equipment using the global positioning system (GPS) must meet in order to be identified with the applicable TSO marking. Airbor...

48 CFR 2452.216-75 - Unpriced task orders.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Unpriced task orders. 2452... 2452.216-75 Unpriced task orders. As prescribed in 2416.506-70(a), insert the following clause: Unpriced Task Orders (FEB 2006) (a) Prior to the issuance of a task order under this contract, it is...

Appropriateness of Antibiotic Prescribing in U. S. Children’s Hospitals: A National Point Prevalence Survey

PubMed Central

Tribble, Alison; Lee, Brian; Handy, Lori; Gerber, Jeffrey S; Hersh, Adam L; Kronman, Matthew; Terrill, Cindy; Newland, Jason

2017-01-01

Abstract Background Multiple studies estimate that inappropriate antibiotic prescribing ranges from 30–50% in hospitalized patients, but few have included pediatric patients. Pediatric studies characterizing inappropriate prescribing are needed to target and improve antimicrobial stewardship program (ASP) efforts. Methods Cross-sectional analysis of antimicrobial prescribing at 30 U.S. children’s hospitals. Participating hospitals were academic, tertiary care hospitals in the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative. Subjects were children 0–17 years with an active antibiotic order at 0800 on a single day during three consecutive calendar quarters (Q3 2016 – Q1 2017). Each hospital’s ASP used a standardized survey to collect data on antibiotic orders and evaluate appropriateness. Data were pooled from the three surveys. The primary outcome was the pooled estimate for the percentage of prescriptions classified as inappropriate. Secondary outcomes were pooled estimates for indication, reason for inappropriate use, and ASP review status for each antibiotic. Results Of 19,598 children hospitalized on survey days, 6,922 (35%) had ≥1 active antibiotic order. Median age of children receiving antibiotics was 3.7 years (0.5, 10.9). Figures 1 and 2 show the most common antibiotics and indications. Of all antibiotic orders, 1,514 (15%) were classified as inappropriate, and 19% of patients with antibiotic orders had at least one inappropriate order. The most common reasons for inappropriate use were bug-drug mismatch (26%), surgical prophylaxis > 24 hours (18%) and unnecessary duplicate therapy (12%). ASPs would not have routinely reviewed 50% of all inappropriate orders. An additional 22% of inappropriate orders were for antibiotics typically reviewed by ASPs, but were yet to be reviewed at the time of the survey. Conclusion Across 30 children’s hospitals, approximately 1 in 3 hospitalized children is receiving an antibiotic at any given time. Almost 20% of these children are receiving inappropriate therapy, and a substantial portion of inappropriate use is not captured by current ASP practices. Figures 1 and 2: Disclosures C. Terrill, Merck: Grant Investigator, Research grant; Allergan: Grant Investigator, Research grant; J. Newland, Merck: Grant Investigator, Research grant; Allergan: Grant Investigator, Research grant.

48 CFR 252.239-7004 - Orders for facilities and services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 3 2011-10-01 2011-10-01 false Orders for facilities and... of Provisions And Clauses 252.239-7004 Orders for facilities and services. As prescribed in 239.7411(a), use the following clause: Orders for Facilities and Services (NOV 2005) The Contractor shall...

48 CFR 2052.216-73 - Accelerated task order procedures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... the work, the contractor shall proceed with performance of the task order subject to the monetary... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Accelerated task order....216-73 Accelerated task order procedures. As prescribed at 2016.506-70(b), the contracting officer may...

48 CFR 252.217-7004 - Job orders and compensation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 3 2014-10-01 2014-10-01 false Job orders and... of Provisions And Clauses 252.217-7004 Job orders and compensation. As prescribed in 217.7104(a), use the following clause: Job Orders and Compensation (MAY 2006) (a) The Contracting Officer shall solicit...

48 CFR 252.217-7004 - Job orders and compensation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 3 2013-10-01 2013-10-01 false Job orders and... of Provisions And Clauses 252.217-7004 Job orders and compensation. As prescribed in 217.7104(a), use the following clause: Job Orders and Compensation (MAY 2006) (a) The Contracting Officer shall solicit...

48 CFR 252.217-7004 - Job orders and compensation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 3 2011-10-01 2011-10-01 false Job orders and... of Provisions And Clauses 252.217-7004 Job orders and compensation. As prescribed in 217.7104(a), use the following clause: JOB ORDERS AND COMPENSATION (MAY 2006) (a) The Contracting Officer shall solicit...

48 CFR 252.217-7004 - Job orders and compensation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 48 Federal Acquisition Regulations System 3 2012-10-01 2012-10-01 false Job orders and... of Provisions And Clauses 252.217-7004 Job orders and compensation. As prescribed in 217.7104(a), use the following clause: Job Orders and Compensation (MAY 2006) (a) The Contracting Officer shall solicit...

48 CFR 252.217-7004 - Job orders and compensation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 3 2010-10-01 2010-10-01 false Job orders and... of Provisions And Clauses 252.217-7004 Job orders and compensation. As prescribed in 217.7104(a), use the following clause: JOB ORDERS AND COMPENSATION (MAY 2006) (a) The Contracting Officer shall solicit...

48 CFR 52.243-6 - Change Order Accounting.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 2 2010-10-01 2010-10-01 false Change Order Accounting....243-6 Change Order Accounting. As prescribed in 43.205(f), the contracting officer may insert a clause, substantially the same as follows: Change Order Accounting (APR 1984) The Contracting Officer may require change...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 8 2010-10-01 2010-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY REPATRIATION OF SEAMEN Section 1 What this order does. This order prescribes the manner in which seamen separated from vessels...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 8 2014-10-01 2014-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY REPATRIATION OF SEAMEN Section 1 What this order does. This order prescribes the manner in which seamen separated from vessels...

46 CFR Section 1 - What this order does.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 8 2013-10-01 2013-10-01 false What this order does. Section 1 Section 1 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION A-NATIONAL SHIPPING AUTHORITY REPATRIATION OF SEAMEN Section 1 What this order does. This order prescribes the manner in which seamen separated from vessels...

Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment

PubMed Central

Gong, Cynthia L; Hay, Joel W; Meeker, Daniella; Doctor, Jason N

2016-01-01

Objective To elicit prescribers' preferences for behavioural economics interventions designed to reduce inappropriate antibiotic prescribing, and compare these to actual behaviour. Design Discrete choice experiment (DCE). Setting 47 primary care centres in Boston and Los Angeles. Participants 234 primary care providers, with an average 20 years of practice. Main outcomes and measures Results of a behavioural economic intervention trial were compared to prescribers' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes. In the randomised controlled trial (RCT) component, the 3 computerised prescription order entry-triggered interventions studied included: Suggested Alternatives (SA), an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed; Accountable Justifications (JA), which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient's chart; and Peer Comparison (PC), an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing. A DCE study component was administered to determine whether prescribers felt SA, JA, PC, pay-for-performance or additional clinic time would most effectively reduce their inappropriate antibiotic prescribing. Willingness-to-pay (WTP) was calculated for each intervention. Results In the RCT, PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing, whereas SA was not significantly different from controls. In the DCE however, regardless of treatment intervention received during the RCT, prescribers overwhelmingly preferred SA, followed by PC, then JA. WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $200/month. Conclusions Prescribing behaviour and stated preferences are not concordant, suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions. Trial registration number NCT01454947; Results. PMID:27660322

Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a survey on forces, conditions and jurisdictional control.

PubMed

Kroezen, Marieke; Francke, Anneke L; Groenewegen, Peter P; van Dijk, Liset

2012-08-01

The number of Western European and Anglo-Saxon countries where nurses are legally allowed to prescribe medicines is growing. As the prescribing of medicines has traditionally been the task of the medical profession, nurse prescribing is changing the relationship between the medical and nursing professions. To gain more insight into the forces that led to the introduction of nurse prescribing of medicines in Western European and Anglo-Saxon countries, as well as into the legal, educational and organizational conditions under which nurses prescribe in these countries. Moreover, this study sought to determine which consequences nurse prescribing has for the division of jurisdictional control over prescribing between the nursing and medical professions. International survey. An email survey was sent to 60 stakeholders of professional nursing or medical associations or government bodies, at national, state or provincial level across ten Western European and Anglo-Saxon countries, namely Australia, Canada, Finland, Ireland, the Netherlands, New Zealand, Spain, Sweden, the United Kingdom and the United States of America. The survey addressed the reasons for the introduction of nurse prescribing and the conditions under which nurses are or will be prescribing medicines. The response rate was 65% (n=39). It was shown that a diversity of forces led to the introduction of nurse prescribing, and respondents from nursing and medical associations and government bodies cited different forces as being important for the introduction of nurse prescribing. Representatives of nurses' associations oftentimes emphasized the medication needs of patients living in remote geographical areas, while representatives of medical associations more often pointed to workforce shortages within the health care service. The conditions under which nurses prescribe medicines vary considerably, from countries where nurses prescribe independently to countries in which prescribing by nurses is only allowed under strict conditions and the supervision of physicians. Citing different forces as being important in the introduction of nurse prescribing can be conceived as a professional 'problem construction' in order to gain jurisdiction over the prescribing task. In most countries, nurses prescribe in a subordinate position and the jurisdiction over prescribing remains predominantly with the medical profession. Copyright © 2012 Elsevier Ltd. All rights reserved.

[Requirements for the successful implementation of unity of care: study of a computer-assisted dispensation of pharmaceuticals].

PubMed

Lezin, B; Thouin, A; Besnehard, J; Lobbedez, T; Ollivier, C; Ryckelynck, J P

1999-08-01

Even though computerized workstations bring undisputed benefits in nursing units, introducing them is still hard when most of the staff members have to share the workstation. We took advantage of the implementation of the drug prescription software SAUPHIX in a nephrology department to better define the encountered difficulties. The workstation described in this paper is shared by physicians who enter their prescriptions (proprietary names, doses, routes of administration), nurses who use dosage schedules for drug administration, and the chemist who has authority to control prescription orders. Six months after the implementation of the workstation, physicians and nurses had to fill out an anonymous questionnaire aimed at assessing each function of the software. Prescriptions proved to be more accurate and legible, while management of drugs was more precise. However, interns complained that entering data was time consuming. Furthermore, they raised objections to control of prescription orders. Nurses criticized dosage schedules, the primary reason being that they had to change their practice. The convenience of notebooks was questioned by both physicians and nurses who would have preferred a greater number of desktop computers at their disposition. The implementation of a computerized workstation requires information, diplomacy and negotiations to obtain real implication of the staff. Tasks and schedules must be specified for everybody. The system has to be carefully customized, according to the requirement of the unit. Computers must be properly chosen and allocated in sufficient number. Finally, appropriate preparation, staff training and follow-up of the computerized system are essential.

Rhesus Monkeys (Macaca Mulatta) Maintain Learning Set Despite Second-Order Stimulus-Response Spatial Discontiguity

ERIC Educational Resources Information Center

Beran, Michael J.; Washburn, David A.; Rumbaugh, Duane M.

2007-01-01

In many discrimination-learning tests, spatial separation between stimuli and response loci disrupts performance in rhesus macaques. However, monkeys are unaffected by such stimulus-response spatial discontiguity when responses occur through joystick-based computerized movement of a cursor. To examine this discrepancy, five monkeys were tested on…

Conjoint analysis of nature tourism values in Bahia, Brazil

Treesearch

Thomas Holmes; Chris Zinkhan; Keith Alger; D. Evan Mercer

1996-01-01

This paper uses conjoint analysis to estimate the value of nature tourism attributes in a threatened forest ecosystem in northeastern Brazil. Computerized interviews were conducted using a paired comparison design. An ordinal interpretation of the rating scale was used and marginal utilities were estimated using ordered probit. The empirical results showed that the...

Word Lists and Languages. Technical Report No. 2.

ERIC Educational Resources Information Center

Grimes, Joseph E.

In order to store sociolinguistic information about the world's languages, Cornell University, The University of Oklahoma, and the Summer Institute of Linguistics formed a computerized data base. This report summarizes work done by that project. The first part of the report contains data on the languages of the world. The complete data base,…

Inside EUREKA. The California Career Information System.

ERIC Educational Resources Information Center

Banaghan, Bill; And Others

A computerized career information system named EUREKA has been developed for California. It originated in 1975-76 under the direction of the Bay Area Computer Educators and since that time has received state and VEA funding. It consists of two major components, Quest and information files. Quest asks users twenty-one questions in order to…

An inventory of publications on electronic medical records revisited.

PubMed

Moorman, P W; Schuemie, M J; van der Lei, J

2009-01-01

In this short review we provide an update of our earlier inventories of publications indexed in MedLine with the MeSH term 'Medical Records Systems, Computerized'. We retrieved and analyzed all references to English articles published before January 1, 2008, and indexed in PubMed with the MeSH term 'Medical Records Systems, Computerized'. We retrieved a total of 11,924 publications, of which 3937 (33%) appeared in a journal with an impact factor. Since 2002 the number of yearly publications, and the number of journals in which those publications appeared, increased. A cluster analysis revealed three clusters: an organizational issues cluster, a technically oriented cluster and a cluster about order-entry and research. Although our previous inventory in 2003 suggested a constant yearly production of publications on electronic medical records since 1998, the current inventory shows another rise in production since 2002. In addition, many new journals and countries have shown interest during the last five years. In the last 15 years, interest in organizational issues remained fairly constant, order entry and research with systems gained attention, while interest in technical issues relatively decreased.

Age influence on attitudes of office workers faced with new computerized technologies: a questionnaire analysis.

PubMed

Marquié, J C; Thon, B; Baracat, B

1994-06-01

The study of Bue and Gollac (1988) provided evidence that a significantly lower proportion of workers aged 45 years and over make use of computer technology compared with younger ones. The aim of the present survey was to explain this fact by a more intensive analysis of the older workers' attitude with respect to the computerization of work situations in relation to other individual and organizational factors. Six hundred and twenty office workers from 18 to 70 years old, either users or non-users of computerized devices, were asked to complete a questionnaire. The questions allowed the assessment of various aspects of the workers' current situation, such as the computer training they had received, the degree of consultation they were subjected to during the computerization process, their representation of the effects of these new technologies on working conditions and employment, the rate of use of new technologies outside the work context, and the perceived usefulness of computers for their own work. The analysis of the questionnaire revealed that as long as the step towards using computer tools, even minimally, has not been taken, then attitudes with respect to computerization are on the whole not very positive and are a source of anxiety for many workers. Age, and even more, seniority in the department, increase such negative representations. The effects of age and seniority were also found among users, as well as the effects of other factors such as qualification, education level, type and rate of computer use, and size of the firm. For the older workers, the expectation of less positive consequences for their career, or even the fear that computerization might be accompanied by threats to their own employment and the less clear knowledge of how computers operate, appeared to account for a significant part of the observed age and seniority differences in attitudes. Although the difference in the amount of computer training between age groups was smaller than expected, the study revealed that one third of the users never received any specific training, and that many of those who benefited from it were trained for only a few days. Consultation of the staff during the computerization process also appeared to be poor, to apply mostly to the best trained and qualified workers, and to be more highly developed in small companies. The results are discussed in the light of more qualitative data recorded during the survey. They suggest the need to increase information, training and involvement of all personnel from the very first stages of computerization (or other technical changes) in order to lessen fears and the feeling of disruption, which are particularly obvious among the oldest workers.

Opioid vs nonopioid prescribers: Variations in care for a standardized acute back pain case.

PubMed

Hanley, Kathleen; Zabar, Sondra; Altshuler, Lisa; Lee, Hillary; Ross, Jasmine; Rivera, Nicomedes; Marvilli, Christian; Gillespie, Colleen

2017-01-01

Opioid analgesics are effective and appropriate therapy for many types of acute pain. Epidemiologic evidence supports a direct relationship between increased opioid prescribing and increases in opioid use disorders and overdoses. To tailor our residency curriculum, we designed and fielded an unannounced standardized patient (USP) case involving a patient with acute back pain who is requesting Vicodin (5/325 mg). We describe residents' case management and examine whether their management decisions, including opioid prescribing, were related to their core clinical skills. Results are based on 50 (USP) visits with residents in 2 urban primary care clinics. Highly trained USPs portrayed a patient with acute lower back pain who was taking leftover Vicodin with effective pain relief but was running out. We describe how residents managed this case, using both USP report and chart review data, and compare summary clinical skills scores between those who prescribed Vicodin and those who did not. Of the 50 residents, 18 prescribed Vicodin (10-60 pills). Among those who did not prescribe (32/50), most (50%) prescribed ibuprofen. Eighty-three percent of the prescribers and 72% of nonprescribers ordered physical therapy (nonsignificant). Of the 18 prescribers, 13 documented checking the prescription monitoring database. Prescribers had significantly better communication scores than nonprescribers (relationship development: 80% vs. 58% well done, P = .029; patient education: 59% vs. 31% well done, P = .018). Assessment summary scores were also higher (60% vs. 46%) but not significantly (P = .060). Patient satisfaction and activation scores were higher in the prescribers than nonprescribers (71% vs. 39%, P = .004 and 48% vs. 26%, P = .034, respectively). Most Vicodin prescribers did not follow prescribing guidelines, and they demonstrated better communication and assessment skills than the nonprescribers. Results suggest the need to guide residents in using a systematic approach to prescribing opioids safely and to develop an acceptable alternative pain management plan when they decide against prescribing.

Implementation of a pharmacy automation system (robotics) to ensure medication safety at Norwalk hospital.

PubMed

Bepko, Robert J; Moore, John R; Coleman, John R

2009-01-01

This article reports an intervention to improve the quality and safety of hospital patient care by introducing the use of pharmacy robotics into the medication distribution process. Medication safety is vitally important. The integration of pharmacy robotics with computerized practitioner order entry and bedside medication bar coding produces a significant reduction in medication errors. The creation of a safe medication-from initial ordering to bedside administration-provides enormous benefits to patients, to health care providers, and to the organization as well.

Device for data-acquisition from transient signals: kinetic considerations

PubMed Central

Sampedro, A. Sanchez; Vives, S. Sagrado

1990-01-01

This paper reports on the evaluation and testing of a home-made device. Data-acquisition, treatment of transient signals and the hardware and software involved are discussed. Some practical aspects are developed in order to power the autonomy of procedures using the device. Kinetic and multi-signal calculations are considered in order to cover the actual tendencies in continuous-flow analysis. Somepractical advantages versus the use of classical chart recorders or commercial computerized-instrument devices are pointed out. PMID:18925275

Lagrangian particle method for compressible fluid dynamics

NASA Astrophysics Data System (ADS)

Samulyak, Roman; Wang, Xingyu; Chen, Hsin-Chiang

2018-06-01

A new Lagrangian particle method for solving Euler equations for compressible inviscid fluid or gas flows is proposed. Similar to smoothed particle hydrodynamics (SPH), the method represents fluid cells with Lagrangian particles and is suitable for the simulation of complex free surface/multiphase flows. The main contributions of our method, which is different from SPH in all other aspects, are (a) significant improvement of approximation of differential operators based on a polynomial fit via weighted least squares approximation and the convergence of prescribed order, (b) a second-order particle-based algorithm that reduces to the first-order upwind method at local extremal points, providing accuracy and long term stability, and (c) more accurate resolution of entropy discontinuities and states at free interfaces. While the method is consistent and convergent to a prescribed order, the conservation of momentum and energy is not exact and depends on the convergence order. The method is generalizable to coupled hyperbolic-elliptic systems. Numerical verification tests demonstrating the convergence order are presented as well as examples of complex multiphase flows.

Impact of generic substitution decision support on electronic prescribing behavior.

PubMed

Stenner, Shane P; Chen, Qingxia; Johnson, Kevin B

2010-01-01

To evaluate the impact of generic substitution decision support on electronic (e-) prescribing of generic medications. The authors analyzed retrospective outpatient e-prescribing data from an academic medical center and affiliated network for July 1, 2005-September 30, 2008 using an interrupted time-series design to assess the rate of generic prescribing before and after implementing generic substitution decision support. To assess background secular trends, e-prescribing was compared with a concurrent random sample of hand-generated prescriptions. Proportion of generic medications prescribed before and after the intervention, evaluated over time, and compared with a sample of prescriptions generated without e-prescribing. The proportion of generic medication prescriptions increased from 32.1% to 54.2% after the intervention (22.1% increase, 95% CI 21.9% to 22.3%), with no diminution in magnitude of improvement post-intervention. In the concurrent control group, increases in proportion of generic prescriptions (29.3% to 31.4% to 37.4% in the pre-intervention, post-intervention, and end-of-study periods, respectively) were not commensurate with the intervention. There was a larger change in generic prescribing rates among authorized prescribers (24.6%) than nurses (18.5%; adjusted OR 1.38, 95% CI 1.17 to 1.63). Two years after the intervention, the proportion of generic prescribing remained significantly higher for e-prescriptions (58.1%; 95% CI 57.5% to 58.7%) than for hand-generated prescriptions ordered at the same time (37.4%; 95% CI 34.9% to 39.9%) (p<0.0001). Generic prescribing increased significantly in every specialty. Implementation of generic substitution decision support was associated with dramatic and sustained improvements in the rate of outpatient generic e-prescribing across all specialties.

Impact of generic substitution decision support on electronic prescribing behavior

PubMed Central

Chen, Qingxia; Johnson, Kevin B

2010-01-01

Objective To evaluate the impact of generic substitution decision support on electronic (e-) prescribing of generic medications. Design The authors analyzed retrospective outpatient e-prescribing data from an academic medical center and affiliated network for July 1, 2005–September 30, 2008 using an interrupted time-series design to assess the rate of generic prescribing before and after implementing generic substitution decision support. To assess background secular trends, e-prescribing was compared with a concurrent random sample of hand-generated prescriptions. Measurements Proportion of generic medications prescribed before and after the intervention, evaluated over time, and compared with a sample of prescriptions generated without e-prescribing. Results The proportion of generic medication prescriptions increased from 32.1% to 54.2% after the intervention (22.1% increase, 95% CI 21.9% to 22.3%), with no diminution in magnitude of improvement post-intervention. In the concurrent control group, increases in proportion of generic prescriptions (29.3% to 31.4% to 37.4% in the pre-intervention, post-intervention, and end-of-study periods, respectively) were not commensurate with the intervention. There was a larger change in generic prescribing rates among authorized prescribers (24.6%) than nurses (18.5%; adjusted OR 1.38, 95% CI 1.17 to 1.63). Two years after the intervention, the proportion of generic prescribing remained significantly higher for e-prescriptions (58.1%; 95% CI 57.5% to 58.7%) than for hand-generated prescriptions ordered at the same time (37.4%; 95% CI 34.9% to 39.9%) (p<0.0001). Generic prescribing increased significantly in every specialty. Conclusion Implementation of generic substitution decision support was associated with dramatic and sustained improvements in the rate of outpatient generic e-prescribing across all specialties. PMID:20962131

Electronic Prescribing and Medication Management at a Residential Aged Care Facility: Uptake by General Practitioners and Qualitative Evaluation of the Benefits and Barriers.

