Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

BACKGROUND: The critical role that middle managers play in enacting organisational culture change designed to address unprofessional co-worker behaviours has gone largely unexplored. We aimed to explore middle managers' perspectives on i) whether they speak up when they or their team members experience unprofessional behaviours (UBs); ii) how concerns are handled; iii) the outcomes; and iv) the role of a professional accountability culture change program (known as Ethos) in driving change. METHODS: Qualitative, constructivist approach. Five metropolitan hospitals in Australia which had implemented Ethos. Purposive sampling was used to invite middle-level managers from medicine, nursing, and non-clinical support services. Semi-structured interviews conducted remotely. Inductive, reflexive thematic and descriptive thematic analyses undertaken using NVivo. RESULTS: Thirty interviews (approximately 60 min; August 2020 to May 2021): Nursing (n = 12), Support Services (n = 10), and Medical (n = 8) staff, working in public (n = 18) and private (n = 12) hospitals. One-third (n = 10) had a formal role in Ethos. All middle managers (hearers) had experienced the raising of UBs by their team (speakers). Themes representing reasons for ongoing UBs were: staying silent but active; history and hierarchy; and double-edged swords. The Ethos program was valued as a confidential, informal, non-punitive system but required improvements in profile and effectiveness. Participants described four response stages: i) determining if reports were genuine; ii) taking action depending on the speaker's preference, behaviour factors (type, frequency, impact), if the person was known/unknown; iii) exploring for additional information; and iv) addressing either indirectly (e.g., change rosters) or directly (e.g., become a speaker). CONCLUSIONS: Addressing UBs requires an organisational-level approach beyond supporting staff to speak up, to include those hearing and addressing UBs. We propose a new hearer's model that details middle managers' processes after a concern is raised, identifying where action can be taken to minimise avoidant behaviours to improve hospital culture, staff and patient safety.

Trends, determinants and differences in antibiotic use in 68 residential aged care homes in Australia, 2014-2017: a longitudinal analysis of electronic health record data.

BACKGROUND: Internationally, point prevalence surveys are the main source of antibiotic use data in residential aged care (RAC). Our objective was to describe temporal trends in antibiotic use and antibiotics flagged for restricted use, resident characteristics associated with use, and variation in use by RAC home, using electronic health record data. METHODS: We conducted a retrospective cohort study of 9793 unique residents aged ≥65 years in 68 RAC homes between September 2014 and September 2017, using electronic health records. We modelled the primary outcome of days of antibiotic therapy /1000 resident days (DOT/1000 days), and secondary outcomes of number of courses/1000 days and the annual prevalence of antibiotic use. Antibiotic use was examined for all antibiotics and antibiotics on the World Health Organization's (WHO) Watch List (i.e. antibiotics flagged for restricted use). RESULTS: In 2017, there were 85 DOT/1000 days (99% CI: 79, 92), 8.0 courses/1000 days (99% CI: 7.6, 8.5), and 63.4% (99% CI: 61.9, 65.0) of residents received at least one course of antibiotics. There were 7.7 DOT/1000 days (99% CI: 6.69, 8.77) of antibiotics on the WHO Watch List administered in 2017. Antibiotic use increased annually by 4.09 DOT/1000 days (99% CI: 1.18, 6.99) before adjusting for resident factors, and 3.12 DOT/1000 days (99% CI: - 0.05, 6.29) after adjustment. Annual prevalence of antibiotic use decreased from 68.4% (99% CI: 66.9, 69.9) in 2015 to 63.4% (99% CI: 61.9, 65.0) in 2017, suggesting fewer residents were on antibiotics, but using them for longer. Resident factors associated with higher use were increasing age; chronic respiratory disease; a history of urinary tract infections, and skin and soft tissue infections; but dementia was associated with lower use. RAC home level antibiotic use ranged between 44.0 to 169.2 DOT/1000 days in 2016. Adjusting for resident factors marginally reduced this range (42.6 to 155.5 DOT/1000 days). CONCLUSIONS: Antibiotic course length and RAC homes with high use should be a focus of antimicrobial stewardship interventions. Practices in RAC homes with low use could inform interventions and warrant further investigation. This study provides a model for using electronic health records as a data source for antibiotic use surveillance in RAC.

Drug-drug interactions and their harmful effects in hospitalised patients: a systematic review and meta-analysis.

