Systematic root cause analysis of adverse drug events in a tertiary referral hospital

BACKGROUND: Adverse drug events (ADEs) occur frequently, and serious ADEs are associated with mortality or prolonged morbidity. As many ADEs are preventable, identification and modification of systems and processes that permit ADEs has the potential to reduce the rate of ADEs. METHODS: Root cause analysis was systematically employed in a blame-free fashion to investigate the patterns of serious ADEs that occurred during a 29-month period at Hermann Hospital (Houston), and process improvements were implemented on the basis of these findings. The consistently nonpunitive responses to the results of the initial and subsequent root cause analyses was gradually seen, accepted, and ultimately embraced by the hospital staff. RESULTS: The most commonly identified root causes were environmental factors (for example, increased census, increased acuity, change of shift) and staffing issues (for example, personnel new to a unit). Policy changes that led to increased use of forcing or constraining functions (for example, removal of concentrated intravenous potassium solutions from floor stocks) and better personnel support (for example, early awareness and response to localized increases in census and acuity) were particularly effective. Although limited by our lack of active surveillance and not necessarily directly due to the process changes that we implemented, the rate of voluntarily reported serious ADEs/100,000 patient days decreased during this time from 7.2 to 4.0, a decline of 45% (p < 0.001). CONCLUSION: Systematic application of root cause analysis followed by implementation of process changes that target the underlying cause(s) of each event can be successfully implemented in a large hospital.     

Using an improvement model to reduce adverse drug events in VA facilities

BACKGROUND: Adverse drug events cause significant morbidity and mortality in health care. Many adverse drug events are due to medication errors and are preventable. In 1999 and 2000 the Patient Safety Center of Inquiry collaborated with the Institute for Healthcare Improvement (IHI) to implement a quality improvement (QI) project designed to reduce medication errors within the Veterans Administration system. METHODS: During a 6- to 9-month period, interdisciplinary teams that want to achieve much higher levels of performance work on a common aim, under the guidance of faculty, and come together for three 2-day educational and planning sessions. Between these sessions, teams implement some of the suggested changes, measure the results of those changes, and report back to the larger group. RESULTS: During the formal project, teams collected allergy information on more than 20,000 veterans and averted 1,833 medication errors that had the potential to cause adverse events. At 6-month follow-up, the majority of teams remained intact, continued to collect data, and maintained their gains, approximately doubling the results obtained during the formal project. Half of the teams expanded their efforts to other settings, and one-third of the teams expanded beyond their original topics. Returns on investment in the QI effort were substantial. CONCLUSIONS: The results suggest that gains made in organized QI efforts can be maintained for 6 months without additional external support or coaching if team structure and leadership support remain intact. Facilitators of QI efforts should focus on teams that are having difficulty learning new techniques. Finally, this effort appeared to generate cost savings.     

Biofouling: lessons from nature

Biofouling is generally undesirable for many applications. An overview of the medical, marine and industrial fields susceptible to fouling is presented. Two types of fouling include biofouling from organism colonization and inorganic fouling from non-living particles. Nature offers many solutions to control fouling through various physical and chemical control mechanisms. Examples include low drag, low adhesion, wettability (water repellency and attraction), microtexture, grooming, sloughing, various miscellaneous behaviours and chemical secretions. A survey of nature's flora and fauna was taken in order to discover new antifouling methods that could be mimicked for engineering applications. Antifouling methods currently employed, ranging from coatings to cleaning techniques, are described. New antifouling methods will presumably incorporate a combination of physical and chemical controls.     

Policy SEA: lessons from development co-operation

This professional practice report reflects upon lessons learned from piloting and evaluating an innovative approach to policy strategic environmental assessment (SEA) in developing countries. The primary analytical focuses of the approach are institutions and governance characteristics, plus it places strong emphasis on learning. The piloting provides valuable insights about the conduct of SEA at the policy level and in socio-political where there is limited experience with SEA. From our observations we reflect upon the importance of appropriate ownership of an SEA; the practical implications of working in contested political environments; the challenges in using SEA as a tool to promote good governance; and the centrality of a long-term perspective to environmental and social mainstreaming.     

