Increasing access to cataract surgery in Counties Manukau by optimising the clinical pathway: a quality improvement report.

AIM: To streamline the cataract surgery pathway to improve the time from first specialist assessment (FSA) to surgery, while reducing the clinical priority assessment criteria (CPAC) score from 55 to 50. METHOD: A quality improvement project using Lean Six Sigma tools and the Model for Improvement. Most data were collected from the i.Patient Manager (iPM) system and analysed using statistical process control charts. Change interventions included combining FSA and pre-admission clinics (PAC); post-operative telephone review by non senior medical officers (SMO); and using our own surgeons in private theatres. RESULTS: The standard cataract pathway was reduced from 5 to 3 appointments. This removed 1,514 hours of appointments, released 113 SMO hours and saved patients NZ$156,000 in indirect costs over a year. The average waiting time from FSA to surgery decreased from 90 to 77 days (-13.5%). The number of overdue patients reduced from 127 to 44 (-35%). The average number of patients on the FSA waiting list dropped from 322 to 205 (-40%). There was no change to the proportions of surgeries or appointment attendance rates by ethnicity. Average monthly cataract surgeries increased from 192 to 215 (+12%), and the CPAC score threshold was decreased to 50 in February 2021. CONCLUSION: Despite significant demand pressures, and the disruptions of COVID-19, we were able to reduce the CPAC score for accessing cataract surgery by optimising the clinical pathway to better utilise staff capacity and maximise value for patients.

A multi-taxon analysis of European Red Lists reveals major threats to biodiversity.

Biodiversity loss is a major global challenge and minimizing extinction rates is the goal of several multilateral environmental agreements. Policy decisions require comprehensive, spatially explicit information on species' distributions and threats. We present an analysis of the conservation status of 14,669 European terrestrial, freshwater and marine species (ca. 10% of the continental fauna and flora), including all vertebrates and selected groups of invertebrates and plants. Our results reveal that 19% of European species are threatened with extinction, with higher extinction risks for plants (27%) and invertebrates (24%) compared to vertebrates (18%). These numbers exceed recent IPBES (Intergovernmental Platform on Biodiversity and Ecosystem Services) assumptions of extinction risk. Changes in agricultural practices and associated habitat loss, overharvesting, pollution and development are major threats to biodiversity. Maintaining and restoring sustainable land and water use practices is crucial to minimize future biodiversity declines.

Assessing the extinction risk of insular, understudied marine species.

Hydrothermal vents are rare deep-sea oases that house faunal assemblages with a similar density of life as coral reefs. Only approximately 600 of these hotspots are known worldwide, most only one-third of a football field in size. With advancing development of the deep-sea mining industry, there is an urgent need to protect these unique, insular ecosystems and their specialist endemic faunas. We applied the IUCN (International Union for the Conservation of Nature) Red List criteria to assess the extinction risk of vent-endemic molluscs with varying exposure to potential deep-sea mining. We assessed 31 species from three key areas under different regulatory frameworks in the Indian, West Pacific, and Southern Oceans. Three vent mollusc species were also examined as case studies of different threat contexts (protected or not from potential mining) to explore the interaction of local regulatory frameworks and IUCN Red List category assignment. We found that these assessments were robust even when there was some uncertainty in the total range of individual species, allowing assessment of species that have only recently been named and described. For vent-endemic species, regulatory changes to area-based management can have a greater impact on IUCN Red List assessment outcomes than incorporating additional data about species distributions. Our approach revealed the most useful IUCN Red List criteria for vent-endemic species: criteria B and D2. This approach, combining regulatory framework and distribution, has the potential to rapidly gauge assessment outcomes for species in insular systems worldwide.

