Melissa T. Baysari

Understanding the human factors contribution to railway accidents and incidents in Australia

Forty rail safety investigation reports were reviewed and a theoretical framework (the Human Factors Analysis and Classification System; HFACS) adopted as a means of identifying errors associated with rail accidents/incidents in Australia. Overall, HFACS proved useful in categorising errors from existing investigation reports and in capturing the full range of relevant rail human factors data. It was revealed that nearly half the incidents resulted from an equipment failure, most of these the product of inadequate maintenance or monitoring programs. In the remaining cases, slips of attention (i.e. skilled-based errors), associated with decreased alertness and physical fatigue, were the most common unsafe acts leading to accidents and incidents. Inadequate equipment design (e.g. driver safety systems) was frequently identified as an organisational influence and possibly contributed to the relatively large number of incidents/accidents resulting from attention failures. Nearly all incidents were associated with at least one organisational influence, suggesting that improvements to resource management, organisational climate and organisational processes are critical for Australian accident and incident reduction. Future work will aim to modify HFACS to generate a rail-specific framework for future error identification, accident analysis and accident investigation.

Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study

In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals

Objectives To compare the manifestations, mechanisms, and rates of system-related errors associated with two electronic prescribing systems (e-PS). To determine if the rate of system-related prescribing errors is greater than the rate of errors prevented. Methods Audit of 629 inpatient admissions at two hospitals in Sydney, Australia using the CSC MedChart and Cerner Millennium e-PS. System related errors were classified by manifestation (eg, wrong dose), mechanism, and severity. A mechanism typology comprised errors made: selecting items from drop-down menus; constructing orders; editing orders; or failing to complete new e-PS tasks. Proportions and rates of errors by manifestation, mechanism, and e-PS were calculated. Results 42.4% (n=493) of 1164 prescribing errors were system-related (78/100 admissions). This result did not differ by e-PS (MedChart 42.6% (95% CI 39.1 to 46.1); Cerner 41.9% (37.1 to 46.8)). For 13.4% (n=66) of system-related errors there was evidence that the error was detected prior to study audit. 27.4% (n=135) of system-related errors manifested as timing errors and 22.5% (n=111) wrong drug strength errors. Selection errors accounted for 43.4% (34.2/100 admissions), editing errors 21.1% (16.5/100 admissions), and failure to complete new e-PS tasks 32.0% (32.0/100 admissions). MedChart generated more selection errors (OR=4.17; p=0.00002) but fewer new task failures (OR=0.37; p=0.003) relative to the Cerner e-PS. The two systems prevented significantly more errors than they generated (220/100 admissions (95% CI 180 to 261) vs 78 (95% CI 66 to 91)). Conclusions System-related errors are frequent, yet few are detected. e-PS require new tasks of prescribers, creating additional cognitive load and error opportunities. Dual classification, by manifestation and mechanism, allowed identification of design features which increase risk and potential solutions. e-PS designs with fewer drop-down menu selections may reduce error risk.

The effectiveness of information technology to improve antimicrobial prescribing in hospitals: A systematic review and meta-analysis

OBJECTIVE To review evidence of the effectiveness of information technology (IT) interventions to improve antimicrobial prescribing in hospitals. METHOD MEDLINE (1950-March 2015), EMBASE (1947-March 2015) and PubMED (1966-March 2015) were searched for studies where an IT intervention involving any device (e.g. computer, mobile phone) was evaluated in practice. All papers were assessed for quality using a 10-point rating scale. RESULTS We identified 45 articles that evaluated an IT intervention to improve antimicrobial prescribing in hospitals. IT interventions took four main forms: (1) stand-alone computerized decision support systems (CDSSs), (2) decision support embedded within a hospitals electronic medical record (EMR) or computerized provider order entry (CPOE) system, (3) computerized antimicrobial approval systems (cAAS), and (4) surveillance systems (SSs). Results reported allowed us to perform meta-analyses for three outcome measures: appropriate use of antimicrobials, patient mortality and hospital length of stay (LOS). IT interventions increased appropriate use of antimicrobials (pooled RR: 1.49, 95%CI: 1.07-2.08); however no evidence of an effect was found when analysis included only studies with a quality score of five or above on the 10-point quality scale (pooled RR: 1.53, 95%CI: 0.96-2.44). There was little evidence of an effect of IT interventions on patient mortality or LOS. The range of study designs and outcome measures prevented meaningful comparisons between different IT intervention types to be made. CONCLUSION IT interventions can improve the appropriateness of antimicrobial prescribing. However, high quality, systematic multi-site comparative studies are critically needed to assist organizations in making informed decisions about the most effective IT interventions.

High ambient temperature reduces rate of body-weight loss produced by wheel running

This study examined the effect of ambient temperature (AT) on the relationship between activity and weight loss. Compared with a neutral AT of 21°C, high ATs of 27–29°C produced a slower rate of weight loss in rats given 1.5-hr food access and 22.5-hr running-wheel access in a standard activity-based anorexia (ABA) procedure (Experiments 1 and 2). The high AT did not affect food intake or wheel running in Experiment 1, but did reduce running in Experiment 2. Switching from neutral to high AT had only a transient effect on weight loss when wheel access was maintained (Experiment 2) but resulted in less weight loss when wheel access was prevented (Experiment 3). Giving rats only 3 hr of wheel access each day at a neutral AT also produced substantial weight loss, but less if for the rest of each day they were maintained at a high AT (Experiment 4).