PubMed

Elliott, Rohan A; Lee, Cik Yin; Hussainy, Safeera Y

2016-01-01

A cloud-based mobile electronic prescribing and medication management system (ePMMS), in which prescribers' orders directly populate residential aged care facility (RACF) medication administration records (MARs) and are communicated electronically to the RACF's pharmacy, may create efficiencies and improve patient safety when compared to the paper-based and hybrid paper-electronic medication management systems used in most Australian RACFs. Little is known about general-practitioners' (GPs'), nurses' and pharmacists' acceptance of, or experiences with, ePMMS. To explore the uptake of an ePMMS by GPs, and the experiences and perceptions of GPs, nurses and pharmacists, at a 90-bed RACF that tested a beta-version ePMMS. Retrospective audit to determine the proportion of medicines ordered by GPs via the ePMMS over a three-month period. Focus groups conducted three-to-four months after implementation: one with GPs (n=5), one with nurses (n=12); in-depth interview/survey of pharmacists (n=2). Qualitative data were analysed thematically. Three of seven GPs used the ePMMS to order medicines; 53/205(25.9%) medicines were ordered via the ePMMS by GPs. Two broad themes were identified: benefits of the ePMMS, and barriers/limitations. Benefits related to patient safety and workforce efficiency, and included GPs' ability to access and modify residents' MARs remotely, no need for nurses to fax orders to the pharmacy, and no need for pharmacy transcription of GPs' handwritten orders to create electronic MARs. Barriers and limitations related to inefficiency, low GP uptake and training/support, and included slower prescribing compared to written orders, the need for GP-signed paper copies of the MAR, lack of integration with GP clinic software, and low GP motivation to use the system, especially GPs with few patients at the RACF. GPs, nurses and pharmacists felt the ePMMS improved medication-safety and workforce-efficiency, however a number of barriers were identified that contributed to low GP-uptake and limited the benefits.

Validation of diabetes mellitus and hypertension diagnosis in computerized medical records in primary health care

PubMed Central

2011-01-01

Background Computerized Clinical Records, which are incorporated in primary health care practice, have great potential for research. In order to use this information, data quality and reliability must be assessed to prevent compromising the validity of the results. The aim of this study is to validate the diagnosis of hypertension and diabetes mellitus in the computerized clinical records of primary health care, taking the diagnosis criteria established in the most prominently used clinical guidelines as the gold standard against which what measure the sensitivity, specificity, and determine the predictive values. The gold standard for diabetes mellitus was the diagnostic criteria established in 2003 American Diabetes Association Consensus Statement for diabetic subjects. The gold standard for hypertension was the diagnostic criteria established in the Joint National Committee published in 2003. Methods A cross-sectional multicentre validation study of diabetes mellitus and hypertension diagnoses in computerized clinical records of primary health care was carried out. Diagnostic criteria from the most prominently clinical practice guidelines were considered for standard reference. Sensitivity, specificity, positive and negative predictive values, and global agreement (with kappa index), were calculated. Results were shown overall and stratified by sex and age groups. Results The agreement for diabetes mellitus with the reference standard as determined by the guideline was almost perfect (κ = 0.990), with a sensitivity of 99.53%, a specificity of 99.49%, a positive predictive value of 91.23% and a negative predictive value of 99.98%. Hypertension diagnosis showed substantial agreement with the reference standard as determined by the guideline (κ = 0.778), the sensitivity was 85.22%, the specificity 96.95%, the positive predictive value 85.24%, and the negative predictive value was 96.95%. Sensitivity results were worse in patients who also had diabetes and in those aged 70 years or over. Conclusions Our results substantiate the validity of using diagnoses of diabetes and hypertension found within the computerized clinical records for epidemiologic studies. PMID:22035202

Patient, Physician and Organizational Influences on Variation in Antipsychotic Prescribing Behavior

PubMed Central

Tang, Yan; Chang, Chung-Chou H.; Lave, Judith R.; Gellad, Walid F.; Huskamp, Haiden A.; Donohue, Julie M.

2016-01-01

Background Physicians face the choice of multiple ingredients when prescribing drugs in many therapeutic categories. For conditions with considerable patient heterogeneity in treatment response, customizing treatment to individual patient needs and preferences may improve outcomes. Aims of the Study To assess variation in the diversity of antipsychotic prescribing for mental health conditions, a necessary although not sufficient condition for personalizing treatment. To identify patient caseload, physician, and organizational factors associated with the diversity of antipsychotic prescribing. Methods Using 2011 data from Pennsylvania’s Medicaid program, IMS Health’s HCOS™ database, and the AMA Masterfile, we identified 764 psychiatrists who prescribed antipsychotics to ≥10 patients. We constructed three physician-level measures of diversity/concentration of antipsychotic prescribing: number of ingredients prescribed, share of prescriptions for most preferred ingredient, and Herfindahl-Hirschman index (HHI). We used multiple membership linear mixed models to examine patient caseload, physician, and healthcare organizational predictors of physician concentration of antipsychotic prescribing. Results There was substantial variability in antipsychotic prescribing concentration among psychiatrists, with number of ingredients ranging from 2-17, share for most preferred ingredient from 16%-85%, and HHI from 1,088-7,270. On average, psychiatrist prescribing behavior was relatively diversified; however, 11% of psychiatrists wrote an average of 55% of their prescriptions for their most preferred ingredient. Female prescribers and those with smaller shares of disabled or serious mental illness patients had more concentrated prescribing behavior on average. Discussion Antipsychotic prescribing by individual psychiatrists in a large state Medicaid program varied substantially across psychiatrists. Our findings illustrate the importance of understanding physicians’ prescribing behavior and indicate that even among specialties regularly prescribing a therapeutic category, some physicians rely heavily on a small number of agents. Implications for Health Policies, Health Care Provision and Use Health systems may need to offer educational interventions to clinicians in order to improve their ability to tailor treatment decisions to the needs of individual patients. Implications for Future Research Future studies should examine the impact of the diversity of antipsychotic prescribing to determine whether more diversified prescribing improves patient adherence and outcomes. PMID:27084793

The Effect of Automated Alerts on Provider Ordering Behavior in an Outpatient Setting

PubMed Central

Steele, Andrew W; Eisert, Sheri; Witter, Joel; Lyons, Pat; Jones, Michael A; Gabow, Patricia; Ortiz, Eduardo

2005-01-01

Background Computerized order entry systems have the potential to prevent medication errors and decrease adverse drug events with the use of clinical-decision support systems presenting alerts to providers. Despite the large volume of medications prescribed in the outpatient setting, few studies have assessed the impact of automated alerts on medication errors related to drug–laboratory interactions in an outpatient primary-care setting. Methods and Findings A primary-care clinic in an integrated safety net institution was the setting for the study. In collaboration with commercial information technology vendors, rules were developed to address a set of drug–laboratory interactions. All patients seen in the clinic during the study period were eligible for the intervention. As providers ordered medications on a computer, an alert was displayed if a relevant drug–laboratory interaction existed. Comparisons were made between baseline and postintervention time periods. Provider ordering behavior was monitored focusing on the number of medication orders not completed and the number of rule-associated laboratory test orders initiated after alert display. Adverse drug events were assessed by doing a random sample of chart reviews using the Naranjo scoring scale. The rule processed 16,291 times during the study period on all possible medication orders: 7,017 during the pre-intervention period and 9,274 during the postintervention period. During the postintervention period, an alert was displayed for 11.8% (1,093 out of 9,274) of the times the rule processed, with 5.6% for only “missing laboratory values,” 6.0% for only “abnormal laboratory values,” and 0.2% for both types of alerts. Focusing on 18 high-volume and high-risk medications revealed a significant increase in the percentage of time the provider stopped the ordering process and did not complete the medication order when an alert for an abnormal rule-associated laboratory result was displayed (5.6% vs. 10.9%, p = 0.03, Generalized Estimating Equations test). The provider also increased ordering of the rule-associated laboratory test when an alert was displayed (39% at baseline vs. 51% during post intervention, p < 0.001). There was a non-statistically significant difference towards less “definite” or “probable” adverse drug events defined by Naranjo scoring (10.3% at baseline vs. 4.3% during postintervention, p = 0.23). Conclusion Providers will adhere to alerts and will use this information to improve patient care. Specifically, in response to drug–laboratory interaction alerts, providers will significantly increase the ordering of appropriate laboratory tests. There may be a concomitant change in adverse drug events that would require a larger study to confirm. Implementation of rules technology to prevent medication errors could be an effective tool for reducing medication errors in an outpatient setting. PMID:16128621

Comparative study of smile analysis by subjective and computerized methods.

PubMed

Basting, Roberta Tarkany; da Trindade, Rita de Cássia Silva; Flório, Flávia Martão

2006-01-01

This study compared: 1) the subjective analyses of a smile done by specialists with advanced training and by general dentists; 2) the subjective analysis of a smile, or that associated with the face, by specialists with advanced training and general dentists; 3) subjective analysis using a computerized analysis of the smile by specialists with advanced training, verifying the midline, labial line, smile line, the line between commissures and the golden proportion. The sample consisted of 100 adults with natural dentition; 200 photographs were taken (100 of the smile and 100 of the entire face). Computerized analysis using AutoCAD software was performed, together with the subjective analyses of 2 groups of professionals (3 general dentists and 3 specialists with advanced training), using the following assessment factors: the midline, labial line, smile line, line between the commissures and the golden proportion. The smile itself and the smile associated with the entire face were recorded as being agreeable or not agreeable by the professionals. The McNemar test showed a highly significant difference (p=0.0000) among the subjective analyses performed by specialists compared to general dentists. Between the 2 groups of dental professionals, there were highly significant differences (p=0.0000) found between the subjective analyses of the smile and that of the face. The McNemar test showed statistical differences in all factors assessed, with the exception of the midline (p=0.1951), when the computerized analysis and subjective analysis of the specialists were compared. In order to establish harmony of the smile, it was not possible to establish a greater or lesser relevance among the factors analyzed.

45 CFR 307.11 - Functional requirements for computerized support enforcement systems in operation by October 1...

Code of Federal Regulations, 2014 CFR

2014-10-01

... (2) The capability to perform the following tasks with the frequency and in the manner required under... business days after receipt of notice of income, and the income source subject to withholding from a court... orders through an automated information network in meeting paragraph (e)(2)(ii) of this section provided...

An Evaluation of Results and Effectiveness of Job Banks: Volume I, Parts I and II.

ERIC Educational Resources Information Center

Ultrasystems, Inc., Irvine, CA.

In order to assist the Manpower Administration of the U. S. Department of Labor in the planning, development, and expansion of over a hundred computerized "job banks," located in nearly every State, field interviews were conducted with job applicants, employers, Employment Service staff, and community agencies to evaluate the current…

Mood Assessment via Animated Characters: A Novel Instrument to Evaluate Feelings in Young Children with Anxiety Disorders

ERIC Educational Resources Information Center

Manassis, Katharina; Mendlowitz, Sandra; Kreindler, David; Lumsden, Charles; Sharpe, Jason; Simon, Mark D.; Woolridge, Nicholas; Monga, Suneeta; Adler-Nevo, Gili

2009-01-01

We evaluated a novel, computerized feelings assessment instrument (MAAC) in 54 children with anxiety disorders and 35 nonanxious children ages 5 to 11. They rated their feelings relative to 16 feeling animations. Ratings of feelings, order of feeling selection, and correlations with standardized anxiety measures were examined. Positive emotions…

45 CFR 307.11 - Functional requirements for computerized support enforcement systems in operation by October 1...

Code of Federal Regulations, 2010 CFR

2010-10-01

...; (ii) Social security numbers; (iii) Dates of birth; (iv) Case identification numbers; (v) Other... collected amounts; (v) The birth date and, beginning no later than October 1, 1999, the name and social... orders through an automated information network in meeting paragraph (e)(2)(ii) of this section provided...

12 CFR 978.8 - Computer data.

Code of Federal Regulations, 2010 CFR

2010-01-01

... security of the computerized data stored in a Bank's computer and restrict access to such data in order to... 12 Banks and Banking 7 2010-01-01 2010-01-01 false Computer data. 978.8 Section 978.8 Banks and... REQUESTS FOR INFORMATION § 978.8 Computer data. Nothing in this part shall preclude a Bank from arranging...

12 CFR 978.8 - Computer data.

Code of Federal Regulations, 2011 CFR

2011-01-01

... security of the computerized data stored in a Bank's computer and restrict access to such data in order to... 12 Banks and Banking 7 2011-01-01 2011-01-01 false Computer data. 978.8 Section 978.8 Banks and... REQUESTS FOR INFORMATION § 978.8 Computer data. Nothing in this part shall preclude a Bank from arranging...

12 CFR 978.8 - Computer data.

Code of Federal Regulations, 2013 CFR

2013-01-01

... security of the computerized data stored in a Bank's computer and restrict access to such data in order to... 12 Banks and Banking 8 2013-01-01 2013-01-01 false Computer data. 978.8 Section 978.8 Banks and... REQUESTS FOR INFORMATION § 978.8 Computer data. Nothing in this part shall preclude a Bank from arranging...

12 CFR 978.8 - Computer data.

Code of Federal Regulations, 2012 CFR

2012-01-01

... security of the computerized data stored in a Bank's computer and restrict access to such data in order to... 12 Banks and Banking 8 2012-01-01 2012-01-01 false Computer data. 978.8 Section 978.8 Banks and... REQUESTS FOR INFORMATION § 978.8 Computer data. Nothing in this part shall preclude a Bank from arranging...

29 CFR 1205.3 - General Order No. 1.

Code of Federal Regulations, 2010 CFR

2010-07-01

... order prescribes that such notices are to be standard as to contents, dimensions of sheet, and size of... may be necessary to make them accessible to all employees. Such notices must not be hidden by other...

Classification of medication incidents associated with information technology.

PubMed

Cheung, Ka-Chun; van der Veen, Willem; Bouvy, Marcel L; Wensing, Michel; van den Bemt, Patricia M L A; de Smet, Peter A G M

2014-02-01

Information technology (IT) plays a pivotal role in improving patient safety, but can also cause new problems for patient safety. This study analyzed the nature and consequences of a large sample of IT-related medication incidents, as reported by healthcare professionals in community pharmacies and hospitals. The medication incidents submitted to the Dutch central medication incidents registration (CMR) reporting system were analyzed from the perspective of the healthcare professional with the Magrabi classification. During classification new terms were added, if necessary. The principal source of the IT-related problem, nature of error. Additional measures: consequences of incidents, IT systems, phases of the medication process. From March 2010 to February 2011 the CMR received 4161 incidents: 1643 (39.5%) from community pharmacies and 2518 (60.5%) from hospitals. Eventually one of six incidents (16.1%, n=668) were related to IT; in community pharmacies more incidents (21.5%, n=351) were related to IT than in hospitals (12.6%, n=317). In community pharmacies 41.0% (n=150) of the incidents were about choosing the wrong medicine. Most of the erroneous exchanges were associated with confusion of medicine names and poor design of screens. In hospitals 55.3% (n=187) of incidents concerned human-machine interaction-related input during the use of computerized prescriber order entry. These use problems were also a major problem in pharmacy information systems outside the hospital. A large sample of incidents shows that many of the incidents are related to IT, both in community pharmacies and hospitals. The interaction between human and machine plays a pivotal role in IT incidents in both settings.

Short-term effects of prescribed fire on mixed oak forests in the southern Appalachians: vegetation response

Treesearch

Katherine Elliott; James Vose

2010-01-01

We examined vegetation responses to prescribed fire on three mixed-oak sites located in the Blue Ridge Physiographic province of the southern Appalachian Mountains: Alarka Laurel Branch (AL), Robin Branch (RB), and Roach Mill Branch (RM). Each of the study sites was within a sub-watershed that drained a first order stream. Our objectives were to: 1) evaluate overstory...

The lexeme hypotheses: Their use to generate highly grammatical and completely computerized medical records.

PubMed

Macfarlane, Donald

2016-07-01

Medical records often contain free text created by harried clinicians. Free text often contains errors which make it an unsuitable target for computerized data extraction. The cost of healthcare can be reduced by creating medical records that are fully computerized at their inception. We examine hypotheses that enable us to construct such records. We regard the text of the medical record as being an ordered collection of meaningful fragments. The intellectual content (or "lexeme") of each text fragment in the record is considered separately from the language that used to express it. We further consider that each lexeme exists as a combination of a lexeme query (defining the issue being addressed) and a lexeme response to that query. The medical record can then be perceived as a stream of these responses. The responses can be expressed in any style or language, including computer code. Examining medical records in this light gives rise to a number of observations and hypotheses. The physical location and nature of the medical episode (which we term "context") determines the general layout of the record. The order that lexeme-queries are addressed in within the record is highly consistent ("coherence"). Issues are only addressed if they are logically called-for by the context or by a previously-selected lexeme response ("predicance"), and only to a needed depth of detail ("level"). We hypothesize that all of the lexeme queries required to write any clinical notes can be stored in a large database ("lexicon") in coherence order, wherein each lexeme query is associated with its own collection of lexeme responses. We hypothesize that the issue a note-writer will need to address next is identifiable purely by using the rules of coherence, level and predicance. We have tested these hypotheses with a computer program which repeatedly offers the user a menu of lexeme responses with associated text. On selection, the program issues the text fragment, and its corresponding computer code, to output files. The program then uses coherence, predicance and level to navigate to the next appropriate lexeme query for presentation to the user. The net result is that the user creates a grammatically correct and completely computerized note at the time of its inception. The value of this approach and its practical implementation to create medical records are discussed. In our work so far, the hypotheses appear not to be false, but further testing is needed using a larger lexicon to establish their robustness in actual clinical practice. Copyright © 2016 Elsevier Ltd. All rights reserved.

48 CFR 252.251-7000 - Ordering from Government supply sources.

Code of Federal Regulations, 2011 CFR

2011-10-01

... use without approval of the Contractor. (e) Government invoices shall be submitted to the Contractor's... 48 Federal Acquisition Regulations System 3 2011-10-01 2011-10-01 false Ordering from Government... CLAUSES Text of Provisions And Clauses 252.251-7000 Ordering from Government supply sources. As prescribed...

48 CFR 552.216-71 - Economic Price Adjustment-Special Order Program Contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 4 2010-10-01 2010-10-01 false Economic Price Adjustment... Provisions and Clauses 552.216-71 Economic Price Adjustment—Special Order Program Contracts. As prescribed in 516.203-4(a), insert the following clause: Economic Price Adjustment—Special Order Program Contracts...

48 CFR 552.216-71 - Economic Price Adjustment-Special Order Program Contracts.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 4 2011-10-01 2011-10-01 false Economic Price Adjustment... Provisions and Clauses 552.216-71 Economic Price Adjustment—Special Order Program Contracts. As prescribed in 516.203-4(a), insert the following clause: Economic Price Adjustment—Special Order Program Contracts...

48 CFR 552.216-71 - Economic Price Adjustment-Special Order Program Contracts.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 4 2014-10-01 2014-10-01 false Economic Price Adjustment... Provisions and Clauses 552.216-71 Economic Price Adjustment—Special Order Program Contracts. As prescribed in 516.203-4(a), insert the following clause: Economic Price Adjustment—Special Order Program Contracts...

48 CFR 552.216-71 - Economic Price Adjustment-Special Order Program Contracts.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 4 2013-10-01 2013-10-01 false Economic Price Adjustment... Provisions and Clauses 552.216-71 Economic Price Adjustment—Special Order Program Contracts. As prescribed in 516.203-4(a), insert the following clause: Economic Price Adjustment—Special Order Program Contracts...

48 CFR 552.216-71 - Economic Price Adjustment-Special Order Program Contracts.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 48 Federal Acquisition Regulations System 4 2012-10-01 2012-10-01 false Economic Price Adjustment... Provisions and Clauses 552.216-71 Economic Price Adjustment—Special Order Program Contracts. As prescribed in 516.203-4(a), insert the following clause: Economic Price Adjustment—Special Order Program Contracts...

TRICARE program; clarification of benefit coverage of durable equipment and ordering or prescribing durable equipment; clarification of benefit coverage of assistive technology devises under the Extended Care Health Option Program. Final rule.

PubMed

2014-12-31

This final rule modifies the TRICARE regulation to add a definition of assistive technology (AT) devices for purposes of benefit coverage under the TRICARE Extended Care Health Option (ECHO) Program and to amend the definitions of durable equipment (DE) and durable medical equipment (DME) to better conform the language in the regulation to the statute. The final rule amends the language that specifically limits ordering or prescribing of DME to only a physician under the Basic Program, as this amendment will allow certain other TRICARE authorized individual professional providers, acting within the scope of their licensure, to order or prescribe DME. This final rule also incorporates a policy clarification relating to luxury, deluxe, or immaterial features of equipment or devices. That is, TRICARE cannot reimburse for the luxury, deluxe, or immaterial features of equipment or devices, but can reimburse for the base or basic equipment or device that meet the beneficiary's needs. Beneficiaries may choose to pay the provider for the luxury, deluxe, or immaterial features if they desire their equipment or device to have these "extra features."

Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan

PubMed Central

Liu, Pang-Hsiang; Wang, Jung-Der

2008-01-01

Background Knowledge of existing prescription patterns in the treatment of newly-diagnosed hypertension can provide useful information for improving clinical practice in this field. The aims of this study are to determine the prescription patterns and time trends for antihypertensive medication in newly-diagnosed cases of uncomplicated hypertension in Taiwan and to compare these with current clinical guidelines. Methods A total of 6,536 newly-diagnosed patients with uncomplicated hypertension, aged ≥30 years, were identified from the representative 200,000-person sample in the computerized reimbursement database of the National Health Insurance in Taiwan. These patients were followed from 1998 to 2004 with all diagnoses, prescription data and medication charges being retrieved for subsequent analysis. Results Prescription patterns varied by age, gender and clinical facilities, with mono-therapies being found to be dominant in the first year, albeit declining over time. Calcium channel blockers and beta-blockers were the most frequently prescribed antihypertensive drugs, either alone or in combinations. Although least expensive, the prescription rates of diuretics were low, at 8.3% for mono-therapies and 19.9% overall. The prescription rate for angiotensin receptor blockers (ARBs) was elevated considerably over time. After controlling for other related factors by multiple logistic regression analysis, ARBs were found to be prescribed mainly by medical centers or regional hospitals. Conclusion These findings indicate the existence of a gap between current clinical practice and the desired goal of cost-effectiveness in antihypertensive treatment in Taiwan, which should be corrected. PMID:18559115

Antihypertensive medication prescription patterns and time trends for newly-diagnosed uncomplicated hypertension patients in Taiwan.

PubMed

Liu, Pang-Hsiang; Wang, Jung-Der

2008-06-18

Knowledge of existing prescription patterns in the treatment of newly-diagnosed hypertension can provide useful information for improving clinical practice in this field. The aims of this study are to determine the prescription patterns and time trends for antihypertensive medication in newly-diagnosed cases of uncomplicated hypertension in Taiwan and to compare these with current clinical guidelines. A total of 6,536 newly-diagnosed patients with uncomplicated hypertension, aged >/=30 years, were identified from the representative 200,000-person sample in the computerized reimbursement database of the National Health Insurance in Taiwan. These patients were followed from 1998 to 2004 with all diagnoses, prescription data and medication charges being retrieved for subsequent analysis. Prescription patterns varied by age, gender and clinical facilities, with mono-therapies being found to be dominant in the first year, albeit declining over time. Calcium channel blockers and beta-blockers were the most frequently prescribed antihypertensive drugs, either alone or in combinations. Although least expensive, the prescription rates of diuretics were low, at 8.3% for mono-therapies and 19.9% overall. The prescription rate for angiotensin receptor blockers (ARBs) was elevated considerably over time. After controlling for other related factors by multiple logistic regression analysis, ARBs were found to be prescribed mainly by medical centers or regional hospitals. These findings indicate the existence of a gap between current clinical practice and the desired goal of cost-effectiveness in antihypertensive treatment in Taiwan, which should be corrected.

Impact of a stance phase microprocessor-controlled knee prosthesis on level walking in lower functioning individuals with a transfemoral amputation.