Evaluación del Riesgo de Extinción de Especies Marinas Insulares Poco Estudiadas Resumen Los respiraderos hidrotermales son oasis poco comunes en las profundidades del mar en donde se encuentran conjuntos de fauna con una densidad similar a la de los arrecifes de coral. A nivel mundial, sólo se conocen aproximadamente 600 de estos puntos calientes, la mayoría solamente del tamaño de un tercio de una cancha de fútbol. Conforme avanza el desarrollo de la industria minera en mares profundos, también hay una urgente necesidad por proteger estos ecosistemas únicos e insulares y a su fauna endémica especialista. Aplicamos el criterio de la Lista Roja de la UICN (Unión Internacional para la Conservación de la Naturaleza) para evaluar el riesgo de extinción que tienen los moluscos endémicos de los respiraderos ante una exposición variable a la potencial minería de mar profundo. Evaluamos 31 especies de tres áreas importantes bajo diferentes marcos regulatorios en los océanos Índico, Pacífico Occidental y del Sur. Analizamos tres especies de moluscos de los respiraderos como estudios de caso para diferentes contextos de amenazas (protegidas o no de la minería potencial) para explorar la interacción de los marcos regulatorios locales y la clasificación categórica dentro de la Lista Roja de la UICN. Descubrimos que estos análisis eran sólidos incluso cuando existía algo de incertidumbre en cuanto a la extensión total de la especie individual, lo que permite la valoración de especies que han sido descritas y nombradas recientemente. Para las especies endémicas de las chimeneas, los cambios regulatorios a un manejo basado en el área pueden tener un mayor impacto sobre los resultados de evaluación de la Lista Roja de la UICN que la incorporación de datos adicionales sobre la distribución de las especies. Nuestra estrategia reveló los criterios más útiles de la Lista Roja de la UICN para las especies endémicas de las chimeneas: los criterios B y D2. Esta estrategia, que combina un marco regulatorio con la distribución, tiene el potencial para medir rápidamente los resultados de las evaluaciones para las especies que se encuentran en sistemas insulares en todo el mundo.

Post-COVID-19 vaccination occurrence of splenic infarction due to arterial thrombosis.

We present the case of an 82-year-old woman admitted to a regional emergency general surgery centre with severe left upper quadrant abdominal pain and tenderness within 21 days of receiving the first dose of the ChAdOx1 nCov-19 vaccine (Vaxzevria, AstraZeneca). Following further investigation through CT imaging, a thrombus was discovered in the patient's splenic artery resulting in a large splenic infarct. Splenic infarcts are rare and it is important to note the association between time of administration of the first dose of vaccine and the occurrence of thromboembolic complications in the noted absence of other risk factors for this condition. We hypothesise a link between Vaxzevria vaccine injection and a rare form of thromboembolic complication: thrombosis of the splenic artery.

Alarming decline of freshwater trigger species in western Mediterranean key biodiversity areas.

Theidentification of key biodiversity areas (KBA) was initiated by the International Union for Conservation of Nature in 2004 to overcome taxonomic biases in the selection of important areas for conservation, including freshwater ecosystems. Since then, several KBAs have been identified mainly based on the presence of trigger species (i.e., species that trigger either the vulnerability and or the irreplaceability criterion and thus identify a site as a KBA). However, to our knowledge, many of these KBAs have not been validated. Therefore, classical surveys of the taxa used to identify freshwater KBAs (fishes, molluscs, odonates, and aquatic plants) were conducted in Douro (Iberian Peninsula) and Sebou (Morocco) River basins in the Mediterranean Biodiversity Hotspot. Environmental DNA analyses were undertaken in the Moroccan KBAs. There was a mismatch between the supposed and actual presence of trigger species. None of the trigger species were found in 43% and 50% of all KBAs surveyed in the Douro and Sebou basins, respectively. Shortcomings of freshwater KBA identification relate to flawed or lack of distribution data for trigger species. This situation results from a misleading initial identification of KBAs based on poor (or even inaccurate) ecological information or due to increased human disturbance between initial KBA identification and the present. To improve identification of future freshwater KBAs, we suggest selecting trigger species with a more conservative approach; use of local expert knowledge and digital data (to assess habitat quality, species distribution, and potential threats); consideration of the subcatchment when delineating KBAs boundaries; thoughtful consideration of terrestrial special areas for conservation limits; and periodic field validation.

