David Gerrett

A survey of validity and utility of electronic patient records in a general practice

Abstract Objective: To develop methods of measuring the validity and utility of electronic patient records in general practice. Design: A survey of the main functional areas of a practice and use of independent criteria to measure the validity of the practice database. Setting: A fully computerised general practice in Skipton, north Yorkshire. Subjects: The records of all registered practice patients. Main outcome measures: Validity of the main functional areas of the practice clinical system. Measures of the completeness, accuracy, validity, and utility of the morbidity data for 15 clinical diagnoses using recognised diagnostic standards to confirm diagnoses and identify further cases. Development of a method and statistical toolkit to validate clinical databases in general practice. Results: The practice electronic patient records were valid, complete, and accurate for prescribed items (99.7%), consultations (98.1%), laboratory tests (100%), hospital episodes (100%), and childhood immunisations (97%). The morbidity data for 15 clinical diagnoses were complete (mean sensitivity=87%) and accurate (mean positive predictive value=96%). The presence of the Read codes for the 15 diagnoses was strongly indicative of the true presence of those conditions (mean likelihood ratio=3917). New interpretations of descriptive statistics are described that can be used to estimate both the number of true cases that are unrecorded and quantify the benefits of validating a clinical database for coded entries. Conclusion: This study has developed a method and toolkit for measuring the validity and utility of general practice electronic patient records. What is already known on this topic Delivering the performance management agenda in the NHS will depend on the availability of high quality information in general practice Record entries in GP systems generally consist of a mixture of text and Read coded entries Sensitivity and positive predictive value have been used to measure the completeness and accuracy of data recording in electronic patient record systems What this study adds This study has developed a standard method and toolkit for measuring the validity and utility of electronic patient record systems The principal innovation in this study is to consider the Read codes in the records as tests for the true presence of the associated diagnoses This study has developed a new approach to the validation of electronic patient record systems.

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010)

A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526 186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394 951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44 952) from primary care, representing 8.5% of the total. Of 86 821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263 228; 50%) and prescribing (97 097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82 028; 16%) and wrong dose (80 170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance.

Labeling of Medicines and Patient Safety: Evaluating Methods of Reducing Drug Name Confusion:

Objective: We report three experiments evaluating the proposal that highlighting sections of drug names using uppercase (“tall man”) lettering and/or color may reduce the confusability of similar drug names. Background: Medication errors commonly involve drug names that look or sound alike. One potential method of reducing these errors is to highlight sections of names on labels in order to emphasize the differences between similar products. Method: In Experiments 1 and 2, participants were timed as they decided whether similar name pairs were the same name or two different names. Experiment 3 was a recognition memory task. Results: Results from Experiments 1 and 2 showed that highlighting sections of words using tall man lettering can make similar names easier to distinguish if participants are aware that this is the purpose of the intervention. Results from Experiment 3 suggested that tall man lettering and/or color does not make names less confusable in memory but that tall man letters may increase attention. Conclusion: These findings offer some support for the use of tall man letters in order to reduce errors caused by confusion between drug products with look-alike names. Application: The use of tall man letters could be applied in a variety of visual presentations of drug names - for example, by manufacturers on packaging, labeling, and computer software, and in pharmacies on shelf labels. Additionally, this paper demonstrates two meaningful behavioral measures that can be used during product design to objectively assess confusability of packaging and labeling.

A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia

OBJECTIVE To determine whether the rate of instrumental birth in nulliparous women using epidural analgesia is affected by maternal position in the passive second stage of labour. DESIGN A pragmatic prospective randomised trial. SETTING Consultant maternity unit in the Midlands. PARTICIPANTS One hundred and seven nulliparous women using epidural analgesia and reaching the second stage of labour with no contraindications to spontaneous birth. INTERVENTIONS The lateral versus the supported sitting position during the passive second stage of labour. MEASUREMENTS Mode of birth, incidence of episiotomy, and perineal suturing. FINDINGS Recruitment was lower than anticipated (107 vs. 220 planned). Lateral position was associated with lower rates of instrumental birth rate (lateral group 33%; sitting group 52%; p=0.05, RR 0.64, CI for RR: 0.40-1.01; Number-needed-to-treat (NNT)=5), of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI for RR: 0.44-1.00, NNT=5), and of perineal suturing (78% vs. 86%; p=0.243, RR 0.75, CI for RR 0.47-1.17). The odds ratio for instrumental birth in the sitting group was 2.2 (CI 1.00-4.6). Logistic regression of potential confounder variables was undertaken, due to a large variation in maternal weight between the randomised groups. Of the nine possible confounders tested, only position of the babys head at full dilation affected the risk of instrumental birth significantly (p=0.4, OR 2.7 where the fetal head was in the lateral or posterior position). Maternal weight did not appear to have any effect. The odds ratio for instrumental delivery for women randomised to the sitting position was slightly higher within the logistic regression model (adjusted OR 2.3). KEY CONCLUSIONS Women randomised to the lateral position had a better chance of a spontaneous vaginal birth than those randomised to the supported sitting position. Position of the babies head at full dilation had an additional effect on mode of birth. These effects are not conclusively generalizable. RECOMMENDATIONS FOR PRACTICE: The lateral position is likely to be at best beneficial, and at the worst no less harmful than the sitting position for most women and their babies who meet the criteria set for this study. Conclusive evidence for or against the technique should be established using larger trials.

