Reducing medication errors for adults in hospital settings

Background: Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. Objectives: To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. Search methods: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020. Selection criteria: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. Data collection and analysis: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible. Main results: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation –the process of comparing a patient's medication orders to the medications that the patient has been taking– was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation. Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131). Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724). Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311). Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS). Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88). Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications. Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours. Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors. Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system. Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). Authors' conclusions: Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies –including those that involve patients– should also be evaluated.Fil: Ciapponi, Agustín. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Fernandez Nievas, Simon E. No especifíca;Fil: Seijo, Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Inmunología, Genética y Metabolismo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Inmunología, Genética y Metabolismo; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Rodriguez, Maria Belén. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Vietto, Valeria. Instituto Universidad Escuela de Medicina del Hospital Italiano; ArgentinaFil: García Perdomo, Herney A.. Universidad del Valle; ColombiaFil: Virgilio, Sacha. No especifíca;Fil: Fajreldines, Ana V.. Universidad Austral; ArgentinaFil: Tost, Josep. No especifíca;Fil: Rose, Christopher J.. No especifíca;Fil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentin

Activity pattern of female pampas deer (Ozotoceros bezoarticus) in different reproductive phases, in Pantanal Sul-Mato-Grossense

A organização espaço-temporal de atividades de fêmeas de veado-campeiro (Ozotoceros bezoarticus) foi estudada para a compreensão das estratégias comportamentais desses organismos, frente aos altos requerimentos energéticos da reprodução e às características sazonais do Pantanal. Cinco animais foram monitorados com colares GPS, em meses equivalentes às fases de Acasalamento (Fevereiro/2009), Gestação (Junho/2009) e Lactação (Outubro/2008/2009), para obtenção de dados de atividade e deslocamento ao longo do ciclo 24-h, e do tempo de dedicação em diferentes classes comportamentais. Simultaneamente, dados climáticos de temperatura, umidade, precipitação e velocidade do vento também foram obtidos. Os animais apresentaram concentração dos maiores valores de atividade e deslocamento na fase clara do dia, com aumento expressivo em horários crepusculares. Apenas a umidade do ambiente mostrou-se relevante para o comportamento dos animais. O padrão de atividade diferiu entre as fases reprodutivas, revelando que as fêmeas tornam-se mais ativas quando estão lactantes. O padrão de deslocamento foi similar entre as fases. A condição reprodutiva parece não influenciar o tempo de dedicação a diferentes comportamentos, sendo predominantes os comportamentos de repouso (45,53 ± 23,60%) e forrageamento (45,57 ± 18,36 %). Entretanto, foi evidente o aumento progressivo da atividade de forrageamento ao longo das estações de acasalamento, gestação e lactação. Os resultados sugerem que o padrão comportamental das fêmeas é pouco influenciado pela sazonalidade do ambiente, e que a condição reprodutiva modula principalmente a atividade de forrageamento dos animais, que é mais elevada na fase de lactação, frente ao alto custo energético da produção de leite e proteção do filhote.The space-temporal organization of activities of female pampas deer (Ozotoceros bezoarticus) was studied to understand the behavioral strategies of these organisms, due to the high energy requirements of reproduction and seasonal characteristics of the Pantanal. Five animals were monitored with GPS collars in months equivalent to the stages of mating (February/2009), pregnancy (June/2009) and lactation (October/2008/2009) to obtain the activity and displacement along the 24-h cycle and the time dedicated to different classes of behavior. At the same time, climatic data of temperature, humidity, precipitation and wind speed were also obtained. The animals showed higher values of concentration of activity and displacement during the light phase of the day, with significant increase in twilight hours. Only the ambient humidity was relevant to the behavior of animals. The pattern of activity differed between the reproductive phases, revealing that females become more active when they are lactating. The pattern of displacement was similar between phases. The reproductive condition does not influence the time dedicated to different behaviors. At all stages, the animals were predominantly resting (45.53 ± 23.60%) and foraging (45.57 ± 18.36%). However, there was clearly a progressive increase in foraging activity during the season of mating, pregnancy and lactation. The results suggest that the behavioral patterns of females pampas deer is less influenced by the seasonality of the environment, and the reproductive condition modulates mainly foraging activity. The foraging activity is highest during lactation, when there is a high energy cost of milk production and protection of offspring

Behavioral ecology of capybaras (Hydrochoerus hydrochaeris) in anthropic environments

