Randi Cartmill

Immigrants and Violence: The Importance of Neighborhood Context.

This study examined the relationship between violence and immigration. The importance of neighborhood context, including alcohol availability, was also investigated. Using data from block groups, these relationships were examined in three California communities with significant immigrant populations. Data on socioeconomic characteristics were combined with police data concerning youth and data on alcohol availability. These data were geocoded in a block group, and population-based rates were calculated. A specialized regression package was used to examine these relationships. Results indicated that immigration and youth violence were not related, but that violence was predicted by alcohol availability. Contextual factors such as family breakdown and professional role models were also found to be significant predictors of youth violence. Furthermore, the context of violence is important in understanding why violence varies within communities. Violence prevention efforts may benefit from regulatory efforts to reduce the high concentrations of alcohol outlets that exist in Latino neighborhoods.

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

OBJECTIVE To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors. DESIGN CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). MEASUREMENT Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. RESULTS Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. CONCLUSIONS Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.

Alcohol and Homicide in the United States 1934-1995 - or One Reason Why U.S. Rates of Violence May Be Going Down

In the last few years, a great deal of attention has been devoted to the apparent decline in rates of homicide and other kinds of violence in the United States. Commentators debate whether rates of violence are actually declining, and what are the reasons for this apparent decline. The purpose of this paper is to explore the possibility that one reason for the apparent recent decline in homicide may be its relationship to the rate of alcohol consumption during this same time period. As there is a growing body of research that shows a significant relationship between alcohol and violence at different levels of aggregation, in different countries and sub-units of countries, among different types of people, and across time periods, we will also explore the homicide and alcohol relationship by race and by type of alcoholic beverage. There are also the beginnings of a theoretical body of knowledge that would explain why variations in alcohol consumption and availability should be considered part of the explanation for variations in the rate of homicide and other types of violence. These issues will be discussed in detail in this

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units

Objective To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process. Methods Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. Results An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16–24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. Conclusions Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit

OBJECTIVE To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation. DESIGN EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007. MEASUREMENT We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU). RESULTS EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed. CONCLUSIONS The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

The work of adult and pediatric intensive care unit nurses.

Background:Researchers have used various methods to describe and quantify the work of nurses. Many of these studies were focused on nursing in general care settings; therefore, less is known about the unique work nurses perform in intensive care units (ICUs). Objectives:The aim of this study was to observe adult and pediatric ICU nurses in order to quantify and compare the duration and frequency of nursing tasks across four ICUs as well as within two discrete workflows: nurse handoffs at shift change and patient interdisciplinary rounds. Methods:A behavioral task analysis of adult and pediatric nurses was used to allow unobtrusive, real-time observation. A total of 147 hours of observation were conducted in an adult medical–surgical, a cardiac, a pediatric, and a neonatal ICU at one rural, tertiary care community teaching hospital. Results:Over 75% of ICU nurses’ time was spent on patient care activities. Approximately 50% of this time was spent on direct patient care, over 20% on care coordination, 28% on nonpatient care, and approximately 2% on indirect patient care activities. Variations were observed between units; for example, nurses in the two adult units spent more time using monitors and devices. A high rate and variety of tasks were also observed: Nurses performed about 125 activities per hour, averaging a switch between tasks every 29 seconds. Discussion:This study provides useful information about how nurses spend their time in various ICUs. The methodology can be used in future research to examine changes in work related to, for example, implementation of health information technology.

Challenges to care coordination posed by the use of multiple health IT applications

Coordinating care for hospitalized patients requires the use of multiple sources of information. Using a macroergonomic framework (i.e. the work system model), we conducted interviews and observations of care managers involved in care coordination across transitions of care. When information is distributed across multiple health IT applications, care managers experience a range of challenges, including organizational barriers, technology design problems, skills and knowledge issues, and task performance demands (i.e. issues related to individual information processing and management and sharing of information). These challenges can be used as a checklist to evaluate the proposed IT infrastructure that will allow the integration of multiple health IT applications and, therefore, support coordination across transitions of care.

The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units

The literature shows that communication in health care is one of the most important factors associated with quality of care and patients safety. Especially in Intensive Care Units (ICUs) communication is of importance, due to the characteristics of the setting. However, relatively little is known about the different aspects of communication in health care and how Computerized Provider Order Entry (CPOE) implementation may impact communication, and consequently, quality of care. In this study we adapted an existing questionnaire developed by Shortell et al. to examine the impact of CPOE implementation on communication in a repeated cross-sectional design (6 months before implementation, 3 months after implementation and one-year after implementation). Results show overall that CPOE did not have a negative effect on communication, especially in the long term.

Multi-stakeholder collaboration in the redesign of family-centered rounds process

A human factors approach to healthcare system redesign emphasizes the involvement of multiple healthcare stakeholders (e.g., patients and families, healthcare providers) in the redesign process. This study explores the experience of multiple stakeholders with collaboration in a healthcare system redesign project. Interviews were conducted with ten stakeholder representatives who participated in the redesign of the family-centered rounds process in a pediatric hospital. Qualitative interview data were analyzed using a phenomenological approach. A model of collaborative healthcare system redesign was developed, which defined four phases (i.e., setup of the redesign team, preparation for meetings, collaboration in meetings, follow-up after meetings) and two outcomes (i.e., team outcomes, redesign outcomes) of the collaborative process. Challenges to multi-stakeholder collaboration in healthcare system redesign, such as need to represent all relevant stakeholders, scheduling of meetings and managing different perspectives, were identified.

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients

OBJECTIVE To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. METHODS We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. RESULTS The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. DISCUSSION The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.