Does medication safety and diversion education improve medication securement practices in SCU compared to current practice?

Does medication safety and diversion education improve medication securement practices in SCU compared to current practice? Abstract Natasha R. Stankiewicz, MS, RN, NE-BC, CCRN-CMC This safety quality improvement project began as newly hired SCU2 team members saw an opportunity to improve our medication safety practices and culture. The convenience of having certain medications directly available at bedside was priority. There was a lack of awareness and interest in securing medications within the department. However, the risk to our patients, families, visitors and colleagues when medications are left out, available and unsecured was apparent to new staff and others. Prior to our education, the accepted practice of unsecured medications was rampant: medications were left drawn up or exposed, setting in various open areas at bedside or within the room, in clinician’s pockets, and often transferred from one clinician to another during shift handoff. This safety project focused on creating buy-in through multidisciplinary education and analysis; the end goal was to alter the team’s workflow habits by increasing diversion and medication safety knowledge and awareness. SCU2’s Medication Safety QI project began by introducing the topic at two March staff meetings. A clinical pharmacist and nurse manager presented the topic of diversion and safe medication handling. The nurse manager then created and posted a translating evidence into practice (TRIP) sheet and PowerPoint for additional educational opportunity. Evidence included \u3e100,000 healthcare workers are dependent or abusing prescriptions each year, medications drawn up and left at bedside have sterility issues, and substance abuse is the number one reason nurses receive disciplinary action by state boards of nursing. To improve safety, the unit utilized MaineHealth’s Operational Excellence program to develop relevant key performance indicators (KPI). The first KPI focused on the entire team reviewing pharmacy and nurse manager\u27s provided education. All PowerPoint presentations were sent out via email in March, and again, in April. All educational materials were also physically posted on unit. A staff sign-off sheet was available once education was reviewed and understood; this knowledge and understanding was self-reported. SCU2’s education KPI ended in mid-April 2017, and our no meds left unsecured at bedside self-reporting KPI was enacted post-education. Team was encouraged to use MMC’s RL Solutions (Risk Management) program to document medication hazards and errors. Current KPI and focus continues to date. Management solicited feedback continually during introduction, education and implementation processes. Improved awareness and securement of medications post-education and quality improvement project was noted via staff sign-off sheet, self-reported KPI documentation for April-September 2017, and additional feedback will be solicited via anonymous survey post-hardwiring. 93.1% of RNs and 87.8% of staff solicited signed-off on at least one form of education. One medication error noted via RL Solutions system and was reviewed by SCU leadership and Risk Management. Based on these documentations and feedback, overall team buy-in was achieved: safety and diversion education improved medication securement practices post-education. Furthermore, this QI project extended to other units within MMC. Challenges sustaining medication safety practice changes occur during times of increased patient acuity, high patient flow and high census. This quality improvement project for SCU2 will continue until safety and culture improvement is ingrained

Genomic Disorders: Molecular Mechanisms for Rearrangements and Conveyed Phenotypes

Rearrangements of our genome can be responsible for inherited as well as sporadic traits. The analyses of chromosome breakpoints in the proximal short arm of Chromosome 17 (17p) reveal nonallelic homologous recombination (NAHR) as a major mechanism for recurrent rearrangements whereas nonhomologous end-joining (NHEJ) can be responsible for many of the nonrecurrent rearrangements. Genome architectural features consisting of low-copy repeats (LCRs), or segmental duplications, can stimulate and mediate NAHR, and there are hotspots for the crossovers within the LCRs. Rearrangements introduce variation into our genome for selection to act upon and as such serve an evolutionary function analogous to base pair changes. Genomic rearrangements may cause Mendelian diseases, produce complex traits such as behaviors, or represent benign polymorphic changes. The mechanisms by which rearrangements convey phenotypes are diverse and include gene dosage, gene interruption, generation of a fusion gene, position effects, unmasking of recessive coding region mutations (single nucleotide polymorphisms, SNPs, in coding DNA) or other functional SNPs, and perhaps by effects on transvection

Pressure effects on charge, spin, and metal-insulator transitions in narrow bandwidth manganite Pr1−x_{1-x}Cax_{x}MnO3_{3}

Pressure effects on the charge and spin states and the relation between the ferromagnetic and metallic states were explored on the small bandwidth manganite Pr$_{1-x}$Ca$_{x}$MnO$_{3}$ (x = 0.25, 0.3, 0.35). Under pressure, the charge ordering state is suppressed and a ferromagnetic metallic state is induced in all three samples. The metal-insulator transition temperature (T$_{MI}$) increases with pressure below a critical point P*, above which T$_{MI}$ decreases and the material becomes insulating as at the ambient pressure. The e$_{g}$ electron bandwidth and/or band-filling mediate the pressure effects on the metal-insulator transition and the magnetic transition. In the small bandwidth and low doping concentration compound (x = 0.25), the T$_{MI}$ and Curie temperature (T$_{C}$) change with pressure in a reverse way and do not couple under pressure. In the x = 0.3 compound, the relation of T$_{MI}$ and T$_{C}$ shows a critical behavior: They are coupled in the range of $\sim$0.8-5 GPa and decoupled outside of this range. In the x = 0.35 compound, T$_{MI}$ and T$_{C}$ are coupled in the measured pressure range where a ferromagnetic state is present

Uncommon branching pattern of the hepatic arteries in a living donor: a case report and brief literature review

Numerous variations of the hepatic arteries are common in surgical patients. We present a 35-year-old woman who was admitted to our department in order to assess possibility of becoming living donor. Preoperative computed tomography scan revealed anomalous branching pattern of the hepatic arteries. In this case right posterior sectoral artery has been given off by the greater pancreatic artery, left hepatic artery has been replaced by the artery arising from the left gastric artery and double segment 4 branches have been observed. To the best of our knowledge, this pattern has not been described in the literature, yet

Does 4D transperineal ultrasound have additional value over 2D transperineal ultrasound for diagnosing posterior pelvic floor disorders in women with obstructed defecation syndrome?