A expansão da atividade antrópica tem gerado contextos ecológicos, em que apenas um grupo homogêneo de espécies poderá tolerar, geralmente com elevada plasticidade comportamental. Um exemplo é a capivara, roedor social neotropical, encontrado em ambientes que vão desde áreas conservadas do Pantanal, até centros urbanos do sudeste brasileiro. Neste estudo, tivemos interesse em investigar as respostas comportamentais de capivaras em ambientes antrópicos do Estado de São Paulo, região onde a espécie ocorre em altas densidades. Tivemos dois temas em foco: o padrão de atividade e movimento, ao longo do ciclo 24 horas; e dinâmica demográfica e social. No primeiro tema, exploramos uma abordagem comparativa da atividade e movimento de animais viventes em áreas antrópicas e no Pantanal brasileiro, buscando avaliar o efeito de variáveis ambientais sobre os padrões comportamentais. Observamos que animais antrópicos apresentam maior variedade de padrões de deslocamento e que, em ambos os tipos de ambientes, a temperatura, ciclo claro-escuro e disponibilidade de recursos são fatores moduladores da atividade. Observamos manutenção de movimento exploratório no crepúsculo, em ambos os tipos de ambiente, ressaltando o valor adaptativo deste padrão comportamental. Por fim, detectamos inversão de picos secundários de atividade que sugerem uma estratégia de desvio de riscos, relacionados aos distúrbios humanos diurnos, em áreas antrópicas, e a predadores naturais noturnos, no Pantanal. No segundo tema, investigamos a socioecologia de um grupo antrópico, vivente sob manejo de restrição de habitat, buscando avaliar o efeito deste manejo sobre uso do espaço e demografia. Ainda, investigamos como parâmetros demográficos e sociais se relacionam, e como a flutuação sazonal de recursos influencia tais parâmetros. Observamos que o manejo restritivo impôs drástica redução da área de vida do grupo, porém este manteve seu tamanho e fluxo de dispersão, similar entre machos e fêmeas. Observamos que fêmeas são mais filopátricas e que, entre elas, podemos encontrar animais dominantes, responsáveis pelo maior cuidado parental. A densidade esteve ligada aos nascimentos e foi forte moduladora das interações intragrupo, uma vez que a maioria foram estabelecidas entre adultos e juvenis. Observamos menor flutuação do número de adultos e uma minoria de interações entre eles, sugerindo maior estabilidade social desses indivíduos. Entretanto, foi possível observar que a disponibilidade de recursos é moduladora da área de vida do grupo e confrontos agonísticos entre adultos, podendo, portanto, aumentar a instabilidade social de indivíduos mais dominantes e estáveis. Esperamos que as informações aqui geradas contribuam para ações de manejo da capivara e paisagem onde vive, fornecendo melhores previsões sobre as respostas comportamentais da espécie frente a ambientes antrópicosThe expansion of anthropic activity has created ecological contexts that only one homogeneous group of species can tolerate, generally with high behavioral plasticity. One example of such species is the capybara, a Neotropical social rodent found in environments that extend from preserved areas of the Pantanal to urban centers of southeastern Brazil. In this study, we were interested in investigating the behavioral responses of capybaras in anthropic environments of São Paulo State, a region where the species occurs in high densities. We focused on two themes: the activity and movement pattern over the 24-hour cycle; and demographic and social dynamics. In the first theme, we used a comparative approach to explore the activity and movement of animals living in anthropic areas and in the Brazilian Pantanal, seeking to assess the effect of environmental variables on behavioral patterns. We found that anthropic animals present a great variety of movement patterns, and that in both types of environment, the temperature, light-dark cycle, and availability of resources are modulating factors of activity. We observed that exploratory movement at dusk was maintained in both types of environment, highlighting the adaptive value of this behavioral pattern. Finally, we detected an inversion of secondary activity peaks, which suggests a risk aversion strategy related to daytime human disturbances in anthropic areas and to natural nocturnal predators in the Pantanal. In the second theme, we investigated the socioecology of an anthropic group living under habitat restriction management, seeking to evaluate the effect of this management on space use and demography. We also investigated how demographic and social parameters are related, and how seasonal fluctuation in resources influences such parameters. We found that restrictive management imposed a drastic reduction in the groups home range but maintained its dispersal size and flow, which was similar between males and females. We observed that females are more philopatric and that, among them, some individuals are dominant, assuming most of the parental care. The density was linked to births and was a strong modulator of intragroup interactions, since most interactions occurred between adults and juveniles. We observed less fluctuation in the number adults and fewer interactions between them, suggesting greater social stability among these individuals. However, resource availability modulates the home range of the group and antagonistic confrontations between adults and can therefore increase the social instability of the most dominant and stable individuals. We expect the information produced here to contribute to management actions for capybara and the landscape where they live, providing better predictions about the species behavioral responses in anthropic environment

Effects of the amendment with almond shell, bio-waste and almond shell-based biochar on the quality of saline-alkali soils

