Automatic dispensing cabinets and governance of controlled drugs: an exploratory study in an intensive care unit.

BACKGROUND: Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance. OBJECTIVES: To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children's hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance. METHODS: We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating. RESULTS: Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; 'blind counts'; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for 'nurses with keys' to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers. CONCLUSIONS: ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls

The 'Back Office' of a Dispensing Cabinet: Technology and Work Contributing to Medication Safety

Automated dispensing cabinets in clinical wards may contribute to improving safety by reducing the likelihood of medications not being available when needed. However, achieving this safety benefit is dependent on a 'back office' sociotechnical infrastructure that combines semi-automated processes with mindful, resilient work practices

Evaluation of an Automated Dispensing Cabinet in Paediatric Intensive Care - Focus on Controlled Medications

Evidence is limited of automated dispensing cabinets (ADCs) impact on effectiveness and efficiency of controlled drugs' (CDs) governance processes. We carried out a mixed-methods study of an ADC in an intensive care unit. We found ADC improved effectiveness and efficiency of governance of CDs through secure storage, alerts and automated recording of transactions. Limitations were associated with ADC design and 'fit' between ADC and some types of CDs

Challenges of Digital Commons: A Qualitative Study of an Automated Dispensing Cabinet in a Paediatric Intensive Care Unit

Missed medication doses can affect patient safety in hospitals. The use of automated dispensing cabinets (ADC) in clinical areas may reduce the occurrence of medications being unavailable at the time of need by alerting pharmacy to replenish stock. However, workarounds in ADC use can affect this capability. We studied nurses' use of an ADC in a paediatric intensive care unit with  54 hours of observation, semi-structure interviews (19 nurses; 4 pharmacy/management staff) and review of reported incidents. We found running out of medication a recurrent problem despite the ADC. Contributing factors affecting data entry in the ADC, and therefore replenishment alerts to pharmacy, included: the organisation of medication activities in the ward, nurses' information needs, patients' medication needs, and ADC design. Running out of medications was a 'tragedy of the commons'. Effective solutions may require going beyond user training and directives for accurate data entry, to work process redesign

Pharmacy Interweaving Safety Within Hospital Health Information Technology

Research on the impact of hospital technology on medication safety usually focuses on prescribing and administration. Less is known about the pharmacy-related processes of reviewing, ordering and dispensing medications and how technology supports this work. We carried out a qualitative exploratory study of a hospital in England (UK) with the aim of gaining insight into processes of digitalisation. We found that hospital pharmacy staff perform safety work with technology aiming to prevent harm, such as ‘scaffolding’ people's thinking processes, or linking-up unintegrated systems. Their work seems to ‘interweave’ safety in between others' medication activities, but they do so sometimes struggling with technological deficiencies

Pharmacy Interweaving Safety Within Hospital Health Information Technology

Research on the impact of hospital technology on medication safety usually focuses on prescribing and administration. Less is known about the pharmacy-related processes of reviewing, ordering and dispensing medications and how technology supports this work. We carried out a qualitative exploratory study of a hospital in England (UK) with the aim of gaining insight into processes of digitalisation. We found that hospital pharmacy staff perform safety work with technology aiming to prevent harm, such as ‘scaffolding’ people's thinking processes, or linking-up unintegrated systems. Their work seems to ‘interweave’ safety in between others' medication activities, but they do so sometimes struggling with technological deficiencies

Automatic dispensing cabinets and governance of controlled drugs: an exploratory study in an intensive care unit

Background Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance. Objectives To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children’s hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance. Methods We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating. Results Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; ‘blind counts’; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for ‘nurses with keys’ to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers. Conclusions ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Background: There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies. Methods: We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive). Results: Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice. Conclusions: Within oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies

Molecular Insights into Reprogramming-Initiation Events Mediated by the OSKM Gene Regulatory Network

Somatic cells can be reprogrammed to induced pluripotent stem cells by over-expression of OCT4, SOX2, KLF4 and c-MYC (OSKM). With the aim of unveiling the early mechanisms underlying the induction of pluripotency, we have analyzed transcriptional profiles at 24, 48 and 72 hours post-transduction of OSKM into human foreskin fibroblasts. Experiments confirmed that upon viral transduction, the immediate response is innate immunity, which induces free radical generation, oxidative DNA damage, p53 activation, senescence, and apoptosis, ultimately leading to a reduction in the reprogramming efficiency. Conversely, nucleofection of OSKM plasmids does not elicit the same cellular stress, suggesting viral response as an early reprogramming roadblock. Additional initiation events include the activation of surface markers associated with pluripotency and the suppression of epithelial-to-mesenchymal transition. Furthermore, reconstruction of an OSKM interaction network highlights intermediate path nodes as candidates for improvement intervention. Overall, the results suggest three strategies to improve reprogramming efficiency employing: 1) anti-inflammatory modulation of innate immune response, 2) pre-selection of cells expressing pluripotency-associated surface antigens, 3) activation of specific interaction paths that amplify the pluripotency signal

Mechanisms of HIV-associated lymphocyte apoptosis: 2010

The inevitable decline of CD4T cells in untreated infection with the Human immunodeficiency virus (HIV) is due in large part to apoptosis, one type of programmed cell death. There is accumulating evidence that the accelerated apoptosis of CD4T cells in HIV infection is multifactorial, with direct viral cytotoxicity, signaling events triggered by viral proteins and aberrant immune activation adding to normal immune defense mechanisms to contribute to this phenomenon. Current antiviral treatment strategies generally lead to reduced apoptosis, but this approach may come at the cost of preserving latent viral reservoirs. It is the purpose of this review to provide an update on the current understanding of the role and mechanisms of accelerated apoptosis of T cells in the immunopathogenesis of HIV infection, and to highlight potential ways in which this seemingly deleterious process could be harnessed to not just control, but treat HIV infection