Medication errors in emergency departments: is electronic medical record an effective barrier?

OBJECTIVE: To compare medication errors in two emergency departments with electronic medical record, to two departments that had conventional handwritten records at the same organization. METHODS: A cross-sectional, retrospective, descriptive, comparative study of medication errors and their classification, according to the National Coordinating Council for Medication Error Reporting and Prevention, associated with the use of electronic and conventional medical records, in emergency departments of the same organization, during one year. RESULTS: There were 88 events per million opportunities in the departments with electronic medical record and 164 events per million opportunities in the units with conventional medical records. There were more medication errors when using conventional medical record - in 9 of 14 categories of the National Coordinating Council for Medication Error Reporting and Prevention. CONCLUSION: The emergency departments using electronic medical records presented lower levels of medication errors, and contributed to a continuous improvement in patients´ safety.

Medication errors in emergency departments: is electronic medical record an effective barrier? / Erros de medicação em unidades de pronto atendimento: prontuário eletrônico, barreira eficaz?

ABSTRACT Objective: To compare medication errors in two emergency departments with electronic medical record, to two departments that had conventional handwritten records at the same organization. Methods: A cross-sectional, retrospective, descriptive, comparative study of medication errors and their classification, according to the National Coordinating Council for Medication Error Reporting and Prevention, associated with the use of electronic and conventional medical records, in emergency departments of the same organization, during one year. Results: There were 88 events per million opportunities in the departments with electronic medical record and 164 events per million opportunities in the units with conventional medical records. There were more medication errors when using conventional medical record - in 9 of 14 categories of the National Coordinating Council for Medication Error Reporting and Prevention. Conclusion: The emergency departments using electronic medical records presented lower levels of medication errors, and contributed to a continuous improvement in patients´ safety.

RESUMO Objetivo: Comparar os erros de medicações de duas unidades de pronto atendimento que possuíam prontuário eletrônico aos de duas unidades que possuíam prontuário convencional manual em uma mesma instituição. Métodos: Estudo transversal, retrospectivo, descritivo, que comparou a incidência de erros de medicações e sua classificação, segundo o National Coordinating Council for Medication Error Reporting and Prevention, associado ao uso do prontuário eletrônico e do convencional, em unidades de pronto atendimento de uma mesma instituição por um ano. Resultados: Foram observados 88 eventos por milhão de oportunidades nas unidades com prontuário eletrônico e 164 por milhão de oportunidades nas unidades com prontuário convencional. Houve mais erros de medicações nas unidades com prontuário convencional − em 9 das 14 categorias da National Coordinating Council for Medication Error Reporting and Prevention analisadas. Conclusão: Com a utilização do prontuário eletrônico, as unidades de pronto atendimento apresentaram menores índices de erros de medicações, contribuindo para melhoria continuada na segurança do paciente.

Evaluation of Influenza A H1N1 infection and antiviral utilization in a tertiary care hospital.

BACKGROUND: Influenza A H1N1 infections carry a significant mortality risk. This study describes inpatients with suspected and confirmed Influenza A H1N1 infection who were prescribed oseltamivir, the risk factors associated with infection, the association between infection and mortality, and the factors associated with in-hospital mortality in infected patients. METHODS: This study was a matched case-control study of hospitalized patients who underwent real-time polymerase chain reaction testing for Influenza A H1N1 and were treated with oseltamivir from 2009 to 2015 in a tertiary care hospital. Cases (patients with positive Influenza A H1N1 testing) were matched 1:1 to controls (patients with negative test results). RESULTS: A total of 1405 inpatients who underwent PCR testing and received treatment with oseltamivir were identified in our study and 157 patients confirmed Influenza A H1N1. Almost one third of patients with Influenza A H1N1 were diagnosed in the pandemic period. There was no difference in mortality between cases and controls. Immunocompromised status, requirement of vasoactive drugs, mechanical ventilation, acute hemodialysis, albumin administration, surgical procedures and thoracic procedures and length of stay were associated with increased risk of death in Influenza A H1N1 infected patients. CONCLUSIONS: We found no increased risk of mortality for patients with proven Influenza A H1N1 when compared to similar patients without confirmed Influenza.

Evaluation of Candida bloodstream infection and antifungal utilization in a tertiary care hospital.