Alarming decline of freshwater trigger species in western Mediterranean Key Biodiversity Areas Resumen La identificación de las áreas clave de biodiversidad (ACB) fue iniciada por la Unión Internacional para la Conservación de la Naturaleza en 2004 con el objetivo de sobreponerse a los sesgos taxonómicos en la selección de áreas importantes para la conservación, incluyendo los ecosistemas de agua dulce. Desde entonces, varias ACB han sido identificadas principalmente con base en la presencia de especies desencadenantes (es decir, especies que desencadenan el criterio de vulnerabilidad o de carácter irremplazable y por lo tanto identifican a un sitio como una ACB). Sin embargo, a nuestro conocimiento, muchas de estas ACB no han sido validadas. Por lo tanto, los censos clásicos de taxones utilizados para identificar las ACB de agua dulce (peces, moluscos, odonatos y plantas acuáticas) fueron realizados en las cuencas de los ríos Duero (Península Ibérica) y Sebou (Marruecos) en el Punto Caliente de Biodiversidad del Mediterráneo. Realizamos análisis de ADN ambiental en las ACB de Marruecos. Hubo una discrepancia entre la supuesta presencia y la actual presencia de especies desencadenantes. Ninguna de las especies desencadenantes se encontró en 43% y 50% de las ACB censadas en las cuencas del Duero y del Sebou, respectivamente. Las deficiencias en la identificación de las ACB de agua dulce están relacionadas con la carencia de datos o datos erróneos sobre la distribución de las especies desencadenantes. Esta situación resulta en una identificación inicial engañosa de las ACB con base en información ecológica deficiente (o incluso incorrecta) o también puede deberse al incremento en las perturbaciones humanas ocurridas entre la identificación de la ACB y el presente. Para mejorar la identificación de ACB de agua dulce en el futuro, sugerimos que la selección de especies desencadenantes se realice con un enfoque más conservador; que se usen el conocimiento local de los expertos y los datos digitales (para evaluar la calidad del hábitat, la distribución de las especies y las amenazas potenciales); que se consideren las subcuencas cuando se delimiten las fronteras de las ACB; que se consideren cuidadosamente las áreas de especies terrestres para los límites de conservación; y que se realicen validaciones periódicas de campo.

Reducing the MRI outpatient waiting list through a capacity and demand time series improvement programme.

INTRODUCTION: A capacity and demand improvement initiative commenced in January 2019 with the goal of reducing the growing outpatient waiting list for magnetic resonance imaging (MRI) at Counties Manukau District Health Board (CMDHB). Initial work showed that the capacity (MRI machines and staff) actually outstripped demand, which challenged pre-existing assumptions. This became the basis for interventions to improve efficiency in the department. Interventions undertaken can be split into three distinct categories: (1) matching capacity to demand, (2) waiting list segmentation and (3) redesigning operational systems. METHODS: A capacity and demand time series during 2019 and 2020 was used as the basis for improving waiting list and operational systems. A combination of the Model for Improvement and Lean principles were used to embed operational improvements. Multiple small tests of change were implemented to various aspects of the MRI waiting list process. Staff engagement was central to the success of the quality improvement (QI) initiatives. The radiological information system (RIS) provided the bulk of the data, and this was supplemented with manual data collection. RESULTS: The number of people waiting for an MRI scan decreased from 1,954 at the start of the project to 413 at its conclusion-an overall reduction of 75%. Moreover, the average waiting time reduced from 96.4 days to 23.1. Achieving the Ministry of Health's (MoH) Priority 2 (P2) target increased from 23% to 87.5%. CONCLUSION: A partnership between Ko Awatea and the radiology department at CMDHB, examining capacity and demand for MRI and using multiple QI techniques, successfully and sustainably reduced the MRI waiting list over a two-year period. The innovative solutions to match capacity to demand may be instructive for other radiology departments, and other waiting list scenarios.

A strategy for the next decade to address data deficiency in neglected biodiversity.

Measuring progress toward international biodiversity targets requires robust information on the conservation status of species, which the International Union for Conservation of Nature (IUCN) Red List of Threatened Species provides. However, data and capacity are lacking for most hyperdiverse groups, such as invertebrates, plants, and fungi, particularly in megadiverse or high-endemism regions. Conservation policies and biodiversity strategies aimed at halting biodiversity loss by 2020 need to be adapted to tackle these information shortfalls after 2020. We devised an 8-point strategy to close existing data gaps by reviving explorative field research on the distribution, abundance, and ecology of species; linking taxonomic research more closely with conservation; improving global biodiversity databases by making the submission of spatially explicit data mandatory for scientific publications; developing a global spatial database on threats to biodiversity to facilitate IUCN Red List assessments; automating preassessments by integrating distribution data and spatial threat data; building capacity in taxonomy, ecology, and biodiversity monitoring in countries with high species richness or endemism; creating species monitoring programs for lesser-known taxa; and developing sufficient funding mechanisms to reduce reliance on voluntary efforts. Implementing these strategies in the post-2020 biodiversity framework will help to overcome the lack of capacity and data regarding the conservation status of biodiversity. This will require a collaborative effort among scientists, policy makers, and conservation practitioners.