PubMed

Eberly, Valerie J; Mulroy, Sara J; Gronley, JoAnne K; Perry, Jacquelin; Yule, William J; Burnfield, Judith M

2014-12-01

For individuals with transfemoral amputation, walking with a prosthesis presents challenges to stability and increases the demand on the hip of the prosthetic limb. Increasing age or comorbidities magnify these challenges. Computerized prosthetic knee joints improve stability and efficiency of gait, but are seldom prescribed for less physically capable walkers who may benefit from them. To compare level walking function while wearing a microprocessor-controlled knee (C-Leg Compact) prosthesis to a traditionally prescribed non-microprocessor-controlled knee prosthesis for Medicare Functional Classification Level K-2 walkers. Crossover. Stride characteristics, kinematics, kinetics, and electromyographic activity were recorded in 10 participants while walking with non-microprocessor-controlled knee and Compact prostheses. Walking with the Compact produced significant increase in velocity, cadence, stride length, single-limb support, and heel-rise timing compared to walking with the non-microprocessor-controlled knee prosthesis. Hip and thigh extension during late stance improved bilaterally. Ankle dorsiflexion, knee extension, and hip flexion moments of the prosthetic limb were significantly improved. Improvements in walking function and stability on the prosthetic limb were demonstrated by the K-2 level walkers when using the C-Leg Compact prosthesis. Understanding the impact of new prosthetic designs on gait mechanics is essential to improve prescription guidelines for deconditioned or older persons with transfemoral amputation. Prosthetic designs that improve stability for safety and walking function have the potential to improve community participation and quality of life. © The International Society for Prosthetics and Orthotics 2013.

Adherence to diagnostic guidelines and quality indicators in asthma and COPD in Swedish primary care.

PubMed

Weidinger, Paolina; Nilsson, J Lars G; Lindblad, Ulf

2009-05-01

To study the clinical evaluation and treatment of patients with asthma and COPD in primary care in Sweden, with a focus on adherence to recommended guidelines and quality indicators. All visits at health care centres in Skaraborg, Sweden, are documented in computerized medical records constituting the Skaraborg Primary Care Database (SPCD). In a register-based retrospective observational study, all patients diagnosed with asthma or COPD during 2000-2005 (n = 12,328) were identified. In a 5% random sample (n = 623), information on performed investigations at initial visits and at follow-up during 2004-2005 was collected. Compliance with procedures as recommended by national guidelines was used for quality assessment. Among 499 patients with asthma, 167 (33%) were investigated with spirometry or Peak Expiratory Flow (PEF) during initial visits in agreement with guidelines. Correspondingly, 40 out of 124 patients with COPD (32%) were investigated with spirometry. During follow-up, evaluation in agreement with guidelines was performed in 130 (60%) of patients with asthma and in 35 patients out of 77 (45%) with COPD. Prescribing of ICS reached quality target, still every second patient made an acute visit during follow-up. Adherence to recommended guidelines in asthma/COPD was low. Acute visits were common and despite the prescribing of ICS according to recommendations, patients still seem uncontrolled in their disease. There is a need for quality improvement in the clinical evaluation and treatment of patients with asthma and COPD.

Utility of routinely acquired primary care data for paediatric disease epidemiology and pharmacoepidemiology

PubMed Central

Helms, Peter J; Daukes, Suzie Ekins; Taylor, Michael W; Simpson, Colin R; McLay, James S

2005-01-01

Background The majority of medicines prescribed for children are prescribed in primary care for common acute and chronic conditions. This is in contrast to prescribing in secondary care where the population of children admitted is small but where a large number of different medicines are prescribed to treat more serious and less common conditions. Methods Data on prescribing was extracted from the General Practice Administration System for Scotland (GPASS) for the year November 1999 to October 2000 and prescribing patterns for children aged 0–16 years expressed as percentages. A comparison of age specific consultations for asthma, as an example of a common paediatric condition, was also made between two separate general practice data sets, the General Practice Research Database (GRPD) and the continuous morbidity recording (CMR) subset of GPASS. Results Of 214 medicines investigated for unlicensed and off-label prescribing no unlicensed prescribing was identified. Off-label prescribing due to age was most common among younger and older children. The most common reasons for off-label prescriptions were, in order of frequency, lower than recommended dose, higher than recommended dose, below the recommended age, and unlicensed formulation. Age and gender specific consultations for asthma were similar in the two representative databases, GPRD and CMR, both showing disappearance of the male predominance in the teenage years. Conclusions Large primary care data sets available within a unified health care system such as the UK National Health Service (NHS) are likely to be broadly compatible and produce similar results. The prescribing of off-label medicines to children is common in primary care, most commonly due to prescribing out with the recommended dosage regimen. PMID:15948933

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.

PubMed

Nanji, Karen C; Rothschild, Jeffrey M; Boehne, Jennifer J; Keohane, Carol A; Ash, Joan S; Poon, Eric G

2014-01-01

Electronic prescribing systems have often been promoted as a tool for reducing medication errors and adverse drug events. Recent evidence has revealed that adoption of electronic prescribing systems can lead to unintended consequences such as the introduction of new errors. The purpose of this study is to identify and characterize the unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in an outpatient pharmacy. A multidisciplinary team conducted direct observations of workflow in an independent pharmacy and semi-structured interviews with pharmacy staff members about their perceptions of the unrealized potential and residual consequences of electronic prescribing systems. We used qualitative methods to iteratively analyze text data using a grounded theory approach, and derive a list of major themes and subthemes related to the unrealized potential and residual consequences of electronic prescribing. We identified the following five themes: Communication, workflow disruption, cost, technology, and opportunity for new errors. These contained 26 unique subthemes representing different facets of our observations and the pharmacy staff's perceptions of the unrealized potential and residual consequences of electronic prescribing. We offer targeted solutions to improve electronic prescribing systems by addressing the unrealized potential and residual consequences that we identified. These recommendations may be applied not only to improve staff perceptions of electronic prescribing systems but also to improve the design and/or selection of these systems in order to optimize communication and workflow within pharmacies while minimizing both cost and the potential for the introduction of new errors.

A qualitative study of GPs' and PCO stakeholders' views on the importance and influence of cost on prescribing.

PubMed

Prosser, Helen; Walley, Tom

2005-03-01

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders. The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs' resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

48 CFR 52.242-15 - Stop-Work Order.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 2 2010-10-01 2010-10-01 false Stop-Work Order. 52.242-15... Stop-Work Order. As prescribed in 42.1305(b), insert the following clause. The 90-day period stated in the clause may be reduced to less than 90 days. Stop-Work Order (AUG 1989) (a) The Contracting Officer...

48 CFR 52.242-15 - Stop-Work Order.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 2 2011-10-01 2011-10-01 false Stop-Work Order. 52.242-15... Stop-Work Order. As prescribed in 42.1305(b), insert the following clause. The 90-day period stated in the clause may be reduced to less than 90 days. Stop-Work Order (AUG 1989) (a) The Contracting Officer...

11 CFR 9033.12 - Production of computerized information.

Code of Federal Regulations, 2011 CFR

2011-01-01

... magnetic media, such as magnetic tapes or magnetic diskettes, containing the computerized information at.... The computerized magnetic media shall be prepared and delivered at the committee's expense and shall... Commission's Computerized Magnetic Media Requirements for title 26 Candidates/Committees Receiving Federal...

Prescribed burning impact on forest soil properties--a Fuzzy Boolean Nets approach.

PubMed

Castro, Ana C Meira; Paulo Carvalho, Joao; Ribeiro, S

2011-02-01

The Portuguese northern forests are often and severely affected by wildfires during the Summer season. These occurrences significantly affect and negatively impact all ecosystems, namely soil, fauna and flora. In order to reduce the occurrences of natural wildfires, some measures to control the availability of fuel mass are regularly implemented. Those preventive actions concern mainly prescribed burnings and vegetation pruning. This work reports on the impact of a prescribed burning on several forest soil properties, namely pH, soil moisture, organic matter content and iron content, by monitoring the soil self-recovery capabilities during a one year span. The experiments were carried out in soil cover over a natural site of Andaluzitic schist, in Gramelas, Caminha, Portugal, which was kept intact from prescribed burnings during a period of four years. Soil samples were collected from five plots at three different layers (0-3, 3-6 and 6-18) 1 day before prescribed fire and at regular intervals after the prescribed fire. This paper presents an approach where Fuzzy Boolean Nets (FBN) and Fuzzy reasoning are used to extract qualitative knowledge regarding the effect of prescribed fire burning on soil properties. FBN were chosen due to the scarcity on available quantitative data. The results showed that soil properties were affected by prescribed burning practice and were unable to recover their initial values after one year. Copyright © 2010 Elsevier Inc. All rights reserved.

Prescribing exercise for older adults: A needs assessment comparing primary care physicians, nurse practitioners, and physician assistants.

PubMed

Dauenhauer, Jason A; Podgorski, Carol A; Karuza, Jurgis

2006-01-01

To inform the development of educational programming designed to teach providers appropriate methods of exercise prescription for older adults, the authors conducted a survey of 177 physicians, physician assistants, and nurse practitioners (39% response rate). The survey was designed to better understand the prevalence of exercise prescriptions, attitudes, barriers, and educational needs of primary care practitioners toward older adults. Forty-seven percent of primary care providers report not prescribing exercise for older adults; 85% of the sample report having no formal training in exercise prescription. Practitioner attitudes were positive toward exercise, but were not predictive of their exercise prescribing behavior, which indicates that education efforts aimed at changing attitudes as a way of increasing exercise-prescribing behaviors would not be sufficient. In order to facilitate and reinforce practice changes to increase exercise-prescribing behaviors of primary care providers, results suggest the need for specific skill training on how to write an exercise prescription and motivate older adults to follow these prescriptions.

Student Practices, Learning, and Attitudes When Using Computerized Ranking Tasks

NASA Astrophysics Data System (ADS)

Lee, Kevin M.; Prather, E. E.; Collaboration of Astronomy Teaching Scholars CATS

2011-01-01

Ranking Tasks are a novel type of conceptual exercise based on a technique called rule assessment. Ranking Tasks present students with a series of four to eight icons that describe slightly different variations of a basic physical situation. Students are then asked to identify the order, or ranking, of the various situations based on some physical outcome or result. The structure of Ranking Tasks makes it difficult for students to rely strictly on memorized answers and mechanical substitution of formulae. In addition, by changing the presentation of the different scenarios (e.g., photographs, line diagrams, graphs, tables, etc.) we find that Ranking Tasks require students to develop mental schema that are more flexible and robust. Ranking tasks may be implemented on the computer which requires students to order the icons through drag-and-drop. Computer implementation allows the incorporation of background material, grading with feedback, and providing additional similar versions of the task through randomization so that students can build expertise through practice. This poster will summarize the results of a study of student usage of computerized ranking tasks. We will investigate 1) student practices (How do they make use of these tools?), 2) knowledge and skill building (Do student scores improve with iteration and are there diminishing returns?), and 3) student attitudes toward using computerized Ranking Tasks (Do they like using them?). This material is based upon work supported by the National Science Foundation under Grant No. 0715517, a CCLI Phase III Grant for the Collaboration of Astronomy Teaching Scholars (CATS). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.

Medication supply chain management through implementation of a hospital pharmacy computerized inventory program in Haiti.

PubMed

Holm, Michelle R; Rudis, Maria I; Wilson, John W

2015-01-01

In the aftermath of the 2010 earthquake in Haiti, St. Luke Hospital was built to help manage the mass casualties and subsequent cholera epidemic. A major problem faced by the hospital system was the lack of an available and sustainable supply of medications. Long-term viability of the hospital system depended largely on developing an uninterrupted medication supply chain. We hypothesized that the implementation of a new Pharmacy Computerized Inventory Program (PCIP) would optimize medication availability and decrease medication shortages. We conducted the research by examining how medications were being utilized and distributed before and after the implementation of PCIP. We measured the number of documented medication transactions in both Phase 1 and Phase 2 as well as user logins to determine if a computerized inventory system would be beneficial in providing a sustainable, long-term solution to their medication management needs. The PCIP incorporated drug ordering, filling the drug requests, distribution, and dispensing of the medications in multiple settings; inventory of currently shelved medications; and graphic reporting of 'real-time' medication usage. During the PCIP initiation and establishment periods, the number of medication transactions increased from 219.6 to 359.5 (p=0.055), respectively, and the mean logins per day increased from 24.3 to 31.5, p<0.0001, respectively. The PCIP allows the hospital staff to identify and order medications with a critically low supply as well as track usage for future medication needs. The pharmacy and nursing staff found the PCIP to be efficient and a significant improvement in their medication utilization. An efficient, customizable, and cost-sensitive PCIP can improve drug inventory management in a simplified and sustainable manner within a resource-constrained hospital.

Medication supply chain management through implementation of a hospital pharmacy computerized inventory program in Haiti

PubMed Central

Holm, Michelle R.; Rudis, Maria I.; Wilson, John W.

2015-01-01

Background In the aftermath of the 2010 earthquake in Haiti, St. Luke Hospital was built to help manage the mass casualties and subsequent cholera epidemic. A major problem faced by the hospital system was the lack of an available and sustainable supply of medications. Long-term viability of the hospital system depended largely on developing an uninterrupted medication supply chain. Objective We hypothesized that the implementation of a new Pharmacy Computerized Inventory Program (PCIP) would optimize medication availability and decrease medication shortages. Design We conducted the research by examining how medications were being utilized and distributed before and after the implementation of PCIP. We measured the number of documented medication transactions in both Phase 1 and Phase 2 as well as user logins to determine if a computerized inventory system would be beneficial in providing a sustainable, long-term solution to their medication management needs. Results The PCIP incorporated drug ordering, filling the drug requests, distribution, and dispensing of the medications in multiple settings; inventory of currently shelved medications; and graphic reporting of ‘real-time’ medication usage. During the PCIP initiation and establishment periods, the number of medication transactions increased from 219.6 to 359.5 (p=0.055), respectively, and the mean logins per day increased from 24.3 to 31.5, p<0.0001, respectively. The PCIP allows the hospital staff to identify and order medications with a critically low supply as well as track usage for future medication needs. The pharmacy and nursing staff found the PCIP to be efficient and a significant improvement in their medication utilization. Conclusions An efficient, customizable, and cost-sensitive PCIP can improve drug inventory management in a simplified and sustainable manner within a resource-constrained hospital. PMID:25623613

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.

PubMed

Baldwin, Abigail; Rodriguez, Elizabeth S

2016-02-01

The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. This article will describe the role of the VN and details of the verification process. To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

Critical factors influencing physicians' intention to use computerized clinical practice guidelines: an integrative model of activity theory and the technology acceptance model.

PubMed

Hsiao, Ju-Ling; Chen, Rai-Fu

2016-01-16

With the widespread use of information communication technologies, computerized clinical practice guidelines are developed and considered as effective decision supporting tools in assisting the processes of clinical activities. However, the development of computerized clinical practice guidelines in Taiwan is still at the early stage and acceptance level among major users (physicians) of computerized clinical practice guidelines is not satisfactory. This study aims to investigate critical factors influencing physicians' intention to computerized clinical practice guideline use through an integrative model of activity theory and the technology acceptance model. The survey methodology was employed to collect data from physicians of the investigated hospitals that have implemented computerized clinical practice guidelines. A total of 505 questionnaires were sent out, with 238 completed copies returned, indicating a valid response rate of 47.1 %. The collected data was then analyzed by structural equation modeling technique. The results showed that attitudes toward using computerized clinical practice guidelines (γ = 0.451, p < 0.001), organizational support (γ = 0.285, p < 0.001), perceived usefulness of computerized clinical practice guidelines (γ = 0.219, p < 0.05), and social influence (γ = 0.213, p < 0.05) were critical factors influencing physicians' intention to use computerized clinical practice guidelines, and these factors can explain 68.6 % of the variance in intention to use computerized clinical practice guidelines. This study confirmed that some subject (human) factors, environment (organization) factors, tool (technology) factors mentioned in the activity theory should be carefully considered when introducing computerized clinical practice guidelines. Managers should pay much attention on those identified factors and provide adequate resources and incentives to help the promotion and use of computerized clinical practice guidelines. Through the appropriate use of computerized clinical practice guidelines, the clinical benefits, particularly in improving quality of care and facilitating the clinical processes, will be realized.

39 CFR 501.15 - Computerized Meter Resetting System.

Code of Federal Regulations, 2010 CFR

2010-07-01

... AND DISTRIBUTE POSTAGE EVIDENCING SYSTEMS § 501.15 Computerized Meter Resetting System. (a) Description. The Computerized Meter Resetting System (CMRS) permits customers to reset their postage meters at... 39 Postal Service 1 2010-07-01 2010-07-01 false Computerized Meter Resetting System. 501.15...

Delivered volumes of enteral nutrition exceed prescribed volumes.

PubMed

Walker, Renee Nichole; Utech, Anne; Velez, Maria Eugenia; Schwartz, Katie

2014-10-01

Enteral nutrition (EN) provisions are typically calculated based on a 24-hour infusion period. However, feedings are often interrupted for daily activities, procedures, or gastrointestinal intolerance. The study's objective was to determine the delivered EN quantities provided to stable hospitalized patients, using cellular time and measured volumes to verify our EN calculation adjustment. A supply of consecutively numbered ready-to-hang (RTH) EN product was delivered to the bedside of 26 inpatients with established EN tolerance at goal rates on various types of nursing units. The dietitian weighed the volume remaining in the infusing product and recorded the measurement time. On the following days, the dietitian continued to weigh the infusing RTH product and the empty RTH bottles saved by nursing. The primary outcome was the difference between the prescribed and delivered EN provisions, which was calculated with a paired t test. Patients received significantly more calories in the delivered enteral feeding (mean [SD], 1678 [385] kcal) than prescribed calories in the EN order (1489 [246 kcal]; t = 3.736, P = .001), adjusting for observed time. No significant differences were found between nursing units, product, and rate. EN delivered may actually exceed ordered amounts by 5%–21% (mean, 12%) with feeding pump inaccuracy as the primary contributing factor. This differs from what others have found. Our findings support using a volume-based ordering system vs a rate-based ordering system for more accurate EN delivery.

Generalized Orienteering Problem with Resource Dependent Rewards

DTIC Science & Technology

2013-02-19

School, Monterey, California February 19, 2013 Abstract We introduce a generalized Orienteering Problem where, as usual, a vehicle is routed from a ...prescribed start node, through a directed network, to a prescribed destination node, collecting rewards at each node visited, in order to maximize the...total reward along the path. In our generalization, transit on arcs in the network and reward collection at nodes both consume a variable amount of the

21 CFR 884.2800 - Computerized Labor Monitoring System.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Computerized Labor Monitoring System. 884.2800... Devices § 884.2800 Computerized Labor Monitoring System. (a) Identification. A computerized labor monitoring system is a system intended to continuously measure cervical dilation and fetal head descent and...

Reducing medication errors and increasing patient safety: case studies in clinical pharmacology.

PubMed

Benjamin, David M

2003-07-01

Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the now politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to "prevention" and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is "an act that through ingnorance, deficiency, or accident departs from or fails to achieve what should be done." What should be done is generally known as "the five rights": the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. "System errors" are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the "safety net" that failed. Examples of reengineering the system to make it more "error proof" are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faculty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.

[Development and application of a computerized nursing process program for orthopedic surgery inpatients-- NANDA, NOC, and NIC linkages].

PubMed

Kim, Hye-Suk

2005-10-01

The purpose of this study was to develop and to apply the NANDA, NOC, and NIC (NNN) linkages into a computerized nursing process program using the classification systems of nursing diagnoses, nursing outcomes and nursing interventions. The program was developed with planning, analysis, design and performance stages. The program was applied to 117 patients who were admitted to orthopedic surgery nursing units from January to February, 2004. Thirty-five of fifty-three nursing diagnoses were identified. Five nursing diagnoses in order of frequency were: Acute pain (28.4%), Impaired physical mobility (15.6%), Impaired walking (8.7%), Chronic pain (5.5%) and Risk for disuse syndrome (5.0%). The nursing outcomes of the 'Acute pain' nursing diagnosis tended to have higher frequencies (cumulative) in order of Pain management (95.2%), Comfort level (35.5%) and Pain level (17.7%). The nursing interventions of the 'Acute pain' nursing diagnosis tended to have higher frequencies (cumulative) in order of Pain management (71.0%), Splinting (24.2%) and Analgesic administration (17.7%). In comparison of outcome indicator scores between before and after the intervention according to the 61 nursing outcomes, the mean scores of 52 outcome indicators after the intervention were significantly higher than before the intervention. It is expected that this program will help nurses perform their nursing processes more efficiently.

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2011 CFR

2011-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2012 CFR

2012-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2014 CFR

2014-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

14 CFR 13.127 - Reports, decisions and orders.

Code of Federal Regulations, 2013 CFR

2013-01-01

... Section 13.127 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... Investigation § 13.127 Reports, decisions and orders. The Presiding Officer shall issue a written report based... publication as prescribed by section 313(b) of the Federal Aviation Act. ...

7 CFR 981.46 - Withholding reserve.

Code of Federal Regulations, 2010 CFR

2010-01-01

... and Orders; Fruits, Vegetables, Nuts), DEPARTMENT OF AGRICULTURE ALMONDS GROWN IN CALIFORNIA Order... for any crop year, as hereinafter provided, no handler shall handle almonds except on condition that he comply with the requirements in respect to withholding reserve almonds and the prescribed...

Research on the Impact of a Computerized Circulation System on the Performance of a Large College Library. Final Report.

ERIC Educational Resources Information Center

Frohmberg, Katherine A.; Moffett, William A.

In order to study the effects of introducing an automated circulation system at Oberlin College, Ohio, data were collected from September 1978 until June 1982 on book availability, usage of library facilities, attitudes of library users toward the library, and the efficiency of circulation activities. Data collection methods included circulation…

Various Solution Methods, Accompanied by Dynamic Investigation, for the Same Problem as a Means for Enriching the Mathematical Toolbox

ERIC Educational Resources Information Center

Oxman, Victor; Stupel, Moshe

2018-01-01

A geometrical task is presented with multiple solutions using different methods, in order to show the connection between various branches of mathematics and to highlight the importance of providing the students with an extensive 'mathematical toolbox'. Investigation of the property that appears in the task was carried out using a computerized tool.

Various solution methods, accompanied by dynamic investigation, for the same problem as a means for enriching the mathematical toolbox

NASA Astrophysics Data System (ADS)

Oxman, Victor; Stupel, Moshe

2018-04-01

A geometrical task is presented with multiple solutions using different methods, in order to show the connection between various branches of mathematics and to highlight the importance of providing the students with an extensive 'mathematical toolbox'. Investigation of the property that appears in the task was carried out using a computerized tool.

Cognitive Science and Instructional Technology: Improvements in Higher Order Thinking Strategies.

ERIC Educational Resources Information Center

Tennyson, Robert D.

This paper examines the cognitive processes associated with higher-order thinking strategies--i.e., cognitive processes directly associated with the employment of knowledge in the service of problem solving and creativity--in order to more clearly define a prescribed instructional method to improve problem-solving skills. The first section of the…

Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.

PubMed

Moran, John; Scanlon, Dennis

2013-01-01

In response to the Institute of Medicine's To Err Is Human report on the prevalence of medical errors, the Leapfrog Group, an organization that promotes hospital safety and quality, established a voluntary hospital survey assessing compliance with several safety standards. Using data from the period 2002-07, we conducted the first longitudinal assessment of how hospitals in specific cities and states initially selected by Leapfrog progressed on public reporting and adoption of standards requiring the use of computerized drug order entry and hospital intensivists. Overall, little progress was observed. Reporting rates were unchanged over the study period. Adoption of computerized drug order entry increased from 2.94 percent to 8.13 percent, and intensivist staffing increased from 14.74 percent to 21.40 percent. These findings should not be viewed as an indictment of Leapfrog but may reflect various challenges. For example, hospitals faced no serious threats to their market share if purchasers shifted business away from those that either didn't report data or didn't meet the standards. In the absence of mandatory reporting, policy makers might need to act to address these challenges to ensure improvements in quality.

