How policy makers can smooth the way for communication-and- resolution programs.

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. CRPs have existed for years, but they are being tested in new settings and primed for broad implementation through grants from the Agency for Healthcare Research and Quality. These projects do not require changing laws. However, grantees' experiences suggest that the path to successful dissemination of CRPs would be smoother if the legal environment supported them. State and federal policy makers should try to allay potential defendants' fears of litigation (for example, by protecting apologies from use in court), facilitate patient participation (for example, by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (for example, by clarifying practices governing National Practitioner Data Bank reporting and payers' financial recourse following medical error).

Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.

Communicating openly and honestly with patients and families about unexpected medical events-a policy known as full disclosure-improves outcomes for patients and providers. Although many certification and licensing organizations have declared full disclosure to be imperative, the adoption of and adherence to a full disclosure protocol is not common practice in most clinical settings. We conducted a case study of Ascension Health's implementation of a full disclosure protocol at five labor and delivery demonstration sites. Twenty-seven months after implementation, the rate of full disclosure had increased by 221 percent. Practitioners saw insurers' acceptance of the full disclosure protocol, consistent and ongoing leadership by local practitioners and hospitals, the establishment of a well-trained local investigation and disclosure team, and disclosure training for practitioners as key catalysts for change. Lessons learned from this multisite initiative can inform liability insurers and guide providers who are committed to ensuring that full disclosure becomes the only response to unexpected medical events.

A sensitive method for the determination of entecavir at picogram per milliliter level in human plasma by solid phase extraction and high-pH LC-MS/MS.

Entecavir is a guanine nucleoside analogue used in the treatment of hepatitis B virus (HBV) infection. In this paper, we describe an LC-MS/MS method that was developed and validated for the quantitation of entecavir in human EDTA plasma with both high sensitivity (lower limit of quantitation (LLOQ) of 5 pg/mL) and a wide concentration range (5000-fold) intended for low dose ascending clinical studies. High enrichment was achieved by taking advantage of the excellent loading capacity and reproducibility of Oasis HLB 96-well solid phase extraction plate, which allowed 1 mL of plasma samples to be processed in two equal sequential loading steps. Lobucavir, a structural analogue, was used as the internal standard. A filtration step following the reconstitution proved to be vital for the method robustness. The analyte and internal standard were separated on an Xterra MS C18 column with a gradient elution and high-pH mobile phases. Analytes were detected by positive ion electrospray tandem mass spectrometry. The high-pH mobile phase provided both excellent analyte on-column retention and peak shape, leading to the desired sensitivity. Validation results show good intra-assay (12.3%CV) and inter-assay (3.1%CV) precisions, and good assay accuracy (+/-7.6%Dev). Recovery was high (approximately 80%), however, the large volume of plasma used did result in a considerable matrix effect (approximately 0.45) which was well compensated by the analog internal standard. The method was applied to sample analysis of a Phase I clinical study.

Eliminating adverse drug events at Ascension Health.

Improvement in ADE rate did not occur at either hospital with any one particular intervention, or even after several conventional interventions had time to take effect. Instead, instituting many simultaneous system changes, proactively assessing risk, and expanding the scope of intervention were each essential to sustaining the described reductions in harm. The next step toward eliminating ADEs requires simultaneous communication across systems in a way that is manageable, approachable, and adaptable, and that supports the elements of change. A system of mutually informed processes--from medication selection and entry through preparation and dispensing, administration, monitoring, and reconciliation--should result in safe, patient-centered, reliable, and efficient medication use. In March 2007, Ascension Health, drawing on the work described in this article, began developing such a system.

A strategy for liquid chromatography/tandem mass spectrometric assays of intracellular drugs: application to the validation of the triphosphorylated anabolite of antiretrovirals in peripheral blood mononuclear cells.

The pharmacokinetics of intracellular drugs have recently aroused new interest because monitoring a drug's behaviour near the site of action can enhance knowledge of its efficacy and toxicity. Liquid chromatography coupled with tandem mass spectrometry (LC/MS/MS) is particularly attractive for intracellular analytes. Very few papers deal precisely with special features encountered in intracellular drug assay or with how closely the assay matches the actual recommendations. Particular problems are encountered mainly because the analytes are located intracellularly. This mainly concerns the handling of biological media, including provision of blank samples using Ficoll gradient separation, cell counts, optimisation of cell lysis, sample extraction, plotting standard curves using either fmol/10(6) cells or fmol/ml of extract or fmol/sample, the matrix effect as a function of the number of cells, stability before and during cell separation, as well as in storage conditions using clinical samples, biological matrix replacement and interference by endogenous compounds. This paper describes a strategy for the full validation and routine use of an LC/MS/MS assay applied to the simultaneous intracellular determination of the triphosphorylated anabolites of didanosine (2',3'-dideoxyadenosine triphosphate or ddA-TP) and stavudine (2',3'-didehydro-3'-deoxythymidine triphosphate or d4T-TP), two nucleoside reverse transcriptase inhibitors of HIV, in human peripheral blood mononuclear cells (PBMCs), as a guide for further LC/MS/MS assay of intracellular drugs.

Establishing the fitness for purpose of mass spectrometric methods.

This report is submitted by a working group sponsored by the ASMS Measurements and Standards Committee. The group responded to a 1998 opinion piece dealing with mass spectrometry in trace analysis (Bethem, R. A.; Boyd, R. K. J. Am. Soc. Mass Spectrom. 1998, 9, 643-648) which proposed that the concept of fitness for purpose addresses the needs of a wide range of analytical problems. There is a need to define fitness for purpose within the current context of mass spectrometry and to recommend processes for developing and evaluating methods according to suitability for a particular purpose. The key element in our proposal is for the interested parties to define in advance the acceptable degree of measurement uncertainty and the desired degree of identification confidence. These choices can serve as guideposts during method development and targets for retrospective evaluation of methods. A series of more detailed recommendations are derived from basic principles and also from reviews of current practice. This report highlights some areas where consensus is evident, but also revealed the need for further work in other areas. The recommendations are aimed primarily for the laboratory analyst but we hope they will be accessible to the non-scientist as well. Our goal was to provide a framework that can support informed decisions and foster discussion of the issues, because ultimately it is the responsibility of the analyst to make choices, provide supporting data, and interpret results according to scientific principles and qualified judgment.