BACKGROUND: Candida bloodstream infections carry a significant mortality risk, justifying the importance of adequate antifungal therapy. This study describes trends in antifungal consumption using the Defined Daily Dose (DDD) and Days of Therapy (DOT) metrics, identifies the microbiological profile, the time to initiation of empirical therapy, the adjustment after positive blood culture results for Candida, and the impact on in-hospital mortality rate in patients with candidemia. METHODS: An analysis of antifungal consumption from 2008 to 2016, and of candidemia cases from 2012 to 2016 was carried out in a private tertiary hospital. RESULTS: A total of 11,273 admissions were identified with a prescription for at least one type of antifungal therapy. Fluconazole was the most prescribed antifungal drug in terms of general consumption. Through the DDD and DOT metrics, we observed that over time, there was an increase in the consumption of liposomal amphotericin B, micafungin and voriconazole. Candida albicans was the most isolated species in blood cultures. Regarding candidemia, we analyzed samples from 115 patients. Empirical therapy was started within 24 h of blood culture in 44.3% of the cases, and in 81.7% of the cases, the antifungal was deemed to be adequate based in antifungal susceptibility testing, both of which were not associated with the in-hospital mortality rate. CONCLUSIONS: Our study reinforces the importance of monitoring the consumption of antifungal agents, which helps in proposing actions that lead to their rational use and, consequently, reduces the appearance of resistant strains.

Analysis Treatment Guideline versus Clinical Practice Protocol in Patients Hospitalized due to Heart Failure / Análise de Diretriz de Tratamento versus Protocolo Assistencial em Pacientes Internados por Insuficiência Cardíaca

Background: Despite the availability of guidelines for treatment of heart failure (HF), only a few studies have assessed how hospitals adhere to the recommended therapies. Objectives: Compare the rates of adherence to the prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARB) at hospital discharge, which is considered a quality indicator by the Joint Commission International, and to the prescription of beta-blockers at hospital discharge, which is recommended by national and international guidelines, in a hospital with a case management program to supervise the implementation of a clinical practice protocol (HCP) and another hospital that follows treatment guidelines (HCG). Methods: Prospective observational study that evaluated patients consecutively admitted to both hospitals due to decompensated HF between August 1st, 2006, and December 31st, 2008. We used as comparing parameters the prescription rates of beta-blockers and ACEI/ARB at hospital discharge and in-hospital mortality. Results: We analyzed 1,052 patients (30% female, mean age 70.6 ± 14.1 years), 381 (36%) of whom were seen at HCG and 781 (64%) at HCP. The prescription rates of beta-blockers at discharge at HCG and HCP were both 69% (p = 0.458), whereas those of ACEI/ARB were 83% and 86%, respectively (p = 0.162). In-hospital mortality rates were 16.5% at HCP and 27.8% at HCG (p < 0.001). Conclusion: There was no difference in prescription rates of beta-blocker and ACEI/ARB at hospital discharge between the institutions, but HCP had lower in-hospital mortality. This difference in mortality may be attributed to different clinical characteristics of the patients in both hospitals.

Fundamento: Apesar da disponibilidade de diretrizes de tratamento para insuficiência cardíaca (IC), há poucos estudos avaliando a adesão dos hospitais ao tratamento preconizado. Objetivos: Comparar as taxas de adesão à prescrição de inibidor da enzima conversora da angiotensina ou antagonista do receptor de angiotensina II (IECA/BRA) na alta hospitalar, considerada indicadora de qualidade pela Joint Commission International, e à prescrição de betabloqueador na alta hospitalar, preconizada por diretrizes nacionais e internacionais, em um hospital que utiliza gerenciamento de casos para supervisionar a implementação de um protocolo assistencial (HPA) e outro que utiliza diretrizes de tratamento (HDT). Métodos: Estudo observacional prospectivo que avaliou pacientes consecutivamente admitidos em ambos os hospitais por IC descompensada entre 1º de agosto de 2006 a 31 de dezembro de 2008. Os parâmetros comparados entre os hospitais foram as taxas de prescrição de betabloqueador e IECA/BRA na alta hospitalar e a mortalidade intra-hospitalar. Resultados: Analisamos 1.052 pacientes (30% do sexo feminino, média de idade 70,6 ± 14,1 anos) dos quais 381 (36%) eram do HDT e 781 (64%) do HPA. No HDT e no HPA, as taxas de prescrição de betabloqueador na alta foram ambas de 69% (p = 0,458), e de prescrição de IECA/BRA foi de 83% e 86%, respectivamente (p = 0,162). A mortalidade intra-hospitalar foi de 16,5% no HPA e de 27,8% no HDT (p < 0,001). Conclusão: Não houve diferença entre as instituições em relação à prescrição de betabloqueador e IECA/BRA na alta hospitalar, mas a mortalidade intra-hospitalar foi menor no HPA. Esta diferença na mortalidade pode ser atribuída às características clínicas distintas dos pacientes em ambos os hospitais.