Objective To establish the diagnostic test accuracy of two‐dimensional (2D) and four‐dimensional (4D) transperineal ultrasound (TPUS) for diagnosis of posterior pelvic floor disorders in women with obstructed defecation syndrome (ODS), in order to assess if 4D ultrasound imaging provides additional value. Methods This was a prospective cohort study of 121 consecutive women with ODS. Symptoms of ODS and pelvic organ prolapse on clinical examination were assessed using validated methods. All women underwent both 2D‐ and 4D‐TPUS. Imaging analysis was performed by two blinded observers. Posterior pelvic floor disorders were dichotomized into presence or absence, according to predefined cut‐off values. In the absence of a reference standard, a composite reference standard was created from a combination of results of evacuation proctography, magnetic resonance imaging and endovaginal ultrasound. Primary outcome measures were diagnostic test characteristics of 2D‐ and 4D‐TPUS for rectocele, enterocele, intussusception and anismus. Secondary outcome measures were interobserver agreement, agreement between the two imaging techniques, and association of severity of ODS symptoms and degree of posterior vaginal wall prolapse with conditions observed on imaging. Results For diagnosis of all four posterior pelvic floor disorders, there was no difference in sensitivity or specificity between 2D‐ and 4D‐TPUS (P = 0.131–1.000). Good agreement between 2D‐ and 4D‐TPUS was found for diagnosis of rectocele (κ = 0.675) and moderate agreement for diagnoses of enterocele, intussusception and anismus (κ = 0.465–0.545). There was no difference in rectocele depth measurements between the techniques (19.9 mm for 2D vs 19.0 mm for 4D, P = 0.802). Interobserver agreement was comparable for both techniques, although 2D‐TPUS had excellent interobserver agreement for diagnosis of enterocele and rectocele depth measurements, while this was only moderate and good, respectively, for 4D‐TPUS. Diagnoses of rectocele and enterocele on both 2D‐ and 4D‐TPUS were significantly associated with degree of posterior vaginal wall prolapse on clinical examination (odds ratio (OR) = 1.89–2.72). The conditions observed using either imaging technique were not associated with severity of ODS symptoms (OR = 0.82–1.13). Conclusions There is no evidence of superiority of 4D ultrasound acquisition to dynamic 2D ultrasound acquisition for the diagnosis of posterior pelvic floor disorders. 2D‐ and 4D‐TPUS could be used interchangeably to screen women with symptoms of ODS

Parent of Origin, Mosaicism, and Recurrence Risk: Probabilistic Modeling Explains the Broken Symmetry of Transmission Genetics

Most new mutations are observed to arise in fathers, and increasing paternal age positively correlates with the risk of new variants. Interestingly, new mutations in X-linked recessive disease show elevated familial recurrence rates. In male offspring, these mutations must be inherited from mothers. We previously developed a simulation model to consider parental mosaicism as a source of transmitted mutations. In this paper, we extend and formalize the model to provide analytical results and flexible formulas. The results implicate parent of origin and parental mosaicism as central variables in recurrence risk. Consistent with empirical data, our model predicts that more transmitted mutations arise in fathers and that this tendency increases as fathers age. Notably, the lack of expansion later in the male germline determines relatively lower variance in the proportion of mutants, which decreases with paternal age. Subsequently, observation of a transmitted mutation has less impact on the expected risk for future offspring. Conversely, for the female germline, which arrests after clonal expansion in early development, variance in the mutant proportion is higher, and observation of a transmitted mutation dramatically increases the expected risk of recurrence in another pregnancy. Parental somatic mosaicism considerably elevates risk for both parents. These findings have important implications for genetic counseling and for understanding patterns of recurrence in transmission genetics. We provide a convenient online tool and source code implementing our analytical results. These tools permit varying the underlying parameters that influence recurrence risk and could be useful for analyzing risk in diverse family structures

Electronic structure of the (111) and (-1-1-1) surfaces of cubic BN: A local-density-functional ab initio study

We present ab initio local-density-functional electronic structure calculations for the (111) and (-1-1-1) surfaces of cubic BN. The energetically stable reconstructions, namely the N adatom, N3 triangle models on the (111), the (2x1), boron and nitrogen triangle patterns on the (-1-1-1) surface are investigated. Band structure and properties of the surface states are discussed in detail.Comment: 8 pages, 12 figure

Preliminary Design of Reactive Distillation Columns

A procedure that combines feasibility analysis, synthesis and design of reactive distillation columns is introduced. The main interest of this methodology lies on a progressive introduction of the process complexity. From minimal information concerning the physicochemical properties of the system, three steps lead to the design of the unit and the specification of its operating conditions. Most of the methodology exploits and enriches approaches found in the literature. Each step is described and our contribution is underlined. Its application is currently limited to equilibrium reactive systems where degree of freedom is equal to 2 or less than 2. This methodology which provides a reliable initialization point for the optimization of the process has been applied with success to different synthesis. The production of methyl-tert-butyl-ether (MTBE) and methyl acetate are presented as examples