John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety

BACKGROUND: In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. A NOVEL APPROACH: To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. KEY ACTION ITEMS AND RESULTS RELATED TO RCA: NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.     

A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice

BACKGROUND: Disease registries are powerful tools with the potential to transform the way chronic diseases are managed. To date, however, little work has been done to determine how to optimize the implementation of a chronic disease registry in practice. METHODS: Twenty-nine physicians and their nurse teams in a large community internal medicine practice participated in this 6-month prospective randomized trial in 2000. Teams were assigned to one of three implementation strategies using information from a diabetes registry. Process and outcome measures for diabetes management were analyzed. Process measures included the percentage of patients completing glycosylated hemoglobin (Hgb) testing within 6 months and low-density lipoprotein (LDL) testing within 12 months. Outcome measures included the percentage of patients with a glycosylated Hgb > 9.3% (equivalent to a HgbA1c > 8.0%), the percentage of patients with an LDL cholesterol > 130 mg/dl, and the percentage of patients with controlled blood pressure, defined as < 130/85 millimeters of mercury. Mean change in LDL and glycosylated Hgb values was also measured. RESULTS: Teams randomized to an intervention strategy that included direct letters to patients showed significant improvement across a number of measures. The improvement was most apparent among patients without recent testing or with poorly controlled disease. The two interventions that did not include direct patient letters resulted in limited improvement. DISCUSSION: Disease registries can be used to improve outcomes in the management of diabetes and other chronic diseases. Better outcomes were seen in patients who received letters based on registry-generated data. This strategy should be included as part of a comprehensive chronic disease management plan. Further refinements in the use of registries should result in further incremental improvement.     

Attenuation coefficient and propagation speed estimates of rat and pig intercostal tissue as a function of temperature

Attenuation coefficient and propagation speed of intercostal tissues were estimated as functions of temperature (22, 30, and 37 degrees C) from fresh chest walls from eight 10- to 11-week-old female Sprague-Dawley (SD) rats, eight 21- to 24-week-old female Long-Evans (LE) rats, and ten 6- to 10-week-old mixed sex Yorkshire (York) pigs. The primary purpose of the study was to estimate the temperature dependence of the intercostal tissue's attenuation coefficient so that accurate estimates of the in situ (at the pleural surface) acoustic pressure levels could be made for our ultrasound-induced lung hemorrhage studies. The attenuation coefficient of intercostal tissue for both species was independent of the temperature at the discrete frequencies of 3.1 MHz (-0.0076, 0.0065, and 0.016 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively) and 6.2 MHz (-0.015, 0.014, and 0.014 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively). However, the temperature-dependent regressions yielded a significant temperature dependency of the intercostal tissue attenuation coefficients in SD and LE rats (over the 3.1 to 9.6 MHz frequency range); there was no temperature dependency in York pigs (over the 3.1 to 8.6 MHz frequency range). There was no significant temperature dependency of the intercostal tissue propagation speed in SD rats; there was a temperature dependency in LE rats and York pigs (-0.59, -1.6, and -2.9 m/s/degrees C for SD rats, LE rats, and York pigs, respectively). Even though the attenuation coefficient's temperature dependency was significant from the linear regression functions, the differences were not very great (-0.040 to -0.13, 0.011 to 0.18, and 0.055 to 0.10 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively, over the data frequency range). These findings suggest that it is not necessary to determine the attenuation coefficient of intercostal tissue at body temperature (37 degrees C), but rather it is sufficient to determine the attenuation coefficient at room temperature (22 degrees C), a much easier experimental procedure.     

Nondestructive subharmonic imaging

Ultrasound contrast agent microbubbles are intravascular agents that can be used to estimate blood perfusion. Blood perfusion may be estimated by destroying the bubbles in a vascular bed and observing the refresh of contrast agents back into the vascular bed. Contrast agents can be readily destroyed by traditional imaging techniques. The design of a nondestructive imaging technique is necessary for the accurate quantification of contrast agent refresh. In this work, subharmonic imaging is investigated as a method for nondestructive imaging with the contrast agent microbubble MP1950 (Mallinckrodt, Inc., St. Louis, MO). Optical observation during insonation, in conjunction with a modified Rayleigh-Plesset (R-P) analysis, provides insight into the mechanisms of and parameters required for subharmonic frequency generation. Subharmonic imaging with a transmission frequency that is the same as the resonant frequency of the bubble is shown to require a minimum pressure of insonation that is greater than the experimentally-observed bubble destruction threshold. Subharmonic imaging with a transmission frequency that is twice the resonant frequency of the bubble produces a subharmonic frequency response while minimizing bubble instability. Optimization is performed using optical experimental analysis and R-P analysis     