Computerized Cognitive Training with Older Adults: A Systematic Review

PubMed Central

Kueider, Alexandra M.; Parisi, Jeanine M.; Gross, Alden L.; Rebok, George W.

2012-01-01

A systematic review to examine the efficacy of computer-based cognitive interventions for cognitively healthy older adults was conducted. Studies were included if they met the following criteria: average sample age of at least 55 years at time of training; participants did not have Alzheimer’s disease or mild cognitive impairment; and the study measured cognitive outcomes as a result of training. Theoretical articles, review articles, and book chapters that did not include original data were excluded. We identified 151 studies published between 1984 and 2011, of which 38 met inclusion criteria and were further classified into three groups by the type of computerized program used: classic cognitive training tasks, neuropsychological software, and video games. Reported pre-post training effect sizes for intervention groups ranged from 0.06 to 6.32 for classic cognitive training interventions, 0.19 to 7.14 for neuropsychological software interventions, and 0.09 to 1.70 for video game interventions. Most studies reported older adults did not need to be technologically savvy in order to successfully complete or benefit from training. Overall, findings are comparable or better than those from reviews of more traditional, paper-and-pencil cognitive training approaches suggesting that computerized training is an effective, less labor intensive alternative. PMID:22792378

Lagrangian particle method for compressible fluid dynamics

DOE Office of Scientific and Technical Information (OSTI.GOV)

Samulyak, Roman; Wang, Xingyu; Chen, Hsin -Chiang

A new Lagrangian particle method for solving Euler equations for compressible inviscid fluid or gas flows is proposed. Similar to smoothed particle hydrodynamics (SPH), the method represents fluid cells with Lagrangian particles and is suitable for the simulation of complex free surface / multi-phase flows. The main contributions of our method, which is different from SPH in all other aspects, are (a) significant improvement of approximation of differential operators based on a polynomial fit via weighted least squares approximation and the convergence of prescribed order, (b) a second-order particle-based algorithm that reduces to the first-order upwind method at local extremalmore » points, providing accuracy and long term stability, and (c) more accurate resolution of entropy discontinuities and states at free inter-faces. While the method is consistent and convergent to a prescribed order, the conservation of momentum and energy is not exact and depends on the convergence order . The method is generalizable to coupled hyperbolic-elliptic systems. As a result, numerical verification tests demonstrating the convergence order are presented as well as examples of complex multiphase flows.« less

Lagrangian particle method for compressible fluid dynamics

DOE PAGES

Samulyak, Roman; Wang, Xingyu; Chen, Hsin -Chiang

2018-02-09

A new Lagrangian particle method for solving Euler equations for compressible inviscid fluid or gas flows is proposed. Similar to smoothed particle hydrodynamics (SPH), the method represents fluid cells with Lagrangian particles and is suitable for the simulation of complex free surface / multi-phase flows. The main contributions of our method, which is different from SPH in all other aspects, are (a) significant improvement of approximation of differential operators based on a polynomial fit via weighted least squares approximation and the convergence of prescribed order, (b) a second-order particle-based algorithm that reduces to the first-order upwind method at local extremalmore » points, providing accuracy and long term stability, and (c) more accurate resolution of entropy discontinuities and states at free inter-faces. While the method is consistent and convergent to a prescribed order, the conservation of momentum and energy is not exact and depends on the convergence order . The method is generalizable to coupled hyperbolic-elliptic systems. As a result, numerical verification tests demonstrating the convergence order are presented as well as examples of complex multiphase flows.« less

Expansion of the gravitational potential with computerized Poisson series

NASA Technical Reports Server (NTRS)

Broucke, R.

1976-01-01

The paper describes a recursive formulation for the expansion of the gravitational potential valid for both the tesseral and zonal harmonics. The expansion is primarily in rectangular coordinates, but the classical orbit elements or equinoctial orbit elements can be easily substituted. The equations of motion for the zonal harmonics in both classical and equinoctial orbital elements are described in a form which will result in closed-form expressions for the first-order perturbations. In order to achieve this result, the true longitude or true anomaly have to be used as independent variables.

Improving the quality of the order-writing process for inpatient orders in a teaching hospital.

PubMed

Boehringer, Peter A; Rylander, Jeanette; Dizon, Dominic T; Peterson, Michael W

2007-01-01

Physicians' illegible handwriting is a notorious contributing factor to medical errors. Furthermore, an illegible signature or failure to print prescribers' name interferes with the ability of staff to clarify orders. We surveyed support medical staff at a teaching hospital before and 2 months after providing all internal medicine department residents a self-inking stamp with their name and pager number. Responses were received from 51% at the first and 36% at the second survey of 401 eligible staff. Responses to questions regarding illegible or absent signature, illegible or absent pager number, and failure to print prescribers' name showed a significant improvement (P < .0001) after 52 residents working in the hospital started to sign orders with their stamp. The support staff also noted a significant reduction in the time required to contact a physician to clarify orders, from more than 10 minutes to 1 to 5 minutes (P < .0001). Physicians signing orders using a stamp with their name and pager number provide support staff legible identification, leading to an improvement in the quality of the order-writing process. This kind of signature allows clarification of orders in a timely fashion.

45 CFR 307.15 - Approval of advance planning documents for computerized support enforcement systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... computerized support enforcement systems. 307.15 Section 307.15 Public Welfare Regulations Relating to Public... CHILDREN AND FAMILIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES COMPUTERIZED SUPPORT ENFORCEMENT SYSTEMS § 307.15 Approval of advance planning documents for computerized support enforcement systems. (a...

Arkansas' Curriculum Guide. Competency Based Computerized Accounting.

ERIC Educational Resources Information Center

Arkansas State Dept. of Education, Little Rock. Div. of Vocational, Technical and Adult Education.

This guide contains the essential parts of a total curriculum for a one-year secondary-level course in computerized accounting. Addressed in the individual sections of the guide are the following topics: the complete accounting cycle, computer operations for accounting, computerized accounting and general ledgers, computerized accounts payable,…

[Quality insurance system establishment in the management of home-based chemotherapy: example of hospital at home "Assistance publique-Hôpitaux de Paris"].

PubMed

Benizri, F; Balladur, E; Darse, J; Guérin, J; Boudy, V; Echard, M; Brodin, M; Hagenmüller, J B; Prognon, P; Bonan, B

2010-09-01

While home-based chemotherapy improves comfort and quality of life of patients, quality and safety conditions must be equivalent to hospital settings. In addition, organization is much more complex. At the hospital at home "Assistance publique-Hôpitaux de Paris", prescribers are potentially spread across 21 health facilities. The administration of chemotherapy is performed by about 300 nurses at the patient's home in Paris and its suburbs. Centralized preparations of chemotherapy began in September 2009 by the pharmacy department of Georges-Pompidou European hospital, with a progressive increase of the activity. This article describes the quality insurance system established with this new organization to meet the specific challenges of home therapy: choice of eligible anticancer drugs, computerized information systems and networking with other heath facilities, secure transport conditions, traceability from the prescription to the administration, security of administration. This experience can offer an important support for other centres in their approach of quality insurance for home chemotherapy.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics

PubMed Central

Gellert, George A.; Catzoela, Linda; Patel, Lajja; Bruner, Kylynn; Friedman, Felix; Ramirez, Ricardo; Saucedo, Lilliana; Webster, S. Luke; Gillean, John A.

2017-01-01

Background One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers’ confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications. Objective This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting. Methods A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period. Results We found that a small but not dismissible percentage of orders issued by hospitalists—up to 4.18 percent (95 percent confidence interval, 3.84–4.56 percent) per month—were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed. Conclusion Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution. PMID:28566988

Computerized Adaptive Personality Testing: A Review and Illustration With the MMPI-2 Computerized Adaptive Version.

ERIC Educational Resources Information Center

Forbey, Johnathan D.; Ben-Porath, Yossef S.

2007-01-01

Computerized adaptive testing in personality assessment can improve efficiency by significantly reducing the number of items administered to answer an assessment question. Two approaches have been explored for adaptive testing in computerized personality assessment: item response theory and the countdown method. In this article, the authors…

A Randomized Controlled Trial of the "Cool Teens" CD-ROM Computerized Program for Adolescent Anxiety

ERIC Educational Resources Information Center

Wuthrich, Viviana M.; Rapee, Ronald M.; Cunningham, Michael J.; Lyneham, Heidi J.; Hudson, Jennifer L.; Schniering, Carolyn A.

2012-01-01

Objective: Computerized cognitive behavioral interventions for anxiety disorders in adults have been shown to be efficacious, but limited data are available on the use of computerized interventions with young persons. Adolescents in particular are difficult to engage in treatment and may be especially suited to computerized technologies. This…

Combining computerized social cognitive training with neuroplasticity-based auditory training in schizophrenia.

PubMed

Sacks, Stephanie; Fisher, Melissa; Garrett, Coleman; Alexander, Phillip; Holland, Christine; Rose, Demian; Hooker, Christine; Vinogradov, Sophia

2013-01-01

Social cognitive deficits are an important treatment target in schizophrenia, but it is unclear to what degree they require specialized interventions and which specific components of behavioral interventions are effective. In this pilot study, we explored the effects of a novel computerized neuroplasticity-based auditory training delivered in conjunction with computerized social cognition training (SCT) in patients with schizophrenia. Nineteen clinically stable schizophrenia subjects performed 50 hours of computerized exercises that place implicit, increasing demands on auditory perception, plus 12 hours of computerized training in emotion identification, social perception, and theory of mind tasks. All subjects were assessed with MATRICS-recommended measures of neurocognition and social cognition, plus a measure of self-referential source memory before and after the computerized training. Subjects showed significant improvements on multiple measures of neurocognition. Additionally, subjects showed significant gains on measures of social cognition, including the MSCEIT Perceiving Emotions, MSCEIT Managing Emotions, and self-referential source memory, plus a significant decrease in positive symptoms. Computerized training of auditory processing/verbal learning in schizophrenia results in significant basic neurocognitive gains. Further, addition of computerized social cognition training results in significant gains in several social cognitive outcome measures. Computerized cognitive training that directly targets social cognitive processes can drive improvements in these crucial functions.

Modifications and integration of the electronic tracking board in a pediatric emergency department.

PubMed

Dexheimer, Judith W; Kennebeck, Stephanie

2013-07-01

Electronic health records (EHRs) are used for data storage; provider, laboratory, and patient communication; clinical decision support; procedure and medication orders; and decision support alerts. Clinical decision support is part of any EHR and is designed to help providers make better decisions. The emergency department (ED) poses a unique environment to the use of EHRs and clinical decision support. Used effectively, computerized tracking boards can help improve flow, communication, and the dissemination of pertinent visit information between providers and other departments in a busy ED. We discuss the unique modifications and decisions made in the implementation of an EHR and computerized tracking board in a pediatric ED. We discuss the changing views based on provider roles, customization to the user interface including the layout and colors, decision support, tracking board best practices collected from other institutions and colleagues, and a case study of using reminders on the electronic tracking board to drive pain reassessments.

A mapping of information security in health Information Systems in Latin America and Brazil.

PubMed

Pereira, Samáris Ramiro; Fernandes, João Carlos Lopes; Labrada, Luis; Bandiera-Paiva, Paulo

2013-01-01

In health, Information Systems are patient records, hospital administration or other, have advantages such as cost, availability and integration. However, for these benefits to be fully met, it is necessary to guarantee the security of information maintained and provided by the systems. The lack of security can lead to serious consequences such as lawsuits and induction to medical errors. The management of information security is complex and is used in various fields of knowledge. Often, it is left in the background for not being the ultimate goal of a computer system, causing huge financial losses to corporations. This paper by systematic review methodologies, presented a mapping in the literature, in order to identify the most relevant aspects that are addressed by security researchers of health information, as to the development of computerized systems. They conclude through the results, some important aspects, for which the managers of computerized health systems should remain alert.

Standardization in software conversion of (ROM) estimating

NASA Technical Reports Server (NTRS)

Roat, G. H.

1984-01-01

Technical problems and their solutions comprise by far the majority of work involved in space simulation engineering. Fixed price contracts with schedule award fees are becoming more and more prevalent. Accurate estimation of these jobs is critical to maintain costs within limits and to predict realistic contract schedule dates. Computerized estimating may hold the answer to these new problems, though up to now computerized estimating has been complex, expensive, and geared to the business world, not to technical people. The objective of this effort was to provide a simple program on a desk top computer capable of providing a Rough Order of Magnitude (ROM) estimate in a short time. This program is not intended to provide a highly detailed breakdown of costs to a customer, but to provide a number which can be used as a rough estimate on short notice. With more debugging and fine tuning, a more detailed estimate can be made.

Opioid analgesic use in Australia and The Netherlands: a cross-country comparison.

PubMed

Wagemaakers, Francisca N; Hollingworth, Samantha A; Kreijkamp-Kaspers, Sanne; Tee, Ernest H L; Leendertse, Anne J; van Driel, Mieke L

2017-08-01

Background Increasing use of opioid analgesics (OA) has been reported worldwide. Objective To compare the use of OA in two countries in order to better understand these trends. Setting Outpatient settings in Australia and The Netherlands. Method We analysed publicly available government data on outpatient OA dispensing over 15 years (2000-2014). We compared dispensing trends for specific OA and explored medical (national clinical guidelines), contextual and policy-related factors to explain differences in use between the two countries. Main outcome measure OA prescribing in Australia and The Netherlands, absolute volume of use, preferred types of opioids and changes over time. Results The average annual increase in OA prescribing was 10% in Australia and 8% in The Netherlands between 2000 and 2014. In 2014, the total use of OA was 10.0 daily defined doses (DDD)/1000 population/day in Australia and 9.4 DDD/1000 population/day in The Netherlands. In Australia, the most commonly prescribed opioids were oxycodone and tramadol, compared to fentanyl and tramadol in The Netherlands. We found differences in prescribing guidelines, culture of prescribing and regulatory frameworks that could explain some of the observed differences. Conclusion OA prescribing has increased remarkably in both countries between 2000 and 2014 but the types of prescribed OA vary. Differences in national evidence-based guidelines influenced the types of OA used. Prescribing culture as well as regulatory policies and costs, may also contribute to the different patterns of OA use.

Improving the utility of the fine motor skills subscale of the comprehensive developmental inventory for infants and toddlers: a computerized adaptive test.

PubMed

Huang, Chien-Yu; Tung, Li-Chen; Chou, Yeh-Tai; Chou, Willy; Chen, Kuan-Lin; Hsieh, Ching-Lin

2017-07-27

This study aimed at improving the utility of the fine motor subscale of the comprehensive developmental inventory for infants and toddlers (CDIIT) by developing a computerized adaptive test of fine motor skills. We built an item bank for the computerized adaptive test of fine motor skills using the fine motor subscale of the CDIIT items fitting the Rasch model. We also examined the psychometric properties and efficiency of the computerized adaptive test of fine motor skills with simulated computerized adaptive tests. Data from 1742 children with suspected developmental delays were retrieved. The mean scores of the fine motor subscale of the CDIIT increased along with age groups (mean scores = 1.36-36.97). The computerized adaptive test of fine motor skills contains 31 items meeting the Rasch model's assumptions (infit mean square = 0.57-1.21, outfit mean square = 0.11-1.17). For children of 6-71 months, the computerized adaptive test of fine motor skills had high Rasch person reliability (average reliability >0.90), high concurrent validity (rs = 0.67-0.99), adequate to excellent diagnostic accuracy (area under receiver operating characteristic = 0.71-1.00), and large responsiveness (effect size = 1.05-3.93). The computerized adaptive test of fine motor skills used 48-84% fewer items than the fine motor subscale of the CDIIT. The computerized adaptive test of fine motor skills used fewer items for assessment but was as reliable and valid as the fine motor subscale of the CDIIT. Implications for Rehabilitation We developed a computerized adaptive test based on the comprehensive developmental inventory for infants and toddlers (CDIIT) for assessing fine motor skills. The computerized adaptive test has been shown to be efficient because it uses fewer items than the original measure and automatically presents the results right after the test is completed. The computerized adaptive test is as reliable and valid as the CDIIT.

Evaluation of factors affecting prescribing behaviors, in iran pharmaceutical market by econometric methods.

PubMed

Tahmasebi, Nima; Kebriaeezadeh, Abbas

2015-01-01

Prescribing behavior of physicians affected by many factors. The present study is aimed at discovering the simultaneous effects of the evaluated factors (including: price, promotion and demographic characteristics of physicians) and quantification of these effects. In order to estimate these effects, Fluvoxamine (an antidepressant drug) was selected and the model was figured out by panel data method in econometrics. We found that insurance and advertisement respectively are the most effective on increasing the frequency of prescribing, whilst negative correlation was observed between price and the frequency of prescribing a drug. Also brand type is more sensitive to negative effect of price than to generic. Furthermore, demand for a prescription drug is related with physician demographics (age and sex). According to the results of this study, pharmaceutical companies should pay more attention to the demographic characteristics of physicians (age and sex) and their advertisement and pricing strategies.

Evaluation of Factors Affecting Prescribing Behaviors, in Iran Pharmaceutical Market by Econometric Methods

PubMed Central

Tahmasebi, Nima; Kebriaeezadeh, Abbas

2015-01-01

Prescribing behavior of physicians affected by many factors. The present study is aimed at discovering the simultaneous effects of the evaluated factors (including: price, promotion and demographic characteristics of physicians) and quantification of these effects. In order to estimate these effects, Fluvoxamine (an antidepressant drug) was selected and the model was figured out by panel data method in econometrics. We found that insurance and advertisement respectively are the most effective on increasing the frequency of prescribing, whilst negative correlation was observed between price and the frequency of prescribing a drug. Also brand type is more sensitive to negative effect of price than to generic. Furthermore, demand for a prescription drug is related with physician demographics (age and sex). According to the results of this study, pharmaceutical companies should pay more attention to the demographic characteristics of physicians (age and sex) and their advertisement and pricing strategies. PMID:25901174

City public service learns to speed read. [Computerized routing system for meter reading

DOE Office of Scientific and Technical Information (OSTI.GOV)

Aitken, E.L.

1994-02-01

City Public Service (CPS) of San Antonio, TX is a municipally owned utility that serves a densely populated 1,566 square miles in and around San Antonio. CPS's service area is divided into 21 meter reading districts, each of which is broken down into no more than 99 regular routes. Every day, a CPS employee reads one of the districts, following one or more routes. In 1991, CPS began using handheld computers to record reads for regular routes, which are stored on the devices themselves. In contrast, rereads and final reads occur at random throughout the service area. Because they changemore » every day, the process of creating routes that can be loaded onto a handheld device is difficult. Until recently, rereads and final reads were printed on paper orders, and route schedulers would spend close to two hours sorting the paper orders into routes. Meter readers would then hand-sequence the orders on their routes, often using a city map, before taking them into the field in stacks. When the meter readers returned, their completed orders had to be separated by type of reread, and then keyed into the mainframe computer before bill processing could begin. CPS's data processing department developed a computerized routing system of its own that saves time and labor, as well as paper. The system eliminates paper orders entirely, enabling schedulers to create reread and final read routes graphically on a PC. Information no longer needs to be keyed from hard copy, reducing the margin of error and streamlining bill processing by incorporating automated data transfer between systems.« less

Computerized clinical decision support systems for drug prescribing and management: a decision-maker-researcher partnership systematic review.

PubMed

Hemens, Brian J; Holbrook, Anne; Tonkin, Marita; Mackay, Jean A; Weise-Kelly, Lorraine; Navarro, Tamara; Wilczynski, Nancy L; Haynes, R Brian

2011-08-03

Computerized clinical decision support systems (CCDSSs) for drug therapy management are designed to promote safe and effective medication use. Evidence documenting the effectiveness of CCDSSs for improving drug therapy is necessary for informed adoption decisions. The objective of this review was to systematically review randomized controlled trials assessing the effects of CCDSSs for drug therapy management on process of care and patient outcomes. We also sought to identify system and study characteristics that predicted benefit. We conducted a decision-maker-researcher partnership systematic review. We updated our earlier reviews (1998, 2005) by searching MEDLINE, EMBASE, EBM Reviews, Inspec, and other databases, and consulting reference lists through January 2010. Authors of 82% of included studies confirmed or supplemented extracted data. We included only randomized controlled trials that evaluated the effect on process of care or patient outcomes of a CCDSS for drug therapy management compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Sixty-five studies met our inclusion criteria, including 41 new studies since our previous review. Methodological quality was generally high and unchanged with time. CCDSSs improved process of care performance in 37 of the 59 studies assessing this type of outcome (64%, 57% of all studies). Twenty-nine trials assessed patient outcomes, of which six trials (21%, 9% of all trials) reported improvements. CCDSSs inconsistently improved process of care measures and seldomly improved patient outcomes. Lack of clear patient benefit and lack of data on harms and costs preclude a recommendation to adopt CCDSSs for drug therapy management.

Impact of a Computerized Antithrombotic Risk Assessment Tool on the Prescription of Thromboprophylaxis in Atrial Fibrillation: Hospital Setting.

PubMed

Pandya, E; Masood, N; Wang, Y; Krass, I; Bajorek, B

2018-01-01

The computerized antithrombotic risk assessment tool (CARAT) is an online decision-support algorithm that facilitates a systematic review of a patient's stroke risk, bleeding risk, and pertinent medication safety considerations, to generate an individualized treatment recommendation. The CARAT was prospectively applied across 2 hospitals in the greater Sydney area. Its impact on antithrombotics utilization for thromboprophylaxis in patients with nonvalvular atrial fibrillation was evaluated. Factors influencing prescribers' treatment selection were identified. The CARAT recommended a change in baseline therapy for 51.8% of patients. Among anticoagulant-eligible patients (ie, where the risk of stroke outweighed the risk of bleeding) using "nil therapy" or antiplatelet therapy at baseline, the CARAT recommended an upgrade to warfarin in 60 (30.8%) patients. For those in whom the bleeding risk outweighed the stroke risk, the CARAT recommended a downgrade from warfarin to safer alternatives (eg, aspirin) in 37 (19%) patients. Among the "most eligible" (ie, high stroke risk, low bleeding risk, no contraindications; n = 75), the CARAT recommended warfarin for all cases. Discharge therapy observed a marginal increase in anticoagulation prescription in eligible patients (n = 116; 57.8% vs 64.7%, P = .35) compared to baseline. Predictors of warfarin use (vs antiplatelets) included congestive cardiac failure, diabetes mellitus, and polypharmacy. The CARAT was able to optimize the selection of therapy, increasing anticoagulant use among eligible patients. With the increasing complexity of decision-making, such tools may be useful adjuncts in therapy selection in atrial fibrillation. Future studies should explore the utility of such tools in selecting therapies from within an expanded treatment armamentarium comprising the non-vitamin K antagonist oral anticoagulants.

The path of least resistance in oral surgery.

PubMed

Fee, Laura

2016-01-01

Antibiotic resistance is an imminent threat to worldwide public health. Dental professionals must demonstrate judicious use of antibiotics and educate their patients about the risks associated with their overuse. PURPOSE OF THE PAPER: To encourage the dental profession to prescribe responsibly in order to optimise the use of antibiotics in oral surgery. Antibiotic stewardship programmes are recommended to help reduce the emergence of infections that are multidrug-resistant. Clinical practice audits are encouraged to help dentists ensure conservative prescribing patterns. The dental profession has a duty of care to prescribe antibiotics in adherence with current best practice oral surgery guidelines. The dental profession must show leadership in slowing antibiotic resistance by pledgina to safeguard their appropriate use.

