A flow electrochemistry-enabled synthesis of 2-substituted N-(methyl-d)piperidines.

A synthesis of N-monodeuteriomethyl-2-substituted piperidines is described. An efficient and readily scalable anodic methoxylation of N-formylpiperidine in an undivided microfluidic electrolysis cell delivers methoxylated piperidine 3, which is a precursor to a N-formyliminium ion and enables C-nucleophiles to be introduced at the 2-position. The isotopically labelled N-deuteriomethyl group is installed using the Eschweiler-Clarke reaction with formic acid-d2 and unlabelled formaldehyde. Monodeuterated N-methyl groups in these molecular systems possess small isotropic proton chemical shift differences important in the investigation of molecules that are able to support long-lived nuclear spin states in solution nuclear magnetic resonance.

Flow Electrolysis Cells for the Synthetic Organic Chemistry Laboratory.

Electrosynthesis has much to offer to the synthetic organic chemist. But in order to be widely accepted as a routine procedure in an organic synthesis laboratory, electrosynthesis needs to be presented in a much more user-friendly way. The literature is largely based on electrolysis in a glass beaker or H-cells that often give poor performance for synthesis with a very slow rate of conversion and, often, low selectivity and reproducibility. Flow cells can lead to much improved performance. Electrolysis is participating in the trend toward continuous flow synthesis, and this has led to a number of innovations in flow cell design that make possible selective syntheses with high conversion of reactant to product with a single passage of the reactant solution through the cell. In addition, the needs of the synthetic organic chemist can often be met by flow cells operating with recycle of the reactant solution. These cells give a high rate of product formation while the reactant concentration is high, but they perform best at low conversion. Both approaches are considered in this review and the important features of each cell design are discussed. Throughout, the application of the cell designs is illustrated with syntheses that have been reported.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration: clinicaltrials.gov Identifier: NCT02876588.

A New Approach for the Synthesis of Highly Substituted Aromatic Rings: The Alkyne-Mediated Approach.

Pentasubstituted aromatic rings serve as templates for drug design and can be conveniently prepared by the thermolysis of suitably substituted alkynes under microwave conditions.

Intercepting wrong-patient orders in a computerized provider order entry system.

STUDY OBJECTIVE: We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments. METHODS: A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. RESULTS: Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. CONCLUSION: A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.

Indication alerts to improve problem list documentation.

BACKGROUND: Problem lists represent an integral component of high-quality care. However, they are often inaccurate and incomplete. We studied the effects of alerts integrated into the inpatient and outpatient computerized provider order entry systems to assist in adding problems to the problem list when ordering medications that lacked a corresponding indication. METHODS: We analyzed medication orders from 2 healthcare systems that used an innovative indication alert. We collected data at site 1 between December 2018 and January 2020, and at site 2 between May and June 2021. We reviewed random samples of 100 charts from each site that had problems added in response to the alert. Outcomes were: (1) alert yield, the proportion of triggered alerts that led to a problem added and (2) problem accuracy, the proportion of problems placed that were accurate by chart review. RESULTS: Alerts were triggered 131 134, and 6178 times at sites 1 and 2, respectively, resulting in a yield of 109 055 (83.2%) and 2874 (46.5%), P< .001. Orders were abandoned, for example, not completed, in 11.1% and 9.6% of orders, respectively, P<.001. Of the 100 sample problems, reviewers deemed 88% ± 3% and 91% ± 3% to be accurate, respectively, P = .65, with a mean of 90% ± 2%. CONCLUSIONS: Indication alerts triggered by medication orders initiated in the absence of a justifying diagnosis were useful for populating problem lists, with yields of 83.2% and 46.5% at 2 healthcare systems. Problems were placed with a reasonable level of accuracy, with 90% ± 2% of problems deemed accurate based on chart review.

Observation and Patients' Perceptions of Incorporating Their Photograph Into the Electronic Health Record.

OBJECTIVES: Wrong-patient errors are common and have the potential to cause serious harm. The Office of the National Coordinator for Health Information Technology Patient Identification SAFER Guide recommends displaying patient photographs in electronic health record (EHR) systems to facilitate patient identification and reduce wrong-patient errors. A potential barrier to implementation is patient refusal; however, patients' perceptions about having their photograph captured during registration and integrated into the EHR are unknown. METHODS: The study was conducted in an emergency department (ED) and primary care outpatient clinic within a large integrated health system in New York City. The study consisted of 2 components: (1) direct observation of the registration process to quantify the frequency of patient refusals and (2) semistructured interviews to elicit patients' feedback on perceived benefits and barriers to integrating their photograph into the EHR. RESULTS: Of 172 registrations where patients were asked to take a photograph for patient identification, 0 refusals were observed (ED, 0 of 87; primary care outpatient clinic, 0 of 85). A convenience sample of 30 patients were interviewed (female, 70%; age ≥55 years, 43%; Hispanic/Latino, 67%; Black, 23%). Perceived benefits of integrating patient photographs into the EHR included improved security (40%), improved patient identification (23%), and ease of registration (17%). A small proportion of patients raised privacy concerns. CONCLUSIONS: Patient refusal was not found to be a barrier to implementation of patient photographs in the EHR. Efforts to identify and address other potential barriers would help ensure that the highest proportion of patients has photographs in their medical record.

Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals.

MOTIVATION: Catheter-associated urinary tract infections (CAUTI) are a common and serious healthcare-associated infection. Despite many efforts to reduce the occurrence of CAUTI, there remains a gap in the literature about CAUTI risk factors, especially pertaining to the effect of catheter dwell-time on CAUTI development and patient comorbidities. OBJECTIVE: To examine how the risk for CAUTI changes over time. Additionally, to assess whether time from catheter insertion to CAUTI event varied according to risk factors such as age, sex, patient type (surgical vs medical) and comorbidities. DESIGN: Retrospective cohort study of all patients who were catheterised from 2012 to 2016, including those who did and did not develop CAUTIs. Both paediatric and adult patients were included. Indwelling urinary catheterisation is the exposure variable. The variable is interval, as all participants were exposed but for different lengths of time. SETTING: Urban academic health system of over 2500 beds. The system encompasses two large academic medical centres, two community hospitals and a paediatric hospital. RESULTS: The study population was 47 926 patients who had 61 047 catheterisations, of which 861 (1.41%) resulted in a CAUTI. CAUTI rates were found to increase non-linearly for each additional day of catheterisation; CAUTI-free survival was 97.3% (CI: 97.1 to 97.6) at 10 days, 88.2% (CI: 86.9 to 89.5) at 30 days and 71.8% (CI: 66.3 to 77.8) at 60 days. This translated to an instantaneous HR of. 49%-1.65% in the 10-60 day time range. Paraplegia, cerebrovascular disease and female sex were found to statistically increase the chances of a CAUTI. CONCLUSIONS: Using a very large data set, we demonstrated the incremental risk of CAUTI associated with each additional day of catheterisation, as well as the risk factors that increase the hazard for CAUTI. Special attention should be given to patients carrying these risk factors, for example, females or those with mobility issues.

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems.

IMPORTANCE: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. OBJECTIVES: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. MAIN OUTCOMES AND MEASURES: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. RESULTS: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. CONCLUSIONS AND RELEVANCE: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.

The nature and occurrence of registration errors in the emergency department.

Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decisions is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified "grounded theory," which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patient's identification information with those of another. Further analysis traced the root of the errors to ED registration. These results indicate that the nature of errors in the emergency department are complex, multi-layered and result from an intertwined web of activity, in which stress in the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.

Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system.

OBJECTIVE: To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).Design, Setting, and ParticipantsThis 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.InterventionsPhase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication. RESULTS: Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153-0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719-0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834-0·959; P=·0017). CONCLUSIONS: The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.

Emergency department access to a longitudinal medical record.

Our goal is to assess how clinical information from previous visits is used in the emergency department. We used detailed user audit logs to measure access to different data types. We found that clinician-authored notes and laboratory and radiology data were used most often (common data types were used up to 5% to 20% of the time). Data were accessed less than half the time (up to 20% to 50%) even when the user was alerted to the presence of data. Our access rate indicates that health information exchange projects should be conservative in estimating how often shared data will be used and the wide breadth of data accessed indicates that although a clinical summary is likely to be useful, an ideal solution will supply a broad variety of data.

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.

Several studies have shown that there is information loss during interruptions, and that multitasking creates higher memory load, both of which contribute to medical error. Nowhere is this more critical than in the emergency department (ED), where the emphasis of clinical decision is on the timely evaluation and stabilization of patients. This paper reports on the nature of multitasking and shift change and its implications for patient safety in an adult ED, using the methods of ethnographic observation and interviews. Data were analyzed using grounded theory to study cognition in the context of the work environment. Analysis revealed that interruptions within the ED were prevalent and diverse in nature. On average, there was an interruption every 9 and 14 min for the attending physicians and the residents, respectively. In addition, the workflow analysis showed gaps in information flow due to multitasking and shift changes. Transfer of information began at the point of hand-offs/shift changes and continued through various other activities, such as documentation, consultation, teaching activities and utilization of computer resources. The results show that the nature of the communication process in the ED is complex and cognitively taxing for the clinicians, which can compromise patient safety. The need to tailor existing generic electronic tools to support adaptive processes like multitasking and handoffs in a time-constrained environment is discussed.

Electrochemical Deprotection of para-Methoxybenzyl Ethers in a Flow Electrolysis Cell.

Electrochemical deprotection of p-methoxybenzyl (PMB) ethers was performed in an undivided electrochemical flow reactor in MeOH solution, leading to the unmasked alcohol and p-methoxybenzaldehyde dimethyl acetal as a byproduct. The electrochemical method removes the need for chemical oxidants, and added electrolyte (BF4NEt4) can be recovered and reused. The method was applied to 17 substrates with high conversions in a single pass, yields up to 92%, and up to 7.5 g h-1 productivity. The PMB protecting group was also selectively removed in the presence of some other common alcohol protecting groups.

