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OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN:Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS:We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS:Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio T herapeutic drugs are a core component of the practice of medicine; 75% of office visits to primary care providers involve the initiation or continuation of drug therapy. 1 Adverse drug events (ADEs), defined as injuries due to drugs, occur commonly in the hospital setting. In the ADE Prevention Study, ADEs occurred at a rate of 6.5 per 100 admissions, and 28% of these events were preventable. 2 Many other studies have also been done to characterize inpatient ADEs. [3][4][5][6] Data suggest that ADEs among outpatients are an important problem as well. A recent meta-analysis suggested that in 1994 more than 1 million outpatients in the United States experienced an ADE that required admission to the hospital, and that 4.7% of admissions were caused by drugs. 7 The study also suggested that there were 106,000 fatal ADEs in the United States in 1994, which would place them between the fourth and sixth leading causes of death, although these projections may be high. 8 A recent study of U.S. death certificates showed that the number of people who reportedly died from medication errors increased by 2. 5-fold from 1983 to 1993, 9 suggesting that the problem may be worsening. However, compared with the inpatient setting, there is relatively little information about ADEs in the ambulatory setting. Estimates of the proportion of outpatients experiencing an ADE per year have ranged from 5% to 35%. 10,11 Several reasons exist for the relative lack of information about ADEs in the ambulatory setting. In contrast to inpatients, outpatients are responsible for both obtaining and administering their medications. Therefore, the process is much less controlled. Also, physicians have less regular contact with outpatients and are less likely to hear about their problems. Chart review also has limitations related to high costs and inadequate documentation. 12 Therefore, previous studies of outpatients have relied heavily on patient report, which has inherent limitations. Dependence on patients' recall during interviews or on re-[

ImportanceMedication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.ObjectivesThe objectives of this study are to (a) analyse medication error reports where CPOE was reported as a ‘contributing cause’ and (b) develop ‘use cases’ based on these reports to test vulnerability of current CPOE systems to these errors.MethodsA review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.ResultsBetween 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being ‘easily’ placed, another 101 (28.3%) with only minor workarounds and no warnings.Conclusions and relevanceMedication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.

The goal of this study was to develop and validate clinical prediction rules for bacteremia and subtypes of bacteremia in patients with sepsis syndrome. Thus, a prospective cohort study, including a stratified random sample of 1342 episodes of sepsis syndrome, was done in eight academic tertiary care hospitals. The derivation set included 881 episodes, and the validation set included 461. Main outcome measures were bacteremia caused by any organism, gram-negative rods, gram-positive cocci, and fungal bloodstream infection. The spread in probability between low- and high-risk groups in the derivation sets was from 14.5% to 60.6% for bacteremia of any type, from 9.8% to 32.8% for gram-positive bacteremia, from 5.3% to 41.9% for gram-negative bacteremia, and from 0.6% to 26.1% for fungemia. Because the model for gram-positive bacteremia performed poorly, a model predicting Staphylococcus aureus bacteremia was developed; it performed better, with a low- to high-risk spread of from 2.6% to 21.0%. The prediction models allow stratification of patients according to risk of bloodstream infections; their clinical utility remains to be demonstrated.

Iatrogenic injuries are important because they are frequent and many may be preventable; those caused by therapeutic drugs are among the most frequent. While medication errors are common, most have little potential for harm. However, some errors, such as giving a patient a drug to which they have a known allergy, are more likely to cause injury. Error theory provides insights into the changes required to reduce medication error injury rates. Data from the Adverse Drug Event (ADE) Prevention study suggest that most serious errors occur at the ordering and dispensing stages, while another, smaller, proportion occur at the administration stage. These data suggest that physician computer-order entry, where physicians write orders on-line with decision support, including patient-specific information and alerts about potential problems, has the potential to significantly reduce the number of serious medication errors.

