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1.  Self-Reported Violations During Medication Administration in Two Pediatric Hospitals 
BMJ quality & safety  2012;21(5):408-415.
Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.
To assess the extent of violations in the medication administration process among nurses.
Design, Setting, & Participants
Participants were 199 nurses from two U.S. urban, academic, tertiary care, free-standing pediatric hospitals who worked in: a pediatric intensive care unit (PICU), a hematology-oncology-transplant (HOT) unit, or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.
Main Outcome Measure
Self-reported violations of three medication administration protocols were made using a 7-point 0-6 scale from “not at all” to “a great deal.”
Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses, and then Med/Surge unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant 3-way interaction among Violation Situation, Step in the process, and Unit, which is explained in detail in the Results.
Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital Unit, Step in the process, and Violation Situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol in order to accomplish job tasks.
PMCID: PMC4174297  PMID: 22447818
Patient safety; Compliance; Medication Administration; Violation; Compliance; Human error; Human factors; Medical error; measurement/epidemiology; Patient safety
2.  That’s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care 
Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.
PMCID: PMC3113497  PMID: 21686318
health information technology; bar coded medication administration; process change; patient safety; human factors engineering
3.  A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life 
BMJ quality & safety  2011;20(1):15-24.
Nursing workload is increasingly thought to contribute to both nurses’ quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualizing and measuring the effects of workload in health care. In contrast, we conceptualized a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.
To test this model, we analyzed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care pediatric hospitals.
Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading = .31) and burnout (path loading = .45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading = .25) and medication error likelihood (path loading = 1.04). Job-level workload was not uniquely and significantly associated with any outcomes.
The human factors engineering model of nursing workload was supported by data from two pediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
PMCID: PMC3058823  PMID: 21228071
workload; mental workload; patient safety; medication error; quality of working life
4.  Effects of mental demands during dispensing on perceived medication safety and employee well being: A study of workload in pediatric hospital pharmacies 
Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes such as job satisfaction.
This study sought to measure the effect of workload on safety and employee outcomes in two pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.
Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, rushing) and internal (concentration, effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.
Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, rushing) negatively impacted medication safety and employee well being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout, and even had a positive effect on job satisfaction.
Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
PMCID: PMC3052977  PMID: 21111387
Workload; mental demands; medication error; safety; employee well being; human factors
5.  MMP-9 functions as a tumor suppressor in colitis-associated cancer 
Cancer research  2010;70(2):792.
We have demonstrated that epithelial derived MMP-9 is upregulated during inflammatory bowel disease, mediates tissue damage during colitis and regulates goblet cell differentiation through proteoltic cleavage of Notch-1 in colon. Association of MMP-9 and Notch-1 with colon cancer has been well documented. In this study, we sought to address the role and mechanism by which MMP-9 mediates the colitis-associated colon cancer (CAC). Wild type (WT) and MMP-9 knock-out (MMP-9-/-) mice were used for in vivo studies and enterocyte cell line, Caco2-BBE, were used for in vitro studies. Azoxymethane and dextran sodium sulfate were used to induce CAC. MMP-9-/- mice showed increased susceptibility to CAC as evidenced by increased tumor multiplicity, size and mortality. CAC in MMP-9-/- is associated with increased proliferation and decreased apoptosis compared to CAC in WT mice. MMP-9-/- mice exhibited p21WAF1/Cip1 expression, but increased β-catenin expression compared to WT mice in CAC. In vitro studies of MMP-9 overexpression showed increased Notch-1 activation and reciprocal decrease in β-catenin. Notch and β-catenin/Wnt signaling are well documented as crucial molecular pathways deciding the gut epithelium differentiation and carcinogenesis. Despite being a mediator of pro-inflammatory response, MMP-9 plays a protective role and acts as a tumor suppressor in CAC by modulating Notch activation resulting in the activation of p21WAF1/Cip1 leading to suppression of β-catenin.
PMCID: PMC2821688  PMID: 20068187
6.  The Epidemiology of Medication Prescribing Errors in the Emergency Department 
Medication errors are a major concern in the Emergency Department (ED). We examined the epidemiology of medication prescribing errors among consecutive adult ED patients during two 10-day periods in the adult ED prior to implementing computerized provider order entry. 479 patients had no medication orders and 1,301 had 3,393 orders. Per 100 orders there were 3.7 potential adverse drug events, 337.1 medication prescribing errors, and 24.2 rule violations.
PMCID: PMC1839368  PMID: 17238587

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