Una Estrategia para la Siguiente Década para Enfrentar la Deficiencia de Datos de la Biodiversidad Ignorada Resumen La medida del avance hacia los objetivos internacionales para la biodiversidad requiere información sólida sobre el estado de conservación de las especies, la cual proporciona la Lista Roja de Especies Amenazadas de la Unión Internacional para la Conservación de la Naturaleza (UICN). Sin embargo, los grupos más hiperdiversos, como los invertebrados, las plantas y los hongos, carecen de datos y capacidad, particularmente en regiones megadiversas o de endemismo alto. Las políticas de conservación y las estrategias de biodiversidad dirigidas hacia el cese de la pérdida de biodiversidad para el 2020 necesitan ser adaptadas para solucionar estas insuficiencias de información para después del año 2020. Diseñamos una estrategia de ocho puntos para cerrar las brechas existentes en los datos mediante la reactivación de la investigación exploratoria en el campo sobre la distribución, abundancia y ecología de las especies; la vinculación más cercana entre la investigación taxonómica y la conservación; la mejora a las bases de datos mundiales sobre biodiversidad mediante la presentación obligatoria de datos espacialmente explícitos para las publicaciones científicas; el desarrollo de una base mundial de datos espaciales sobre las amenazas para la biodiversidad para facilitar las valoraciones de la Lista Roja de la UICN; la automatización de las preevaluaciones mediante la integración de datos de distribución y datos de amenazas espaciales; el desarrollo de la capacidad en la taxonomía, la ecología y el monitoreo de la biodiversidad en países con una gran riqueza de especies o endemismos; la creación de programas de monitoreo de especies para los taxones menos conocidos; el desarrollo de suficientes mecanismos de financiamiento para reducir la dependencia de los esfuerzos voluntarios. La implementación de estas estrategias en el marco de trabajo para la biodiversidad posterior al 2020 ayudará a superar la falta de capacidad y datos con respecto al estado de conservación de la biodiversidad. Lo anterior requerirá de un esfuerzo colaborativo entre científicos, formuladores de políticas y practicantes de la conservación.

Feasibility and reliability of clinical coding surveillance for the routine monitoring of adverse drug events in New Zealand hospitals.

AIM: To explore the feasibility and reliability of Clinical Coding Surveillance (CCS) for the routine monitoring of Adverse Drug Events (ADE) and describe the characteristics of harm identified through this approach in a large district health board (DHB). METHOD: All hospital admissions at Waitemata DHB from 2015 to 2016 with an ADE-related ICD10-AM code of Y40-Y59, X40-X49 or T36-T50 were extracted from clinical coded data. The data was analysed using descriptive statistics, statistical process control and Pareto charts. Two clinicians assessed a random sample of 140 ADEs for their accuracy against what was clinically documented in medical records. RESULTS: A total of 11,999 ADEs were identified in 244,992 admissions (4.9 ADEs per 100 admissions). ADEs were more prevalent in older adults and associated with longer average length of stays and medicines such as analgesics, antibiotics, anticoagulants and diuretics. Only 2,164 (18%) of ADEs were classified as originating within hospital. Of ADEs originating outside of the hospital, the main causes were poisoning by psychotropics, anti-epileptics and anti-parkinsonism agents and non-opioid analgesics. Clinicians agreed that 91% of ADE positive admissions were accurately classified as per clinical documentation. CONCLUSION: CCS is a feasible and reliable approach for the routine monitoring of ADEs in hospitals.

Medication-related patient harm in New Zealand hospitals.