Improving inpatient antibiotic prescribing: insights from participation in a national collaborative

BACKGROUND: Increasing rates of antimicrobial resistance and the role antibiotic overuse plays in contributing to this problem have been widely documented and have prompted appeals to change prescribing practices. How to actually achieve such changes represents a major challenge. As part of the Institute for Healthcare Improvement (IHI) Breakthrough Series project Improving Prescribing Practices (IPP), in 1997-1998, Cook County Hospital (Chicago) worked with other institutions that chose antibiotics as their focus in this national collaborative. PRACTICAL SUGGESTIONS: Practical suggestions are offered within six categories--adopting a general approach to improving antibiotic prescribing (marshalling credible evidence, addressing physician concerns and skepticism, and removing barriers to make it easier for prescribers to change); rethinking guidelines (providing syndrome-based guidance, revising national guidelines for local use, defining scenarios in which drug(s) can be safely withheld, offering alternatives, prospectively resolving conflicts over drug of choice and empiric regimens, and defining situations in which immediate treatment is and is not critical); getting the message out and changes implemented (using antibiotic order forms, computer order entry, and infectious disease specialist consultation); building viable linkages to leverage change (bridging disciplines); improving measurement; and promoting nondrug strategies and patients' roles in treating and preventing infection. CONCLUSION: Antimicrobials are unique, being the only class of drug therapy that affects not only the patient to whom it is prescribed but other current and future patients as well. Institutions therefore have a special responsibility to ensure their efficient and judicious use. It is often easier to prescribe antibiotics than to exercise restraint.     

Death by a thousand cuts: The physics of device failure through a series of activated,microscopic events

A physical model describes device failure in terms of a series of n microscopic events (such as defect creation) which are describable in terms of an identifiable activation energy. The results show a ‘Weibull like’ time dependence, but the temperature dependence is not of the simple Arrhenius form. Application is made to the ‘dark’ leakage current in a PIN photodiode and to the deviation in threshold voltage in a MOSFET. In particular the threshold voltage is shown to depend on a series of activated processes, and the required number of such processes to cause failure increases with the width of the gate electrode.     

An end to unemployment in Europe: from breakdown to breakthrough

Despite signs of another economic upturn, persistent unemployment in the fifteen countries comprising the EEC remains at a level that affects eighteen million individuals and their families. Statistically, it is clear that funds now doled out as unemployment compensation could, if channeled into the creation of valid jobs in the private and public sectors, end unemployment in Western Europe. This article proposes the establishment of a European Employment Trust as an intersectoral instrument to accelerate job creation within the EEC. The Trust, managed by fiduciaries who have earned the confidence of labor unions, employers' associations, and governments, would invest in enterprises that have demonstrated the capability of creating growth and profitability while increasing the number of persons they employ. Young people without requisite skills or experience, or those who wish to devote a year to environmental enhancement or the rescue and relief of populations suffering from natural disasters would be accepted as volunteers in a Conservation and Rescue Service, as described in an earlier volume of this Journal (1996, Vol. 18, No. 4, pp. 419–442). The combined programs offer Europe a “win-win” strategy that would restore its cohesion, self-confidence, and prosperity. The cumulative impact of the European Employment Trust and a Conservation and Rescue Service would terminate the scourge of unemployment without further burdens on government or taxpayer budgets, would not require the creation of additional bureaucracies, and would provide new opportunities for private investment and co-investment.     

Validation of design methods: lessons from medicine

This paper discusses the validation of design methods. The challenges and opportunities in validation are illustrated by drawing an analogy to medical research and development. Specific validation practices such as clinical studies and use of models of human disease are discussed, including specific ways to adapt them to engineering design. The implications are explored for three active areas of design research: robust design, axiomatic design, and design decision making. It is argued that medical research and development has highly-developed, well-documented validation methods and that many specific practices such as natural experiments and model-based evaluations can profitably be adapted for use in engineering design research.     

Toward better renoprotection: lessons from angiotensin receptor blockers

The rising tide of chronic kidney disease (CKD), especially diabetic nephropathy, has become a worldwide catastrophe. However, therapeutic options to prevent or retard the progression of CKD still remain very limited. The understanding of its molecular mechanisms and the delineation of tools able to modify them are thus of critical importance. The discovery that some antihypertensive agents inhibiting the renin-angiotensin system, such as angiotensin II type 1 receptor blockers, protect the kidney opens new therapeutic perspectives. In this article, we focus on their renoprotective actions beyond blood pressure lowering.     

Managing innovation: lessons from the cardiac-pacing industry.

In this article, the authors argue that innovation is a surefire way for a firm to increase its sales and market share. This, in turn, can stimulate American industries and make American firms more competitive in international markets. Through their study of the cardiac-pacing industry, they draw conclusions about what factors contribute to a successful innovation in other industries besides medical electronics. They identify general patterns and stages of the innovation process, key roles top management must fill in an organization, and effective policies that foster important innovations.     