Design and Use of a Joint Order Vocabulary Knowledge Representation Tier in a Multi-tier CPOE Architecture

PubMed Central

Rucker, Donald W.; Steele, Andrew W.; Douglas, Ivor S.; Couderc, Carmela A.; Hardel, Gary G.

2006-01-01

Two major barriers to adoption of computerized physician order entry (CPOE) systems are the initial physician effort to learn the system and ongoing time costs to use the system. These barriers stem from the CPOE system’s need to reformulate physician orders into services that can be electronically communicated to ancillary clinical systems such as pharmacy, nursing, lab or radiology as well as to billing systems. Typical CPOE systems use significant custom user interface programming to match the terms used by physicians to order services as well as the aggregation of those orders into order sets with the underlying orderable services. We describe the design and implementation of a commercial CPOE system that has a formal separate intermediate mapping layer to match physician screen vocabulary and ordering behaviors to underlying services, both individually and in groups, supported by powerful search tools. PMID:17238425

45 CFR 310.40 - What requirements apply for accessing systems and records for monitoring Computerized Tribal IV-D...

Code of Federal Regulations, 2010 CFR

2010-10-01

... records for monitoring Computerized Tribal IV-D Systems and Office Automation? 310.40 Section 310.40... COMPUTERIZED TRIBAL IV-D SYSTEMS AND OFFICE AUTOMATION Accountability and Monitoring Procedures for... monitoring Computerized Tribal IV-D Systems and Office Automation? In accordance with Part 95 of this title...

78 FR 30782 - Avocados Grown in South Florida; Change in Minimum Grade Requirements

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-23

..., regardless of market destination. However, maintaining the current minimum grade requirement for avocados... Service 7 CFR Part 915 [Doc. No. AMS-FV-12-0067; FV13-915-1 PR] Avocados Grown in South Florida; Change in... prescribed under the Florida avocado marketing order (order). The order regulates the handling of avocados...

Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting

PubMed Central

Harshberger, Cara A.; Harper, Abigail J.; Carro, George W.; Spath, Wayne E.; Hui, Wendy C.; Lawton, Jessica M.; Brockstein, Bruce E.

2011-01-01

Purpose: Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites. Methods: This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems. Results: The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system. Conclusion: Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety. PMID:22043187

75 FR 22637 - Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-29

... the form prescribed for use by registered investment companies in certain circumstances to request orders of the Commission declaring that the registration of that investment company cease to be in effect. The form requests, from investment companies seeking a deregistration order, information about (i) the...

Decreasing Medication Turnaround Time with Digital Scanning Technology in a Canadian Health Region

PubMed Central

Neville, Heather; Nodwell, Lisa; Alsharif, Sahar

2014-01-01

Background: Reducing medication turnaround time can improve efficiency, patient safety, and quality of care in the hospital setting. Digital scanning technology (DST) can be used to electronically transmit scanned prescriber orders to a pharmacy computer queue for verification and processing, which may help to improve medication turnaround time. Objectives: To evaluate medication turnaround time before and after implementation of DST for all medications and for antibiotics only. Methods: Medication turnaround times were evaluated retrospectively for periods before (June 6–10, 2011) and after (September 26–30, 2011) implementation of DST at 2 hospital sites in 1 health region. Medication turnaround time was defined as the time from composition of a medication order by the prescriber to its verification by the pharmacy (phase 1) and the time from prescriber composition to administration to the patient by a nurse (total). Median turnaround times were analyzed with SPSS software using the Mann–Whitney U test. Results: In total, 304 and 244 medication orders were audited before and after DST implementation, respectively. Median phase 1 turnaround time for all medications declined significantly, from 2 h 23 min before DST implementation to 1 h 33 min after DST implementation (p < 0.001). Antibiotics were also processed significantly faster (1 h 51 min versus 1 h 9 min, p = 0.015). However, total turnaround time for all medications did not differ significantly (5 h 15 min versus 5 h 0 min, p = 0.42). Conclusions: Implementation of DST was associated with a 50-min decrease in medication turnaround time for the period from when an order was prescribed to the time it was processed by the pharmacy. Regular evaluation of medication turnaround times is recommended to compare with benchmarks, to ensure that hospital standards are being met, and to measure the effects of policy changes and implementation of new technology on medication-use processes. PMID:25548397

Decreasing medication turnaround time with digital scanning technology in a canadian health region.

PubMed

Neville, Heather; Nodwell, Lisa; Alsharif, Sahar

2014-11-01

Reducing medication turnaround time can improve efficiency, patient safety, and quality of care in the hospital setting. Digital scanning technology (DST) can be used to electronically transmit scanned prescriber orders to a pharmacy computer queue for verification and processing, which may help to improve medication turnaround time. To evaluate medication turnaround time before and after implementation of DST for all medications and for antibiotics only. Medication turnaround times were evaluated retrospectively for periods before (June 6-10, 2011) and after (September 26-30, 2011) implementation of DST at 2 hospital sites in 1 health region. Medication turnaround time was defined as the time from composition of a medication order by the prescriber to its verification by the pharmacy (phase 1) and the time from prescriber composition to administration to the patient by a nurse (total). Median turnaround times were analyzed with SPSS software using the Mann-Whitney U test. In total, 304 and 244 medication orders were audited before and after DST implementation, respectively. Median phase 1 turnaround time for all medications declined significantly, from 2 h 23 min before DST implementation to 1 h 33 min after DST implementation (p < 0.001). Antibiotics were also processed significantly faster (1 h 51 min versus 1 h 9 min, p = 0.015). However, total turnaround time for all medications did not differ significantly (5 h 15 min versus 5 h 0 min, p = 0.42). Implementation of DST was associated with a 50-min decrease in medication turnaround time for the period from when an order was prescribed to the time it was processed by the pharmacy. Regular evaluation of medication turnaround times is recommended to compare with benchmarks, to ensure that hospital standards are being met, and to measure the effects of policy changes and implementation of new technology on medication-use processes.

What do providers want to know about opioid prescribing? A qualitative analysis of their questions.

PubMed

Cushman, Phoebe A; Liebschutz, Jane M; Hodgkin, Joseph G; Shanahan, Christopher W; White, Julie L; Hardesty, Ilana; Alford, Daniel P

2017-01-01

In 2012, the US Food and Drug Administration (FDA) responded to the opioid crisis with a Risk Evaluation and Mitigation Strategy, requiring manufacturers of extended-release/long-acting opioids to fund continuing medical education based on the "FDA Blueprint for Prescriber Education." Topics in the Blueprint are "Assessing Patients for Treatment," "Initiating Therapy, Modifying Dosing, and Discontinuing Use," "Managing Therapy," "Counseling Patients and Caregivers about Safe Use," "General Drug Information," and "Specific Drug Information." Based on the FDA Blueprint, Boston University School of Medicine's "Safe and Competent Opioid Prescribing Education" (SCOPE of Pain) offers live trainings for physicians and other prescribers. During trainings, participants submit written questions about the curriculum and/or their clinical experiences. The objective was to compare themes that arose from questions asked by SCOPE of Pain participants with content of the FDA Blueprint in order to evaluate how well the Blueprint answers prescribers' concerns. The authors conducted qualitative analyses of all 1309 questions submitted by participants in 29 trainings across 16 states from May 2013 to May 2015, using conventional content analysis to code the questions. Themes that emerged from participants' questions were then compared with the Blueprint. Most themes fell into the topic categories of the Blueprint. Five main themes diverged: Participants sought information on (1) safe alternatives to opioids, (2) overcoming barriers to safe opioid prescribing, (3) government regulations of opioid prescribing, (4) the role of marijuana in opioid prescribing, and (5) maintaining a positive provider-patient relationship while prescribing opioids. In addition to learning the mechanics of safe opioid prescribing, providers want to understand government regulations and effective patient communication skills. Aware of the limitations of opioids in managing chronic pain, providers seek advice on alternatives therapies. Future updates to the FDA Blueprint and other educational guidelines on opioid prescribing should address providers' additional questions.

Computerizing medical records in Japan.

PubMed

Yasunaga, Hideo; Imamura, Tomoaki; Yamaki, Shintaro; Endo, Hiroyoshi

2008-10-01

The present study reports the current status of computerizing medical records in Japan. In 2001, the Ministry of Health, Labour and Welfare formulated the Grand Design for the Development of Information Systems in the Healthcare and Medical Fields. The Grand Design stated a numerical target for "spreading the use of electronic medical records (EMR) in at least 60% of Japan's hospitals with 400 or more beds by 2006." The objective of this study was to examine the extent to which EMR and order entry systems (OES) have been adopted as of February 2007 and to evaluate the Japanese government's policy regarding the computerization of medical records. We conducted a postal survey targeting medical institutions throughout Japan. In February 2007, we mailed self-administered questionnaires to all 1574 hospitals with 300 or more beds, and to a random selection of 1000 hospitals with less than 300 beds in addition to 4000 clinics. Responses were received from 812 (51.6%), 504 (50.5%), and 1769 (44.8%), respectively. We asked questions concerning: (i) the extent to which EMR and OES had been introduced; (ii) the reasons why certain institutions had not introduced EMR and (iii) the subjective evaluation of the efficacy and cost-effectiveness of EMR. The percentage of institutions that had introduced EMR as of February 2007 was 10.0% for hospitals and 10.1% for clinics. Even the percentage for hospitals with 400 or more beds was just 31.2%, illustrating that the government's target had not been reached. The most common reason given for not introducing EMR was: "The cost is high" which was observed in 82.0% of hospitals. It was considered that the introduction of EMR could improve 'inter-hospital networks', and 'time efficiency for physicians' by around 45% and 25% of hospitals, respectively. Healthcare information computerization in Japan is behind schedule because the introductory costs are high. For the computerization of healthcare information to be further promoted, prices of EMR systems should be lowered to a level which individual hospitals can afford. Furthermore, the communication between EMR systems should be further standardized to secure functional and semantic interoperability in Japan.

A comparison of pharmacist travel-health specialists' versus primary care providers' recommendations for travel-related medications, vaccinations, and patient compliance in a college health setting.

PubMed

Durham, Melissa J; Goad, Jeffery A; Neinstein, Lawrence S; Lou, Mimi

2011-01-01

Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health. A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations. The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001). A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care. © 2010 International Society of Travel Medicine.

Computerized training for the hardwood sawmill industry: The edging and trimmer trainer (version 3.0)

Treesearch

Philip Araman; A Palmer; Matthew Winn; D Kline

2009-01-01

In the hardwood sawmill industry, decisions made at the various processing stages directly affect the value of the end product. In order to realize maximum product value, it is essential that employees be properly trained. The edging and trimming stage of lumber processing is one area where lack of proper training can result in poor manufacturing decisions and...

The Relationship of Item-Level Response Times with Test-Taker and Item Variables in an Operational CAT Environment. LSAC Research Report Series.

ERIC Educational Resources Information Center

Swygert, Kimberly A.

In this study, data from an operational computerized adaptive test (CAT) were examined in order to gather information concerning item response times in a CAT environment. The CAT under study included multiple-choice items measuring verbal, quantitative, and analytical reasoning. The analyses included the fitting of regression models describing the…

Impact of Training Method on the Behavior of Physicians towards the Use of Computerized Provider Order Entry Systems

ERIC Educational Resources Information Center

Martinez, Fernando

2012-01-01

The use of workflow or simulated training has been used in the training of medical students for several decades. As technology emerged, training using simulation has grown as an effective way of enhancing training outcomes and increasing the clinical effectiveness of medical students. As a result of a heightened focus on the integration of…

Documentation for the machine-readable version of A Catalogue of Extragalactic Radio Source Identifications (Veron-Cetty and Veron 1983)

NASA Technical Reports Server (NTRS)

Warren, W. H., Jr.

1983-01-01

Detailed descriptions of the data and reference files of the updated and final version of the machine-readable catalog are given. The computerized catalog has greatly expanded since the original published version (1974), and additional information is given. A separate reference file contains bibliographical citations ordered simultaneously by numerical reference and alphabetically by author.

A multiplet table for Mn I (Adelman, Svatek, Van Winkler, Warren 1989): Documentation for the machine-readable version

NASA Technical Reports Server (NTRS)

Warren, Wayne H., Jr.; Adelman, Saul J.

1989-01-01

The machine-readable version of the multiplet table, as it is currently being distributed from the Astronomical Data Center, is described. The computerized version of the table contains data on excitation potentials, J values, multiplet terms, intensities of the transitions, and multiplet numbers. Files ordered by multiplet and by wavelength are included in the distributed version.

Low order H∞ optimal control for ACFA blended wing body aircraft

NASA Astrophysics Data System (ADS)

Haniš, T.; Kucera, V.; Hromčík, M.

2013-12-01

Advanced nonconvex nonsmooth optimization techniques for fixed-order H∞ robust control are proposed in this paper for design of flight control systems (FCS) with prescribed structure. Compared to classical techniques - tuning of and successive closures of particular single-input single-output (SISO) loops like dampers, attitude stabilizers, etc. - all loops are designed simultaneously by means of quite intuitive weighting filters selection. In contrast to standard optimization techniques, though (H2, H∞ optimization), the resulting controller respects the prescribed structure in terms of engaged channels and orders (e. g., proportional (P), proportional-integral (PI), and proportional-integralderivative (PID) controllers). In addition, robustness with regard to multimodel uncertainty is also addressed which is of most importance for aerospace applications as well. Such a way, robust controllers for various Mach numbers, altitudes, or mass cases can be obtained directly, based only on particular mathematical models for respective combinations of the §ight parameters.

The Effects of Interactive Stratospheric Chemistry on Antarctic and Southern Ocean Climate Change in an AOGCM

NASA Technical Reports Server (NTRS)

Li, Feng; Newman, Paul; Pawson, Steven; Waugh, Darryn

2014-01-01

Stratospheric ozone depletion has played a dominant role in driving Antarctic climate change in the last decades. In order to capture the stratospheric ozone forcing, many coupled atmosphere-ocean general circulation models (AOGCMs) prescribe the Antarctic ozone hole using monthly and zonally averaged ozone field. However, the prescribed ozone hole has a high ozone bias and lacks zonal asymmetry. The impacts of these biases on model simulations, particularly on Southern Ocean and the Antarctic sea ice, are not well understood. The purpose of this study is to determine the effects of using interactive stratospheric chemistry instead of prescribed ozone on Antarctic and Southern Ocean climate change in an AOGCM. We compare two sets of ensemble simulations for the 1960-2010 period using different versions of the Goddard Earth Observing System 5 - AOGCM: one with interactive stratospheric chemistry, and the other with prescribed monthly and zonally averaged ozone and 6 other stratospheric radiative species calculated from the interactive chemistry simulations. Consistent with previous studies using prescribed sea surface temperatures and sea ice concentrations, the interactive chemistry runs simulate a deeper Antarctic ozone hole and consistently larger changes in surface pressure and winds than the prescribed ozone runs. The use of a coupled atmosphere-ocean model in this study enables us to determine the impact of these surface changes on Southern Ocean circulation and Antarctic sea ice. The larger surface wind trends in the interactive chemistry case lead to larger Southern Ocean circulation trends with stronger changes in northerly and westerly surface flow near the Antarctica continent and stronger upwelling near 60S. Using interactive chemistry also simulates a larger decrease of sea ice concentrations. Our results highlight the importance of using interactive chemistry in order to correctly capture the influences of stratospheric ozone depletion on climate change over Antarctic and the Southern Ocean.

An Observational Study of Antibiotic Prescribing Behavior and the Hawthorne Effect

PubMed Central

Mangione-Smith, Rita; Elliott, Marc N; McDonald, Laurie; McGlynn, Elizabeth A

2002-01-01

Objectives To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. Data Sources/Setting (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96–3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96–3/97) and one year after (10/97–3/98) the observational study period. Ten pediatricians in two community practices were studied. Study Design Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. Data Collection/Extraction Methods For the observational study (10/96–2/97), diagnosis and treatment choices were obtained from questionnaires completed by physicians immediately following the visit. For the nonstudy encounters (10/96–3/97 and 10/97–3/98), data were abstracted from medical records one year after the observational study was completed. Principal Findings The proportion of viral cases in which an antibiotic was prescribed was 29 percentage points lower for the observational study compared to the retrospective analysis (p <.05). In one of two study sites, the proportion of cases assigned a bacterial diagnosis was 29 percentage points lower in the observational study period compared to the retrospective study (p <.05). Conclusions Observational study procedures including questionnaires and audio recording can affect antibiotic prescribing behavior. Future observational studies aimed at examining the frequency of inappropriate antibiotic prescribing should measure and adjust for the Hawthorne effect; without such adjustments, the results will likely underestimate the true degree of the problem. Future interventions aimed at decreasing inappropriate antibiotic prescribing should consider “harnessing” the Hawthorne effect through performance feedback to participating physicians. PMID:12546288

Phenolic compounds of Pinus laricio needles: a bioindicator of the effects of prescribed burning in function of season.

PubMed

Cannac, Magali; Pasqualini, Vanina; Barboni, Toussaint; Morandini, Frederic; Ferrat, Lila

2009-07-15

Fire is a dominant ecological factor in Mediterranean-type ecosystems. Forest management includes many preventive tools, in particular for fire prevention, such as mechanical treatments and prescribed burning. Prescribed burning is a commonly used method for treating fuel loads, but fuel reduction targets for reducing wildfire hazards must be balanced against fuel retention targets in order to maintain habitat and other forest functions. This approach was used on Pinus nigra ssp laricio var. Corsicana, a pine endemic to Corsica of great ecological and economic importance. Many studies of plant phenolic compounds have been carried out concerning responses to various stresses. The aim of this study was to understand i) the effects of prescribed burning 1 to 16 months later and ii) the effects of the seasonality of burning, spring or fall, on the production of phenolic compounds in Pinus laricio. After prescribed burning conducted in spring, Pinus laricio increases the synthesis of total phenolic compounds for a period of 7 months. The increase is greater after spring-burning than fall-burning. With regard to simple phenols, only dihydroferulic acid responds about 1 year after both types of prescribed burning. The causes of these increases are discussed in this paper. Total phenolic compounds could be used as a bioindicator for the short-term response of Pinus laricio needles to prescribed burning. Simple phenols may be useful for revealing the medium-term effects of prescribed burning. The results of this study include recommending forest managers to use prescribed burning in the fall rather than spring to reduce fuel loads and have less impact on the trees.

Prescribed fires effects on physico-chemical properties and quantity of runoff and soil erosion in a Mediterranean forest

NASA Astrophysics Data System (ADS)

Esteban Lucas-Borja, Manuel; Plaza Alvaréz, Pedro Antonio; Sagra, Javier; Alfaro Sánchez, Raquel; Moya, Daniel; Ferrandiz Gotor, Pablo; De las Heras Ibañez, Jorge

2017-04-01

Wildfires have an important influence in forest ecosystems. Contrary to high severity fire, which may have negative impacts on the ecosystems, low severity induce small changes on soil properties. Thus and in order to reduce fire risk, low-severity prescribed fires have been widely used as a fuel reduction tool and silvicultural treatment in Mediterranean forest ecosystems. However, fire may alter microsite conditions and little is known about the impact of prescribed burning on the physico-chemical properties of runoff. In this study, we compared the effects of prescribed burning on physico-chemical properties and quantity of runoff and soil erosion during twelve months after a low severity prescribed fire applied in twelve 16 m2 plot (6 burned plots and 6 control plots used for comparison) set up in the Lezuza forest (Albacete, central-eastern Spain). Physico-chemical properties and quantity of runoff and soil losses were monitored after each rainfall event (five rainfall events in total). Also, different forest stand characteristics (slope, tree density, basal area and shrub/herbal cover) affecting each plot were measured. Results showed that forest stand characteristics were very similar in all used plots. Also, physico-chemical runoff properties were highly modified after the prescribed fire, increasing water pH, carbonates, bicarbonates, total dissolved solids and organic matter content dissolved in water. Electrical conductivity, calcium, sodium, chloride and magnesium were not affected by prescribed fire. Soil losses were highly related to precipitation intensity and tree interception. Tree intercepted the rainfall and significantly reduced soil losses and also runoff quantity. In conclusion and after the first six-month experiment, the influence of prescribed fires on physico-chemical runoff properties should be taken into account for developing proper prescribed burnings guidelines.

On the numeric integration of dynamic attitude equations

NASA Technical Reports Server (NTRS)

Crouch, P. E.; Yan, Y.; Grossman, Robert

1992-01-01

We describe new types of numerical integration algorithms developed by the authors. The main aim of the algorithms is to numerically integrate differential equations which evolve on geometric objects, such as the rotation group. The algorithms provide iterates which lie on the prescribed geometric object, either exactly, or to some prescribed accuracy, independent of the order of the algorithm. This paper describes applications of these algorithms to the evolution of the attitude of a rigid body.

Computerized adaptive control weld skate with CCTV weld guidance project

NASA Technical Reports Server (NTRS)

Wall, W. A.

1976-01-01

This report summarizes progress of the automatic computerized weld skate development portion of the Computerized Weld Skate with Closed Circuit Television (CCTV) Arc Guidance Project. The main goal of the project is to develop an automatic welding skate demonstration model equipped with CCTV weld guidance. The three main goals of the overall project are to: (1) develop a demonstration model computerized weld skate system, (2) develop a demonstration model automatic CCTV guidance system, and (3) integrate the two systems into a demonstration model of computerized weld skate with CCTV weld guidance for welding contoured parts.

7 CFR 989.702 - Minimum grade standards for packed raisins.

Code of Federal Regulations, 2011 CFR

2011-01-01

... MARKETING SERVICE (Marketing Agreements and Orders; Fruits, Vegetables, Nuts), DEPARTMENT OF AGRICULTURE... the raisins shall be well-matured or reasonably well-matured. With respect to select-sized and mixed... shall at least meet the requirements of Marketing Order Grade B prescribed in this paragraph. The...

3 CFR 13593 - Executive Order 13593 of December 13, 2011. 2011 Amendments to the Manual for Courts-Martial...

Code of Federal Regulations, 2012 CFR

2012-01-01

... United States of America, including chapter 47 of title 10, United States Code (Uniform Code of Military Justice, 10 U.S.C. 801-946), and in order to prescribe amendments to the Manual for Courts-Martial, United...

3 CFR 13643 - Executive Order 13643 of May 15, 2013. 2013 Amendments to the Manual for Courts-Martial, United...

Code of Federal Regulations, 2014 CFR

2014-01-01

... States of America, including chapter 47 of title 10, United States Code (Uniform Code of Military Justice, 10 U.S.C. 801-946), and in order to prescribe amendments to the Manual for Courts-Martial, United...

3 CFR 13552 - Executive Order 13552 of August 31, 2010. 2010 Amendments to the Manual for Courts-Martial...

Code of Federal Regulations, 2011 CFR

2011-01-01

... States of America, including chapter 47 of title 10, United States Code (Uniform Code of Military Justice, 10 U.S.C. 801-946), and in order to prescribe amendments to the Manual for Courts-Martial, United...

A study of the prevalence of significant increases in serum creatinine following angiotension-converting enzyme inhibitor administration.