AIM: The purpose of this study is to identify patterns of medication-related harm from a national perspective, and to use this information to inform decisions on where to focus medication safety efforts. This study updates a 2013 study using the same methodology. METHOD: District health boards (DHBs) still actively using either the Adverse Drug Event (ADE) Trigger Tool (TT) or the Global Trigger Tool (GTT), submitted two years of anonymised ADE data (1 July 2013-30 June 2015) to the Health Quality & Safety Commission (the Commission) using a standard template. Analyses were conducted using aggregated data only. RESULTS: Of eight DHBs who submitted data, six datasets were included, representing a total of 2,659 chart reviews. From these reviews, 923 harms were identified in 751 patients, with 28% of patients experiencing one or more harms. Harms occurred at a rate of 34.7 per 100 admissions, 42.5 per 1,000 bed days and 28% of patients experienced one or more medication-related harms. Those harmed were more likely to be older, female and have an increased length of stay. Most harms (65%) occurred during an inpatient stay, however, a substantial number (29%) originated in the community and precipitated an admission. Across all levels of severity, the most common types of medication harm were constipation, hypotension and bleeding. In the more serious harm categories, bleeding, hypotension and delirium/confusion/over-sedation were most common. Six groups of medicines caused the greatest amount of harm: opioids (including tramadol), anticoagulants/antiplatelet agents, antibiotics, antianginals (beta-blockers, nitrates, calcium channel blockers and others), diuretics and other cardiovascular medicines (angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARBs), centrally acting agents and statins). Opioids and anticoagulants/antiplatelet agents not only accounted for 40% of all harm, they were implicated in the most severe harm. CONCLUSION: This paper confirms earlier work that medication-related harms are common, occur both in hospitals and in the community, and are a substantial burden for patients and our healthcare system. Work is underway at local and national levels to decrease this harm, with a focus on the high-risk medicines most commonly implicated.

Conservation status of freshwater mussels in Europe: state of the art and future challenges.

Freshwater mussels of the Order Unionida provide important ecosystem functions and services, yet many of their populations are in decline. We comprehensively review the status of the 16 currently recognized species in Europe, collating for the first time their life-history traits, distribution, conservation status, habitat preferences, and main threats in order to suggest future management actions. In northern, central, and eastern Europe, a relatively homogeneous species composition is found in most basins. In southern Europe, despite the lower species richness, spatially restricted species make these basins a high conservation priority. Information on freshwater mussels in Europe is unevenly distributed with considerable differences in data quality and quantity among countries and species. To make conservation more effective in the future, we suggest greater international cooperation using standardized protocols and methods to monitor and manage European freshwater mussel diversity. Such an approach will not only help conserve this vulnerable group but also, through the protection of these important organisms, will offer wider benefits to freshwater ecosystems.

Validation of the assessment of risk tool: patient prioritisation technology for clinical pharmacist interventions.

BACKGROUND: Adverse drug events (ADEs) pose a heavy burden on health systems worldwide. The assessment of risk tool (ART) was developed to help prioritise hospitalised patients for interventions such as medication reconciliation (MR) and review, and to reduce potential ADEs from unintentional medication discrepancies and prescribing errors. AIM: To validate ART, and to determine which of the selected 25 flags were significantly associated with risk of unintentional medication discrepancies and prescribing errors. METHOD: This was a prospective observational study of 247 admissions to two medical teams in a New Zealand hospital. Study pharmacists undertook MR and review for all eligible admissions over 5 months. A Kruskal-Wallis test was used to determine differences in numbers of unintentional medication discrepancies and prescribing errors, followed by generalised linear modelling, to find the estimated ratio of the mean number of unintentional medication discrepancies between the three ART groups. In part 2 of the study, using multivariable logistic regression, combinations of flags significantly associated with risk were identified. RESULTS: Significant differences in the number of unintentional medication discrepancieswere found between the ART risk groups (p<0.0001, Kruskal-Wallis test). Patients in the high-risk group had a significantly greater number of unintentional medication discrepancies than those in the medium- and low-risk groups. There were no significant differences in prescribing errors between the ART risk groups (p=0.08, Kruskal-Wallis test). Flags significantly associated with risk, included 'more than eight admission medications', OR=3.7 (95% CI 2.2 to 6.4) and 'readmission within 30 days', OR=6.8 (95% CI 3.0 to 15.2), p<0.0001. CONCLUSION: ART was effective for prioritising patients for interventions such as MR.

Clarifying misconceptions of extinction risk assessment with the IUCN Red List.

The identification of species at risk of extinction is a central goal of conservation. As the use of data compiled for IUCN Red List assessments expands, a number of misconceptions regarding the purpose, application and use of the IUCN Red List categories and criteria have arisen. We outline five such classes of misconception; the most consequential drive proposals for adapted versions of the criteria, rendering assessments among species incomparable. A key challenge for the future will be to recognize the point where understanding has developed so markedly that it is time for the next generation of the Red List criteria. We do not believe we are there yet but, recognizing the need for scrutiny and continued development of Red Listing, conclude by suggesting areas where additional research could be valuable in improving the understanding of extinction risk among species.