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic survey via 2 national listservs. Among 167 inpatient and outpatient study facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Decision-making centered on efforts to balance safety and efficiency, but there was disagreement among organizations about how to achieve that balance. Results demonstrate no consensus on the number of records to be allowed open at once in EHRs. Rigorous studies are needed to determine the optimal number of records that balances safety and efficiency.

Return on investment in pay for performance: a diabetes case study.

With purchasers' increasing frustration with healthcare costs, more innovative approaches to performance-based reimbursement are in demand. Establishing pay-for-performance programs has become a popular strategy for reorienting payments from rewarding volume to rewarding adherence to performance measures. However, while performance on quality measures has improved, no reports exist about the return on investment (ROI) of pay-for-performance programs. This article compares the overall costs of implementing and maintaining a pay-for-performance program with the resulting cost trend savings for diabetes care for a health maintenance organization's (HMO's) population. The program was a five-year partnership (2000-2004) between a health plan and an independent practice association (IPA) for the HMO product. It reported performance scores on quality, patient satisfaction, and practitioner efficiency at the individual physician level. Physician performance reporting began in 1999, and payment for that performance began in 2002. The cost of the program was 1,150,000 dollars yearly. Savings for diabetes alone in 2003, the first post-intervention year, were 1,894,471dollars. Second-year (2004) savings against the two-year rolling trend were 2,923,761 dollars. For 2003, the resulting ROI was 1.6:1, and for 2004, it was 2.5:1. To our knowledge, this article is the first report of a positive ROI for an HMO-based pay-for-performance program, and it begins to answer the question of whether the investment in such programs is worth the effort.

N-Heterocyclic Carbene-Mediated Microfluidic Oxidative Electrosynthesis of Amides from Aldehydes.

A flow process for N-Heterocyclic Carbene (NHC)-mediated anodic oxidative amidation of aldehydes is described, employing an undivided microfluidic electrolysis cell to oxidize Breslow intermediates. After electrochemical oxidation, the reaction of the intermediate N-acylated thiazolium cation with primary amines is completed by passage through a heating cell to achieve high conversion in a single pass. The flow mixing regimen circumvented the issue of competing imine formation between the aldehyde and amine substrates, which otherwise prevented formation of the desired product. High yields (71-99%), productivities (up to 2.6 g h(-1)), and current efficiencies (65-91%) were realized for 19 amides.

N-Heterocyclic Carbene-Mediated Oxidative Electrosynthesis of Esters in a Microflow Cell.

An efficient N-heterocyclic carbene (NHC)-mediated oxidative esterification of aldehydes has been achieved in an undivided microfluidic electrolysis cell at ambient temperature. Productivities of up to 4.3 g h(-1) in a single pass are demonstrated, with excellent yields and conversions for 19 examples presented. Notably, the oxidative acylation reactions were shown to proceed with a 1:1 stoichiometry of aldehyde and alcohol (for primary alcohols), with remarkably short residence times in the electrolysis cell (<13 s), and without added electrolyte.

Emergency department visits for home medical device failure during the 2003 North America blackout.

OBJECTIVES: During a widespread North American blackout in August 2003, the authors identified a cluster of patients presenting to their northern Manhattan emergency department (ED) with complaints related to medical device failure. The characteristics of this group with respect to presenting complaint, type of device failure, time spent in the ED, and disposition are described in an effort to better understand the resource needs of this population. METHODS: This was a retrospective chart review for all patients evaluated in an urban teaching ED during a 24-hour period spanning the duration of regional power failure. Charts for patients presenting with medical device failure as part of their triage complaint were abstracted. RESULTS: Twenty-three of 255 patients coming to the ED during the 24-hour period presented with medical device failure. Nineteen of the device failures were due to nonfunctioning oxygen conservers, three to ventilator failure, and two to airway suction device failure (one patient had two devices fail). Thirteen of these patients were admitted to the hospital and accounted for 22% of all admissions during the study interval. Discharged patients spent a mean of 15.1 hours (range: 3.8-24.4 hours) in the ED. CONCLUSIONS: Patients using electrical medical devices seek care in the ED when power failure occurs, and they require significant ED and hospital resources. Effective disaster planning should anticipate the needs of this population.

Designing a clinical dashboard to fill information gaps in the emergency department.

Data fragmentation within electronic health records causes gaps in the information readily available to clinicians. We investigated the information needs of emergency medicine clinicians in order to design an electronic dashboard to fill information gaps in the emergency department. An online survey was distributed to all emergency medicine physicians at a large, urban academic medical center. The survey response rate was 48% (52/109). The clinical information items reported to be most helpful while caring for patients in the emergency department were vital signs, electrocardiogram (ECG) reports, previous discharge summaries, and previous lab results. Brief structured interviews were also conducted with 18 clinicians during their shifts in the emergency department. From the interviews, three themes emerged: 1) difficulty accessing vital signs, 2) difficulty accessing point-of-care tests, and 3) difficulty comparing the current ECG with the previous ECG. An emergency medicine clinical dashboard was developed to address these difficulties.