PubMed

Thorp, M L; Ditmer, D G; Nash, M K; Wise, R; Jaderholm, P L; Smith, J D; Chan, W

2005-05-01

Angiontension-converting enzyme inhibitors (ACEIs) are beneficial in the treatment of diabetic and nondiabetic kidney disease, coronary artery disease and congestive heart failure. One adverse effect of ACEIs use is a rise in serum creatinine and potential renal failure. This paper attempts to quantify this risk and assess the need for pre- and post-ACEI serum creatinine measurements. A computerized search of Kaiser Permanente Northwest's electronic medical record was conducted to find patients over the age of 40 years taking lisinopril between July 1, 2000 and June 30, 2002. Patient demographic information and presence in diabetes and coronary artery disease registries was collected. A subsequent search for pre- and postlisinopril serum creatinine levels within 6 months of initial lisinopril prescription was conducted. Patients with prelisinopril creatinine < or = 1.2 mg/dl and postlisinopril creatinine > 2.5 mg/dl underwent chart review to discern adverse events associated with the rise in serum creatinine. A total of 18,977 patients were prescribed lisinopril between July 1, 2000 and June 30, 2002. In all 13 166 patients had a pre- and postlisinopril creatinine checked. In all, 31 patients had a rise in creatinine from < or = 1.2 mg/dl to > 2.5 mg/dl (0.2%). Possible contributors to rise in creatinine included congestive heart failure, dehydration and infection. No patients developed end-stage renal disease, although three died. In conclusion, end-stage renal disease is an unlikely outcome among patients prescribed lisinopril and is most likely associated with other events.

Optimizing prescribed fire allocation for managing fire risk in central Catalonia.

PubMed

Alcasena, Fermín J; Ager, Alan A; Salis, Michele; Day, Michelle A; Vega-Garcia, Cristina

2018-04-15

We used spatial optimization to allocate and prioritize prescribed fire treatments in the fire-prone Bages County, central Catalonia (northeastern Spain). The goal of this study was to identify suitable strategic locations on forest lands for fuel treatments in order to: 1) disrupt major fire movements, 2) reduce ember emissions, and 3) reduce the likelihood of large fires burning into residential communities. We first modeled fire spread, hazard and exposure metrics under historical extreme fire weather conditions, including node influence grid for surface fire pathways, crown fraction burned and fire transmission to residential structures. Then, we performed an optimization analysis on individual planning areas to identify production possibility frontiers for addressing fire exposure and explore alternative prescribed fire treatment configurations. The results revealed strong trade-offs among different fire exposure metrics, showed treatment mosaics that optimize the allocation of prescribed fire, and identified specific opportunities to achieve multiple objectives. Our methods can contribute to improving the efficiency of prescribed fire treatment investments and wildfire management programs aimed at creating fire resilient ecosystems, facilitating safe and efficient fire suppression, and safeguarding rural communities from catastrophic wildfires. The analysis framework can be used to optimally allocate prescribed fire in other fire-prone areas within the Mediterranean region and elsewhere. Copyright © 2017 Elsevier B.V. All rights reserved.

An Application of Computerized Axial Tomography (CAT) Technology to Mass Raid Tracking

DTIC Science & Technology

1989-08-01

ESD-TR-89-305 MTR-10542 An Application of Computerized Axial Tomography ( CAT ) Technology to Mass Raid Tracking By John K. Barr August 1989...NO 11. TITLE (Include Security Classification) An Application of Computerized Axial Tomography ( CAT ) Technology to Mass Raid Tracking 12...by block number) Computerized Axial Tomography ( CAT ) Scanner Electronic Support Measures (ESM) Fusion (continued) 19. ABSTRACT (Continue on

Increasing profitability through computerization.

PubMed

Sokol, D J

1988-01-01

The author explores the pragmatic or financial justification for computerizing a dental practice and discusses a computerized approach to precollection and collection for the dental office. The article also deals with the use of computerized correspondence to augment the recall policy of the office and to help generate new patient referrals and discusses the pros and cons of utilizing a dental computer service bureau in implementing these policies.

Special postoperative diet orders: Irrational, obsolete, and imprudent.

PubMed

Sriram, Krishnan; Ramasubramanian, Vidhya; Meguid, Michael M

2016-04-01

There are no indications to prescribed special diets for postoperative patients. Low-sodium and low-fat or low-cholesterol diets are examples of restricted diets, especially in patients with heart disease and atherosclerosis. These restricted diets are unpalatable. Postoperative nausea, paralytic ileus, and vomiting caused by residual anesthetic effects and opioids used for pain control further contribute to the problem. Long-term adherence to these diets is necessary to derive benefits. Prescribing regular and palatable diets in the immediate postoperative period to meet protein and energy goals is important for wound healing and is commensurate with best clinical practices. In the following, we review the pertinent literature and offer clinical evidence that routine special diet orders for postoperative patients are not necessary. Published by Elsevier Inc.

Controlling postoperative use of i.v. acetaminophen at an academic medical center.

PubMed

Vincent, William R; Huiras, Paul; Empfield, Jennifer; Horbowicz, Kevin J; Lewis, Keith; McAneny, David; Twitchell, David

2018-04-15

Results of an interprofessional formulary initiative to decrease postoperative prescribing of i.v. acetaminophen are reported. After a medical center added i.v. acetaminophen to its formulary, increased prescribing of the i.v. formulation and a 3-fold price increase resulted in monthly spending of more than $40,000, prompting an organizationwide effort to curtail that cost while maintaining effective pain management. The surgery, anesthesia, and pharmacy departments applied the Institute for Healthcare Improvement's Model for Improvement to implement (1) pharmacist-led enforcement of prescribing restrictions, (2) retrospective evaluation of i.v. acetaminophen's impact on rates of opioid-related adverse effects, (3) restriction of prescribing of the drug to 1 postoperative dose on select patient care services, and (4) guideline-driven pain management according to an enhanced recovery after surgery (ERAS) protocol. Monitored metrics included the monthly i.v. acetaminophen prescribing rate, the proportion of i.v. acetaminophen orders requiring pharmacist intervention to enforce prescribing restrictions, and prescribing rates for select adjunctive analgesics. Within a year of project implementation, the mean monthly i.v. acetaminophen prescribing rate decreased by 83% from baseline to about 6 doses per 100 patient-days, with a decline in the monthly drug cost to about $4,000. Documented pharmacist interventions increased 2.7-fold, and use of oral acetaminophen, ketorolac, and gabapentin in ERAS areas increased by 18% overall. An interprofessional initiative at a large medical center reduced postoperative use of i.v. acetaminophen by more than 80% and yielded over $400,000 in annual cost savings. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Time Trends and Geographical Variation in Prescribing of Drugs for Diabetes in England 1998-2017.

PubMed

Curtis, Helen J; Dennis, John M; Shields, Beverley M; Walker, Alex J; Bacon, Seb; Hattersley, Andrew T; Jones, Angus G; Goldacre, Ben

2018-05-07

UK guidelines for type II diabetes leave the choice of glucose lowering therapies after metformin largely to prescribers. They vary greatly in cost, and comparative effectiveness data is lacking. We set out to measure the variation in prescribing of these second-line non-insulin diabetes drugs. We evaluated time trends 1998-2016, using England's publicly available prescribing datasets, and stratified by the order prescribed to patients using the Clinical Practice Research Datalink (CPRD). We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated geographical variation in prescribing using general practice-level data for the latest 12-months (to August 2017), with aggregation to Clinical Commissioning Groups (CCGs). We calculated percentiles, ranges and plotted maps. Prescribing of therapy after metformin is changing rapidly. DPP4-inhibitor use has increased markedly, now the most common second-line drug (43% prescriptions in 2016). Use of SGLT-2 inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There is wide geographical variation in choice of therapies and average spend per patient. In contrast, metformin is consistently used first-line in accordance with guidelines. In England there is extensive geographical variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP4-inhibitors and SGLT-2 inhibitors over low-cost sulfonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs. This article is protected by copyright. All rights reserved.

76 FR 53842 - Irish Potatoes Grown in Colorado; Modification of the Handling Regulation for Area No. 3

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-30

... Service 7 CFR Part 948 [Doc. No. AMS-FV-11-0051; FV11-948-1 PR] Irish Potatoes Grown in Colorado... prescribed under the Colorado potato marketing order (order). The order regulates the handling of Irish potatoes grown in Colorado, and is administered locally by the Colorado Potato Administrative Committee for...

78 FR 36807 - Self-Regulatory Organizations; NASDAQ OMX PHLX LLC; Notice of Filing and Immediate Effectiveness...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-19

...)(iii).\\4\\ \\4\\ 17 CFR 240.19b-4(f)(6)(iii). The text of the proposed rule change is below. Proposed... term ``Order Type'' shall mean the unique processing prescribed for designated orders that are eligible... responsible single plan processor in order to comply with the quotation requirements for Market Makers set...

10 CFR 2.307 - Extension and reduction of time limits; delegated authority to order use of procedures for access...

Code of Federal Regulations, 2010 CFR

2010-01-01

... authority to order use of procedures for access by potential parties to certain sensitive unclassified... authority to order use of procedures for access by potential parties to certain sensitive unclassified... Commission or the presiding officer. (b) If this part does not prescribe a time limit for an action to be...

Computerized detection of vertebral compression fractures on lateral chest radiographs: Preliminary results with a tool for early detection of osteoporosis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kasai, Satoshi; Li Feng; Shiraishi, Junji

Vertebral fracture (or vertebral deformity) is a very common outcome of osteoporosis, which is one of the major public health concerns in the world. Early detection of vertebral fractures is important because timely pharmacologic intervention can reduce the risk of subsequent additional fractures. Chest radiographs are used routinely for detection of lung and heart diseases, and vertebral fractures can be visible on lateral chest radiographs. However, investigators noted that about 50% of vertebral fractures visible on lateral chest radiographs were underdiagnosed or under-reported, even when the fractures were severe. Therefore, our goal was to develop a computerized method for detectionmore » of vertebral fractures on lateral chest radiographs in order to assist radiologists' image interpretation and thus allow the early diagnosis of osteoporosis. The cases used in this study were 20 patients with severe vertebral fractures and 118 patients without fractures, as confirmed by the consensus of two radiologists. Radiologists identified the locations of fractured vertebrae, and they provided morphometric data on the vertebral shape for evaluation of the accuracy of detecting vertebral end plates by computer. In our computerized method, a curved search area, which included a number of vertebral end plates, was first extracted automatically, and was straightened so that vertebral end plates became oriented horizontally. Edge candidates were enhanced by use of a horizontal line-enhancement filter in the straightened image, and a multiple thresholding technique, followed by feature analysis, was used for identification of the vertebral end plates. The height of each vertebra was determined from locations of identified vertebral end plates, and fractured vertebrae were detected by comparison of the measured vertebral height with the expected height. The sensitivity of our computerized method for detection of fracture cases was 95% (19/20), with 1.03 (139/135) false-positive fractures per image. The accuracy of identifying vertebral end plates, marked by radiologists in a morphometric study, was 76.6% (400/522) and 70.9% (420/592) for cases used for training and those for testing, respectively. We prepared 32 additional fracture cases for a validation test, and we examined the detection accuracy of our computerized method. The sensitivity for these cases was 75% (24/32) at 1.03 (33/32) false-positive fractures per image. Our preliminary results show that the automated computerized scheme for detecting vertebral fractures on lateral chest radiographs has the potential to assist radiologists in detecting vertebral fractures.« less

A prospective audit of a nurse independent prescribing within critical care.

PubMed

Carberry, Martin; Connelly, Sarah; Murphy, Jennifer

2013-05-01

To determine the prescribing activity of different staff groups within intensive care unit (ICU) and combined high dependency unit (HDU), namely trainee and consultant medical staff and advanced nurse practitioners in critical care (ANPCC); to determine the number and type of prescription errors; to compare error rates between prescribing groups and to raise awareness of prescribing activity within critical care. The introduction of government legislation has led to the development of non-medical prescribing roles in acute care. This has facilitated an opportunity for the ANPCC working in critical care to develop a prescribing role. The audit was performed over 7 days (Monday-Sunday), on rolling days over a 7-week period in September and October 2011 in three ICUs. All drug entries made on the ICU prescription by the three groups, trainee medical staff, ANPCCs and consultant anaesthetists, were audited once for errors. Data were collected by reviewing all drug entries for errors namely, patient data, drug dose, concentration, rate and frequency, legibility and prescriber signature. A paper data collection tool was used initially; data was later entered onto a Microsoft Access data base. A total of 1418 drug entries were audited from 77 patient prescription Cardexes. Error rates were reported as, 40 errors in 1418 prescriptions (2·8%): ANPCC errors, n = 2 in 388 prescriptions (0·6%); trainee medical staff errors, n = 33 in 984 (3·4%); consultant errors, n = 5 in 73 (6·8%). The error rates were significantly different for different prescribing groups (p < 0·01). This audit shows that prescribing error rates were low (2·8%). Having the lowest error rate, the nurse practitioners are at least as effective as other prescribing groups within this audit, in terms of errors only, in prescribing diligence. National data is required in order to benchmark independent nurse prescribing practice in critical care. These findings could be used to inform research and role development within the critical care. © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses.

Influence of computerized sounding out on spelling performance for children who do and do not rely on AAC.

PubMed

McCarthy, Jillian H; Hogan, Tiffany P; Beukelman, David R; Schwarz, Ilsa E

2015-05-01

Spelling is an important skill for individuals who rely on augmentative and alternative communication (AAC). The purpose of this study was to investigate how computerized sounding out influenced spelling accuracy of pseudo-words. Computerized sounding out was defined as a word elongated, thus providing an opportunity for a child to hear all the sounds in the word at a slower rate. Seven children with cerebral palsy, four who use AAC and three who do not, participated in a single subject AB design. The results of the study indicated that the use of computerized sounding out increased the phonologic accuracy of the pseudo-words produced by participants. The study provides preliminary evidence for the use of computerized sounding out during spelling tasks for children with cerebral palsy who do and do not use AAC. Future directions and clinical implications are discussed. We investigated how computerized sounding out influenced spelling accuracy of pseudowords for children with complex communication needs who did and did not use augmentative and alternative communication (AAC). Results indicated that the use of computerized sounding out increased the phonologic accuracy of the pseudo-words by participants, suggesting that computerized sounding out might assist in more accurate spelling for children who use AAC. Future research is needed to determine how language and reading abilities influence the use of computerized sounding out with children who have a range of speech intelligibility abilities and do and do not use AAC.

Prescribed performance distributed consensus control for nonlinear multi-agent systems with unknown dead-zone input

NASA Astrophysics Data System (ADS)

Cui, Guozeng; Xu, Shengyuan; Ma, Qian; Li, Yongmin; Zhang, Zhengqiang

2018-05-01

In this paper, the problem of prescribed performance distributed output consensus for higher-order non-affine nonlinear multi-agent systems with unknown dead-zone input is investigated. Fuzzy logical systems are utilised to identify the unknown nonlinearities. By introducing prescribed performance, the transient and steady performance of synchronisation errors are guaranteed. Based on Lyapunov stability theory and the dynamic surface control technique, a new distributed consensus algorithm for non-affine nonlinear multi-agent systems is proposed, which ensures cooperatively uniformly ultimately boundedness of all signals in the closed-loop systems and enables the output of each follower to synchronise with the leader within predefined bounded error. Finally, simulation examples are provided to demonstrate the effectiveness of the proposed control scheme.

Computerized analysis of fetal heart rate variability signal during the stages of labor.

PubMed

Annunziata, Maria Laura; Tagliaferri, Salvatore; Esposito, Francesca Giovanna; Giuliano, Natascia; Mereghini, Flavia; Di Lieto, Andrea; Campanile, Marta

2016-03-01

To analyze computerized cardiotocographic (cCTG) parameters (baseline fetal heart rate, baseline FHR; short term variability, STV; approximate entropy, ApEn; low frequency, LF; movement frequency, MF; high frequency, HF) in physiological pregnancy in order to correlate them with the stages of labor. This could provide more information for understanding the mechanisms of nervous system control of FHR during labor progression. A total of 534 pregnant women were monitored on cCTG from the 37th week before the onset of spontaneous labor and during the first and the second stage of labor. Statistical analysis was performed using Kruskal-Wallis test and Wilcoxon rank-sum test with the Bonferroni adjusted α (< 0.05). Statistically significant differences were seen between baseline FHR, MF and HF (P < 0.001), in which the first two were reduced and the third was increased when compared between pre-labor, and the first and second stages of labor. Differences between some of the stages were found for ApEn, LF and for LF/(HF + MF), where the first and the third were reduced and the second was increased. cCTG modifications during labor may reflect the physiologic increased activation of the autonomous nervous system. Using computerized fetal heart rate analysis during labor it may be possible to obtain more information from the fetal cardiac signal, in comparison with the traditional tracing. © 2016 Japan Society of Obstetrics and Gynecology.

48 CFR 252.217-7005 - Inspection and manner of doing work.

Code of Federal Regulations, 2013 CFR

2013-10-01

... time of Contractor's submission of bid (or acceptance of the job order, if negotiated). (2) When Navy specifications are specified in the job order, the Contractor shall follow Navy standards of material and workmanship. The solicitation shall prescribe the Navy standard whenever applicable. (c) The Government may...

48 CFR 252.217-7005 - Inspection and manner of doing work.

Code of Federal Regulations, 2011 CFR

2011-10-01

... time of Contractor's submission of bid (or acceptance of the job order, if negotiated). (2) When Navy specifications are specified in the job order, the Contractor shall follow Navy standards of material and workmanship. The solicitation shall prescribe the Navy standard whenever applicable. (c) The Government may...

48 CFR 252.217-7005 - Inspection and manner of doing work.

Code of Federal Regulations, 2012 CFR

2012-10-01

... time of Contractor's submission of bid (or acceptance of the job order, if negotiated). (2) When Navy specifications are specified in the job order, the Contractor shall follow Navy standards of material and workmanship. The solicitation shall prescribe the Navy standard whenever applicable. (c) The Government may...

48 CFR 252.217-7005 - Inspection and manner of doing work.

Code of Federal Regulations, 2014 CFR

2014-10-01

... time of Contractor's submission of bid (or acceptance of the job order, if negotiated). (2) When Navy specifications are specified in the job order, the Contractor shall follow Navy standards of material and workmanship. The solicitation shall prescribe the Navy standard whenever applicable. (c) The Government may...

48 CFR 252.217-7005 - Inspection and manner of doing work.

Code of Federal Regulations, 2010 CFR

2010-10-01

... time of Contractor's submission of bid (or acceptance of the job order, if negotiated). (2) When Navy specifications are specified in the job order, the Contractor shall follow Navy standards of material and workmanship. The solicitation shall prescribe the Navy standard whenever applicable. (c) The Government may...

Viscoelastic Timoshenko Beams with Occasionally Constant Relaxation Functions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tatar, Nasser-eddine, E-mail: tatarn@kfupm.edu.sa

2012-08-15

For a prescribed desirable arbitrary decay suitable viscoelastic materials are determined through their relaxation functions. It is shown that if we wish to have a decay of order {gamma}(t) then the kernels should be of the same order. That is their product with this function should be summable.

Evaluation of real-time clinical decision support systems for platelet and cryoprecipitate orders.

PubMed

Collins, Ryan A; Triulzi, Darrell J; Waters, Jonathan H; Reddy, Vivek; Yazer, Mark H

2014-01-01

To evaluate cryoprecipitate and platelet ordering practices after the implementation of real-time clinical decision support systems (CDSSs) in a computerized physician order entry (CPOE) system. Uniform platelet and cryoprecipitate transfusion thresholds were implemented at 11 hospitals in a regional health care system with a common CPOE system. Over 6 months, a variety of information was collected on the ordering physicians and the number of alerts generated by the CDSSs when these products were ordered outside of the institutional guidelines. There were 1,889 orders for platelets and 152 orders for cryoprecipitate placed in 6 months. Of these, 1,102 (58.3%) platelet and 74 (48.7%) cryoprecipitate orders triggered an alert. The proportion of orders canceled after an alert was generated ranged from 13.5% to 17.9% for platelets and 0% to 50.0% for cryoprecipitate orders. CDSS alerts reduce, but do not eliminate, platelet and cryoprecipitate transfusions that do not meet institutional guidelines.

Assessment of Apixaban Prescribing Patterns for Nonvalvular Atrial Fibrillation in Hospitalized Patients.

PubMed

Gibson, Caitlin M; Smith, Carmen B; Davis, Sondra; Scalese, Michael J

2018-01-01

Apixaban is a direct oral anticoagulant (DOAC) for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). Other DOACs require renal dose adjustments based solely on creatinine clearance. Apixaban differs in that its dose adjustments are more complex, potentially leading to prescribing errors. To determine if adherence to Food and Drug Administration (FDA)-approved dosing for apixaban is maintained in hospitalized patients with NVAF. Patients ≥18 years old with NVAF who received apixaban during admission to 1 of 3 hospitals were evaluated. The primary outcome was to determine if providers order apixaban in accordance with FDA-approved dosages. Secondary outcomes included determining if pharmacist review increased the number of orders in accordance with FDA-approved dosing, which of the 3 criteria (age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) were met in patients receiving off-label dosing, and the rationale for off-label prescribing. A total of 556 patients met inclusion criteria. Apixaban was dosed according to FDA labeling by providers in 83.4% (n = 464) of orders. After pharmacist review, 87.0% (n = 484) of orders were at the approved dose, 12.2% (n = 68) were underdosed, and 0.7% (n = 4) were overdosed. Most patients who were underdosed met only 1 dose reduction criterion-most commonly age ≥80 years (56.0%). Reasons for off-label dosing included home dose continuation (39.0%), history of or perceived bleeding risk (30.5%), or unspecified/other (30.5%). The majority of apixaban orders for NVAF were based on FDA-approved dosages after provider entry and pharmacist review.

Fault Tolerant Considerations and Methods for Guidance and Control Systems

DTIC Science & Technology

1987-07-01

multifunction devices such as microprocessors with software. In striving toward the economic goal, however, a cost is incurred in a different coin, i.e...therefore been developed which reduces the software risk to acceptable proportions. Several of the techniques thus developed incur no significant cost ...complex that their design and implementation need computerized tools in order to be cost -effective (in a broad sense, including the capability of

Similarity Search in Large Collections of Biometric Data

DTIC Science & Technology

2009-10-01

instantaneous identification of a person by converting the biometric into a digital form and then comparing it against a computerized database . They can...combined to get reliable results. Exact match in biometric collections have very little meaning and only a relative ordering of database objects with...running several indices for different aspects of the data, e.g. facial features, fingerprints and palmprints of a person, together. The system then

[Analysis of drug-related problems in a tertiary university hospital in Barcelona (Spain)].

PubMed

Ferrández, Olivia; Casañ, Borja; Grau, Santiago; Louro, Javier; Salas, Esther; Castells, Xavier; Sala, Maria

2018-05-07

To describe drug-related problems identified in hospitalized patients and to assess physicians' acceptance rate of pharmacists' recommendations. Retrospective observational study that included all drug-related problems detected in hospitalized patients during 2014-2015. Statistical analysis included a descriptive analysis of the data and a multivariate logistic regression to evaluate the association between pharmacists' recommendation acceptance rate and the variable of interest. During the study period 4587 drug-related problems were identified in 44,870 hospitalized patients. Main drug-related problems were prescription errors due to incorrect use of the computerized physician order entry (18.1%), inappropriate drug-drug combination (13.3%) and dose adjustment by renal and/or hepatic function (11.5%). Acceptance rate of pharmacist therapy advice in evaluable cases was 81.0%. Medical versus surgical admitting department, specific types of intervention (addition of a new drug, drug discontinuation and correction of a prescription error) and oral communication of the recommendation were associated with a higher acceptance rate. The results of this study allow areas to be identified on which to implement optimization strategies. These include training courses for physicians on the computerized physician order entry, on drugs that need dose adjustment with renal impairment, and on relevant drug interactions. Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Standard practices for computerized clinical decision support in community hospitals: a national survey

PubMed Central

McCormack, James L; Sittig, Dean F; Wright, Adam; McMullen, Carmit; Bates, David W

2012-01-01

Objective Computerized provider order entry (CPOE) with clinical decision support (CDS) can help hospitals improve care. Little is known about what CDS is presently in use and how it is managed, however, especially in community hospitals. This study sought to address this knowledge gap by identifying standard practices related to CDS in US community hospitals with mature CPOE systems. Materials and Methods Representatives of 34 community hospitals, each of which had over 5 years experience with CPOE, were interviewed to identify standard practices related to CDS. Data were analyzed with a mix of descriptive statistics and qualitative approaches to the identification of patterns, themes and trends. Results This broad sample of community hospitals had robust levels of CDS despite their small size and the independent nature of many of their physician staff members. The hospitals uniformly used medication alerts and order sets, had sophisticated governance procedures for CDS, and employed staff to customize CDS. Discussion The level of customization needed for most CDS before implementation was greater than expected. Customization requires skilled individuals who represent an emerging manpower need at this type of hospital. Conclusion These results bode well for robust diffusion of CDS to similar hospitals in the process of adopting CDS and suggest that national policies to promote CDS use may be successful. PMID:22707744

[Opinion of primary care physicians from Ourense on various features of the pharmaceutical prescription].