Evaluating the crash and citation rates of Utah drivers licensed with medical conditions, 1992-1996

BACKGROUND: Medical problems may affect the ability to drive motor vehicles, and programs that control the issuing of driver licenses to individuals with medical conditions exist in most states. The main activity of these programs is the imposition of restrictions upon the driving privileges of individuals with medical conditions that are deemed to pose some risk to public safety. However, little is known about the effectiveness of these licensing programs. OBJECTIVE: The objective of this study was to compare the rates of adverse driving events (crash, at-fault crash and citations) experienced by drivers licensed with medical conditions to those of age-, sex- and location-matched controls. Separate comparisons were made for drivers reporting medical conditions licensed with full driving privileges, and those with restricted driving privileges (e.g. speed, area and time of day). DESIGN: Retrospective case-control. METHODS: The study population was all drivers licensed in the state of Utah who reported a medical condition on their driver license application, over the 5-year period 1992-1996. Drivers enter the program by self-reporting their medical problems. Control drivers were chosen from the entire population of drivers licensed in Utah for the same period. Information on driver license status, participation in the medical conditions program, citations, involvement in crashes, and death certificate data was obtained from the relevant state agencies. Probabilistic linkage methodology was used to link the records in these disparate databases for eventual analysis. Rates of citation, crashes and at-fault crashes, expressed as events per 10000 license days, were calculated separately for program drivers and their corresponding control groups for each medical condition category and restriction status. These data were used to determine an estimate of relative risk (RR) and 95% confidence intervals. Results: As a group, medical conditions drivers had modestly elevated rates of adverse driving events compared with control drivers (RR 1.09-1.74). Rates in the largest medical category, 'cardiovascular conditions', were not higher than controls. Rates were higher than control for some conditions, such as 'alcohol' and 'learning and memory', for some adverse events (RR 2.2 -5.75). Drivers with more than one medical condition appeared comparable to the general group of medical conditions program drivers. CONCLUSIONS: Drivers in Utah medical conditions program had modestly elevated rates of adverse driving events compared to matched controls. Possible underreporting of medical conditions and accurate assessment of exposure rates are potential weaknesses in the program.     

Noniterative blind data restoration by use of an extracted filter function

A signal-processing algorithm has been developed where a filter function is extracted from degraded data through mathematical operations. The filter function can then be used to restore much of the degraded content of the data through use of a deconvolution algorithm. This process can be performed without prior knowledge of the detection system, a technique known as blind deconvolution. The extraction process, designated self-deconvolving data reconstruction algorithm, has been used successfully to restore digitized photographs, digitized acoustic waveforms, and other forms of data. The process is noniterative, computationally efficient, and requires little user input. Implementation is straightforward, allowing inclusion into many types of signal-processing software and hardware. The novelty of the invention is the application of a power law and smoothing function to the degraded data in frequency space. Two methods for determining the value of the power law are discussed. The first method assumes the power law is frequency dependent. The function derived comparing the frequency spectrum of the degraded data with the spectrum of a signal with the desired frequency response. The second method assumes this function is a constant of frequency. This approach requires little knowledge of the original data or the degradation.     

Rainbow refractometry: simultaneous measurement of temperature, refractive index, and size of droplets

The capabilities and limitations of rainbow refractometry, specifically the minimum measurable droplet size and the errors in the refractive index (temperature), have been studied. We evaluate what we believe is a new method of indirectly applying the Lorenz-Mie theory to rainbow refractometry. The results show that this new method reduces the errors and eliminates the biases that may occur if the Airy theory is used. A more precise method to filter the high-frequency oscillations associated with the measurement signals was developed. Finally, it was discovered that the errors associated with rainbow refractometry are such that a single droplet measurement is unreliable. A mean refractive index should be determined on the basis of multiple droplet measurements.     

Atomic-precision multilayer coating of the first set of optics for an extreme-ultraviolet lithography prototype system

We present our results of coating a first set of optical elements for an extreme-ultraviolet (EUV) lithography system. The optics were coated with Mo-Si multilayer mirrors by dc magnetron sputtering and characterized by synchrotron radiation. Near-normal incidence reflectances above 65% were achieved at 13.35 nm. The run-to-run reproducibility of the reflectance peak wavelength was maintained to within 0.4%, and the thickness uniformity (or gradient) was controlled to within +/-0.05% peak to valley, exceeding the prescribed specification. The deposition technique used for this study is an enabling technology for EUV lithography, making it possible to fabricate multilayer-coated optics to accuracies commensurate with atomic dimensions.