Standards of lithium monitoring in mental health trusts in the UK

BackgroundLithium is a commonly prescribed drug with a narrow therapeutic index, and recognised adverse effects on the kidneys and thyroid. Clinical guidelines for the management of bipolar affective disorder published by The National Institute for Health and Clinical Excellence (NICE) recommend checks of renal and thyroid function before lithium is prescribed. They further recommend that all patients who are prescribed lithium should have their renal and thyroid function checked every six months, and their serum lithium checked every three months. Adherence to these recommendations has not been subject to national UK audit.MethodsThe Prescribing Observatory for Mental Health (POMH-UK) invited all National Health Service Mental Health Trusts in the UK to participate in a benchmarking audit of lithium monitoring against recommended standards. Data were collected retrospectively from clinical records and submitted electronically.Results436 clinical teams from 38 Trusts submitted data for 3,373 patients. In patients recently starting lithium, there was a documented baseline measure of renal or thyroid function in 84% and 82% respectively. For patients prescribed lithium for a year or more, the NICE standards for monitoring lithium serum levels, and renal and thyroid function were met in 30%, 55% and 50% of cases respectively.ConclusionsThe quality of lithium monitoring in patients who are in contact with mental health services falls short of recognised standards and targets. Findings from this audit, along with reports of harm received by the National Patient Safety Agency, prompted a Patient Safety Alert mandating primary care, mental health and acute Trusts, and laboratory staff to work together to ensure systems are in place to support recommended lithium monitoring by December 2010.

‘It’s the best of two evils’: a study of patients’ perceived information needs about oral steroids for asthma

Objectives To explore the sources of patients’ knowledge about the potential side‐effects of oral steroids prescribed to treat asthma.

Prescribing and monitoring lithium therapy: summary of a safety report from the National Patient Safety Agency

Lithium is a commonly prescribed drug for treating bipolar disorder and unipolar (refractory) depression. Over 800 000 prescriptions for lithium salts were dispensed in England in 2008.1 Lithium has a narrow therapeutic range and may be affected by changes in renal function and fluid balance (for example, when a person is dehydrated or pregnant).2 Its tolerability profile also provides challenges for prescribing, as adverse effects such as fine tremor may be confused with the coarse tremor seen in toxicity. Lithium treatment increases the risk of clinical hypothyroidism and renal insufficiency (both acute and chronic). Thus tailoring doses for individual patients, with careful monitoring of lithium concentrations, estimated glomerular filtration rate, and thyroid stimulating hormone, is essential. Treatment is usually started by a psychiatrist, with longer term care and monitoring by a general practitioner, who can be guided by the relevant quality outcome framework (QOF) target for lithium monitoring in the general practitioner contract. The 2006 guidelines from the National Institute for Health and Clinical Excellence (NICE) set out clear standards for lithium monitoring, including measurement of serum lithium concentrations every three months and assessment of thyroid and renal function every six months.3 These guidelines are more stringent than the current quality outcome framework targets for England. A quality improvement programme showed that mental health trusts often do not have electronic systems that reliably communicate test results between the laboratory and the clinical team or between primary and secondary care.4 It also showed the shortcomings in the monitoring …

Medicines Reconciliation on Admission to Inpatient Psychiatric Care: Findings from a UK Quality Improvement Programme.

Objective: Medication errors are a common cause of avoidable morbidity, and transfer between clinical settings is a known risk factor for such errors. Medicines reconciliation means there is no unintended discrepancy between the medication prescribed for a patient prior to admission and on admission. Our aim was to improve the quality of practice supporting medicines reconciliation at the point of admission to a psychiatric ward. Methods: An audit-based quality improvement programme (QIP), using the proxy measure for medicines reconciliation of two or more sources of information being consulted about current medicines, and compared. Results: At baseline audit, 42 Trusts submitted data for 1790 patients. At re-audit 16 months later, 43 Trusts submitted data for 2296 patients. While doctors were most commonly identified in Trust policies as having overall responsibility for medicines reconciliation, the task was most often undertaken by pharmacy staff, with most activity occurring within 24 h of admission. The proportion of patients in whom medicines reconciliation was possible was 71% at baseline and 79% at re-audit. In such patients, discrepancies were identified in 25% at baseline and 31% at re-audit; a small proportion of these discrepancies were clearly clinically significant. Conclusions: This QIP achieved modest improvement in medicines reconciliation practice.

Identification of medication error through community pharmacies

Objective The objective of this study was to record medication error against specific categories identified through community pharmacies in Southern Derbyshire.

Quality assurance for computer‐based teaching and learning packages

A fundamental challenge is facing the development of multimedia teaching and learning (MTL) material, namely how to ensure that a suitable level of quality is being maintained. Argues for the use of principles of good practice as a means of ensuring quality and describes how this approach may be implemented within a university‐wide quality assurance framework. Peer review using a “Multimedia advisory group” made up of academics invited from a variety of schools, which uses a panel evaluation approach in conjunction with the set of principles of good practice, is seen as the key to maintaining quality in MTL material. It is anticipated that this will overcome a transient lack of specific quality assurance experience at the school level.