Reducing prescribing errors through creatinine clearance alert redesign

Background Literature has shown that computerized creatinine clearance alerts reduce errors during prescribing, and applying human factors principles may further reduce errors. Our objective was to apply human factors principles to creatinine clearance alert design and assess whether the redesigned alerts increase usability and reduce prescribing errors compared with the original alerts. Methods Twenty Veterans Affairs (VA) outpatient providers (14 physicians, 2 nurse practitioners, and 4 clinical pharmacists) completed 2 usability sessions in a counterbalanced study to evaluate original and redesigned alerts. Each session consisted of fictional patient scenarios with 3 medications that warranted prescribing changes because of renal impairment, each associated with creatinine clearance alerts. Quantitative and qualitative data were collected to assess alert usability and the occurrence of prescribing errors. Results There were 43% fewer prescribing errors with the redesigned alerts compared with the original alerts (P = .001). Compared with the original alerts, redesigned alerts significantly reduced prescribing errors for allopurinol and ibuprofen (85% vs 40% and 65% vs 25%, P = .012 and P = .008, respectively), but not for spironolactone (85% vs 65%). Nine providers (45%) voiced confusion about why the alert was appearing when they encountered the original alert design. When laboratory links were presented on the redesigned alert, laboratory information was accessed 3.5 times more frequently. Conclusions Although prescribing errors were high with both alert designs, the redesigned alerts significantly improved prescribing outcomes. This investigation provides some of the first evidence on how alerts may be designed to support safer prescribing for patients with renal impairment

Development of the Circulation Control Flow Scheme Used in the NTF Semi-Span FAST-MAC Model

The application of a circulation control system for high Reynolds numbers was experimentally validated with the Fundamental Aerodynamic Subsonic Transonic Modular Active Control semi-span model in the NASA Langley National Transonic Facility. This model utilized four independent flow paths to modify the lift and thrust performance of a representative advanced transport type of wing. The design of the internal flow paths highlights the challenges associated with high Reynolds number testing in a cryogenic pressurized wind tunnel. Weight flow boundaries for the air delivery system were identified at mildly cryogenic conditions ranging from 0.1 to 10 lbm/sec. Results from the test verified system performance and identified solutions associated with the weight-flow metering system that are linked to internal perforated plates used to achieve flow uniformity at the jet exit

Enhancements to the FAST-MAC Circulation Control Model and Recent High-Reynolds Number Testing in the National Transonic Facility

A second wind tunnel test of the FAST-MAC circulation control model was recently completed in the National Transonic Facility at the NASA Langley Research Center. The model was equipped with four onboard flow control valves allowing independent control of the circulation control plenums, which were directed over a 15% chord simple-hinged flap. The model was configured for low-speed high-lift testing with flap deflections of 30 and 60 degrees, along with the transonic cruise configuration with zero degree flap deflection. Testing was again conducted over a wide range of Mach numbers up to 0.88, and Reynolds numbers up to 30 million based on the mean chord. The first wind tunnel test had poor transonic force and moment data repeatability at mild cryogenic conditions due to inadequate thermal conditioning of the balance. The second test demonstrated that an improvement to the balance heating system significantly improved the transonic data repeatability, but also indicated further improvements are still needed. The low-speed highlift performance of the model was improved by testing various blowing slot heights, and the circulation control was again demonstrated to be effective in re-attaching the flow over the wing at off-design transonic conditions. A new tailored spanwise blowing technique was also demonstrated to be effective at transonic conditions with the benefit of reduced mass flow requirements

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

OBJECTIVE: To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. MATERIALS AND METHODS: We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. RESULTS: Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). DISCUSSION: Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. CONCLUSIONS: This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes

The Development of a Point of Care Clinical Guidelines Mobile Application Following a User-Centred Design Approach

This paper describes the development of a point of care clinical guidelines mobile application. A user-centred design approach was utilised to inform the design of a smartphone application, this included: Observations; a survey; focus groups and an analysis of popular apps utilised by clinicians in a UK NHS Trust. Usability testing was conducted to inform iterations of the application, which presents clinicians with a variety of integrated tools to aid in decision making and information retrieval. The study found that clinicians use a mixture of technology to retrieve information, which is often inefficient or has poor usability. It also shows that smartphone application development for use in UK hospitals needs to consider the variety of users and their clinical knowledge and work pattern. This study highlights the need for applying user-centred design methods in the design of information presented to clinicians and the need for clinical information delivery that is efficient and easy to use at the bedside

