Evaluation of electronic medication management systems on inpatient omitted dose rates at 2 acute metropolitan hospitals

Rationale, aim and objectives: Medication error is common and the most common form of administration error is omission. Implementation of Electronic Medication Management systems (eMMS) has been hypothesized to decrease the rate of omitted doses due to the creation of a number of forcing functions and decision support tools however there is limited evidence currently available in the literature to support this assumption. This study therefore aims to ascertain if implementation of eMMS at 2 acute metropolitan hospitals reduces the rate of omitted doses Method: A retrospective cohort study was undertaken pre and post implementation of eMMS. Patients meeting eligibility criteria had all medication charts from their admission reviewed and an omitted dose rate calculated. For each omitted dose identified; medication name, imprest availability, dispensing history, administration time and frequency were recorded. Results: 386 patients met eligibility criteria for this study (11,796 opportunities for omission). The implementation of eMMS was associated with a significant reduction in omitted doses (3.6% vs 1.8% p<0.01). Benefit was not consistent among subgroups. eMMS implementation at the hospital with the higher baseline omitted dose rate was associated with a significant reduction in omitted doses (5.8% vs 0.9% p<0.01) but not at the hospital with a lower baseline rate (2.7% vs 2.4% p=0.3). The most common times for an omitted dose to occur were 0800 (33%) and 2000 (18%). The most common frequencies for an omitted dose were daily (35%) and twice daily (32%). Conclusion: The introduction of eMMS was associated with a decrease rate of omitted doses. Greatest benefit is likely to occur in areas with a high baseline rate of omission.

Deterring Illegal Entry: Migrant Sanctions and Recidivism in Border Apprehensions

During the 2008 to 2012 period, the US Border Patrol enacted new sanctions on migrants apprehended while attempting to enter the United States illegally. Using administrative records on apprehensions of Mexican nationals that include fingerprint-based IDs and other details, we detect if an apprehended migrant is subject to penalties and if he is later reapprehended. Exploiting plausibly random variation in the rollout of sanctions, we estimate econometrically that exposure to penalties reduced the 18-month reapprehension rate for males by 4.6 to 6.1 percentage points off of a baseline rate of 24.2 percent. These magnitudes imply that sanctions can account for 28 to 44 percent of the observed decline in recidivism in apprehensions. Further results suggest that the drop in recidivism was associated with a reduction in attempted illegal entry. (JEL K37, J15, J18)

Antenatal magnesium sulfate to prevent cerebral palsy

Magnesium sulfate given to women before birth at <30 weeks’ gestation reduces the risk of cerebral palsy in their children. Our study aimed to assess the impact of a local quality improvement programme, primarily using plan-do-study-act cycles, to increase the use of antenatal magnesium sulfate. After implementing our quality improvement programme, an average of 86% of babies delivered at <30 weeks’ gestation were exposed to antenatal magnesium sulfate compared with a historical baseline rate of 63%. Our study strengthens the case for embedding quality improvement programmes in maternal perinatal care to reduce the impact of cerebral palsy on families and society.

Enforcement policies: Frequency of inspection is more important than the severity of punishment

External enforcement policies aimed to reduce violations differ on two key components: the probability of inspection and the severity of punishments. Different lines of research offer competing predictions regarding the relative importance of each component. In three incentive compatible studies, students and Prolific crowdsourcing participants (Ntotal=430) repeatedly faced temptations to commit violations under two enforcement policies. Controlling for expected value, the results indicated that a policy combining High probability of Inspection with Low Severity of fine (HILS) was more effective than a policy combining Low probability of Inspection with High Severity of fine (LIHS). Consistent with the prediction of Decisions from Experience research, this finding held even when the severity of the fine was stated in advance to boost deterrence. In addition, the advantage of HILS over LIHS was greater as participants’ baseline rate of violation (without enforcement) was higher, implying that HILS is more effective among frequent offenders.

On the subseasonal clustering of European extreme precipitation events and its relationship to large-scale atmospheric drivers