Leather processing in Ethiopia and Kenya: lessons from India

This article discusses the successful value-added chain within India's leather industry, and then draws contrasts with the evolution of the leather products industries of Kenya and Ethiopia. Much of India's success derives from the ability of its stakeholders—from government to industry—to set their own policies and priorities regarding the development of the leather industry. The fact that India selectively liberalized the entry of a variety of industries into the global economy added to the improved performance of its leather products sub-sector. By contrast, both Ethiopia and Kenya followed different policies regarding liberalization, with differing results. Although the leather industry is important for both countries, moving up the value-added chain remains tenuous at best for Kenya and only slightly better for Ethiopia. This article recommends that both countries need to formulate and implement policies that will move the leather industry from raw and semi-processed production outward to the leather products and leather goods sub-sectors.     

Integrated safety assessment of Indian nuclear power plants for extreme events: Reducing impact on public mind

Nuclear energy professionals need to understand and address the catastrophe syndrome that of late seems to be increasingly at work in public mind in the context of nuclear energy. Classically the nuclear power reactor design and system evolution has been based on the logic of minimization of risk to an acceptable level and its quantification based on a deterministic approach and backed up by a further assessment based on the probabilistic methodology. However, in spite of minimization of risk, the reasons for anxiety and trauma in public mind that still prevails in the context of severe accidents needs to be understood and addressed. Margins between maximum credible accidents factored in the design and the ultimate load withstanding capacities of relevant systems need to be enhanced and guaranteed with a view to minimize release of radioactivity and avoid serious impact in public domain. A more realistic basis for management of an accident in public domain also needs to be quantified for this purpose. Assurance to public on limiting the consequences to a level that does not lead to a trauma is something that we need to be able to credibly demonstrate and confirm. The findings from Chernobyl reports point to significant psychological effects and related health disorders due to large scale emergency relocation of people that could have been possibly reduced by an order of magnitude without significant additional safety detriment. A combination of probabilistic and deterministic approaches should be evolved further to minimize consequences in public domain through enhancing safety margins and adding greater precision to quantitatively predicting accident progression and its management. The paper presents the case studies of the extreme external event such as tsunami and its impact on the coastal nuclear plants in India, the containment integrity assessment under the extreme internal event of over-pressurization and aircraft impact along with hydrogen deflagration/detonation-induced loadings. These are at the moment extremely burning issues due to the severe accidents of Fukushima, Chernobyl and Three Mile Island reactors. In the present day context identifying the extreme loadings in a separate category and the corresponding margin assessment is necessary in addition to the implementation of the mitigation and upgraded safety measures. Further, the paper attempts to address the question of public trauma in the event of a serious nuclear reactor accident, a need that has been felt in view of the recent Fukushima and earlier Chernobyl accidents and the resulting large scale relocation due to the present deficient policies and the inherent limitations of Linear No Threshold (LNT) principle.     

Separating a weak periodic component from a nonstationary time series

Various approaches to separating a weak periodic component from a noisy nonstationary time series are considered in the case when aprioric information about useful signal is unavailable and multiply repeated measurements are impossible. The proposed methods have been used for studying the time variation of the mass of a dendritic crystal of ammonium chloride growing from an aqueous solution. It is established that the kinetic curves obtained for growth rates above 20 μm/s exhibit low-frequency oscillations with a period of about 3 s.     

Urban sustainability indicators re-visited: lessons from property-led urban development in China

This paper proposes a bespoke urban sustainability indicator framework in the context of China’s prevalent property-led urban development. Emphasising local characteristics and incorporating underlying institutions, it advocates a more nuanced, holistic and dynamic approach when addressing sustainability issues. Selection of indicators were based on extensive literature reviews and tested through an international expert survey comprising both China-based and overseas-based experts. The two groups of experts have shown divergent views, with the former prioritising economic and institutional aspects over environmental and social factors. It also provides transferable policy insights into developing countries more generally, given many similarities in broader development challenges. Discussion on recent literature and urban development reinforces the applicability of these tailor-made indicators to not only monitoring but also explaining and predicting urban changes. We argue it is necessary to recognise the centrality of property-led urban development in urban sustainable development, and the need for examining the complex relations between the property sector and urban sustainability via inclusion of institutional analysis and a multi-method approach combining quantitative and qualitative evaluations.