An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Intravenous infusion practices across England and their impact on patient safety: a mixed-methods observational study

BACKGROUND: Intravenous (IV) medication administration has traditionally been regarded to be error-prone with high potential for harm. A recent US multisite study revealed surprisingly few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error. OBJECTIVES: To determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation in errors, discrepancies and practices, including the contribution of smart pumps. DESIGN: Phase 1 comprised an observational point-prevalence study of IV infusions, with debrief interviews and focus groups. Observers compared each infusion against the medication order and local policy. Deviations were classified as either errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs, and analytically in supplementary analyses. Phase 2 comprised in-depth observational studies at five of the participating sites to better understand causes of error and how safety is maintained. Workshops were held with key stakeholder groups, including health professionals and policy-makers, the public and industry. SETTING: Sixteen English NHS hospital trusts. RESULTS: Point-prevalence data were collected from 1326 patients and 2008 infusions. In total, 240 errors were observed in 231 infusions and 1489 discrepancies were observed in 1065 infusions. Twenty-three errors (1.1% of all infusions) were considered potentially harmful; one might have resulted in short-term patient harm had it not been intercepted, but none was judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of deviations varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or to respond to patient need. Smart pumps, as currently implemented, had little effect. Staff had developed practices to manage efficiency and safety pragmatically by working around systemic challenges. LIMITATIONS: Local observers may have assessed errors differently across sites, although steps were taken to minimise differences through observer training, debriefs, and review and cleaning of data. Each in-depth study involved a single researcher, and these were limited in scale and scope. CONCLUSIONS: Errors and discrepancies are common in everyday infusion administration but most have low potential for patient harm. Findings are best understood by viewing IV infusion administration as a complex adaptive system. Better understanding of performance variability to strategically manage risk may be more helpful for improving patient safety than striving to eliminate all deviations. FUTURE WORK: There is potential value in reviewing policy around IV infusion administration to reduce unnecessary variability, manage staff workload and engage patients, while retaining the principle that policy has to be fit for purpose, contextualised to the particular ward situation and treatment protocol, and sensitive to the risks of different medications. Further work on understanding infusion administration as a complex adaptive system might deliver new insights into managing patient safety. FUNDING: This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information

Intelligent decision support systems for optimised diabetes

Computers now pervade the field of medicine extensively; one recent innovation is the development of intelligent decision support systems for inexperienced or non-specialist pbysicians, or in some cases for use by patients. In this thesis a critical review of computer systems in medicine, with special reference to decision support systems, is followed by a detailed description of the development and evaluation of two new, interacting, intelligent decision support systems in the domain of diabetes. Since the discovery of insulin in 1922, insulin replacement therapy for the treatment of diabetes mellitus bas evolved into a complex process; there are many different formulations of insulin and much more information about the factors which affect patient management (e.g. diet, exercise and progression of complications) are recognised. Physicians have to decide on the most appropriate anti-diabetic therapy to prescribe to their patients. Insulin-treated patients also have to monitor their blood glucose and decide how much insulin to inject and when to inject it. In order to help patients determine the most appropriate dose of insulin to take, a simple-to-use, hand-held decision support system has been developed. Algorithms for insulin adjustment have been elicited and combined with general rules of therapy to offer advice for every dose. The utility of the system has been evaluated by clinical trials and simulation studies. In order to aid physician management, a clinic-based decision support system has also been developed. The system provides wide-ranging advice on all aspects of diabetes care and advises an appropriate therapy regimen according to individual patient circumstances. Decisions advised by the pbysician-related system have been evaluated by a panel of expert physicians and the system has undergone informal primary evaluation within the clinic setting. An interesting aspect of both systems is their ability to provide advice even in cases where information is lacking or uncertain

Complementary Pediatrics

Complementary Pediatrics covers complementary issues of pediatric subspecialties consisting of ophthalmologic, surgical, psychosocial and administrative issues of frequently used medications. This book volume with its 16 chapters will help get us and patients enlightened with the new developments on these subspecialties' area

Advancing clinical practice in the management of Deep Vein Thrombosis: development, application and evaluation of the Autar DVT scale

Deep Vein Thrombosis (DVT) is a disease of hospitalised patients and is a precursor of Pulmonary Embolism (PE), a potentially fatal complication. DVT and PE are preventable and venous thromboprophylaxis consensus groups recommend that patients be risk assessed and accordingly receive appropriate prophylaxis. The Scope of Professional Practice (UKCC, 1992) enables nurses with appropriate knowledge and clinical competence to explore· new territories, previously the exclusive province of doctors. In the spirit of the position statement of professional practice framework, the Autar DVT scale (1994) was developed to identify patients at risk, so that appropriate venous thromboprophylaxis can be initiated. The scale is composed of seven categories of risk factors derived from Virchow's triad in the genesis of DVT. In this study, the DVT scale was re-validated on 150 patients across three distinct clinical specialities in order to allow for generalisation of the findings. DVT is a continuing problem and for this significant reason, the patients were followed up for a minimum of three months after discharge from hospital. Interestingly, 39 per cent of the patients with DVT (11/28) developed this insidious condition at home. Five reproducibility studies on the orthopaedic, medical and surgical directorates achieved kappa values ranging between 0.88 to 0.95, confirming the consistency of the instrument. A Receiver Operating Characteristic (ROC) curve was constructed to determine the optimal predictive accuracy of the DVT scale and a cutoff score of 11 yielded approximately 70 per cent sensitivity. Data from two patients, who could not be followed up, on account of discharge to no fixed abodes, were excluded for the sensitivity analysis of the DVT scale. Overall, 115 patients out of the 148 (78%) were correctly classified. However, the administration of venous thromboprophylaxis masked the predictive efficiency of the DVT scale in relation to its sensitivity and specificity. A high predictive value of 84 per cent of negative outcome was achieved at the cost of a predictive value of 37 per cent of positive outcome. The DVT scale exhibited good clinical and practical application. Data extrapolation also suggests that although the clinical areas use some venous thromboprophylaxis strategies, in practice they are not consistently applied