Hospital electronic prescribing and medicines administration system implementation into a district general hospital: a mixed method evaluation of discharge communication.

Hospital electronic prescribing and medicines administration (HEPMA) system implementation is advocated by national e-health strategies to produce patient safety benefits. No previous study has evaluated the impact of HEPMA implementation on either discharge information communication or occurence of discharge prescribing errors. The aims of this thesis were to assess the impact of HEPMA system implementation on medicines-related discharge communication and prescribing errors, and to understand the perspective of hospital staff involved in the communication process. Following a narrative literature review, a convergent parallel mixed methods approach was selected, consisting of interpretative phenomenology, and experimental before-and-after study design. Face-to-face semi-structured interviews were undertaken with a purposive sample of hospital staff involved in discharge information communication, using the Theoretical Domains Framework (TDF) as a theoretical lens. In addition, a quasi-experimental retrospective case notes review was completed both before and after implementation. Pre-implementation, staff described patient safety concerns with traditional discharge communication processes. They cited frequent prescribing errors, and associated adverse events and hospital readmissions. HEPMA implementation was anticipated to improve patient safety and create more efficient discharge communication. Post-implementation staff articulated improved information quality highlighting fewer omitted medicines and improved patient safety. TDF findings of behaviour change highlighted behavioural alteration including adoption of processes to improve discharge quality. Quantitative data collection (n = 159 before and after) confirmed qualitative findings, showing increased compliance with discharge documentation. For example: staff grade recorded increased from 40% to 100% (p < 0.001); prescribing error quantity and severity were reduced, with errors reduced from 99% to 23% of patients (p < 0.001) and only 22% of identified errors likely to cause harm; and omitted medicines decreased from 42% to 11% of patients (p < 0.001). The findings contribute original knowledge concerning the impact of HEPMA implementation on discharge information communication and prescribing errors. The study demonstrated reduced prescribing errors and improved patient safety, which potentially impacted health and wellbeing. Qualitative findings and quantitative results are transferable, and applicable to other NHS organisations or similar healthcare settings

Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study.

The study aimed to test the hypothesis that hospital electronic prescribing and medicine administration (HEPMA) system implementation impacted patient discharge letter quality, and the nature and frequency of prescribing errors. A quasi experimental before and after retrospective case note review was conducted in one United Kingdom district general hospital. The total sample size was 318 (random samples of 159 before and after implementation), calculated to achieve a 10% error reduction with a power of 80% and p < 0.05. Adult patients discharged after ≥24 hour inpatient stay were assessed for discharge information documentation quality using a modified validated discharge document template. Prescribing errors were classified as medicine omissions, commissions, incorrect dose/frequency/ duration, drug interactions, therapeutic duplications or missing/inaccurate allergy information. Post-implementation assessments were undertaken four months after HEPMA implementation. Error severity was determined by a multidisciplinary panel consensus using the Medications at Transitions and Clinical Handoffs (MATCH) study validated scoring system. There were no statistically significant differences in patient demographics between the pre and post-implementation groups. Discharge information documentation quality improved; allergy documentation increased from 11 to 159/159 (p < 0.0001). The number of patients with prescribing errors reduced significantly from 158 to 37/159 (p < 0.001).Prescribing error category incidence identified in preimplementation patients was reduced (e.g. omission incidence from 66 to 18/159 (p < 0.001)), although a new error type (sociotechnical [errors caused by the system]) was identified post-implementation (n=8 patients). Post-implementation prescribing errors severity rating identified 8/37 as likely to cause potential patient harm. In conclusion, HEPMA implementation was associated with improved discharge documentation quality, statistically significant prescribing error reduction and prescribing error type alteration. There remains a need to be alert for potential prescribing errors

Hospital staff views of prescribing and discharge communication before and after electronic prescribing system implementation.

Background Electronic prescribing system implementation is recommended to improve patient safety and general practitioner's discharge information communication. There is a paucity of information about hospital staff perspectives before and after system implementation. Objective To explore hospital staff views regarding prescribing and discharge communication systems before and after hospital electronic prescribing and medicines administration (HEPMA) system implementation. Setting A 560 bed United Kingdom district general hospital. Methods Semi-structured face-to-face qualitative interviews with a purposive sample of hospital staff involved in the prescribing and discharge communication process. Interviews transcribed verbatim and coded using the Framework Approach. Behavioural aspects mapped to Theoretical Domains Framework (TDF) to highlight associated behavioural change determinants. Main outcome measure Staff perceptions before and after implementation. Results Nineteen hospital staff (consultant doctors, junior doctors, pharmacists and advanced nurse practitioners) participated before and after implementation. Pre-implementation main themes were inpatient chart and discharge letter design and discharge communication process with issues of illegible and inaccurate information. Improved safety was anticipated after implementation. Post-implementation themes were improved inpatient chart clarity and discharge letter quality. TDF domains relevant to staff behavioural determinants preimplementation were knowledge (task or environment); skills (competence); social/professional roles and identity; beliefs about capabilities; environmental context and resources (including incidents). An additional two were relevant post-implementation: social influences and behavioural regulation (including self-monitoring). Participants described challenges and patient safety concerns pre-implementation which were mostly resolved post-implementation. Conclusion HEPMA implementation produced perceptions of patient safety improvement. TDF use enabled behaviour change analysis due to implementation, for example, staff adoption of behaviours to ensure general practitioners receive good quality discharge information

Hospital discharge information communication and prescribing errors: a narrative literature overview.

