Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing.

Objectives: To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors. Design: A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart. Setting: A London teaching hospital. Interventions/methods: A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation. Results: Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart. Conclusions: In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts

The Impact of the Evolving Satellite Data Record on Reanalysis Water and Energy Fluxes During the Past 30 Years

Retrospective analyses (reanalyses) use a fixed assimilation model to take diverse observations and synthesize consistent, time-dependent fields of state variables and fluxes (e.g. temperature, moisture, momentum, turbulent and radiative fluxes). Because they offer data sets of these quantities at regular space / time intervals, atmospheric reanalyses have become a mainstay of the climate community for diagnostic purposes and for driving offline ocean and land models. Of course, one weakness of these data sets is the susceptibility of the flux products to uncertainties because of shortcomings in parameterized model physics. Another issue, perhaps less appreciated, is the fact that the discreet changes in the evolving observational system, particularly from satellite sensors, may also introduce artifacts in the time series of quantities. In this paper we examine the ability of the NASA MERRA (Modern Era Retrospective Analysis for Research and Applications) and other recent reanalyses to determine variability in the climate system over the satellite record (~ the last 30 years). In particular we highlight the effect on reanalyses of discontinuities at the junctures of the onset of passive microwave imaging (Special Sensor Microwave Imager) in late 1987 as well as improved sounding and imaging with the Advanced Microwave Sounding Unit, AMSU-A, in 1998. We examine these data sets from two perspectives. The first is the ability to capture modes of variability that have coherent spatial structure (e.g. ENSO events and near-decadal coupling to SST changes) and how these modes are contained within trends in near global averages of key quantities. Secondly, we consider diagnostics that measure the consistency in energetic scaling in the hydrologic cycle, particularly the fractional changes in column-integrated water vapor versus precipitation as they are coupled to radiative flux constraints. These results will be discussed in the context of implications for science objectives and priorities of the NASA Energy and Water Cycle Study, NEWS

The Effect of Satellite Observing System Changes on MERRA Water and Energy Fluxes

Because reanalysis data sets offer state variables and fluxes at regular space / time intervals, atmospheric reanalyses have become a mainstay of the climate community for diagnostic purposes and for driving offline ocean and land models. Although one weakness of these data sets is the susceptibility of the flux products to uncertainties because of shortcomings in parameterized model physics, another issue, perhaps less appreciated, is the fact that continual but discreet changes in the evolving observational system, particularly from satellite sensors, may also introduce artifacts in the time series of quantities. In this paper we examine the ability of the NASA MERRA (Modern Era Retrospective Analysis for Research and Applications) and other recent reanalyses to determine variability in the climate system over the satellite record (approximately the last 30 years). In particular we highlight the effect on the reanalysis of discontinuities at the junctures of the onset of passive microwave imaging (Special Sensor Microwave Imager) in late 1987 as well as improved sounding and imaging with the Advanced Microwave Sounding Unit, AMSU-A, in 1998. We first examine MERRA fluxes from the perspective of how physical modes of variability (e.g. ENSO events, Pacific Decadal Variability) are contaminated by artificial step-like trends induced by the onset of new moisture data these two satellite observing systems. Secondly, we show how Redundancy Analysis, a statistical regression methodology, is effective in relating these artifact signals in the moisture and temperature analysis increments to their presence in the physical flux terms (e.g. precipitation, radiation). This procedure is shown to be effective greatly reducing the artificial trends in the flux quantities

Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists

Objective To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself