Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

Changing trends in the use of seizure prophylaxis after traumatic brain injury: a shift from phenytoin to levetiracetam

PURPOSE

Current guidelines for traumatic brain injury (TBI) recommend antiepileptic drugs (AEDs) for 7 days after injury to decrease posttraumatic seizure risk. Phenytoin decreases seizure risk 73% vs placebo during this time. Levetiracetam (LEV) is an alternative; however, no published data validate comparable efficacy. Our objective was to evaluate seizure incidence 7 days after TBI in patients treated with phenytoin (PHT) vs LEV and to characterize practice of AED selection.

METHODS

A retrospective observational study was conducted using a Trauma Registry (Collector Trauma Registry; Digital Innovation, Inc, Forrest Hill, Md) to evaluate patients with TBI. Patients with an initial Head/Neck Abbreviated Injury Scale score of 3 or higher and a Glasgow Coma Scale of 8 or less were included.

RESULTS

Of 109 patients, 89 received PHT, and 20, LEV. Two patients experienced posttraumatic seizure, 1 in each group. Sixty-eight patients survived to hospital discharge; 65% received prophylactic AED greater than 7 days. Ninety-eight percent of 81 patients admitted between 2000 and 2007 received PHT, whereas 64% of 28 patients admitted between 2008 and 2010 received LEV.

CONCLUSION

Only 2 patients experienced posttraumatic seizure after receiving AED, indicating low incidence. Most surviving to hospital discharge received AED prophylaxis greater than 7 days despite guideline recommendations. After approval of intravenous LEV, a trend favoring LEV was observed.

Counselling women about choice

Patient choice-informed consent and informed refusal-is an important ethical and legal principle in medicine. In pregnancy this issue is not straightforward: should a pregnant woman's autonomous choice be respected when she may cause fetal harm by declining recommended caesarean section? Should a pregnant women be free to choose elective caesarean section as an alternative to labour and vaginal delivery? This chapter reviews cases of court-ordered caesarean, and the ethical and legal paradigms for informed refusal in pregnancy. In general, clinicians should not seek court authority to support medical recommendations. This chapter also reviews arguments for and against offering women elective caesarean without strict medical indication. Although compelling arguments in favour of caesarean on demand can be made, clear evidence showing adequate safety and advantages of elective caesarean over vaginal delivery does not yet exist. Ethics, law, politics and history all inform the issue of choice with respect to caesarean in important ways.

Rethinking maternal-fetal conflict: gender and equality in perinatal ethics

Practitioners who care for pregnant women face dilemmas when their patients use illicit drugs, reject medical recommendations, or cause fetal harm. Many ethics scholars characterize those situations as maternal-fetal conflicts. In conflict-based models, maternal rights are considered to conflict with fetal rights, or moral obligations owed to pregnant women are considered to conflict with those owed to their fetuses. I offer an alternative model of pregnancy ethics by applying relational and equality-based moral theories to situations of fetal harm by pregnant women. In this model, clinicians faced with ethical dilemmas should attempt to understand pregnant women and their decisions within their broad social networks and communities, ask how the clinician's personal standpoint influences outcomes judged to be ethical, and determine whether the clinician's ethical formulations reduce or enhance existing gender, class, or racial inequality. This model focuses on the mutual needs of pregnant women and fetuses rather than on their mutually exclusive needs. It also avoids many pitfalls of traditional ethical formulations, specifically their tendency to neglect gender-specific modes of moral reasoning, their implicit assumptions that application of universal principles like autonomy and beneficence results in objective ethical solutions, and their failure to account for the ways that projecting fetal needs perpetuates social inequalities. This model provides the ethical foundations for moving law and policy away from criminalization and toward prevention of prenatal harm.

Ethics and politics of embryo and stem cell research: reinscribing the abortion debate

Research on human embryos is controversial. Whether federal dollars can or should fund this work has been debated for 25 years, without satisfactory resolution. Many commentators point out that current conflict over embryo research grows out of this country's seemingly intractable conflict over abortion and the moral status of the fetus. This commentary reviews the most recent iteration of the embryo research debate--federal funding of human embryonic stem cell investigation--and explores the ways in which the terms of this debate not only reflect abortion disputes, but may in turn be shifted to strengthen feminist claims vis-à-vis abortion.

Values expressed in philosophies of nursing services

Do nurses value "caring"? Does it matter that nurses respect individual rights while caring for groups of patients? What values are shared by nurses and are they evident in institutions? How important are nursing values in a changing healthcare system? Should nurse administrators ensure that nursing values remain integral to managed care? What is the nurse's responsibility for communicating nursing values throughout the organization? The authors discuss the values expressed in nursing service philosophies and how they reflect a changing healthcare system.

