Designing a continuous data-driven feedback and learning initiative to improve electronic prescribing: an interdisciplinary quality improvement study

Introduction

The WHO Global Patient Safety Challenge aims to reduce severe avoidable medication-related harm by 50% by 2023[1]. Research suggests that providing timely, trusted feedback that incorporates relevant action can improve practice. However, a key barrier is lack of prescribing error data. Hospital electronic prescribing (EP) data may help address this gap.

Aims

To explore approaches for continuously monitoring medication safety signals using existing or new EP data, and to deliver personalised prescribing feedback and learning to improve patient safety.

Methods

We conducted a feasibility study (November 2019 - February 2020) on a 28-bed adult gastroenterology. This ward was chosen because of a high prescribing error rate. All foundation year 1 and 2 doctors, and pharmacists on the ward, participated in the study. The study team comprised pharmacists, doctors, quality improvement experts and clinical analysts, and used a quality improvement approach to design and test (i) methods for extracting electronic data to calculate prescribing accuracy rates, (ii) ways to refine a paper-prototype of an electronic pharmacists’ interventions form, (iii) potential digital medication safety indicators, and (iv) approaches for feedback for doctors to augment existing verbal feedback from pharmacists. Data were documented in accordance with local information governance and analysed using Excel. Acceptability and usability was assessed through verbal feedback from participants during weekly huddles. Outcome measures: feasibility of using EP to determine prescribing accuracy, user acceptability and usability of data collection, feedback and learning by pharmacists and doctors. We also measured changes in prescribing accuracy rate, pharmacists’ interventions, and quality of prescribing for targeted problematic medications.

Results

Extracting EP data required multiple data linkages to be configured and validated, and not all required data were available. Potential digital medication safety indicators: utility of the reason code ‘prescribed in error’ and actions by pharmacists to modify medications were limited by underuse and lack of data granularity. After testing different ways to extract relevant EP data, we eventually used a combination of EP and manual retrospective review of electronic patient records to determine prescribing accuracy rates. An intervention form was redesigned to tally interventions and capture details for contextual learning for email feedback to doctors and weekly prescribing improvement huddles. Doctors reported emails as timely and helpful for gaining new prescribing- and system-related knowledge. Pharmacists reported intervention data as providing invaluable evidence to drive improvement.

Statistical process control charts showed no special cause variation around a mean prescription accuracy rate of 98% for inpatient orders, and 87% for discharge orders. By contrast, pharmacists recorded a mean of 10 interventions/day with 7 special cause variation (above upper control limit of 19) in the first two months. Omission of venous thromboembolism prophylaxis was identified as a priority medication issue. Specific prescriber- and system-based improvements were suggested (Jan 2020), some implemented (Feb 2020) and others fed back to the thrombosis committee (Feb 2020).

Conclusion

Harnessing the potential of EP data to improve medication safety requires the workforce to have a deeper understanding of the EP data structure and processes. Using a quality improvement approach, we developed a feedback and learning model that is acceptable and useful to pharmacists and doctors. Further research should explore adapting the approach to other clinical areas.

Reference

1. Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, M. and Donaldson, L. The Third Global Patient Safety Challenge: Tackling Medication-Related Harm. Bulletin of the World Health Organization. World Health Organisation. 2017;95:546-546A.

Regulation of RNA-dependent RNA polymerase 1 and isochorismate synthase gene expression in Arabidopsis

Background

RNA-dependent RNA polymerases (RDRs) function in anti-viral silencing in Arabidopsis thaliana and other plants. Salicylic acid (SA), an important defensive signal, increases RDR1 gene expression, suggesting that RDR1 contributes to SA-induced virus resistance. In Nicotiana attenuata RDR1 also regulates plant-insect interactions and is induced by another important signal, jasmonic acid (JA). Despite its importance in defense RDR1 regulation has not been investigated in detail.

Methodology/Principal Findings

In Arabidopsis, SA-induced RDR1 expression was dependent on ‘NON-EXPRESSER OF PATHOGENESIS-RELATED GENES 1’, indicating regulation involves the same mechanism controlling many other SA- defense-related genes, including pathogenesis-related 1 (PR1). Isochorismate synthase 1 (ICS1) is required for SA biosynthesis. In defensive signal transduction RDR1 lies downstream of ICS1. However, supplying exogenous SA to ics1-mutant plants did not induce RDR1 or PR1 expression to the same extent as seen in wild type plants. Analysing ICS1 gene expression using transgenic plants expressing ICS1 promoter:reporter gene (β-glucuronidase) constructs and by measuring steady-state ICS1 transcript levels showed that SA positively regulates ICS1. In contrast, ICS2, which is expressed at lower levels than ICS1, is unaffected by SA. The wound-response hormone JA affects expression of Arabidopsis RDR1 but jasmonate-induced expression is independent of CORONATINE-INSENSITIVE 1, which conditions expression of many other JA-responsive genes. Transiently increased RDR1 expression following tobacco mosaic virus inoculation was due to wounding and was not a direct effect of infection. RDR1 gene expression was induced by ethylene and by abscisic acid (an important regulator of drought resistance). However, rdr1-mutant plants showed normal responses to drought.

Conclusions/Significance

RDR1 is regulated by a much broader range of phytohormones than previously thought, indicating that it plays roles beyond those already suggested in virus resistance and plant-insect interactions. SA positively regulates ICS1.