PURPOSE: Drug-drug interactions (DDIs) are often avoidable and, if undetected, can lead to patient harm. This review aimed to determine the prevalence of potential DDIs (pDDIs), clinically relevant DDIs (DDIs that could lead to measurable patient harm, taking into account the patient's individual clinical profile) and DDIs that resulted in actual patient harm during hospitalisation. METHOD: Four databases were scanned for English papers published from 2000 to 2016. Papers that reported prevalence of DDIs in the outpatient setting, at admission or discharge, involving only specific drugs, or in specific disease populations or age groups were excluded. RESULTS: Twenty-seven papers met the inclusion criteria and were graded for quality using the Critical Appraisal Skills Programme (CASP) cohort study checklist. Ten papers were rated as 'poor', 14 as 'fair' and only three papers as 'good'. Overall, the meta-analysis revealed that 33% of general patients and 67% of intensive care patients experienced a pDDI during their hospital stay. It was not possible to determine the prevalence of clinically relevant DDIs or DDIs that resulted in actual patient harm as data on these categories were limited. Of the very few studies that reported on harm, only a small proportion of DDIs were found to have resulted in actual patient harm. CONCLUSIONS: Standardisation of DDI definitions and research methods are required to allow meaningful prevalence rates to be obtained and compared. Studies that go further than measuring pDDIs are critically needed to determine the impact of DDIs on patient safety.

A time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect?

BACKGROUND: Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends. AIM: To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week. METHODS: Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks. RESULTS: Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001). CONCLUSION: On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands.

Modeling seasonal migration of fall armyworm moths.

Fall armyworm, Spodoptera frugiperda (J.E. Smith), is a highly mobile insect pest of a wide range of host crops. However, this pest of tropical origin cannot survive extended periods of freezing temperature but must migrate northward each spring if it is to re-infest cropping areas in temperate regions. The northward limit of the winter-breeding region for North America extends to southern regions of Texas and Florida, but infestations are regularly reported as far north as Québec and Ontario provinces in Canada by the end of summer. Recent genetic analyses have characterized migratory pathways from these winter-breeding regions, but knowledge is lacking on the atmosphere's role in influencing the timing, distance, and direction of migratory flights. The Hybrid Single-Particle Lagrangian Integrated Trajectory (HYSPLIT) model was used to simulate migratory flight of fall armyworm moths from distinct winter-breeding source areas. Model simulations identified regions of dominant immigration from the Florida and Texas source areas and overlapping immigrant populations in the Alabama-Georgia and Pennsylvania-Mid-Atlantic regions. This simulated migratory pattern corroborates a previous migratory map based on the distribution of fall armyworm haplotype profiles. We found a significant regression between the simulated first week of moth immigration and first week of moth capture (for locations which captured ≥ 10 moths), which on average indicated that the model simulated first immigration 2 weeks before first captures in pheromone traps. The results contribute to knowledge of fall armyworm population ecology on a continental scale and will aid in the prediction and interpretation of inter-annual variability of insect migration patterns including those in response to climatic change and adoption rates of transgenic cultivars.

Nuclear medicine incident reporting in Australia: control charts and notification rates inform quality improvement.

BACKGROUND: Australia has a statutory incident reporting system for radiopharmaceutical maladministrations, but additional research into registry data is required for the purpose of quality improvement in nuclear medicine. AIMS: We (i) used control charts to identify factors contributing to special cause variation (indicating higher than expected rates) in maladministrations and (ii) evaluated the impact of heterogeneous notification criteria and extent of underreporting among jurisdictions and individual facilities, respectively. METHODS: Anonymised summaries of Australian Radiation Incident Register reports permitted calculation of national monthly maladministration notification rates for 2007-2012 and preparation of control charts. Multivariate logistic regression assessed the association of population, insurance and regulatory characteristics with maladministration notifications in each Australian State and Territory. Maladministration notification rates from two facilities with familiarity of notification processes and commitment to radiation protection were compared with those elsewhere. RESULTS: Special cause variation occurred in only 3 months, but contributed to 21% of all incidents (42 of 197 patients), mainly because of 'clusters' of maladministrations (n = 24) arising from errors in bulk radiopharmaceutical dispensing. Maladministration notification rates varied significantly between jurisdictions (0 to 12.2 maladministrations per 100 000 procedures (P < 0.05)) and individual facilities (31.7 vs 5.8 per 100 000; χ(2) = 40; 1 degree of freedom, P < 0.001). CONCLUSIONS: Unexpected increases in maladministration notifications predominantly relate to incident 'clusters' affecting multiple patients. The bulk preparation of radiopharmaceuticals is a vulnerable process and merits additional safeguards. Maladministration notification rates in Australia are heterogeneous. Adopting uniform maladministration notification criteria among States and Territories and methods to overcome underreporting are warranted.

Mechanisms of motivation-cognition interaction: challenges and opportunities.