Analysis Treatment Guideline versus Clinical Practice Protocol in Patients Hospitalized due to Heart Failure.

BACKGROUND: Despite the availability of guidelines for treatment of heart failure (HF), only a few studies have assessed how hospitals adhere to the recommended therapies. OBJECTIVES: Compare the rates of adherence to the prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARB) at hospital discharge, which is considered a quality indicator by the Joint Commission International, and to the prescription of beta-blockers at hospital discharge, which is recommended by national and international guidelines, in a hospital with a case management program to supervise the implementation of a clinical practice protocol (HCP) and another hospital that follows treatment guidelines (HCG). METHODS: Prospective observational study that evaluated patients consecutively admitted to both hospitals due to decompensated HF between August 1st, 2006, and December 31st, 2008. We used as comparing parameters the prescription rates of beta-blockers and ACEI/ARB at hospital discharge and in-hospital mortality. RESULTS: We analyzed 1,052 patients (30% female, mean age 70.6 ± 14.1 years), 381 (36%) of whom were seen at HCG and 781 (64%) at HCP. The prescription rates of beta-blockers at discharge at HCG and HCP were both 69% (p = 0.458), whereas those of ACEI/ARB were 83% and 86%, respectively (p = 0.162). In-hospital mortality rates were 16.5% at HCP and 27.8% at HCG (p < 0.001). CONCLUSION: There was no difference in prescription rates of beta-blocker and ACEI/ARB at hospital discharge between the institutions, but HCP had lower in-hospital mortality. This difference in mortality may be attributed to different clinical characteristics of the patients in both hospitals.

Outcomes and Predictive Factors Associated with Adequacy of Antimicrobial Therapy in Patients with Central Line-Associated Bloodstream Infection.

BACKGROUND: Central venous catheters are significant risk factors for bloodstream infection (BSI), which are directly associated with increased morbidity and mortality. METHODS: This study was a retrospective cohort study for the time period of July 2011-June 2014 in patients with central line-associated bloodstream infection (CLABSI) to determine the microbiological profile and antimicrobial adequacy of patients with CLABSI in a tertiary hospital. RESULTS: One hundred and twenty-one CLABSI cases were identified. Ninety-two percent (n = 111) of patients had monomicrobial BSI. Gram-negative bacteria were the most prevalent (49%, n = 63), with Klebsiella spp. predominating (30%, n = 19). Among the Gram-positive bacteria (n = 43, 33%), coagulase-negative staphylococci was the major pathogen (58%, n = 25), and all isolates were methicillin resistant. Antimicrobial therapy was assessed as adequate in 81% (n = 98) of cases. In-hospital mortality was 36% (n = 43 cases). CONCLUSION: Our CLABSI patients had a high mortality, although antimicrobial therapy was appropriate. Gram-negative bacteria were responsible for almost half of the cases and there was a high rate of bacteria resistance to extended-spectrum antibiotics.

Measuring hand hygiene compliance rates at hospital entrances.

BACKGROUND: Despite the importance of hand hygiene in the health care setting, there are no studies evaluating hand hygiene compliance at hospital entrances. METHODS: The study was prospectively performed over a 33-week period from March 30, 2014-November 15, 2014, to evaluate hand hygiene compliance in 2 hospital reception areas. We compared electronic handwash counters with the application of radiofrequency identification (GOJO SMARTLINK) (electronic observer) that counts each activation of alcohol gel dispensers to direct observation (human observer) via remote review of video surveillance. RESULTS: We found low hand hygiene compliance rates of 2.2% (99/4,412) and 1.7% (140/8,277), respectively, at reception areas A and D, detected by direct observation. Using the electronic observer, we measured rates of 17% (15,624/91,724) and 7.1% (51,605/730,357) at reception areas A and D, respectively. For the overall time period of simultaneous electronic and human observation, the human observer captured 1% of the hand hygiene episodes detected by the electronic observer. CONCLUSIONS: Our study showed very low hand hygiene compliance in hospital reception areas, and we found an electronic hand hygiene system to be a useful method to monitor hand hygiene compliance.