Target CLAB Zero: A national improvement collaborative to reduce central line-associated bacteraemia in New Zealand intensive care units.

AIM: Central line-associated bacteraemia (CLAB) is a preventable cause of patient morbidity and mortality in intensive care units. Target CLAB Zero was a national campaign that ran from October 2011 to March 2013 across all New Zealand ICUs (intensive care units). The campaign aimed to reduce the national CLAB rate to less than one incident per 1,000 line days and to establish a national measurement system for CLAB. METHOD: We used Institute for Healthcare Improvement (IHI) Breakthrough Series methodology to structure the campaign. IHI bundles of care for catheter insertion and maintenance were implemented across 25 New Zealand ICUs. We collected monthly data on line days, CLAB infections and compliance with the bundles. Data were analysed using run charts. RESULTS: The rate of CLAB per 1,000 line days fell from 3.32 at baseline to an average of 0.28 between April 2012 and March 2013. In the final 3-month period, January to March 2013, average insertion bundle compliance was 80% and average maintenance bundle compliance was 75%. All ICUs participated in the collaborative. Over 90% of those invited attended all three national learning sessions and bi-monthly regional learning sessions. CONCLUSION: National collaboratives can effect improvement and shared learning in New Zealand. International evidence combined with New Zealand experience, a supportive methodology, partnership, clinical respect and an effective communication plan were keys to successful engagement.

A new web-based Medication Error Reporting Programme (MERP) to supplement pharmacovigilance in New Zealand--findings from a pilot study in primary care.

AIMS: To determine if primary care clinicians would report medication errors using a new web-based system, and to obtain data illustrating the potential of the information collected to improve medication safety. METHOD: The New Zealand Pharmacovigilance Centre led the development of the Medication Error Reporting Programme (MERP) which was then piloted over an 8- month period involving 38 general practice and 28 community pharmacy staff. The Pharmacy Defence Association also contributed dispensing error claims. An analysis of the characteristics of errors was undertaken. RESULTS: A total of 376 reports were submitted; 55 (15%) reported patient harm, 1 of which required lifesaving intervention. The therapeutic groups most commonly implicated were medicines for managing 'nervous' and 'cardiovascular' systems. Wrong dose (25%) and wrong medicine (22%) were the most common error types, occurring predominantly with the prescribing and dispensing of medications. The most frequent contributing factors to errors in general practice were problems in the process of prescribing whereas in community pharmacy they related to product name and packaging factors. Time pressures, workload and interruptions were commonly cited for both settings. CONCLUSION: Primary care clinicians who volunteered for the pilot were willing and able to use the MERP system to report medication errors. The standardised data obtained through MERP enables rapid analysis and has the potential to inform initiatives for improving patient safety.

From ICU to hospital-wide: extending central line associated bacteraemia (CLAB) prevention.

AIMS: To decrease hospital-wide central line associated bacteraemia (CLAB) by spreading the prevention programme beyond the intensive care unit (ICU) in a secondary care hospital in Auckland, New Zealand. METHOD: Over 15 months, four general surgical wards, five inpatient units, and surgical theatres adopted the quality improvement initiative, and were followed for a further 15 months. The initiative included central line insertion and maintenance checklists, a central line insertion pack, training in central line care, and a dedicated database. In addition, a checklist to assess the readiness of each new area was developed; data collection and analysis processes embedded, with rapid feedback to staff and in-depth review of all CLAB events. RESULTS: Compliance measures improved significantly (compliance with insertion increased from a mean of 84% to 92% p=0.001; maintenance from 64% to 85%, p=0.002). The absolute numbers of CLAB fell hospital-wide from a mean of 2.3/month to 0.56/month. The rate of CLAB hospital-wide decreased from 7.04/1,000 line days to 1.37/1,000. CONCLUSION: We have demonstrated that the CLAB prevention work proven effective in the ICU can be successfully adapted and expanded to the rest of the hospital. As central lines are increasingly inserted in units outside the ICU, and maintained in general wards, this work provides some useful insights into tackling this larger problem.

Development of an electronic patient prioritization tool for clinical pharmacist interventions.