PubMed

Díaz Grávalos, G J; Palmeiro Fernández, G; Núnñez Masid, E; Casado Górriz, I

2001-01-01

To learn the opinion of the primary care Physicians of Ourense (Spain) with respect to certain aspects of their prescription of medicines, such as their awareness of the price of drugs, the induced prescribing perceived, their relationship with the pharmaceutical industry and their opinions concerning possible measures for reducing the expenditure on medicines. In this transversal descriptive study, all of the primary care physicians in the province of Ourense (243) were surveyed by means of a previously-approved questionnaire sent to them by post. The questionnaire included demographic characteristics of the physicians, the influence of cost when prescribing medicines, their estimate of the price of 15 drugs routinely prescribed and their opinion on different aspects relating to induced prescription, the pharmaceutical industry and different strategies in order to curtail the expenditure on medicines. In order to analyze the results, the chi 2 and Student's t tests and an analysis of the variance were used, together with the Spearman correlation coefficient with alpha = 0.05. The level of participation of the physicians surveyed was 42.8% (104). The average daily duration of visits by pharmaceutical company representatives was 13.6 minutes, with new specialities being the topic of greatest interest. Close to 27% admitted to having participated in clinical testing sponsored by the industry. 23% considered the price to be a priority when prescribing. Induced prescription accounted for 39.7% of the total. The majority of physicians chose co-payment as the means for reducing expenditure on medicines. In the estimate of prices, the overall percentage of error was 45.7%, underestimating the more expensive medicines and overestimating the less expensive. There is a significant lack of awareness of the price of drugs among the primary care physicians. Most of the physicians do not feel that the price of a drug should be a priority when prescribing medicines. There is a high percentage of induced prescription perceived. With regard to the expenditure on pharmaceuticals, the majority of those surveyed feel that financial measures, specifically co-payment, are the most effective in order to curtail rising costs.

Type Certification Process

DOT National Transportation Integrated Search

1995-03-02

This order prescribes the responsibilities and procedures for Federal Aviation Administration (FAA) aircraft certification personnel responsible for the certification process required by the Federal Aviation Regulations for civil aircraft,aircraft en...

Duplicate laboratory test reduction using a clinical decision support tool.

PubMed

Procop, Gary W; Yerian, Lisa M; Wyllie, Robert; Harrison, A Marc; Kottke-Marchant, Kandice

2014-05-01

Duplicate laboratory tests that are unwarranted increase unnecessary phlebotomy, which contributes to iatrogenic anemia, decreased patient satisfaction, and increased health care costs. We employed a clinical decision support tool (CDST) to block unnecessary duplicate test orders during the computerized physician order entry (CPOE) process. We assessed laboratory cost savings after 2 years and searched for untoward patient events associated with this intervention. This CDST blocked 11,790 unnecessary duplicate test orders in these 2 years, which resulted in a cost savings of $183,586. There were no untoward effects reported associated with this intervention. The movement to CPOE affords real-time interaction between the laboratory and the physician through CDSTs that signal duplicate orders. These interactions save health care dollars and should also increase patient satisfaction and well-being.

A Recommendation Algorithm for Automating Corollary Order Generation

PubMed Central

Klann, Jeffrey; Schadow, Gunther; McCoy, JM

2009-01-01

Manual development and maintenance of decision support content is time-consuming and expensive. We explore recommendation algorithms, e-commerce data-mining tools that use collective order history to suggest purchases, to assist with this. In particular, previous work shows corollary order suggestions are amenable to automated data-mining techniques. Here, an item-based collaborative filtering algorithm augmented with association rule interestingness measures mined suggestions from 866,445 orders made in an inpatient hospital in 2007, generating 584 potential corollary orders. Our expert physician panel evaluated the top 92 and agreed 75.3% were clinically meaningful. Also, at least one felt 47.9% would be directly relevant in guideline development. This automated generation of a rough-cut of corollary orders confirms prior indications about automated tools in building decision support content. It is an important step toward computerized augmentation to decision support development, which could increase development efficiency and content quality while automatically capturing local standards. PMID:20351875

A recommendation algorithm for automating corollary order generation.

PubMed

Klann, Jeffrey; Schadow, Gunther; McCoy, J M

2009-11-14

Manual development and maintenance of decision support content is time-consuming and expensive. We explore recommendation algorithms, e-commerce data-mining tools that use collective order history to suggest purchases, to assist with this. In particular, previous work shows corollary order suggestions are amenable to automated data-mining techniques. Here, an item-based collaborative filtering algorithm augmented with association rule interestingness measures mined suggestions from 866,445 orders made in an inpatient hospital in 2007, generating 584 potential corollary orders. Our expert physician panel evaluated the top 92 and agreed 75.3% were clinically meaningful. Also, at least one felt 47.9% would be directly relevant in guideline development. This automated generation of a rough-cut of corollary orders confirms prior indications about automated tools in building decision support content. It is an important step toward computerized augmentation to decision support development, which could increase development efficiency and content quality while automatically capturing local standards.

11 CFR 9033.12 - Production of computerized information.

Code of Federal Regulations, 2012 CFR

2012-01-01

... conform to the technical specifications, including file requirements, described in the Federal Election Commission's Computerized Magnetic Media Requirements for title 26 Candidates/Committees Receiving Federal... outstanding campaign obligations. (b) Organization of computerized information and technical specifications...

11 CFR 9033.12 - Production of computerized information.

Code of Federal Regulations, 2014 CFR

2014-01-01

... conform to the technical specifications, including file requirements, described in the Federal Election Commission's Computerized Magnetic Media Requirements for title 26 Candidates/Committees Receiving Federal... outstanding campaign obligations. (b) Organization of computerized information and technical specifications...

11 CFR 9033.12 - Production of computerized information.

Code of Federal Regulations, 2013 CFR

2013-01-01

... conform to the technical specifications, including file requirements, described in the Federal Election Commission's Computerized Magnetic Media Requirements for title 26 Candidates/Committees Receiving Federal... outstanding campaign obligations. (b) Organization of computerized information and technical specifications...

Microcomputer Network for Computerized Adaptive Testing (CAT)

DTIC Science & Technology

1984-03-01

PRDC TR 84-33 \\Q.�d-33- \\ MICROCOMPUTER NETWOJlt FOR COMPUTERIZED ADAPTIVE TESTING ( CAT ) Baldwin Quan Thomas A . Park Gary Sandahl John H...ACCEIIION NO NPRDC TR 84-33 4. TITLE (-d Sul>tlllo) MICROCOMP UTER NETWORK FOR COMPUTERIZED ADA PTIVE TESTING ( CAT ) 1. Q B. uan T. A . Park...adaptive testing ( CAT ) Bayesian sequential testing 20. ABSTitACT (Continuo on ro•••• aide II noco .. _, _., ld-tlly ,.,. t.loclt _._.) DO Computerized

Computerized Adaptive Testing (CAT): A User Manual

DTIC Science & Technology

1984-03-12

NPRDC TR 84-32 COMPUTERIZED ADAPTIVE TESTING ( CAT ): A USER MANUAL Susan Hardwick Lawrence Eastman Ross Cooper Rehab Group, Incorporated San...a ~EI’IOD COVIRED COMPUTERIZED ADAPTIVE TESTING ( CAT ) Final Report Aug 1981-June 1982 A USER MANUAL 1. ~l:l’t,ORMINCI ORCI. RE~ORT NUM.I:R 62-83...II nee• .. _, entl ldentll)’ ,,. llloclr _,.,) A joint-service effort is underway to develop a computerized adaptive testing ( CAT ) system and to

Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

PubMed

Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh

2015-09-16

Medication errors (MEs) are important problems in all hospitalized populations, especially in intensive care unit (ICU). Little is known about the prevalence of medication prescribing errors in the ICU of hospitals in Ethiopia. The aim of this study was to assess medication prescribing errors in the ICU of Tikur Anbessa Specialized Hospital using retrospective cross-sectional analysis of patient cards and medication charts. About 220 patient charts were reviewed with a total of 1311 patient-days, and 882 prescription episodes. 359 MEs were detected; with prevalence of 40 per 100 orders. Common prescribing errors were omission errors 154 (42.89%), 101 (28.13%) wrong combination, 48 (13.37%) wrong abbreviation, 30 (8.36%) wrong dose, wrong frequency 18 (5.01%) and wrong indications 8 (2.23%). The present study shows that medication errors are common in medical ICU of Tikur Anbessa Specialized Hospital. These results suggest future targets of prevention strategies to reduce the rate of medication error.

PM2.5 and Carbon Emissions from Prescribed Fire in a Longleaf Pine Ecosystem

NASA Astrophysics Data System (ADS)

Strenfel, S. J.; Clements, C. B.; Hiers, J. K.; Kiefer, C. M.

2008-12-01

Prescribed fires are a frequently utilized land-management tool in the Southeastern US. In order to better characterize emissions and impacts from prescribed fire in longleaf pine ecosystems, in situ data were obtained within the burn perimeter using a 10-m instrumented flux tower. Turbulence and temperature data at 10-m were sampled at 10 Hz using a sonic anemometer and fine-wire thermocouples respectively. Measurements of PM2.5, CO and CO2 emissions were sampled at 10-m within the burn perimeter and PM2.5 and Black Carbon PM2.5 were sampled 0.5 km downwind of the fire front using a 2-m instrumented tripod. Preliminary results indicate PM2.5 and carbon emissions significantly increased during the fire-front passage, and downwind PM concentrations were amplified beyond pre-fire ambient concentrations. In addition, the considerable amount a heat release and flux data gathered from these prescribed fires suggests that near surface atmospheric conditions were directly impacted by increased turbulence generation.

Resources for Improving Computerized Learning Environments.

ERIC Educational Resources Information Center

Yeaman, Andrew R. J.

1989-01-01

Presents an annotated review of human factors literature that discusses computerized environments. Topics discussed include the application of office automation practices to educational environments; video display terminal (VDT) workstations; health and safety hazards; planning educational facilities; ergonomics in computerized offices; and…

Analysis of the prescribed burning practice in the pine forest of northwestern Portugal.

PubMed

Fernandes, P; Botelho, H

2004-01-01

The ignition of low-intensity fires in the dormant season in the pine stands of north-western Portugal seeks to reduce the existing fuel hazard without compromising site quality. The purpose of this study is to characterise this practice and assess its effectiveness, based on information resulting from the normal monitoring process at the management level, and using operational guidelines, fire behaviour models and a newly developed method to classify prescribed fire severity. Although the region's humid climate strongly constrains the activity of prescribed fire, 87% of the fires analysed were undertaken under acceptable meteorological and fuel moisture conditions. In fact, most operations achieved satisfactory results. On average, prescribed fire reduces by 96% the potential intensity of a wildfire occurring under extreme weather conditions, but 36% of the treated sites would still require heavy fire fighting resources to suppress such fire, and 17% would still carry it in the tree canopy. Only 10% of the prescribed burns have an excessive impact on trees or the forest floor, while 89% (normal fire weather) or 59% (extreme fire weather) comply with both ecological integrity maintenance and wildfire protection needs. Improved planning and monitoring procedures are recommended in order to overcome the current deficiencies.

Computerized provider order entry systems - Research imperatives and organizational challenges facing pathology services.

PubMed

Georgiou, Andrew; Westbrook, Johanna; Braithwaite, Jeffrey

2010-07-13

Information and communication technologies (ICT) are contributing to major changes taking place in pathology and within health services more generally. In this article, we draw on our research experience for over 7 years investigating the implementation and diffusion of computerized provider order entry (CPOE) systems to articulate some of the key informatics challenges confronting pathology laboratories. The implementation of these systems, with their improved information management and decision support structures, provides the potential for enhancing the role that pathology services play in patient care pathways. Beyond eliminating legibility problems, CPOE systems can also contribute to the efficiency and safety of healthcare, reducing the duplication of test orders and diminishing the risk of misidentification of patient samples and orders. However, despite the enthusiasm for CPOE systems, their diffusion across healthcare settings remains variable and is often beset by implementation problems. Information systems like CPOE may have the ability to integrate work, departments and organizations, but unfortunately, health professionals, departments and organizations do not always want to be integrated in ways that information systems allow. A persistent theme that emerges from the research evidence is that one size does not fit all, and system success or otherwise is reliant on the conditions and circumstances in which they are located. These conditions and circumstances are part of what is negotiated in the complex, messy and challenging area of ICT implementation. The solution is not likely to be simple and easy, but current evidence suggests that a combination of concerted efforts, better research designs, more sophisticated theories and hypotheses as well as more skilled, multidisciplinary research teams, tackling this area of study will bring substantial benefits, improving the effectiveness of pathology services, and, as a direct corollary, the quality of patient care.

The impact of the heparin-induced thrombocytopenia (HIT) computerized alert on provider behaviors and patient outcomes.

PubMed

Austrian, Jonathan S; Adelman, Jason S; Reissman, Stan H; Cohen, Hillel W; Billett, Henny H

2011-01-01

The aim of this study was to measure the effect of an electronic heparin-induced thrombocytopenia (HIT) alert on provider ordering behaviors and on patient outcomes. A pop-up alert was created for providers when an individual's platelet values had decreased by 50% or to <100,000/mm(3) in the setting of recent heparin exposure. The authors retrospectively compared inpatients admitted between January 24, 2008 and August 24, 2008 to a control group admitted 1 year prior to the HIT alert. The primary outcome was a change in HIT antibody testing. Secondary outcomes included an assessment of incidence of HIT antibody positivity, percentage of patients started on a direct thrombin inhibitor (DTI), length of stay and overall mortality. There were 1006 and 1081 patients in the control and intervention groups, respectively. There was a 33% relative increase in HIT antibody test orders (p=0.01), and 33% more of these tests were ordered the first day after the criteria were met when a pop-up alert was given (p=0.03). Heparin was discontinued in 25% more patients in the alerted group (p=0.01), and more direct thrombin inhibitors were ordered for them (p=0.03). The number who tested HIT antibody-positive did not differ, however, between the two groups (p=0.99). The length of stay and mortality were similar in both groups. The HIT alert significantly impacted provider behaviors. However, the alert did not result in more cases of HIT being detected or an improvement in overall mortality. Our findings do not support implementation of a computerized HIT alert.

Reducing co-administration of proton pump inhibitors and antibiotics using a computerized order entry alert and prospective audit and feedback.

PubMed

Kandel, Christopher E; Gill, Suzanne; McCready, Janine; Matelski, John; Powis, Jeff E

2016-07-22

Antibiotics and proton pump inhibitors (PPIs) are associated with Clostridium difficile infection (CDI). Both a computer order entry alert to highlight this association as well as antimicrobial stewardship directed prospective audit and feedback represent novel interventions to reduce the co-administration of antibiotics and PPIs among hospitalized patients. Consecutive patients admitted to two General Internal Medicine wards from October 1, 2010 until March 31, 2013 at a teaching hospital in Toronto, Ontario, Canada were evaluated. The baseline observation period was followed by the first phase, which involved the creation of a computerized order entry alert that was triggered when either a PPI or an antibiotic was ordered in the presence of the other. The second phase consisted of the introduction of an antibiotic stewardship-initiated prospective audit and feedback strategy. The primary outcome was the co-administration of antibiotics and PPIs during each phase. This alert led to a significant reduction in the co-administration of antibiotics and PPIs adjusted for month and secular trends, expressed as days of therapy per 100 patient days (4.99 vs. 3.14, p < 0.001) The subsequent introduction of the antibiotic stewardship program further reduced the co-administration (3.14 vs. 1.80, p <0.001). No change was observed in adjusted monthly CDI rates per 100 patient care days between the baseline and alert cohorts (0.12 vs. 0.12, p = 0.99) or the baseline and antibiotic stewardship phases (0.12 vs. 0.13, p = 0.97). Decreasing the co-administration of PPIs and antibiotics can be achieved using a simple automatic alert followed by prospective audit and feedback.

Computerized Provider Order Entry Reduces Length of Stay in a Community Hospital

PubMed Central

Peters, K.; Shaha, S.H.

2014-01-01

Summary Objective Does computerized provider order entry (CPOE) improve clinical, cost, and efficiency outcomes as quantified in shortened hospital length of stay (LOS)? Most prior studies were done in university settings with home-grown electronic records, and are now 20 years old. This study asked whether CPOE exerts a downward force on LOS in the current era of HITECH incentives, using a vendor product in a community hospital. Methods The methodology retrospectively evaluated correlation between CPOE and LOS on a perpatient, per-visit basis over 22 consecutive quarters, organized by discipline. All orders from all areas were eligible, except verbals, and medication orders in the emergency department which were not available via CPOE. These results were compared with quarterly case mix indices organized by discipline. Correlational and regression analyses were cross-checked to ensure validity of R-square coefficients, and data were smoothed for ease of display. Standard models were used to calculate the inflection point. Results Gains in CPOE adoption occurred iteratively house-wide, and in each discipline. LOS decreased in a sigmoid shaped curve. The inflection point shows that once CPOE adoption approaches 60%, further lowering of LOS accelerates. Overall there was a 20.2% reduction in LOS correlated with adoption of CPOE. Case mix index increased during the study period showing that reductions in LOS occurred despite increased patient complexity and resource utilization. Conclusions There was a 20.2% reduction in LOS correlated with rising adoption of CPOE. CPOE contributes to improved clinical, cost, and efficiency outcomes as quantified in reduced LOS, over and above other processes introduced to lower LOS. CPOE enabled a reduction in LOS despite an increase in the case mix index during the time frame of this study. PMID:25298809

An overview of selected information storage and retrieval issues in computerized document processing

NASA Technical Reports Server (NTRS)

Dominick, Wayne D. (Editor); Ihebuzor, Valentine U.

1984-01-01

The rapid development of computerized information storage and retrieval techniques has introduced the possibility of extending the word processing concept to document processing. A major advantage of computerized document processing is the relief of the tedious task of manual editing and composition usually encountered by traditional publishers through the immense speed and storage capacity of computers. Furthermore, computerized document processing provides an author with centralized control, the lack of which is a handicap of the traditional publishing operation. A survey of some computerized document processing techniques is presented with emphasis on related information storage and retrieval issues. String matching algorithms are considered central to document information storage and retrieval and are also discussed.

Prescribing errors during hospital inpatient care: factors influencing identification by pharmacists.

PubMed

Tully, Mary P; Buchan, Iain E

2009-12-01

To investigate the prevalence of prescribing errors identified by pharmacists in hospital inpatients and the factors influencing error identification rates by pharmacists throughout hospital admission. 880-bed university teaching hospital in North-west England. Data about prescribing errors identified by pharmacists (median: 9 (range 4-17) collecting data per day) when conducting routine work were prospectively recorded on 38 randomly selected days over 18 months. Proportion of new medication orders in which an error was identified; predictors of error identification rate, adjusted for workload and seniority of pharmacist, day of week, type of ward or stage of patient admission. 33,012 new medication orders were reviewed for 5,199 patients; 3,455 errors (in 10.5% of orders) were identified for 2,040 patients (39.2%; median 1, range 1-12). Most were problem orders (1,456, 42.1%) or potentially significant errors (1,748, 50.6%); 197 (5.7%) were potentially serious; 1.6% (n = 54) were potentially severe or fatal. Errors were 41% (CI: 28-56%) more likely to be identified at patient's admission than at other times, independent of confounders. Workload was the strongest predictor of error identification rates, with 40% (33-46%) less errors identified on the busiest days than at other times. Errors identified fell by 1.9% (1.5-2.3%) for every additional chart checked, independent of confounders. Pharmacists routinely identify errors but increasing workload may reduce identification rates. Where resources are limited, they may be better spent on identifying and addressing errors immediately after admission to hospital.

A longitudinal analysis of self-prescribed complementary and alternative medicine use by a nationally representative sample of 19,783 Australian women, 2006-2010.

PubMed

Bowe, Steven; Adams, Jon; Lui, Chi-Wai; Sibbritt, David

2015-10-01

Complementary and alternative medicine (CAM) use is increasingly popular amongst general populations around the world with women constituting substantial CAM users. However, self-prescribed CAM use does raise potential safety concerns and so it is important to identify those risk factors associated with self-prescribed CAM use. Data was obtained from the Australian Longitudinal Study on Women's Health (ALSWH). Longitudinal data analyses were conducted on questionnaire data from the 1973-78 cohort (n=9,145) and the 1946-51 cohort (n=10,638), collected over the period 2006-2010. In the 1973-78 cohort, use of self-prescribed CAM was 73.2% in 2006 and 75.3% in 2009. For the 1946-51 cohort, use of self-prescribed CAM was 73.9% in 2007 and 74.7% in 2010. There were similar levels of use of individual self-prescribed CAM, with the exception that the use of herbal medicine was much higher among the 1946-51 cohort (20% vs. 27%). There was a substantial increase over three years in the use of vitamins/minerals in both cohorts (21% and 19%, respectively). In contrast, there was a considerable decline over three years in use of aromatherapy oils in both cohorts (34% and 28%, respectively). Self-prescribed CAM use is popular amongst women in Australia and it is important that conventional practitioners providing women's health care be cognizant of such use amongst their patients. In order to ensure effective practice, there is a need for further research to explore women's decision-making and experiences around self-prescribed CAM use. Copyright © 2015 Elsevier Ltd. All rights reserved.

Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis.

PubMed

Elsaid, K; Truong, T; Monckeberg, M; McCarthy, H; Butera, J; Collins, C

2013-12-01

To evaluate the impact of electronic standardized chemotherapy templates on incidence and types of prescribing errors. A quasi-experimental interrupted time series with segmented regression. A 700-bed multidisciplinary tertiary care hospital with an ambulatory cancer center. A multidisciplinary team including oncology physicians, nurses, pharmacists and information technologists. Standardized, regimen-specific, chemotherapy prescribing forms were developed and implemented over a 32-month period. Trend of monthly prevented prescribing errors per 1000 chemotherapy doses during the pre-implementation phase (30 months), immediate change in the error rate from pre-implementation to implementation and trend of errors during the implementation phase. Errors were analyzed according to their types: errors in communication or transcription, errors in dosing calculation and errors in regimen frequency or treatment duration. Relative risk (RR) of errors in the post-implementation phase (28 months) compared with the pre-implementation phase was computed with 95% confidence interval (CI). Baseline monthly error rate was stable with 16.7 prevented errors per 1000 chemotherapy doses. A 30% reduction in prescribing errors was observed with initiating the intervention. With implementation, a negative change in the slope of prescribing errors was observed (coefficient = -0.338; 95% CI: -0.612 to -0.064). The estimated RR of transcription errors was 0.74; 95% CI (0.59-0.92). The estimated RR of dosing calculation errors was 0.06; 95% CI (0.03-0.10). The estimated RR of chemotherapy frequency/duration errors was 0.51; 95% CI (0.42-0.62). Implementing standardized chemotherapy-prescribing templates significantly reduced all types of prescribing errors and improved chemotherapy safety.