&lt;p&gt;Extreme precipitation events that occur in close succession can have important societal and economic repercussions. Few studies have investigated the link between large-scale atmospheric drivers and temporal clustering of extreme precipitation events on a subseasonal scale, i.e. 20-day time scale. Here we use 40 years of reanalysis data (ERA-5) to investigate the link between possibly influential atmospheric variables and the temporal clustering of catchment-averaged extreme rainfall events in Europe. We define extreme events as exceedances above the 99th percentile and runs of consecutive days are declustered. We then explicitly model the seasonal rate of extreme occurrences using penalized cubic splines. The smoothed seasonal rate of extremes is then used to (i) infer the significance of subseasonal clustering and (ii) serves as the baseline rate for the subsequent modelling step. We use a Poisson generalized linear model with the baseline rate set as an offset to model the relationship between the temporal clustering and predictor variables. These variables are the North Atlantic Oscillation (NAO), the Arctic Oscillation (AO), atmospheric blocks, and a measure of the recurrence of synoptic-scale Rossby wave packets (RRWPs).&lt;/p&gt;&lt;p&gt;Initial results from four carefully selected catchments reveal the following patterns: for south-western Spain, the NAO, and AO indices tend to be notably lower on significantly clustered extreme rainfall days, whereas for northern Scotland the opposite effect is observed. Also, for south-western Spain, the Greenland atmospheric blocking frequency is significantly enhanced on clustering days. Last, on clustering days in north-western France, Scandinavian blocks are significantly more frequent.&lt;/p&gt;&lt;p&gt;For a complementary study on a methodology to identify subseasonal clustering episodes of extreme precipitation events and their contribution to large accumulations please refer to Kopp et al.&lt;/p&gt;

Elucidating Barriers to Advance Care Planning in Malignant Hematology Clinics: A Single Centre Experience in Ontario, Canada

Introduction: Advance care planning (ACP) is a patient-centered process with clear benefits for patients. Despite the widespread recognition of ACP as an integral part of quality cancer care,compliance with ACP provision remains suboptimal especially in malignant hematology. Many barriers to end-of-life discussions among hematologists have been identified in the literature. This study aims to describe a baseline rate of ACP with hematology outpatients at the end-of-life and the local barriers to ACP, which could inform future quality improvement (QI) initiatives in this area. Setting/participants: Malignant hematologists (n = 10), hematology fellows (n=2), and hematology clinic nurses (n=4) of the Juravinski Cancer Centre (JCC) in Hamilton, Ontario, Canada participated in this study. Methods: A retrospective chart audit was undertaken to establish the baseline rate of ACP for the target population at our centre. Subsequently, key stakeholder interviews were held with our local multiple myeloma (MM) specialists to document barriers to ACP from their perspectives. The emerging themes were synthesized using a Fishbone diagram and validated by the JCC hematology clinic staff through multivoting. Results: The baseline rate of ACP with hematology outpatients at the end-of-life at our centre is 40%. The are three main local barriers to ACP with the target population: 1) lack of patient initiative; 2) time/scheduling constraints; and 3) competing priorities. Discussion: Patients who participate in ACP are much more likely to have their end-of-life wishes followed than those who do not. Malignant hematology patients are at the greatest risk of not having ACP discussions with their clinicians due to several patient, provider, and system barriers. Patient- and system-level barriers have been identified as the most prevalent at the JCC, necessitating a tailored QI initiative to achieve the standard of care. Disclosures Hillis: Roche: Honoraria.

Behavioral Biases and Legal Compliance: A Field Experiment

Many defendants fail to appear (FTA) for court despite the prospect of legal consequences. In a field experiment, we compare the effectiveness of text message reminders to an intervention that combines reminders with personalized assistance. The treatments are equally effective, reducing FTA by 8 percentage points from a 21 percent baseline rate. However, personalized assistance facilitates greater take-up of court accommodations such as rescheduling and payment plans. For more serious cases, the treatments reduce arrests by two percentage points, implying FTAs have a large effect on arrests. For the least serious cases, an FTA has small effects on fines.

Optimisation of diagnosis and treatment of heart failure in a primary care setting

BackgroundHeart failure (HF) is one of the leading causes of emergency department visits and hospital admissions in the USA. We identified a gap in the diagnosis and the use of guideline-directed medical therapy in patients with HF at the internal medicine clinic.AimTo improve the diagnosis and treatment of HF, as well as to reduce emergency department visits and hospitalisation over 12 months in patients aged 40–75 years.MethodsThe multidisciplinary quality improvement (QI) team performed a root cause analysis and identified barriers to optimal guideline-directed medical therapy. Rates of patients on guideline-directed medical therapy with systolic HF diagnosis, emergency department visits and hospital admissions were the outcome measures. The process measures included echocardiogram order and completion rates, and rates of accurate classification of HF from the baseline rate of less than 10%. We used the focus, analyse, develop, execute and evaluate (FADE) model with five improvement cycles. The major components of interventions included (1) leveraging health information technology; (2) optimising teamwork; and (3) providing education to patients, physicians and internal medicine clinic staff. Data were analysed using statistical process control and run charts.ResultsWe observed a reduction in the total number of emergency department visits (160 vs 108), hospital admissions (117 vs 114) and observation visits (22 vs 16) comparing the 1-year preproject and 1-year postproject periods. An increase in the use of ACE inhibitors or angiotensin receptor blockers occurred from the baseline rate of 20%–37% during the second half of the project and was sustained at 71.4% (median) during 6 months of the postproject period.ConclusionsWe achieved a sustainable increase in the accurate diagnosis of HF and achieved 80% diagnosis during the 6-month poststudy period.