BackgroundWith the aim of improving health care processes through health information technology (HIT), the US government has promulgated requirements for “meaningful use” (MU) of electronic health records (EHRs) as a condition for providers receiving financial incentives for the adoption and use of these systems. Considerable uncertainty remains about the impact of these requirements on the effective application of EHR systems.ObjectiveThe Agency for Healthcare Research and Quality (AHRQ)-sponsored Centers for Education and Research in Therapeutics (CERTs) critically examined the impact of the MU policy relating to the use of medications and jointly developed recommendations to help inform future HIT policy.MethodsWe gathered perspectives from a wide range of stakeholders (N=35) who had experience with MU requirements, including academicians, practitioners, and policy makers from different health care organizations including and beyond the CERTs. Specific issues and recommendations were discussed and agreed on as a group.ResultsStakeholders’ knowledge and experiences from implementing MU requirements fell into 6 domains: (1) accuracy of medication lists and medication reconciliation, (2) problem list accuracy and the shift in HIT priorities, (3) accuracy of allergy lists and allergy-related standards development, (4) support of safer and effective prescribing for children, (5) considerations for rural communities, and (6) general issues with achieving MU. Standards are needed to better facilitate the exchange of data elements between health care settings. Several organizations felt that their preoccupation with fulfilling MU requirements stifled innovation. Greater emphasis should be placed on local HIT configurations that better address population health care needs.ConclusionsAlthough MU has stimulated adoption of EHRs, its effects on quality and safety remain uncertain. Stakeholders felt that MU requirements should be more flexible and recognize that integrated models may achieve information-sharing goals in alternate ways. Future certification rules and requirements should enhance EHR functionalities critical for safer prescribing of medications in children.

ABSTRACT:The extended use of Zircaloy cladding in light water reactors degrades its mechanical properties by a combination of irradiation embrittlement, coolant-side oxidation, hydrogen pickup, and hydride formation. The hydrides are usually concentrated in the form of a dense layer or rim near the cooler outer surface of the cladding. Utilizing plane-strain ringstretch tests to approximate the loading path in a reactivity-initiated accident (RIA) transient, we examined the influence of a hydride rim on the fracture behavior of unirradiated Zircaloy-4 cladding at room temperature and 300°C. Failure is sensitive to hydride-rim thickness such that cladding tubes with a hydride-rim thickness >100 µm (≈700 wppm total hydrogen) exhibit brittle behavior, while those with a thickness <90 µm (≈600 wppm) remain ductile. The mechanism of failure is identified as strain-induced crack initiation within the hydride rim and failure within the uncracked ligament due to either a shear instability or damage-induced fracture. We also report some preliminary results of the uniaxial tensile behavior of low-Sn Zircaloy-4 cladding tubes in a cold-worked, stress-relieved condition in the transverse (hoop) direction at strain rates of 0.001/s and 0.2/s and temperatures of 26-400°C.

Background The ability to generate registries of patients with particular clinical attributes, such as diagnoses or medications taken, is central to measuring and improving the quality of health care. However, it is not known how many providers have the ability to generate such registries.Objectives To assess the proportion of physician practices that can construct registries of patients with specific diagnoses, laboratory results, or medications, and to determine the relationship between electronic health record (EHR) usage and the ability to perform registry functions.Methods We conducted a mail survey of a stratified random sample of physician practices in Massachusetts in the northeastern United States (N = 1884). The survey included questions about the physicians’ ability to generate diagnosis, laboratory result, and medication registries; the presence of EHR; and usage of specific EHR features.Results The response rate was 71% (1345/1884). Overall, 79.8% of physician practices reported being able to generate registries of patients by diagnosis; 56.1% by laboratory result; and 55.8% by medication usage. In logistic regression analyses, adjusting for urban/rural location, practice size and ownership, teaching status, hospital affiliation, and specialty, physician practices with an EHR were more likely to be able to construct diagnosis registries (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.25 - 1.86), laboratory registries (OR 1.42, 95% CI 1.22 - 1.66), and medication registries (OR 2.30, 95% CI 1.96 - 2.70).Conclusions Many physician practices were able to generate registries, but this capability is far from universal. Adoption of EHRs appears to be a useful step toward this end, and practices with EHRs are considerably more likely to be able to carry out registry functions. Because practices need registries to perform broad-based quality improvement, they should consider adopting EHRs that have built-in registry functionality.