Reduced frequency of cardiopulmonary arrests by rapid response teams / Redução de paradas cardiorrespiratórias por times de resposta rápida

OBJECTIVE: To evaluate the impact of the implementation of a rapid response team on the rate of cardiorespiratory arrests in mortality associated with cardiorespiratory arrests and on in-hospital mortality in a high complexity general hospital. METHODS: A retrospective analysis of cardiorespiratory arrests and in-hospital mortality events before and after implementation of a rapid response team. The period analyzed covered 19 months before intervention by the team (August 2005 to February 2007) and 19 months after the intervention (March 2007 to September 2008). RESULTS: During the pre-intervention period, 3.54 events of cardiorespiratory arrest/1,000 discharges and 16.27 deaths/1,000 discharges were noted. After the intervention, there was a reduction in the number of cardiorespiratory arrests and in the rate of in-hospital mortality; respectively, 1.69 events of cardiorespiratory arrest/1,000 discharges (p<0.001) and 14.34 deaths/1,000 discharges (p=0.029). CONCLUSION: The implementation of the rapid response team may have caused a significant reduction in the number of cardiorespiratory arrests. It was estimated that during the period from March 2007 to September 2008, the intervention probably saved 67 lives.

OBJETIVO: Avaliar o impacto da implementação de um time de resposta rápida na incidência de paradas cardiorrespiratórias, na mortalidade associada à parada cardiorrespiratória e na mortalidade hospitalar em um hospital geral, de alta complexidade. MÉTODOS: Análise retrospectiva dos eventos de paradas cardiorrespiratórias e mortalidade hospitalar, antes e depois da implementação de um time de resposta rápida. O período analisado compreendeu 19 meses antes da intervenção desse time (agosto de 2005 a fevereiro de 2007) e 19 meses após sua intervenção (março 2007 a setembro 2008). RESULTADOS: No período pré-intervenção, observaram-se 3,54 eventos de parada cardiorrespiratória/1.000 altas e 16,27 mortes/1.000 altas. Após a intervenção, observou-se redução no número de paradas cardiorrespiratórias e na taxa de mortalidade hospitalar: respectivamente 1,69 eventos de parada cardiorrespiratória/1.000 altas (p<0,001) e 14,34 mortes/1.000 altas (p=0,029). CONCLUSÃO: A implementação do time de resposta rápida, pode ter trazido uma redução significativa no número de paradas cardiorrespiratórias. Estimou-se que, no período de março de 2007 a setembro de 2008, a intervenção provavelmente salvou 67 vidas.

Reduced frequency of cardiopulmonary arrests by rapid response teams.

OBJECTIVE: To evaluate the impact of the implementation of a rapid response team on the rate of cardiorespiratory arrests in mortality associated with cardiorespiratory arrests and on in-hospital mortality in a high complexity general hospital. METHODS: A retrospective analysis of cardiorespiratory arrests and in-hospital mortality events before and after implementation of a rapid response team. The period analyzed covered 19 months before intervention by the team (August 2005 to February 2007) and 19 months after the intervention (March 2007 to September 2008). RESULTS: During the pre-intervention period, 3.54 events of cardiorespiratory arrest/1,000 discharges and 16.27 deaths/1,000 discharges were noted. After the intervention, there was a reduction in the number of cardiorespiratory arrests and in the rate of in-hospital mortality; respectively, 1.69 events of cardiorespiratory arrest/1,000 discharges (p < 0.001) and 14.34 deaths/1,000 discharges (p = 0.029). CONCLUSION: The implementation of the rapid response team may have caused a significant reduction in the number of cardiorespiratory arrests. It was estimated that during the period from March 2007 to September 2008, the intervention probably saved 67 lives.

Cefepime-induced encephalopathy in patient without renal failure / Encefalopatia induzida por cefepime em paciente sem insuficiência renal

This case report describes neurotoxicity in an older patient on cefepime 2 g twice a day. The 81-year-old male patient developed non-convulsive status epilepticus during cefepime treatment with 1 g twice a day. There was recovery 30 days after discontinuation of cefepime.

Este relato descreve neurotoxicidade em um paciente mais idoso em uso de cefepime na dose de 2 g duas vezes ao dia. O paciente de 81 anos desenvolveu estado epiléptico não-convulsivo durante o tratamento com 1 g de cefepime duas vezes ao dia. O paciente se recuperou depois de 30 dias, após a interrupção do cefepime.

Cefepime-induced encephalopathy in patient without renal failure.

This case report describes neurotoxicity in an older patient on cefepime 2 g twice a day. The 81-year-old male patient developed non-convulsive status epilepticus during cefepime treatment with 1 g twice a day. There was recovery 30 days after discontinuation of cefepime.