Perceptions of prescribed burning in a local forest community in Victoria, Australia.

PubMed

Bell, Tina; Oliveras, Immaculada

2006-11-01

The general perceptions of prescribed burning were elicited from forest users for an area that has been subject to this form of land management for at least 20 years. The largest group consisted of local residents living in and around the Wombat State Forest with two smaller groups of students from a nearby university campus and local professional land managers. A questionnaire was given to each participant in order to explore how the forest was used, to determine the level of knowledge of burning in the targeted forest and Victoria and the perception of the appearance, effectiveness of protection, and accessibility to the forest after prescribed burning. Generally all groups had similar responses with community members having stronger views on the effectiveness and practicalities of prescribed burning, whereas students were more neutral in their opinions. All participants claimed knowledge of prescribed burning activities within Victoria, but fewer had experience of planned fires in the Wombat State Forest. All groups agreed that areas that had not been recently burned had a better appearance than those that had, but this result may have included a range of value judgments. Land managers had a greater understanding of the ecological importance of season and timing of burning; however, some students and community members were equally knowledgeable. Prescribed burning did not impede access to the forest, nor did smoke from prescribed burns pose any great problem. The majority of the participants felt that the amount of prescribed burning done in the forest was adequate for engendering a feeling of protection to life and property, yet many were still suspicious of this management practice. These initial findings indicate several areas in which further research would be useful including the efficacy of education programs for community members and improved communication of burn plans by land managers.

Computerized Sociometric Assessment for Preschool Children

ERIC Educational Resources Information Center

Endedijk, Hinke M.; Cillessen, Antonius H. N.

2015-01-01

In preschool classes, sociometric peer ratings are used to measure children's peer relationships. The current study examined a computerized version of preschool sociometric ratings. The psychometric properties were compared of computerized sociometric ratings and traditional peer ratings for preschoolers. The distributions, inter-item…

Active Learning through Online Quizzes: Better Learning and Less (Busy) Work

ERIC Educational Resources Information Center

Cook, Brian Robert; Babon, Andrea

2017-01-01

Active learning is increasingly promoted within institutions of higher education to assist students develop higher order thinking and link knowledge to meaning. In this paper, the authors evaluate the use of weekly online quizzes based on prescribed preparatory material as a tool to incentivize preparatory reading in order to enable and encourage…

48 CFR 252.227-7027 - Deferred ordering of technical data or computer software.

Code of Federal Regulations, 2013 CFR

2013-10-01

... technical data or computer software. 252.227-7027 Section 252.227-7027 Federal Acquisition Regulations... data or computer software. As prescribed at 227.7103-8(b), use the following clause: Deferred Ordering of Technical Data or Computer Software (APR 1988) In addition to technical data or computer software...

48 CFR 252.227-7027 - Deferred ordering of technical data or computer software.

Code of Federal Regulations, 2011 CFR

2011-10-01

... technical data or computer software. 252.227-7027 Section 252.227-7027 Federal Acquisition Regulations... data or computer software. As prescribed at 227.7103-8(b), use the following clause: Deferred Ordering of Technical Data or Computer Software (APR 1988) In addition to technical data or computer software...

48 CFR 252.227-7027 - Deferred ordering of technical data or computer software.

Code of Federal Regulations, 2012 CFR

2012-10-01

... technical data or computer software. 252.227-7027 Section 252.227-7027 Federal Acquisition Regulations... data or computer software. As prescribed at 227.7103-8(b), use the following clause: Deferred Ordering of Technical Data or Computer Software (APR 1988) In addition to technical data or computer software...

48 CFR 252.227-7027 - Deferred ordering of technical data or computer software.

Code of Federal Regulations, 2014 CFR

2014-10-01

... technical data or computer software. 252.227-7027 Section 252.227-7027 Federal Acquisition Regulations... data or computer software. As prescribed at 227.7103-8(b), use the following clause: Deferred Ordering of Technical Data or Computer Software (APR 1988) In addition to technical data or computer software...

48 CFR 252.227-7027 - Deferred ordering of technical data or computer software.

Code of Federal Regulations, 2010 CFR

2010-10-01

... technical data or computer software. 252.227-7027 Section 252.227-7027 Federal Acquisition Regulations... data or computer software. As prescribed at 227.7103-8(b), use the following clause: Deferred Ordering of Technical Data or Computer Software (APR 1988) In addition to technical data or computer software...

The "Simmie" Side of Life: Old Order Amish Youths' Affective Response to Culturally Prescribed Deviance.

ERIC Educational Resources Information Center

Reiling, Denise M.

2002-01-01

Analyzed the counterintuitive affective response Old Order Amish youth make to unique cultural prescriptions for adolescent deviance (constructed by adult Amish culture). Interview data supported the basic principles of Terror Management Theory in an unexpected, indirect fashion. Rather than functioning as a specialized cultural-anxiety buffer…

Increased use of antipsychotic long-acting injections with community treatment orders.

PubMed

Patel, Maxine X; Matonhodze, Jane; Baig, Mirza K; Gilleen, James; Boydell, Jane; Holloway, Frank; Taylor, David; Szmukler, George; Lambert, Tim; David, Anthony S

2011-04-01

Community treatment orders (CTOs) are increasingly being used, despite a weak evidence base, and problems continue regarding Second Opinion Appointed Doctor (SOAD) certification of medication. The aim of the current study was to describe current CTO usage regarding patient characteristics, prescribed medication and CTO conditions. A 1-year prospective cohort study with consecutive sampling was conducted for all patients whose CTO was registered in a large mental health trust. Only the first CTO for each patient was included. Measures included sociodemographic variables, psychiatric diagnosis, CTO date of initiation and conditions, psychotropic medication and date of SOAD certification for medication. This study was conducted in the first year of CTO legislation in England and Wales. A total of195 patients were sampled (mean age 40.6 years, 65% male, 52% black ethnic origin). There was significant geographical variability in rates of CTO use (χ(2) = 11.3, p = 0.012). A total of 53% had their place of residence specified as a condition and 29% were required to allow access into their homes. Of those with schizophrenia, 64% were prescribed an antipsychotic long-acting injection (LAI). Of the total group, 7% received high-dose antipsychotics, 10% were prescribed two antipsychotics and only 15% received SOAD certification in time. There was geographical and ethnic variation in CTO use but higher rates of hospital detention in minority ethnic groups may be contributory. Most patients were prescribed antipsychotic LAIs and CTO conditions may not follow the least restrictive principle.

Barriers to accepting e-prescribing in the U.S.A.

PubMed

Smith, Alan D

2006-01-01

With the number of prescriptions rising nationally each year, it is surprising that Web-based technology is not fully embraced in the pharmacy industry as an aid to quality-assuring prescribing processes. Traditional prescription handling is done in a manual fashion with physicians hand-writing prescriptions for the patients during an office visit, giving the patient the responsibility of taking the prescription to a pharmacy or mailing the prescription to a mail order company for fulfillment. Electronic prescribing (e-prescribing) has the ability not only to streamline the prescription writing process, but also to reduce the number of errors that may be incurred with hand-written prescriptions. The purpose of this paper is to investigate these phenomena in the U.S.A. A number of hypotheses were tested using principal-components analysis (PCA) and factor analyses. As a result, a total of 55 fully employed, professional and semi-professional service management and internet users, representing a college-educated and knowledge-based sample derived from the metropolitan section of Pittsburgh, was selected. The six major constructs generated from the factor loadings in descending order of importance were: profit and risk factors, shipping and handling, saving, customer relationship management (CRM) and ethics, age, and awareness. The dependent variable chosen to be regressed against these major independent factor-based constructs was willingness to purchase prescriptions online. The overall relationship was found to be statistically significant (F = 2.971, p = 0.015) in predicting willingness to use e-prescribing options based on the various independent constructs. However, when testing the various standardized beta coefficients in the linear model, only the factor score-based construct CRM and ethics was found to significantly contribute to predicting the willingness to purchase prescriptions online (t = -3.074, p = 0.003). Although this study appears to represent the e-prescribing process in the U.S.A., the sample size and region studied are only one slice of the general population. Practical implications - Unfortunately, the adoption of e-prescribing has been difficult to attain owing to numerous barriers throughout the industry. Such acceptance barriers include lack of technology trust, associated system costs, and risk of un-securing patient health and medical information. This article documents that increasing numbers of pharmacies today are building their IT-infrastructures to accept electronic prescriptions and it may soon be the preferred method for physicians to write prescriptions. It is with great anticipation that this technology will also enhance the prescription-writing abilities of prescribing physicians globally, giving them electronic access to patient medical records and resources that will assist them in prescribing the correct drug for the patient.

Evaluation of computerized health management information system for primary health care in rural India

PubMed Central

2010-01-01

Background The Comprehensive Rural Health Services Project Ballabgarh, run by All India Institute of Medical Sciences (AIIMS), New Delhi has a computerized Health Management Information System (HMIS) since 1988. The HMIS at Ballabgarh has undergone evolution and is currently in its third version which uses generic and open source software. This study was conducted to evaluate the effectiveness of a computerized Health Management Information System in rural health system in India. Methods The data for evaluation were collected by in-depth interviews of the stakeholders i.e. program managers (authors) and health workers. Health Workers from AIIMS and Non-AIIMS Primary Health Centers were interviewed to compare the manual with computerized HMIS. A cost comparison between the two methods was carried out based on market costs. The resource utilization for both manual and computerized HMIS was identified based on workers' interviews. Results There have been no major hardware problems in use of computerized HMIS. More than 95% of data was found to be accurate. Health workers acknowledge the usefulness of HMIS in service delivery, data storage, generation of workplans and reports. For program managers, it provides a better tool for monitoring and supervision and data management. The initial cost incurred in computerization of two Primary Health Centers was estimated to be Indian National Rupee (INR) 1674,217 (USD 35,622). Equivalent annual incremental cost of capital items was estimated as INR 198,017 (USD 4213). The annual savings is around INR 894,283 (USD 11,924). Conclusion The major advantage of computerization has been in saving of time of health workers in record keeping and report generation. The initial capital costs of computerization can be recovered within two years of implementation if the system is fully operational. Computerization has enabled implementation of a good system for service delivery, monitoring and supervision. PMID:21078203

Self-transcendence and medication adherence in older adults with hypertension.

PubMed

Thomas, Nezbile F; Dunn, Karen S

2014-12-01

The purpose of this study was to examine the relationship between self-transcendence and medication adherence among older adults prescribed antihypertensive medication. Descriptive, correlational research design. Forty-six older adults who were prescribed antihypertensive medications from an independent living facility participated in this study. Participants were given a survey that included a demographic questionnaire, the Morisky Medication Adherence Scale, and Reed's Self-Transcendence Scale. No significant relationship was found between medication adherence and self-transcendence (r = -.20, p = .18). Ninety percent of the participants however, admitted to cutting back or stopping their medication without notifying their providers. Continued investigation is needed to identify reasons why older adults fail to adhere to taking prescribed hypertension medications in order to improve health outcomes in this population. © The Author(s) 2014.

The Norwegian Computerized Adaptive Test of Personality Disorder-Static Form (CAT-PD-SF): Reliability, Factor Structure, and Relationships With Personality Functioning.

PubMed

Thimm, Jens C

2017-12-01

The Computerized Adaptive Test of Personality Disorder-Static Form (CAT-PD-SF) is a self-report inventory developed to assess pathological personality traits. The current study explored the reliability and higher order factor structure of the Norwegian version of the CAT-PD-SF and the relationships between the CAT-PD traits and domains of personality functioning in an undergraduate student sample ( N = 375). In addition to the CAT-PD-SF, the short form of the Severity Indices of Personality Problems and the Brief Symptom Inventory were administered. The results showed that the Norwegian CAT-PD-SF has good score reliability. Factor analysis of the CAT-PD-SF scales indicated five superordinate factors that correspond to the trait domains of the alternative DSM-5 model for personality disorders. The CAT-PD traits were highly predictive of impaired personality functioning after controlling for psychological distress. It is concluded that the CAT-PD-SF is a promising tool for the assessment of personality disorder traits.

BanTeC: a software tool for management of corneal transplantation.

PubMed

López-Alvarez, P; Caballero, F; Trias, J; Cortés, U; López-Navidad, A

2005-11-01

Until recently, all cornea information at our tissue bank was managed manually, no specific database or computer tool had been implemented to provide electronic versions of documents and medical reports. The main objective of the BanTeC project was therefore to create a computerized system to integrate and classify all the information and documents used in the center in order to facilitate management of retrieved, transplanted corneal tissues. We used the Windows platform to develop the project. Microsoft Access and Microsoft Jet Engine were used at the database level and Data Access Objects was the chosen data access technology. In short, the BanTeC software seeks to computerize the tissue bank. All the initial stages of the development have now been completed, from specification of needs, program design and implementation of the software components, to the total integration of the final result in the real production environment. BanTeC will allow the generation of statistical reports for analysis to improve our performance.

Temporal analysis of the October 1989 proton flare using computerized anatomical models

NASA Technical Reports Server (NTRS)

Simonsen, L. C.; Cucinotta, F. A.; Atwell, W.; Nealy, J. E.

1993-01-01

The GOES-7 time history data of hourly averaged integral proton fluxes at various particle kinetic energies are analyzed for the solar proton event that occurred between October 19 and 29, 1989. By analyzing the time history data, the dose rates which may vary over many orders of magnitude in the early phases of the flare can be estimated as well as the cumulative dose as a function of time. Basic transport calculations are coupled with detailed body organ thickness distributions from computerized anatomical models to estimate dose rates and cumulative doses to 20 critical body organs. For a 5-cm-thick water shield, cumulative skin, eye, and blood-forming-organ dose equivalents of 1.27, 1.23, and 0.41 Sv, respectively, are estimated. These results are approximately 40-50 percent less than the widely used 0- and 5-cm slab dose estimates. The risk of cancer incidence and mortality are also estimated for astronauts protected by various water shield thicknesses.

Interpretation and mapping of gypsy moth defoilation from ERTS (LANDSAT)-1 temporal composites

NASA Technical Reports Server (NTRS)

Mcmurtry, G. J.; Petersen, G. W. (Principal Investigator); Kowalik, W. S.

1975-01-01

The author has identified the following significant results. Photointerpretation of temporally composited color Diazo transparencies of ERTS(LANDSAT) images is a practical method for detecting and locating levels of widespread defoliation. ERTS 9 x 9 inch images are essentially orthographic and are produced at a nearly constant 1:1,000,000 scale. This allows direct superposition of scenes for temporal composites. ERTS coverage provides a sweeping 180 km (110 mile) wide view, permitting one interpreter to rapidly delineate defoliation in an area requiring days and weeks of work by aerial surveys or computerized processing. Defoliation boundaries can be located on the images within maximum errors on the order of hundreds of meters. The enhancement process is much less expensive than aerial surveys or computerized processing. Maps produced directly from interpretation are manageable working products. The 18 day periodic coverage of ERTS is not frequent enough to replace aerial survey mapping because defoliation and refoliation move as waves.

78 FR 17940 - Certain Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-25

..., Software, Implants, and Components Thereof; Notice of Receipt of Complaint; Solicitation of Comments... Certain Computerized Orthopedic Surgical Devices, Software, Implants, and Components Thereof, DN 2945; the... importation of certain computerized orthopedic surgical devices, software, implants, and components thereof...

Designing a Computerized Presentation Center.

ERIC Educational Resources Information Center

Christopher, Doris A.

1995-01-01

The Office Systems and Business Education Department at California State University (Los Angeles) developed a computerized presentation center, with multimedia classrooms and a multipurpose room, where students learn computerized presentation design skills, faculty can develop materials for class, and local business can do videoconferencing and…

18 CFR 158.11 - Report of certification.

Code of Federal Regulations, 2011 CFR

2011-04-01

... of the independent accountant certifying approval, covering the subjects and in the format prescribed... of compliance made by an independent accountant under this paragraph. [Order 710, 73 FR 19399, Apr...

18 CFR 158.11 - Report of certification.

Code of Federal Regulations, 2012 CFR

2012-04-01

... of the independent accountant certifying approval, covering the subjects and in the format prescribed... of compliance made by an independent accountant under this paragraph. [Order 710, 73 FR 19399, Apr...

18 CFR 158.11 - Report of certification.

Code of Federal Regulations, 2014 CFR

2014-04-01

... of the independent accountant certifying approval, covering the subjects and in the format prescribed... of compliance made by an independent accountant under this paragraph. [Order 710, 73 FR 19399, Apr...

18 CFR 158.11 - Report of certification.

Code of Federal Regulations, 2010 CFR

2010-04-01

... of the independent accountant certifying approval, covering the subjects and in the format prescribed... of compliance made by an independent accountant under this paragraph. [Order 710, 73 FR 19399, Apr...

18 CFR 158.11 - Report of certification.

Code of Federal Regulations, 2013 CFR

2013-04-01

... of the independent accountant certifying approval, covering the subjects and in the format prescribed... of compliance made by an independent accountant under this paragraph. [Order 710, 73 FR 19399, Apr...

Incentives and Barriers That Influence Clinical Computerization in Hong Kong: A Population-based Physician Survey

PubMed Central

Leung, Gabriel M.; Yu, Philip L. H.; Wong, Irene O. L.; Johnston, Janice M.; Tin, Keith Y. K.

2003-01-01

Objective: Given the slow adoption of medical informatics in Hong Kong and Asia, we sought to understand the contributory barriers and potential incentives associated with information technology implementation. Design and Measurements: A representative sample of 949 doctors (response rate = 77.0%) was asked through a postal survey to rank a list of nine barriers associated with clinical computerization according to self-perceived importance. They ranked seven incentives or catalysts that may influence computerization. We generated mean rank scores and used multidimensional preference analysis to explore key explanatory dimensions of these variables. A hierarchical cluster analysis was performed to identify homogenous subgroups of respondents. We further determined the relationships between the sets of barriers and incentives/catalysts collectively using canonical correlation. Results: Time costs, lack of technical support and large capital investments were the biggest barriers to computerization, whereas improved office efficiency and better-quality care were ranked highest as potential incentives to computerize. Cost vs. noncost, physician-related vs. patient-related, and monetary vs. nonmonetary factors were the key dimensions explaining the barrier variables. Similarly, within-practice vs external and “push” vs “pull” factors accounted for the incentive variables. Four clusters were identified for barriers and three for incentives/catalysts. Canonical correlation revealed that respondents who were concerned with the costs of computerization also perceived financial incentives and government regulation to be important incentives/catalysts toward computerization. Those who found the potential interference with communication important also believed that the promise of improved care from computerization to be a significant incentive. Conclusion: This study provided evidence regarding common barriers associated with clinical computerization. Our findings also identified possible incentive strategies that may be employed to accelerate uptake of computer systems. PMID:12595409

Can computerized tomography accurately stage childhood renal tumors?

PubMed

Abdelhalim, Ahmed; Helmy, Tamer E; Harraz, Ahmed M; Abou-El-Ghar, Mohamed E; Dawaba, Mohamed E; Hafez, Ashraf T

2014-07-01

Staging of childhood renal tumors is crucial for treatment planning and outcome prediction. We sought to identify whether computerized tomography could accurately predict the local stage of childhood renal tumors. We retrospectively reviewed our database for patients diagnosed with childhood renal tumors and treated surgically between 1990 and 2013. Inability to retrieve preoperative computerized tomography, intraoperative tumor spillage and nonWilms childhood renal tumors were exclusion criteria. Local computerized tomography stage was assigned by a single experienced pediatric radiologist blinded to the pathological stage, using a consensus similar to the Children's Oncology Group Wilms tumor staging system. Tumors were stratified into up-front surgery and preoperative chemotherapy groups. The radiological stage of each tumor was compared to the pathological stage. A total of 189 tumors in 179 patients met inclusion criteria. Computerized tomography staging matched pathological staging in 68% of up-front surgery (70 of 103), 31.8% of pre-chemotherapy (21 of 66) and 48.8% of post-chemotherapy scans (42 of 86). Computerized tomography over staged 21.4%, 65.2% and 46.5% of tumors in the up-front surgery, pre-chemotherapy and post-chemotherapy scans, respectively, and under staged 10.7%, 3% and 4.7%. Computerized tomography staging was more accurate in tumors managed by up-front surgery (p <0.001) and those without extracapsular extension (p <0.001). The validity of computerized tomography staging of childhood renal tumors remains doubtful. This staging is more accurate for tumors treated with up-front surgery and those without extracapsular extension. Preoperative computerized tomography can help to exclude capsular breach. Treatment strategy should be based on surgical and pathological staging to avoid the hazards of inaccurate staging. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series

PubMed Central

Lowe, Amanda; Hamilton, Michael; Greenall BScPhm MHSc, Julie; Ma, Jessica; Dhalla, Irfan; Persaud, Nav

2017-01-01

Background: Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies. Methods: In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented. Results: We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors. Interpretation: Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated. PMID:28401133

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

PubMed

Lowe, Amanda; Hamilton, Michael; Greenall BScPhm MHSc, Julie; Ma, Jessica; Dhalla, Irfan; Persaud, Nav

2017-01-01

Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies. In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented. We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors. Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated.

15 CFR 950.9 - Computerized Environmental Data and Information Retrieval Service.

Code of Federal Regulations, 2012 CFR

2012-01-01

... Information Retrieval Service. 950.9 Section 950.9 Commerce and Foreign Trade Regulations Relating to Commerce... Computerized Environmental Data and Information Retrieval Service. The Environmental Data Index (ENDEX... computerized, information retrieval service provides a parallel subject-author-abstract referral service. A...

15 CFR 950.9 - Computerized Environmental Data and Information Retrieval Service.

Code of Federal Regulations, 2013 CFR

2013-01-01

... Information Retrieval Service. 950.9 Section 950.9 Commerce and Foreign Trade Regulations Relating to Commerce... Computerized Environmental Data and Information Retrieval Service. The Environmental Data Index (ENDEX... computerized, information retrieval service provides a parallel subject-author-abstract referral service. A...

15 CFR 950.9 - Computerized Environmental Data and Information Retrieval Service.

Code of Federal Regulations, 2010 CFR

2010-01-01

... Information Retrieval Service. 950.9 Section 950.9 Commerce and Foreign Trade Regulations Relating to Commerce... Computerized Environmental Data and Information Retrieval Service. The Environmental Data Index (ENDEX... computerized, information retrieval service provides a parallel subject-author-abstract referral service. A...

15 CFR 950.9 - Computerized Environmental Data and Information Retrieval Service.

Code of Federal Regulations, 2011 CFR

2011-01-01

... Information Retrieval Service. 950.9 Section 950.9 Commerce and Foreign Trade Regulations Relating to Commerce... Computerized Environmental Data and Information Retrieval Service. The Environmental Data Index (ENDEX... computerized, information retrieval service provides a parallel subject-author-abstract referral service. A...

15 CFR 950.9 - Computerized Environmental Data and Information Retrieval Service.

Code of Federal Regulations, 2014 CFR

2014-01-01

... Information Retrieval Service. 950.9 Section 950.9 Commerce and Foreign Trade Regulations Relating to Commerce... Computerized Environmental Data and Information Retrieval Service. The Environmental Data Index (ENDEX... computerized, information retrieval service provides a parallel subject-author-abstract referral service. A...

Innovations in Computerized Assessment.

ERIC Educational Resources Information Center

Drasgow, Fritz, Ed.; Olson-Buchanan, Julie B., Ed.

Chapters in this book present the challenges and dilemmas faced by researchers as they created new computerized assessments, focusing on issues addressed in developing, scoring, and administering the assessments. Chapters are: (1) "Beyond Bells and Whistles; An Introduction to Computerized Assessment" (Julie B. Olson-Buchanan and Fritz Drasgow);…