KElt-18b: Puffy planet, hot host, probably perturbed

We report the discovery of KELT-18b, a transiting hot Jupiter in a 2.87-day orbit around the bright (V = 10.1), hot, F4V star BD+60 1538 (TYC 3865-1173-1). We present follow-up photometry, spectroscopy, and adaptive optics imaging that allow a detailed characterization of the system. Our preferred model fits yield a host stellar temperature of K and a mass of, situating it as one of only a handful of known transiting planets with hosts that are as hot, massive, and bright. The planet has a mass of, a radius of, and a density of, making it one of the most inflated planets known around a hot star. We argue that KELT-18b\u27s high temperature and low surface gravity, which yield an estimated ∼600 km atmospheric scale height, combined with its hot, bright host, make it an excellent candidate for observations aimed at atmospheric characterization. We also present evidence for a bound stellar companion at a projected separation of ∼1100 au, and speculate that it may have contributed to the strong misalignment we suspect between KELT-18\u27s spin axis and its planet\u27s orbital axis. The inferior conjunction time is 2457542.524998 ± 0.000416 (BJDTDB) and the orbital period is 2.8717510 ± 0.0000029 days. We encourage Rossiter-McLaughlin measurements in the near future to confirm the suspected spin-orbit misalignment of this system

Three dimensional structure directs T-cell epitope dominance associated with allergy

<p>Abstract</p> <p>Background</p> <p>CD4+ T-cell epitope immunodominance is not adequately explained by peptide selectivity in class II major histocompatibility proteins, but it has been correlated with adjacent segments of conformational flexibility in several antigens.</p> <p>Methods</p> <p>The published T-cell responses to two venom allergens and two aeroallergens were used to construct profiles of epitope dominance, which were correlated with the distribution of conformational flexibility, as measured by crystallographic B factors, solvent-accessible surface, COREX residue stability, and sequence entropy.</p> <p>Results</p> <p>Epitopes associated with allergy tended to be excluded from and lie adjacent to flexible segments of the allergen.</p> <p>Conclusion</p> <p>During the initiation of allergy, the N- and/or C-terminal ends of proteolytic processing intermediates were preferentially loaded into antigen presenting proteins for the priming of CD4+ T cells.</p

Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs

Background: There is little empirical evidence regarding the generalisability of relative risk estimates from studies which have relatively low response rates or are of limited representativeness. The aim of this study was to investigate variation in exposure-outcome relationships in studies of the same population with different response rates and designs by comparing estimates from the 45 and Up Study, a population-based cohort study (self-administered postal questionnaire, response rate 18%), and the New South Wales Population Health Survey (PHS) (computer-assisted telephone interview, response rate ~60%). Methods: Logistic regression analysis of questionnaire data from 45 and Up Study participants (n = 101,812) and 2006/ 2007 PHS participants (n = 14,796) was used to calculate prevalence estimates and odds ratios (ORs) for comparable variables, adjusting for age, sex and remoteness. ORs were compared using Wald tests modelling each study separately, with and without sampling weights. Results: Prevalence of some outcomes (smoking, private health insurance, diabetes, hypertension, asthma) varied between the two studies. For highly comparable questionnaire items, exposure-outcome relationship patterns were almost identical between the studies and ORs for eight of the ten relationships examined did not differ significantly. For questionnaire items that were only moderately comparable, the nature of the observed relationships did not differ materially between the two studies, although many ORs differed significantly. Conclusions: These findings show that for a broad range of risk factors, two studies of the same population with varying response rate, sampling frame and mode of questionnaire administration yielded consistent estimates of exposure-outcome relationships. However, ORs varied between the studies where they did not use identical questionnaire items

Evaluation of cell-free DNA approaches for multi-cancer early detection

In the Circulating Cell-free Genome Atlas (NCT02889978) substudy 1, we evaluate several approaches for a circulating cell-free DNA (cfDNA)-based multi-cancer early detection (MCED) test by defining clinical limit of detection (LOD) based on circulating tumor allele fraction (cTAF), enabling performance comparisons. Among 10 machine-learning classifiers trained on the same samples and independently validated, when evaluated at 98% specificity, those using whole-genome (WG) methylation, single nucleotide variants with paired white blood cell background removal, and combined scores from classifiers evaluated in this study show the highest cancer signal detection sensitivities. Compared with clinical stage and tumor type, cTAF is a more significant predictor of classifier performance and may more closely reflect tumor biology. Clinical LODs mirror relative sensitivities for all approaches. The WG methylation feature best predicts cancer signal origin. WG methylation is the most promising technology for MCED and informs development of a targeted methylation MCED test