This study aimed to evaluate the effect of the amendment with almond shell bio-waste (AS) and almond shell-based biochar (ASB), in different mass ratios (5, 10, and 15%), on the physicochemical properties of three different saline soils, using the growth of arugula seedlings as a bioindicator of the enhancement achieved. Data were analyzed based on a completely randomized design in a factorial arrangement with four replications. The results showed that the low-salinity soil (T1) presented the best physicochemical characteristics and growth parameters. The addition of AS and ASB in low proportions to the saline soils reduced the pH and electrical conductivity values. An increase in the amendment proportion led to an increase in these variables. Moisture, organic matter, and organic carbon increased, and the cation exchange capacity decreased, generating positive effects on soil quality. The values of exchangeable sodium percentage (ESP) showed that T3 presented the highest sodicity, followed by T2 and T1. The treatment with 5% ASB produced better results regarding total plant length, fresh and dry weights, leaf area, and leaf chlorophyll content. Finally, linear regression models were applied to describe the dependence of the agronomic variables on the ratio of biochar added.Fil: Sanchez, Eliana. Universidad Nacional de San Juan. Facultad de Ingeniería. Instituto de Ingeniería Química; ArgentinaFil: Zabaleta Nievas, Romina Belén. Universidad Nacional de San Juan. Facultad de Ingeniería. Instituto de Ingeniería Química; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Fabani, Maria Paula. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de San Juan; ArgentinaFil: Rodriguez, Rosa Ana. Universidad Nacional de San Juan; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Mazza, German Delfor. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Patagonia Norte. Instituto de Investigación y Desarrollo en Ingeniería de Procesos, Biotecnología y Energías Alternativas. Universidad Nacional del Comahue. Instituto de Investigación y Desarrollo en Ingeniería de Procesos, Biotecnología y Energías Alternativas; Argentin

Epidemiology of capybara-associated Brazilian spotted fever.

BACKGROUND:Brazilian spotted fever (BSF), caused by the bacterium Rickettsia rickettsii, has been associated with the transmission by the tick Amblyomma sculptum, and one of its main hosts, the capybara (Hydrochoerus hydrochaeris). METHODS:During 2015-2019, we captured capybaras and ticks in seven highly anthropic areas of São Paulo state (three endemic and four nonendemic for BSF) and in two natural areas of the Pantanal biome, all with established populations of capybaras. RESULTS:The BSF-endemic areas were characterized by much higher tick burdens on both capybaras and in the environment, when compared to the BSF-nonendemic areas. Only two tick species (A. sculptum and Amblyomma dubitatum) were found in the anthropic areas; however, with a great predominance of A. sculptum (≈90% of all ticks) in the endemic areas, in contrast to a slight predominance of A. dubitatum (≈60%) in the nonendemic areas. Tick species richness was higher in the natural areas, where six species were found, albeit with a predominance of A. sculptum (≈95% of all ticks) and environmental tick burdens much lower than in the anthropic areas. The BSF-endemic areas were characterized by overgrowth populations of A. sculptum that were sustained chiefly by capybaras, and decreased populations of A. dubitatum. In contrast, the BSF-nonendemic areas with landscape similar to the endemic areas differed by having lower tick burdens and a slight predominance of A. dubitatum over A.sculptum, both sustained chiefly by capybaras. While multiple medium- to large-sized mammals have been incriminated as important hosts for A. sculptum in the natural areas, the capybara was the only important host for this tick in the anthropic areas. CONCLUSIONS:The uneven distribution of R. rickettsii infection among A. sculptum populations in highly anthropic areas of São Paulo state could be related to the tick population size and its proportion to sympatric A. dubitatum populations

The blazar TXS 0506+056 associated with a high-energy neutrino: insights into extragalactic jets and cosmic ray acceleration

International audienceA neutrino with energy ∼290 TeV, IceCube-170922A, was detected in coincidence with the BL Lac object TXS 0506+056 during enhanced gamma-ray activity, with chance coincidence being rejected at ∼3σ level. We monitored the object in the very-high-energy (VHE) band with the Major Atmospheric Gamma-ray Imaging Cherenkov (MAGIC) telescopes for ∼41 hr from 1.3 to 40.4 days after the neutrino detection. Day-timescale variability is clearly resolved. We interpret the quasi-simultaneous neutrino and broadband electromagnetic observations with a novel one-zone lepto-hadronic model, based on interactions of electrons and protons co-accelerated in the jet with external photons originating from a slow-moving plasma sheath surrounding the faster jet spine. We can reproduce the multiwavelength spectra of TXS 0506+056 with neutrino rate and energy compatible with IceCube-170922A, and with plausible values for the jet power of . The steep spectrum observed by MAGIC is concordant with internal γγ absorption above ∼100 GeV entailed by photohadronic production of a ∼290 TeV neutrino, corroborating a genuine connection between the multi-messenger signals. In contrast to previous predictions of predominantly hadronic emission from neutrino sources, the gamma-rays can be mostly ascribed to inverse Compton upscattering of external photons by accelerated electrons. The X-ray and VHE bands provide crucial constraints on the emission from both accelerated electrons and protons. We infer that the maximum energy of protons in the jet comoving frame can be in the range ∼1014 – 1018 eV