Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants

WHAT IS KNOWN AND OBJECTIVE

The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE) + manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA < 33 weeks) in a mixed prescription system.

METHODS

The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose.

RESULTS AND DISCUSSION

The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P = 0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR = 3·3; 95% CI: 1·6-7·0, P < 0·001).

WHAT IS NEW AND CONCLUSION

The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units.

Remanence of lead pollution in an urban river system: a multi-scale temporal and spatial study in the Seine River basin, France

Total lead (Pb) concentration and Pb isotopic ratio ((206)Pb/(20)7Pb) were determined in 140 samples from the Seine River basin (France), covering a period of time from 1945 to 2011 and including bed sediments (bulk and size fractionated samples), suspended particulate matter (SPM), sediment cores, and combined sewer overflow (CSO) particulate matter to constrain the spatial and temporal variability of the lead sources at the scale of the contaminated Seine River basin. A focus on the Orge River subcatchment, which exhibits a contrasted land-use pattern, allows documenting the relation between hydrodynamics, urbanization, and contamination sources. The study reveals that the Pb contamination due to leaded gasoline that peaked in the 1980s has a very limited impact in the river nowadays. In the upstream Seine River, the isotopic ratio analysis suggests a pervasive contamination which origin (coal combustion and/or gasoline lead) should be clarified. The current SPM contamination trend follows the urbanization/industrialization spatial trend. Downstream of Paris, the lead from historical use originating from the Rio Tinto mine, Spain ((206)Pb/(207)Pb=1.1634 ± 0.0001) is the major Pb source. The analysis of the bed sediments (bulk and grain size fractionated) highlights the diversity of the anthropogenic lead sources in relation with the diversity of the human activities that occurred in this basin over the years. The "urban" source, defined by waste waters including the CSO samples ((206)Pb/(207)Pb=1.157 ± 0.003), results of a thorough mixing of leaded gasoline with "historical" lead over the years. Finally, a contamination mixing scheme related to hydrodynamics is proposed.

Secure Teleassistance towards endless medical litigations: identification of liabilities through a protocol using Joint Watermarking-Encryption Evidences

Teleassistance is defined by the help provided through a telemedicine network by a medical practitioner to one other medical practitioner faced to a difficult case. One of the main limiting factors of its development is the fear of the practitioners to be involved in a litigation. In such a situation, the main issue is to determine as quick and as certain as possible if the damage is in relation with the tort of negligence and the liabilities of each involved physician. After a brief summary of the legal context, we present a protocol combining joint watermarking-encryption and a third party to enforce exchange traceability and therefore to bring valuable electronic evidence in case of teleassistance litigations.

Economic analysis of the costs associated with prematurity from a literature review

OBJECTIVES

To analyse published cost-of-illness studies that had assessed the cost of prematurity according to gestational age at birth.

METHODS

A review of the literature was carried out in March 2011 using the following databases: Medline, ScienceDirect, The Cochrane Library, Econlit and Business Source Premier, and a French Public-Health database. Key-word sequences related to 'prematurity' and 'costs' were considered. Studies that assessed costs according to the gestational age (GA) at the premature birth (<37 weeks of gestation) in industrialized countries and during the last two decades were included. Variations in the reported costs were analysed using a check-list, which allowed the studies to be described according to several methodological and contextual criteria.

RESULTS

A total of 18 studies published since 1990 were included. According to these studies, costs were assessed for different follow-up periods (short, medium or long-term), and for different degrees of prematurity (extreme, early, moderate and late). Results showed that whatever the follow-up period, costs correlated inversely with GA. They also showed considerable variability in costs within the same GA group. Differences between studies could be explained by the choices made, concerning i/the study populations, ii/contextual information, iii/and various economic criteria. Despite these variations, a global trend of costs was estimated in the short-term period using mean costs from four American studies that presented similar methodologies. Costs stand at over US$ 100,000 for extreme prematurity, between US$ 40,000 and US$ 100,000 for early prematurity, between US$ 10,000 and US$ 30,000 for moderate prematurity and below US$ 4500 for late prematurity.

CONCLUSION

This review underlined not only the clear inverse relationship between costs and GA at birth, but also the difficulty to transfer the results to the French context. It suggests that studies specific to the French health system need to be carried out.

Classification of hospital pathways in the management of cancer: application to lung cancer in the region of burgundy

CONTEXT

The evaluation of national cancer plans is an important aspect of their implementation. For this evaluation, the principal actors in the field (doctors, nurses, etc.) as well as decision-makers must have access to information that is reliable, synthetic and easy to interpret, and which reflects the implementation process in the field. We propose here a methodology to make this type of information available in the context of reducing inequalities with regard to access to healthcare for patients with lung cancer in the region of Burgundy.

METHODS

We used the national medico-administrative DRG-type database, which gathers together all hospital stays. By using this database, it was possible to identify and reconstruct the care management history of these patients. That is, by linking together all attended hospitals, sorted chronologically. Eligible patients were at least 18 years old, whatever the gender and had undergone surgery for their lung cancer. They had to be residents of Burgundy at the time of the first operation between 2006 and 2008. Patient's pathway was defined as the sequence of all attended hospitals (hospital stays) during the year of follow up linked together using an anonymised patient identifier. We then constructed a pathway typology of pathway using an unsupervised clustering method, and conducted a spatial analysis of this typology.

RESULTS

Between 2006 and 2008, we selected 495 patients in the 4 administrative departments of the Burgundy region. They accounted for a total of 3821 stays during the year of follow-up. There were 393 men (79%) and the mean age was 64 (95% confidence interval: 63-65) years. We reconstructed 94 pathways (about five per patient). Here, neighbourhood's cares accounted for 41% of them, while 44% included a surgical intervention outside the region of Burgundy. We constructed a pathway typology with five classes. Spatial analysis showed that the vast majority of initial surgeries took place in the major regional centres.

CONCLUSION

The construction of a pathway typology leads to better understanding of the reasoning that lies behind the movements of patients. It opens the way for analysis of the collaboration between the different healthcares establishments attended, which should bring to light associations that need to be developed.