Disruption of two defensive signaling pathways by a viral RNA silencing suppressor

The Cucumber mosaic virus (CMV) 2b counter-defense protein disrupts plant antiviral mechanisms mediated by RNA silencing and salicylic acid (SA). We used microarrays to investigate defensive gene expression in 2b-transgenic Arabidopsis thaliana plants. Surprisingly, 2b inhibited expression of few SA-regulated genes and, in some instances, enhanced the effect of SA on certain genes. Strikingly, the 2b protein inhibited changes in the expression of 90% of genes regulated by jasmonic acid (JA). Consistent with this, infection of plants with CMV, but not the 2b gene-deletion mutant CMVDelta2b, strongly inhibited JA-inducible gene expression. JA levels were unaffected by infection with either CMV or CMVDelta2b. Although the CMV-Arabidopsis interaction is a compatible one, SA accumulation, usually considered to be an indicator of plant resistance, was increased in CMV-infected plants but not in CMVDelta2b-infected plants. Thus, the 2b protein inhibits JA signaling at a step downstream of JA biosynthesis but it primes induction of SA biosynthesis by another CMV gene product or by the process of infection itself. Like many plant viruses, CMV is aphid transmitted. JA is important in plant defense against insects. This raises the possibility that disruption of JA-mediated gene expression by the 2b protein may influence CMV transmission by aphids.

Serial evaluation of iron stores in pregnant Nigerians with hemoglobin SS or SC

Iron status of nonpregnant and pregnant Nigerian patients with hemoglobin SS or SC were assessed using serial hematological parameters, measured by Coulter counter, and serial serum ferritin concentrations measured by radioimmunoassays. The median value of 393 micrograms/L (range, 175 to 900 micrograms/L) for serum ferritin in nonpregnant patients with Hb SS and SC was significantly higher than that found in nonpregnant patients with Hb AA (median, 89.8 micrograms/L; range, 13 to 250 micrograms/L). Apart from packed cell volume values, there were no other significant differences between patients with Hb SS or SC and Hb AA in the other parameters assessed: mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration. In both the normal pregnant patients (Hb AA) and pregnant patients with Hb SS and SC the serum ferritin values decreased as pregnancy advanced to 28 weeks and rose gradually thereafter. At similar stages of gestation serum ferritin values were significantly higher in patients with Hb SS or SC than in those with Hb AA. Pregnancy seems to have induced a significant rise in mean corpuscular volume and mean corpuscular hemoglobin values in the patients with Hb SS or SC, especially in the third trimester, than in patients with Hb AA. The pattern of change in mean corpuscular hemoglobin concentration values was similar in both groups of patients. From the data obtained, it seems the iron status in the patients with Hb SS or SC was good, and pregnancy did not push the patients into an iron deficiency state. The use of prophylactic iron supplementation in pregnant patients with Hb SS or SC appears unjustified.

Improving state-funded child psychiatric care: reducing protracted hospitalizations through changes in treatment planning

In late 1986, Millcreek Psychiatric Center for Children changed several of its treatment practices in an attempt to decrease needlessly prolonged hospitalizations. The changes included initiating discharge planning shortly after admission, increasing contacts with community and judicial agencies, improving family therapy services, and educating the community about appropriate use of hospital treatments. The fraction of children hospitalized more than 180 days decreased significantly, as did the average length of stay. Mental health professionals should keep community agencies informed about the nature and limitations of inpatient treatment and about children's needs for adequate after-care services.

Correlation of serum fructosamine activity in type I diabetic children

The serum fructosamine assay is a new commercially available test designed to measure serum glycated protein as an index of glycemic control in diabetes. The test relies on the ability of glucose bound to protein with a ketamine linkage (fructosamine) to act as a reducing agent in alkaline solution. Serum fructosamine activity was studied in 61 Type I diabetic patients attending a 2-week American Diabetes Association sponsored diabetic camp for children. The initial fructosamine level was found to correlate well with the initial HgA1C value (r = .82, p less than .001). To assess if mean blood glucose correlated with these objective parameters, the authors performed capillary blood glucoses preprandially and at bedtime on all 61 diabetic campers during the 2-week period of observation and reassessed serum fructosamine activity and HgA1C on day 14 of camp. We found the HgA1C and fructosamine correlated well with the mean daily blood glucose obtained during the preceding week (r = .45, p less than .01 and r = .58, p less than .01) respectively. Our data suggest that the serum fructosamine is as effective as the HgA1C in correlating to mean blood glucose control in this cross-sectional study of Type I diabetic patients.

Serial serum ferritin and other hematological parameters in normal Nigerian primigravidae

Serial hematological indices using Coulter Counter and serum ferritin using radioimmunoassay techniques were determined in 20 healthy Nigerian primigravidae with hemoglobin genotype AA. PCV fell significantly (P less than 0.001) to a minimum value at 28 weeks that was 6% lower than the mean value at 8 weeks postpartum. PCV at 36 weeks was still significantly (P less than 0.001) lower than the post partum value. There was an insignificant but progressive increase in MCV values throughout pregnancy. Changes in MCH and MCHC were insignificant. Ferritin levels in both the non-pregnant and pregnant subjects were high and probably reflected the high iron content of Nigerian foods. Though the cord serum ferritin level was significantly higher (P less than 0.001) than maternal ferritin at delivery there was no significant correlation between the two.