Rollin J. Fairbanks

Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events

BackgroundPatients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable.ObjectivesTo determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump”) and to suggest potential improvements in smart-pump design.DesignUsing retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges.Participants4,604 critically ill adults at 1 academic and 1 nonacademic hospital.MeasurementsPreventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs.ResultsOf 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might enable them to prevent more IV-ADEs.ConclusionThe smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs.

The emergency medical services safety attitudes questionnaire.

To characterize safety culture in emergency medical services (EMS), the authors modified a validated safety culture instrument, the Safety Attitudes Questionnaire (SAQ). The pilot instrument was administered to 3 EMS agencies in a large metropolitan area. The authors characterized safety culture across 6 domains: safety climate, teamwork climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The feasibility of characterizing safety culture in EMS was evaluated by examining response rate, item missingness, EMS chief administrators’ perceptions of the EMS-SAQ, as well as psychometric properties.The results confirm feasibility with a high response rate, acceptable internal consistency, and model fit validity. However, some agencies voiced concerns about respondent burden and the wording and face validity of several EMS-SAQ items. Variation in safety culture scores across EMS agencies within a single geographic area, as well as variation across respondent characteristics, warrants further investigation.

Emergency Department Status Boards: A Case Study in Information Systems Transition:

Patient status boards play an important role in coordinating and communicating about patient care in hospital emergency departments (EDs). Status boards are transitioning from dry-erase whiteboards to electronic systems. Although electronic systems may preserve some surface features of the manual artifacts, important affordances of the manual technology are not always maintained. We compared information on manual and electronic status boards in an ED. Photographs of the manual board and screen shots of the electronic system were obtained before and after a hospital transitioned between systems. Displayed information as well as detailed content regarding patient chief complaints, clinical plans, and dispositions were coded and analyzed to understand the type and function of information present, as well as the use of features such color. Results indicated that although categories of information found were similar, the frequency with which some types of information appeared on the two system displays was substantially different. In particular, information used to coordinate aspects of patient treatment was more frequently found in the manual system. Results suggest that in the design of new information technologies, simply matching the format or information fields available on an existing system may not be sufficient to sustain current work practices or to prevent unanticipated shifts in use.

Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units

Background:Adverse drug events (ADEs), particularly those involving intravenous medications (IV-ADEs), are common among intensive care unit (ICU) patients and may increase hospitalization costs. Precise cost estimates have not been reported for academic ICUs, and no studies have included nonacademic ICUs. Objectives:To estimate increases in costs and length of stay after IV-ADEs at an academic and a nonacademic hospital. Research Design:This study reviewed medical records to identify IV-ADEs, and then, using a nested case-control design with propensity-score matching, assessed differences in costs and length of stay between cases and controls. Subjects:A total of 4604 adult ICU patients in 3 ICUs at an academic hospital and 2 ICUs at a nonacademic hospital in 2003 and 2004. Measures:Increased cost and length of stay associated with IV-ADEs. Results:Three hundred ninety-seven IV-ADEs were identified: 79% temporary physical injuries, 0% permanent physical injuries, 20% interventions to sustain life, and 2% in-hospital deaths. In the academic ICUs, patients with IV-ADEs had

Electronic Health Record Vendor Adherence to Usability Certification Requirements and Testing Standards

6647 greater costs (P < 0.0001) and 4.8-day longer stays (P = 0.0003) compared with controls. In the nonacademic ICUs, IV-ADEs were not associated with greater costs (

VALIDATION OF USING EMS DISPATCH CODES TO IDENTIFY LOW-ACUITY PATIENTS

188, P = 0.4236) or lengths of stay (−0.3 days, P = 0.8016). Cost and length-of-stay differences between the hospitals were statistically significant (P = 0.0012). However, there were no differences in IV-ADE severity or preventability, and the characteristics of patients experiencing IV-ADEs differed only modestly. Conclusions:IV-ADEs substantially increased hospitalization costs and length of stay in ICUs at an academic hospital but not at a nonacademic hospital, likely because of differences in practices after IV-ADEs occurred.