PURPOSE: A software-based tool to help prioritize inpatients for adverse drug event (ADE) prevention initiatives is described. SUMMARY: The clinical pharmacy department of a New Zealand hospital developed the Assessment of Risk Tool (ART), an application for monitoring prespecified clinical "flags" (some derived from the Institute for Healthcare Improvement's ADE trigger tool) for high-risk medication use and other ADE risk factors. The ART permits ADE risk assessment in virtual real time (i.e., medication-use data and other clinical information are updated multiple times daily). Each of the 38 flags captured by the ART is assigned a weighted score; the item scores are summed to provide a total ART score indicating low, medium, or high ADE risk, and patients are prioritized by the ART score for pharmacist interventions such as clinical review and discharge coordination. In the first 18 months after ART implementation, the average number of patients receiving medication reconciliation each month increased from 280 to 500. During one 8-month period, 765 high-risk patients were prioritized for discharge services and 526 medication errors (MEs) were prevented, including 174 errors deemed to pose a threat of moderate-to-major patient harm. The tool has been well received by clinicians and has generated interest among other New Zealand hospitals. CONCLUSION: By facilitating the identification and monitoring of patients at high risk for MEs and ADEs, the ART has enabled one hospital's clinical pharmacists to conduct interventions such as medication reconciliation and clinical review in a more timely and targeted manner.

The Adverse Drug Event Collaborative: a joint venture to measure medication-related patient harm.

AIM: To measure the extent of patient harm caused by medications (rate of Adverse Drug Events) in three DHBs, using a standardised trigger tool method. METHODS: Counties Manukau, Capital and Coast and Canterbury DHBs decided to work collaboratively to implement the ADE Trigger Tool (TT). Definitions of ADE were agreed on and triggers refined. A random sample of closed charts (from March 2010 to February 2011) was obtained excluding patients who were admitted for <48 hours, children under the age of 18 and psychiatric admissions. In each DHB trained reviewers scanned these in a structured way to identify any of the 19 triggers. If triggers were identified, a more detailed, though time-limited review of the chart was done to determine whether an ADE had occurred. The severity of patient harm was categorised using the National Coordinating Council for Medication Error Reporting and Prevention Index. No attempt was made to determine preventability of harm and ADEs from acts of omission were excluded. RESULTS: The ADE TT was applied to 1210 charts and 353 ADE were identified, with an average rate of 28.9/100 admissions and 38/1,000 bed days. 94.5% of the ADE identified were in the lower severity scales with temporary harm, however in 5 patients it was considered that the ADE contributed to their death, 9 required an intervention to sustain life and 4 suffered permanent harm. The most commonly implicated drugs were morphine and other opioids, anticoagulants, antibiotics, Non Steroidal Anti-Inflammatory Drugs (NSAIDs) and diuretics. Patients who suffered an ADE were more likely to be female, older with more complex medical illnesses, and have a longer length of stay. CONCLUSION: The rate of medication-related harm identified by the ADE TT is considerably higher than that identified through traditional voluntary reporting mechanisms. The ADE TT provides a standardised measure of harm over time that can be used to determine trends and the effect of medication safety improvement programmes. This study not only shows the problem of medication-related patient harm, but it also shows the utility of informal collaboratives as a mechanism for change.

Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit.

AIM: To eliminate Central Line Associated Bacteraemia (CLAB) in the Critical Care Complex (CCC)-Intensive Care Unit (ICU) and High Dependency Unit (HDU)-Middlemore Hospital. METHOD: Multifaceted quality improvement programme that included: engagement with ICU leadership and education of ICU staff; the introduction of a CLAB prevention bundle of care through standardised checklists for central line insertion (December 2008) and line maintenance (July 2009); the development of a central line pack; and rapid, visual feedback of results. RESULTS: Absolute numbers of CLAB in the CCC decreased from 14 in 2008, to 4 in 2009 and 1 in the first 6 months of 2010 (despite increase in bed census and a doubling of admissions). The CLAB rate per 1,000 line days decreased from 6.6 to 0.9. The days between CLAB increased from a median of 30 to >100 days, with zero CLAB for 5 of the last 6 months. Mortality for patients with CLAB was 37%, compared with mortality of 13% for all other ICU patients. The conservative cost savings were $200,000 in 2009 and $260,000 in 2010. CONCLUSION: Using an evidenced-based quality improvement approach, it is possible to significantly decrease Central Line Associated Bacteraemia in the Critical Care Complex. In doing so patient morbidity and mortality are reduced and money is saved for other healthcare needs.