Recent years have seen a rejuvenation of interest in studies of motivation-cognition interactions arising from many different areas of psychology and neuroscience. The present issue of Cognitive, Affective, & Behavioral Neuroscience provides a sampling of some of the latest research from a number of these different areas. In this introductory article, we provide an overview of the current state of the field, in terms of key research developments and candidate neural mechanisms receiving focused investigation as potential sources of motivation-cognition interaction. However, our primary goal is conceptual: to highlight the distinct perspectives taken by different research areas, in terms of how motivation is defined, the relevant dimensions and dissociations that are emphasized, and the theoretical questions being targeted. Together, these distinctions present both challenges and opportunities for efforts aiming toward a more unified and cross-disciplinary approach. We identify a set of pressing research questions calling for this sort of cross-disciplinary approach, with the explicit goal of encouraging integrative and collaborative investigations directed toward them.

iPad use at the bedside: a tool for engaging patients in care processes during ward rounds?

BACKGROUND: Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings. AIMS: To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events. METHODS: Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey. RESULTS: Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief. CONCLUSIONS: Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done.

WSR-88D doppler radar detection of corn earworm moth migration.

Corn earworm (Lepidoptera: Noctuidae) (CEW) populations infesting one crop production area may rapidly migrate and infest distant crop production areas. Although entomological radars have detected corn earworm moth migrations, the spatial extent of the radar coverage has been limited to a small horizontal view above crop production areas. The Weather Service Radar (version 88D) (WSR-88D) continuously monitors the radar-transmitted energy reflected by, and radial speed of, biota as well as by precipitation over areas that may encompass crop production areas. We analyzed data from the WSR-88D radar (S-band) at Brownsville, Texas, and related these data to aerial concentrations of CEW estimated by a scanning entomological radar (X-band) and wind velocity measurements from rawinsonde and pilot balloon ascents. The WSR-88D radar reflectivity was positively correlated (r2=0.21) with the aerial concentration of corn earworm-size insects measured by a scanning X-band radar. WSR-88D radar constant altitude plan position indicator estimates of wind velocity were positively correlated with wind speed (r2=0.56) and wind direction (r2=0.63) measured by pilot balloons and rawinsondes. The results reveal that WSR-88D radar measurements of insect concentration and displacement speed and direction can be used to estimate the migratory flux of corn earworms and other nocturnal insects, information that could benefit areawide pest management programs. In turn, identification of the effects of spatiotemporal patterns of migratory flights of corn earworm-size insects on WSR-88D radar measurements may lead to the development of algorithms that increase the accuracy of WSR-88D radar measurements of reflectivity and wind velocity for operational meteorology.

Shedding light on junior doctors' work practices after hours.

BACKGROUND: It is imperative to understand the current work practices of hospital personnel to inform efforts and secure resources towards the improvement of hospital systems. Research examining doctors' work during night-shifts is limited. AIM: To describe and quantify the night-shift work practices of junior doctors. METHODS: An observational time and motion study was conducted. Eight resident doctors in four general wards were observed for 96 h during night shifts (Monday-Friday, 2200-0800). RESULTS: Doctors spent the highest proportion (28%; 95% CI 21-35) of their time performing social/personal tasks (e.g. sleeping, eating) and indirect care (24%; 95% CI 22-25) (e.g. reviewing notes, ordering tests). Work-related discussion comprised 15% (95% CI 13-17), and most took place at the beginning of the night. Medication-related tasks consumed a small proportion of time (4%; 95% CI 3-4) but attracted a higher level of multitasking and interruptions than most other tasks. On average, 2 h of every shift were spent at a computer and 1.3 h with patient notes. Doctors spent 72% of the night-shift alone, multitasked 6.4% of the time and were interrupted, on average, once every 46 min. CONCLUSIONS: This study provides new data about junior doctors' work at night. Relative to doctors during the day, greater proportions of time were devoted to social/personal tasks (including sleep) and indirect care, but a similar proportion to direct care. Multitasking and interruptions were minimal. Computer activities were an integral part of work. Handovers were observed at the beginning but not the completion of the night shift, which may have implications for patient safety.

Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm.