Ambulance stretcher adverse events

Electronic Health Record Vendor Adherence to Usability Certification Requirements and Testing Standards Many electronic health records (EHRs) have poor usability, leading to user frustration and safety risks.1 Usability is the extent to which the technology helps users achieve their goals in a satisfying, effective, and efficient manner within the constraints and complexities of their work environment.2 The US Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) has established certification requirements to promote usability practices by EHR vendors as a part of the meaningful use program. To develop a certified EHR, vendors are required to attest to using user-centered design (UCD), a process that places the cognitive and information needs of the frontline user at the forefront of software development, and to conduct formal usability testing on 8 different EHR capabilities to ensure the product meets performance objectives.3 Third-party ONC-authorized certification bodies are responsible for certifying EHR products. Vendors are required to provide a written statement naming the UCD process they used and describing the process if it is not a recognized industry standard.3 Vendors must also provide written results of their usability tests, including the number, clinical background, and demographics of the participants. The ONC has endorsed guidelines from the National Institute of Standards and Technology stipulating that usability testing should include at least 15 representative end-user participants.4 Reports must be made public once the product is certified. We analyzed these reports to determine whether usability certification requirements and testing standards were met.

Tort Claims and Adverse Events in Emergency Medical Services

Objective. To validate the predictive ability of previously derived emergency medical services (EMS) dispatch codes to identify patients with low-acuity illnesses. Methods. This prospective descriptive study was conducted in Rochester, New York. An expert panel reviewed andmodified a previously derived set of low-priority EMS dispatch codes. Patients assigned these 21 codes between July 2002 andJune 2003 were included for further analysis. Dispatch data andlevel of EMS care were recorded for each dispatch code. The proportion of low-acuity patients (i.e., those who received only basic life support (BLS) care or those who were not transported using lights andsirens) was determined using previously established definitions. Codes were defined as associated with low-acuity patients if the lower bound of the 95% confidence interval (CI) exceeded 90%. Medical records for patients identified as high-acuity were reviewed to evaluate whether the advanced life support (ALS) level care that was provided had a clinical impact. Results. Emergency medical services cared for 43,602 patients during the study, and7,540 were dispatched as low-priority. We found that 7,197 (95%; 95% CI: 95–96%) of these patients met low-acuity criteria andthat 11 of the evaluated codes were validated, with low-acuity care provided at least 90% of the time. Of the 343 patients identified as high-acuity, 62 (18%; 95% CI: 14–23%) were determined to have received interventions that had a clinical impact. Conclusions. This study prospectively validates 11 EMS dispatch codes as being associated with low-acuity patients. These codes could be used to triage EMS patients based on dispatch information.

An Emergency Medical Services Program to Promote the Health of Older Adults

Introduction: Ambulance personnel use wheeled stretchers for moving patients in the out-of-hospital setting. The nature of adverse events and associated injuries occurring during ambulance stretcher operation was characterised. Methods: Data from the United States Food and Drug Administration’s Manufacturer and User Facility Device Experience Database (MAUDE) were used. All adverse events involving ambulance stretchers during the years 1996–2005 were identified. The nature of the event, the method of stretcher handling, the individuals injured and the nature of the resulting injuries were identified. Results: There were 671 reported adverse events. The most common adverse events were stretcher collapse (54%; 95% CI 50 to 57%), broken, missing or malfunctioning part (28%; 95% CI 25 to 32%) and dropped stretcher (7%; 95% CI 5 to 9%). Adverse events most commonly occurred during unloading of the stretcher from the ambulance (16%; 13 to 19%). Injuries occurred in 121 events (18%; 95% CI 15 to 21%), most often involving sprains/strains (29%), fractures (16%) and lacerations/avulsions (13%). There were three traumatic brain injuries and three deaths. Patients sustained injuries in 52 events (43%), and ambulance personnel sustained injuries in 64 events (53%). More than one individual sustained injuries in 12 events. Conclusion: Adverse events may occur during ambulance stretcher operation and can result in significant injury to patients and ambulance personnel.

Hazards With Medical Devices: The Role of Design

STUDY OBJECTIVE Emergency medical services (EMS) provide care to acutely ill or injured patients in settings less controlled than other health care environments. Although reports describing individual EMS adverse events exist, few broader descriptions exist. The objective of the study is to characterize the types, frequencies, and outcomes of adverse events associated with insurance tort claims against EMS providers. METHODS We performed a retrospective review of insurance liability claims from a national insurer of EMS agencies. We studied closed and open insurance liability claims from January 1, 2003, to December 31, 2004, arising from EMS response to or provision of patient care and associated with injury to patients or other individuals. We excluded events associated with employee injuries only, events with property or vehicle damage only, and emergency vehicle crashes with less than