A reliability and usability study of TRACEr-RAV: The technique for the retrospective analysis of cognitive errors – For rail, Australian version

The aim of this study was to compare the usability and reliability of two human error identification tools: TRACEr-Rail (developed by the Rail Safety and Standards Board in the UK) and TRACEr-RAV (an Australian specific version of the tool). Following an attempt to modify TRACEr-Rail to more appropriately suit the Australian rail context, it was predicted that TRACEr-RAV would be rated as more usable and be applied more consistently by Australian users than TRACEr-Rail. In Experiment 1, twenty-five rail employees used either TRACEr-Rail or TRACEr-RAV1 to extract and classify errors from six Australian rail incident reports. In Experiment 2, eleven university students used both TRACEr-Rail and TRACEr-RAV2 to extract and classify errors from three incident summaries. The results revealed that although modification of TRACEr-Rail to become TRACEr-RAV1 and TRACEr-RAV2 did not result in improved inter-rater reliability, modification resulted in improved ratings of usability in Experiment 2. Most participants in Experiment 2 preferred TRACEr-RAV2 to TRACEr-Rail. The poor inter-rater reliability observed was most likely the result of inadequate training, limited practice in using the tools, and insufficient human factors knowledge.

Barriers to Care in Gout: From Prescriber to Patient

Objective. To explore the understanding of gout and its management by patients and general practitioners (GP), and to identify barriers to optimal gout care. Methods. Semistructured interviews were conducted with 15 GP and 22 patients in Sydney, Australia. Discussions were focused on medication adherence, experiences with gout, and education and perceptions around interventions for gout. Interviews were audio recorded, transcribed verbatim, and analyzed for themes using an analytical framework. Results. Adherence to urate-lowering medications was identified as problematic by GP, but less so by patients with gout. However, patients had little appreciation of the risk of acute attacks related to variable adherence. Patients felt stigmatized that their gout diagnosis was predominantly related to perceptions that alcohol and dietary excess were causal. Patients felt they did not have enough education about gout and how to manage it. A manifestation of this was that uric acid concentrations were infrequently measured. GP were concerned that they did not know enough about managing gout and most were not familiar with current guidelines for management. For example and importantly, the strategies for reducing the risk of acute attacks when commencing urate-lowering therapy (ULT) were not well appreciated by GP or patients. Conclusion. Patients and GP wished to know more about gout and its management. Greater success in establishing and maintaining ULT will require further and better education to substantially benefit patients. Also, given the prevalence, and personal and societal significance of gout, innovative approaches to transforming the management of this eminently treatable disease are needed.

Analysis of Australian newspaper coverage of medication errors

OBJECTIVE To investigate the frequency, style and reliability of newspaper reporting of medication errors. DESIGN Content analysis of articles discussing medication errors that were published in the 10 most widely read Australian daily newspapers between January 2005 and January 2010. Main outcome measure(s) Newspaper source, article type, article topic, leading news actors, identified causes and solutions of medication errors and cited references. RESULTS Ninety-two articles included discussion of medication errors, with the one national newspaper, The Australian, the main source of articles (n = 24). News items were the most frequent type of articles (n = 73), with the majority (n = 55) primarily focused on broader hospital problems. Government representatives, advocacy groups, researchers, health service staff and private industry groups were prominent news actors. A shortage of hospital resources was identified as the central cause of medication errors (n = 38), with efficient error reporting systems most frequently identified as a solution (n = 25). Government reports were cited on 39 occasions, with peer-reviewed publications infrequently cited (n = 4). CONCLUSION Australian newspaper reporting of medication errors was relatively limited. Given the high prevalence of errors and the potential role consumers can play in identifying and preventing errors, there is a clear argument for increasing public awareness and understanding of issues relating to medication safety. Existing coverage of this issue is unrelated to research evidence. This suggests the need for patient safety researchers and advocacy groups to engage more strongly with the media as a strategy to increase the productive public discourse concerning medication errors and gain support for evidence-based interventions.

Flavour aversion produced by running and attenuated by prior exposure to wheels.

In two experiments hungry rats were given access to running wheels. When given the novel flavour, almond, prior to novel access to the wheels, a conditioned aversion to almond was revealed by a subsequent two-bottle test. No such aversion was found in rats with previous experience of wheel running, whether this prior running occurred in the absence of any novel flavour, as in Experiment 1, or following access to saccharin, as in Experiment 2. These results suggest that the failure of rats with prior experience of the running wheels to develop a flavour aversion (unconditioned stimulus, US, preexposure effect) is unlikely to be due to associative blocking. Instead it seems that increasing exposure to a wheel produces habituation of its nausea-inducing properties.