Despite improvements in the clinical management of aneurysmal subarachnoid haemorrhage over the last decade, delayed cerebral ischaemia (DCI) remains the single most important cause of morbidity and mortality in those patients who survive the initial bleed. The pathological mechanisms underlying DCI are still unclear and the calcium channel blocker nimodipine remains the only therapeutic intervention proven to improve functional outcomes after SAH. The recent failure of the drug clazosentan to improve functional outcomes despite reducing vasoconstriction has moved the focus of research into DCI away from cerebral artery constriction towards a more multifactorial aetiology. Novel pathological mechanisms have been suggested, including damage to cerebral tissue in the first 72 h after aneurysm rupture ('early brain injury'), cortical spreading depression, and microthrombosis. A greater understanding of the significance of these pathophysiological mechanisms and potential genetic risk factors is required, if new approaches to the prophylaxis, diagnosis, and treatment of DCI are to be developed. Furthermore, objective and reliable biomarkers are needed for the diagnosis of DCI in poor grade SAH patients requiring sedation and to assess the efficacy of new therapeutic interventions. The purpose of this article is to appraise these recent advances in research into DCI, relate them to current clinical practice, and suggest potential novel avenues for future research.

The feasibility of Dementia Care Mapping (DCM) on a neurorehabilitation ward.

Person-centred care (PCC) is recommended when working with patients with neurological difficulties. Despite this, to date there has been no appropriate methodology for assessing or developing PCC in neurorehabilitation settings. Dementia Care Mapping (DCM) is a well-established tool for assessing and developing PCC in dementia settings and the current study investigated the feasibility of applying DCM on an acute neurorehabilitation ward. DCM procedure and coding required minor adaptations for use in this setting and further recommended adaptations were subsequently identified. It was found that the DCM coding system was generally suitable and could identify strengths, weaknesses and areas for development in ward care. Q-methodology identified that staff views endorsed the feasibility of using DCM in neurorehabilitation, with staff reporting that they found DCM useful and relevant to their work. DCM could be further developed for this setting by amendments to the behaviour coding system, concept and coding of person-centred care, and a population-specific manual. DCM is a promising methodology to develop and promote PCC in neurorehabilitation.

Are specialist physicians missing out on the e-Health boat?

BACKGROUND: Nationally health systems are making increasing investments in the use of clinical information systems. Little is known about current computer use by specialist physicians, particularly outside the hospital setting. AIMS: To identify the extent and reasons physician Fellows of the Royal Australasian College of Physicians (RACP) use computers in their work. METHODS: A self-administered survey was emailed from the RACP to all practising physicians in 2007 that were living in Australia and New Zealand who had consented to email contact with the College. RESULTS: The survey was sent to a total of 7445 eligible physicians, 2328 physicians responded (31.3% response rate), but only 1266 responses (21.0%) were able to be analysed. Most 97.5% had access to computers at work and 96.5% used home computers for work purposes. Physicians in public hospitals (72.6%) were more likely to use computers for work (65.6%) than those in private hospitals (12.6%) or consulting rooms (27.3%). Overall physicians working in public hospitals used a wider range of applications with 70.5% using their computers for searching the internet, 53.7% for receiving results and 52.7% used their computers to engage in specific educational activities. Physicians working from their consulting rooms (33.6%) were more likely to use electronic prescribing (11%) compared with physicians working in public hospitals (5.7%). CONCLUSIONS: Fellows have not incorporated computers into their consulting rooms over which they have control. This is in contrast to general practitioners who have embraced computers after the provision of various incentives. The rate of use of computers by physicians for electronic prescribing in consulting rooms (11%) is very low in comparison with general practitioners (98%). One reason may be that physicians work in multiple locations whereas general practitioners are more likely to work from one location.

Understanding the impact on intensive care staff workflow due to the introduction of a critical care information system: a mixed methods research methodology.

The Intensive Care Unit (ICU) is a complex and dynamic tertiary care environment that requires health care providers to balance many competing tasks and responsibilities. Inefficient and interruption-driven workflow is believed to increase the likelihood of medical errors and, therefore, present a serious risk to patients in the ICU. The introduction of a Critical Care Information System (CCIS), is purported to result in fewer medical errors and better patient care by streamlining workflow. Little objective research, however, has investigated these assertions. This paper reports on the design of a research methodology to explore the impact of a CCIS on the workflow of Respiratory Therapists, Pediatric Intensivists, Nurses, and Unit Clerks in a Pediatric ICU (PICU) and a General Systems ICU (GSICU) in Northern Canada.

A longitudinal study over 5 to 10 years of clinical outcomes in women with idiopathic detrusor overactivity.