Objectives - To provide a narrative overview of the literature on discharge information communication and medicines discharge prescribing error rate in the UK and other similar healthcare systems. Methods - A narrative review of the peer reviewed literature (2000-2014) on communication of discharge information from hospitals to general practitioners. Databases included were MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts, and International Pharmacy Abstracts database. Results - The search yielded 673 results with 15 papers satisfying all inclusion criteria. Direct comparison of studies was not feasible due to differences in study populations and outcome measures. No studies reported post Hospital Electronic Prescribing and Medicine Administration (HEPMA) implementation. Studies (n=6) investigating handwritten discharge communication systems demonstrated medicine information inaccuracy ranging from 0.81 errors per patient to 17.5% medicines with errors and 67% letters missing medicines change information; with 77% assessed as legible. Studies (n=4) comparing interim electronic solutions with traditional showed variable results: improved, unchanged or decreased medicine information accuracy. Studies researching solely interim electronic solutions (n=5) with one including prescribing error rate assessment at 8.4% of prescribed items and identification of a new electronic system-related error type. Conclusion - Implementation of interim electronic discharge solutions resulted in complete legibility but did not eradicate information and prescribing errors. A paucity of information is available about HEPMA implementation impact on discharge information communication and prescribing error rates. There is urgent need for formal evaluation in this area

Cross-ancestry genome-wide association analysis of corneal thickness strengthens link between complex and Mendelian eye diseases

Central corneal thickness (CCT) is a highly heritable trait associated with complex eye diseases such as keratoconus and glaucoma. We perform a genome-wide association meta-analysis of CCT and identify 19 novel regions. In addition to adding support for known connective tissue-related pathways, pathway analyses uncover previously unreported gene sets. Remarkably, >20% of the CCT-loci are near or within Mendelian disorder genes. These included FBN1, ADAMTS2 and TGFB2 which associate with connective tissue disorders (Marfan, Ehlers-Danlos and Loeys-Dietz syndromes), and the LUM-DCN-KERA gene complex involved in myopia, corneal dystrophies and cornea plana. Using index CCT-increasing variants, we find a significant inverse correlation in effect sizes between CCT and keratoconus (r =-0.62, P = 5.30 × 10-5) but not between CCT and primary open-angle glaucoma (r =-0.17, P = 0.2). Our findings provide evidence for shared genetic influences between CCT and keratoconus, and implicate candidate genes acting in collagen and extracellular matrix regulation

Velocity-space sensitivity of the time-of-flight neutron spectrometer at JET

The velocity-space sensitivities of fast-ion diagnostics are often described by so-called weight functions. Recently, we formulated weight functions showing the velocity-space sensitivity of the often dominant beam-target part of neutron energy spectra. These weight functions for neutron emission spectrometry (NES) are independent of the particular NES diagnostic. Here we apply these NES weight functions to the time-of-flight spectrometer TOFOR at JET. By taking the instrumental response function of TOFOR into account, we calculate time-of-flight NES weight functions that enable us to directly determine the velocity-space sensitivity of a given part of a measured time-of-flight spectrum from TOFOR

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements

Relationship of edge localized mode burst times with divertor flux loop signal phase in JET

A phase relationship is identified between sequential edge localized modes (ELMs) occurrence times in a set of H-mode tokamak plasmas to the voltage measured in full flux azimuthal loops in the divertor region. We focus on plasmas in the Joint European Torus where a steady H-mode is sustained over several seconds, during which ELMs are observed in the Be II emission at the divertor. The ELMs analysed arise from intrinsic ELMing, in that there is no deliberate intent to control the ELMing process by external means. We use ELM timings derived from the Be II signal to perform direct time domain analysis of the full flux loop VLD2 and VLD3 signals, which provide a high cadence global measurement proportional to the voltage induced by changes in poloidal magnetic flux. Specifically, we examine how the time interval between pairs of successive ELMs is linked to the time-evolving phase of the full flux loop signals. Each ELM produces a clear early pulse in the full flux loop signals, whose peak time is used to condition our analysis. The arrival time of the following ELM, relative to this pulse, is found to fall into one of two categories: (i) prompt ELMs, which are directly paced by the initial response seen in the flux loop signals; and (ii) all other ELMs, which occur after the initial response of the full flux loop signals has decayed in amplitude. The times at which ELMs in category (ii) occur, relative to the first ELM of the pair, are clustered at times when the instantaneous phase of the full flux loop signal is close to its value at the time of the first ELM