An evaluation of professional education efforts for breast and cervical cancer in public health nurses

This article describes training programs instituted in 1992 by the North Carolina Breast and Cervical Cancer Control Program (BCCCP) to improve skills of public health nurses in breast and cervical cancer education and clinical services. Public health nurses traditionally serve as primary health care providers in medically underserved communities and are the main providers of BCCCP services. The training programs were evaluated by a statewide survey of public health nurses in 1996. The authors discuss the findings of this survey, its limitations, and the goals it has led the authors to set for improving the education program in the future.

Sickle cell disease: care throughout the life span

Families of individuals with sickle cell disease need to be willing to incorporate lifestyle changes to accommodate the needs of the sickle cell patient, while continuing to function as a stable, productive unit. Information in the form of tables is presented that will assist nurses in supporting and guiding patients and their families in adapting to sickle cell's demands. The tables organize the information into a format useful in conceptually relating the various components of the monograph and identify care providers beneficial in assisting patients to make the best use of health resources at various levels of development. It also provides glimpses into the lives of two sickle cell patients and their families.

Biventricular distribution of cold blood cardioplegic solution administered by different retrograde techniques

Although retrograde cardioplegia has been shown to provide adequate overall protection to the myocardium, delivery of cardioplegic solution to the right ventricle and septum is poor. We used an animal model of occlusion of the left anterior descending coronary artery to study the effects of modifying the conditions of retrograde cardioplegia administration on delivery to the right and left ventricles. Adult mongrel dogs (n = 12) were each given five retrograde injections of microsphere-labeled cardioplegic solution at 10-minute intervals. Four injections were made directly into the coronary sinus with ostial balloon occlusion at the following dosages and pressures: (1) 10 ml/kg at 30 mm Hg, (2) 20 ml/kg at 30 mm Hg, (3) 10 ml/kg at 50 mmHg, and (4) 20 ml/kg at 50 mm Hg. A fifth dose (20 ml/kg) was given directly into the right atrium at 50 mm Hg. Delivery of cardioplegic solution to the left and right ventricles was significantly reduced when the right atrial route was compared with the coronary sinus route at the same dosage and pressure (for left ventricle, 6.0% +/- 1.4% versus 22.7% +/- 11.4%/100 gm, p less than 0.001; for right ventricle, 0.7% +/- 0.2% versus 4.1% +/- 0.4%/100 gm, p less than 0.001). Septal delivery was less than that to the anterior and posterior left ventricle (10.4% +/- 1.3% versus 30.3% +/- 3.9% and 27.9% +/- 3.1%/100 gm, p less than 0.0001) for all injections. Delivery to the body of the right ventricle was less than that to the inflow and outflow tracts (1.8% +/- 0.2% versus 4.5% +/- 0.7% and 8.4% +/- 1.5%/100 gm, p less than 0.0001). These results indicate that, in this model, (1) the right atrial route provides less overall cardioplegic solution to both ventricles than direct retrograde coronary sinus cardioplegia and (2) regional abnormalities in distribution with direct retrograde coronary sinus cardioplegia are not affected by changes in the dosage or pressure of injection.

Enhancing supervision of psychotherapy

This paper reports the efforts of a psychiatry training faculty to explicitly study the supervisory process and enhance the faculty's supervisory skills. To accomplish this, a psychiatry resident permitted the videotaping of her supervision. These videotapes were then reviewed and presented in an ongoing conference to members of the training faculty. Through these conferences, the faculty was able to learn methods of elucidating issues within the supervisory process. Techniques for assisting residents in the development of their psychotherapeutic skills were elaborated.

Effects of isoprenaline plus phenylephrine by pressurized aerosol on blood gases, ventilation, and perfusion in chronic obstructive lung disease

The effects of a combined isoprenaline-phenylephrine inhalant in chronic obstructive lung disease were assessed in 23 patients. Significant changes occurred in blood gas tensions after inhalation, together with an overall improvement in ventilation/perfusion ratios. Cardiac output and physiological shunt were not significantly increased. Hence the addition of phenylephrine probably prevents the increase of hypoxaemia which may result from the disproportionate ventilation/perfusion ratio produced by sympathomimetics or xanthines used alone. The combination aerosol has a satisfactory bronchodilator effect, and is additionally safe if used by a severely hypoxic patient unaware of the seriousness of his condition.