OBJECTIVE: To evaluate the long-term clinical outcome in women with idiopathic detrusor overactivity (IDO) and to identify significant prognostic factors. DESIGN: Longitudinal study incorporating retrospective case note review and a postal questionnaire. SETTING: Tertiary referral urogynaecology clinic in Australia. POPULATION: Women with a sole urodynamic diagnosis of IDO. METHODS: Audit of urodynamic records and case notes. Postal questionnaire incorporating validated disease-specific quality-of-life (QoL) instruments. MAIN OUTCOME MEASURE: Subjective assessment of overall improvement on a 4-point scale followed by scoring of short forms of the urogenital distress inventory and incontinence impact questionnaire. RESULTS: One hundred and thirty two women were identified following examination of 1975 consecutive records with 76 (67%) returning questionnaires. Median follow up was 8 years (6-9), and the duration of symptoms was 13 years (9-18). Improvement was achieved in 25 (35%) women. Disease symptoms fluctuated in severity and QoL were worse in nonresponders to therapy (P < 0.0001). Urge incontinence at presentation was associated with treatment failure (P = 0.001) as was nocturia (P = 0.04), but urodynamic variables were not associated with outcome. Only 3 of 46 (6.5%) women not responding to therapy thought that their symptoms would improve with time. CONCLUSIONS: IDO seldom resolves and fluctuates in severity. Individual response is unpredictable, although the presence of urge incontinence is associated with a significantly worse prognosis.

Detection and evolution of resistance to the pyrethroid cypermethrin in Helicoverpa zea (Lepidoptera: Noctuidae) populations in Texas.

The bollworm, Helicoverpa zea (Boddie), is a key pest of cotton in Texas. Bollworm populations are widely controlled with pyrethroid insecticides in cotton and exposed to pyrethroids in other major crops such as grain sorghum, corn, and soybeans. A statewide program that evaluated cypermethrin resistance in male bollworm populations using an adult vial test was conducted from 2003 to 2006 in the major cotton production regions of Texas. Estimated parameters from the most susceptible field population currently available (Burleson County, September 2005) were used to calculate resistance ratios and their statistical significance. Populations from several counties had statistically significant (P < or = 0.05) resistance ratios for the LC(50), indicating that bollworm-resistant populations are widespread in Texas. The highest resistance ratios for the LC(50) were observed for populations in Burleson County in 2000 and 2003, Nueces County in 2004, and Williamson and Uvalde Counties in 2005. These findings explain the observed pyrethroid control failures in various counties in Texas. Based on the assumption that resistance is caused by a single gene, the Hardy-Weinberg equilibrium formula was used for estimation of frequencies for the putative resistant allele (q) using 3 and 10 microg/vial as discriminatory dosages for susceptible and heterozygote resistant insects, respectively. The influence of migration on local levels of resistance was estimated by analysis of wind trajectories, which partially clarifies the rapid evolution of resistance to cypermethrin in bollworm populations. This approach could be used in evaluating resistance evolution in other migratory pests.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.

OBJECTIVES: To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems. METHODS: PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness. RESULTS: Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits. DISCUSSION AND CONCLUSION: The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system.

A systems science perspective on the capacity for change in public hospitals.

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Computerised pathology test order entry reduces laboratory turnaround times and influences tests ordered by hospital clinicians: a controlled before and after study.

OBJECTIVE: To assess the impact of a computerised pathology order entry system on laboratory turnaround times and test ordering within a teaching hospital. METHODS: A controlled before and after study compared test assays ordered from 11 wards two months before (n = 97 851) and after (n = 113 762) the implementation of a computerised pathology order entry system (Cerner Millennium Powerchart). Comparisons were made of laboratory turnaround times, frequency of tests ordered and specimens taken, proportions of patients having tests, average number per patient, and percentage of gentamicin and vancomycin specimens labelled as random. RESULTS: Intervention wards experienced an average decrease in turnaround of 15.5 minutes/test assay (range 73.8 to 58.3 minutes; p<0.001). Reductions were significant for prioritised and non-prioritised tests, and for those done within and outside business hours. There was no significant change in the average number of tests (p = 0.228), or specimens per patient (p = 0.324), and no change in turnaround time for the control ward (p = 0.218). Use of structured order screens enhanced data provided to laboratories. Removing three test assays from the liver function order set resulted in significantly fewer of these tests being done. CONCLUSIONS: Computerised order entry systems are an important element in achieving faster test results. These systems can influence test ordering patterns through structured order screens, manipulation of order sets, and analysis of real time data to assess the impact of such changes, not possible with paper based systems. The extent to which improvements translate into improved patient outcomes remains to be determined. A potentially limiting factor is clinicians' capacity to respond to, and make use of, faster test results.

The PDB data uniformity project.

The Protein Data Bank (PDB; http://www.rcsb.org/pdb/) is the single worldwide archive of structural data of biological macromolecules. This paper describes the data uniformity project that is underway to address the inconsistency in PDB data.