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

Training Students on the Pharmacist Patient Care Process using an Electronic Health Record and Simulations

Objective: To measure the impact of an electronic health record (EHR) and simulated physician encounters on student knowledge and skills related to the implementation phase of the Pharmacist Patient Care Process (PPCP). Secondary objectives were to measure students’ self-perceived abilities. Methods: Students enrolled in a therapeutics course worked-up patient cases within an EHR. Students entered orders/ prescriptions into the computerised provider order entry (CPOE) platform. Faculty graded student work using a rubric. Students completed an instructor-developed pre-post attitudes survey and knowledge quiz. Results: Two hundred students participated in this study and worked-up seven cases. Scores ranged from 67.7% to 88.2% on the case work-ups and 78.6% to 91.1% on the order/prescription-entry components. Individual scores on the quiz improved from 15.3/20 to 17.3/20 (p\u3c0.001). Aggregate ratings on the attitudes survey increased from 23.2 to 31.0 (p\u3c0.001). Conclusion: Use of an EHR coupled with simulation was well-received and improved student understanding of the PPCP

Effectiveness of music interventions to reduce test anxiety in pharmacy students

Background: The main objective of this pilot study was to evaluate the impact of a classroom activity involving music on anxiety associated with preparing for and taking an assessment. Methods: Two hundred and two (202) pharmacy students were randomly assigned to one of two conditions of the experimental study: active music playing (n = 103) versus passive music listening (n = 99). All students completed a pre-test, a mid-test, and a post-test including: an “Attitudes and Perceptions” survey, State-Trait Anxiety Inventory for Adults (STAI Survey), and a knowledge assessment. Data were analyzed to determine the impact each of the music interventions had on students’ test anxiety. Results: Both types of musical interventions produced similar results in terms of anxiety reduction. Faced with an upcoming test prior to the musical intervention, average state-trait anxiety scores increased; after the musical intervention, state-trait anxiety scores decreased. Conclusions: The use of music helped to reduce test anxiety, even after one brief musical intervention, regardless of whether students passively listened to music or actively played music

Synthesis and studying the antitumor activity of novel 5-(2-methylbenzimidazol-5-yl)-1,3,4-oxadiazole-2(3H)-thiones

The influence of the incorporation of 1,3,4-oxadiazole ring into 2-methyl-1H-benzimidazole derivatives producing a series of substituted 5(6)-(2-methylbenzimidazol-5-yl)-1,3,4-oxadiazoles on the antitumor activity was studied in this study. The antitumor activity of the new compounds was tested against breast cancer cell line MCF-7 and lung cancer cell line A549. S-5-(2-methyl-1H-benzo[d]imidazol-5-yl)-1,3,4-oxadiazol-2-yl 2-nitrobenzenesulfonothioate (9) showed potent activity against both MCF-7 and A549 cell lines. Whereas, compounds 7, 11-13 and 15-17 have moderate growth inhibitory activity on the two cell lines

Geostationary Operational Environmental Satellite (GOES)-8 mission flight experience

The Geostationary Operational Environmental Satellite (GOES)-8 spacecraft was launched on April 13, 1994, at 06:04:02 coordinated universal time (UTC), with separation from the Atlas-Centaur launch vehicle occurring at 06:33:05 UTC. The launch was followed by a series of complex, intense operations to maneuver the spacecraft into its geosynchronous mission orbit. The Flight Dynamics Facility (FDF) of the Goddard Space Flight Center (GSFC) Flight Dynamics Division (FDD) was responsible for GOES-8 attitude, orbit maneuver, orbit determination, and station acquisition support during the ascent phase. This paper summarizes the efforts of the FDF support teams and highlights some of the unique challenges the launch team faced during critical GOES-8 mission support. FDF operations experience discussed includes: (1) The abort of apogee maneuver firing-1 (AMF-1), cancellation of AMF-3, and the subsequent replans of the maneuver profile; (2) The unexpectedly large temperature dependence of the digital integrating rate assembly (DIRA) and its effect on GOES-8 attitude targeting in support of perigee raising maneuvers; (3) The significant effect of attitude control thrusting on GOES-8 orbit determination solutions; (4) Adjustment of the trim tab to minimize torque due to solar radiation pressure; and (5) Postlaunch analysis performed to estimate the GOES-8 separation attitude. The paper also discusses some key FDF GOES-8 lessons learned to be considered for the GOES-J launch which is currently scheduled for May 19, 1995

Procedural and documentation variations in intravenous infusion administration: a mixed methods study of policy and practice across 16 hospital trusts in England

Background: Procedural and documentation deviations relating to intravenous (IV) infusion administration can have important safety consequences. However, research on such deviations is limited. To address this we investigated the prevalence of procedural and documentation deviations in IV infusion administration and explored variability in policy and practice across different hospital trusts. / Methods: We conducted a mixed methods study. This involved observations of deviations from local policy including quantitative and qualitative data, and focus groups with clinical staff to explore the causes and contexts of deviations. The observations were conducted across five clinical areas (general medicine, general surgery, critical care, paediatrics and oncology day care) in 16 National Health Service (NHS) trusts in England. All infusions being administered at the time of data collection were included. Deviation rates for procedural and documentation requirements were compared between trusts. Local data collectors and other relevant stakeholders attended focus groups at each trust. Policy details and reasons for deviations were discussed. / Results: At least one procedural or documentation deviation was observed in 961 of 2008 IV infusions (deviation rate 47.9%; 95% confidence interval 45.5–49.8%). Deviation rates at individual trusts ranged from 9.9 to 100% of infusions, with considerable variation in the prevalence of different types of deviation. Focus groups revealed lack of policy awareness, ambiguous policies, safety and practicality concerns, different organisational priorities, and wide variation in policies and practice relating to prescribing and administration of IV flushes and double-checking. / Conclusions: Deviation rates and procedural and documentation requirements varied considerably between hospital trusts. Our findings reveal areas where local policy and practice do not align. Some policies may be impractical and lack utility. We suggest clearer evidence-based standardisation and local procedures that are contextually practical to address these issues

Trajectory Design from GTO to Near-Equatorial Lunar Orbit for the Dark Ages Radio Explorer (DARE) Spacecraft

The trajectory design for the Dark Ages Radio Explorer (DARE) mission concept involves dropping the DARE spacecraft off in a generalized geosynchronous transfer orbit (GTO) as a secondary payload. From GTO, the spacecraft is then required to enter a near-equatorial lunar orbit that is stable (i.e., no station-keeping maneuvers are required) and yields the required number of cumulative hours (1,000) for science measurements while in the lunar farside radio quiet cone over a span of three years. Preliminary and expected results of the corresponding trajectory design are presented herein

Flight Operations for the LCROSS Lunar Impactor Mission

The LCROSS (Lunar CRater Observation and Sensing Satellite) mission was conceived as a low-cost means of determining the nature of hydrogen concentrated at the polar regions of the moon. Co-manifested for launch with LRO (Lunar Reconnaissance Orbiter), LCROSS guided its spent Centaur upper stage into the Cabeus crater as a kinetic impactor, and observed the impact flash and resulting debris plume for signs of water and other compounds from a Shepherding Spacecraft. Led by NASA Ames Research Center, LCROSS flight operations spanned 112 days, from June 18 through October 9, 2009. This paper summarizes the experiences from the LCROSS flight, highlights the challenges faced during the mission, and examines the reasons for its ultimate success