Quality Indicators for Safe Medication Preparation and Administration: A Systematic Review

Background

One-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase, which is predominantly a nursing activity. To monitor, evaluate and improve the quality and safety of this process, evidence-based quality indicators can be used.

Objectives

The aim of study was to identify evidence-based quality indicators (structure, process and outcome) for safe in-hospital medication preparation and administration.

Methods

MEDLINE, EMBASE and CINAHL were searched for relevant studies published up to January 2015. Additionally, nine databases were searched to identify relevant grey literature. Two reviewers independently selected studies if (1) the method for quality indicator development combined a literature search with expert panel opinion, (2) the study contained quality indicators on medication safety, and (3) any of the quality indicators were applicable to hospital medication preparation and administration. A multidisciplinary team appraised the studies independently using the AIRE instrument, which contains four domains and 20 items. Quality indicators applicable to in-hospital medication preparation and administration were extracted using a structured form.

Results

The search identified 1683 studies, of which 64 were reviewed in detail and five met the inclusion criteria. Overall, according to the AIRE domains, all studies were clear on purpose; most of them applied stakeholder involvement and used evidence reasonably; usage of the indicator in practice was scarcely described. A total of 21 quality indicators were identified: 5 structure indicators (e.g. safety management and high alert medication), 11 process indicators (e.g. verification and protocols) and 5 outcome indicators (e.g. harm and death). These quality indicators partially cover the 7 rights.

Conclusion

Despite the relatively small number of included studies, the identified quality indicators can serve as an excellent starting point for further development of nursing specific quality indicators for medication safety. Especially on the right patient, right route, right time and right documentation there is room future development of quality indicators.     

Exposure of Trypanosoma brucei to an N-acetylglucosamine-Binding Lectin Induces VSG Switching and Glycosylation Defects Resulting in Reduced Infectivity

Trypanosoma brucei variant surface glycoproteins (VSG) are glycosylated by both paucimannose and oligomannose structures which are involved in the formation of a protective barrier against the immune system. Here, we report that the stinging nettle lectin (UDA), with predominant N-acetylglucosamine-binding specificity, interacts with glycosylated VSGs and kills parasites by provoking defects in endocytosis together with impaired cytokinesis. Prolonged exposure to UDA induced parasite resistance based on a diminished capacity to bind the lectin due to an enrichment of biantennary paucimannose and a reduction of triantennary oligomannose structures. Two molecular mechanisms involved in resistance were identified: VSG switching and modifications in N-glycan composition. Glycosylation defects were correlated with the down-regulation of the TbSTT3A and/or TbSTT3B genes (coding for oligosaccharyltransferases A and B, respectively) responsible for glycan specificity. Furthermore, UDA-resistant trypanosomes exhibited severely impaired infectivity indicating that the resistant phenotype entails a substantial fitness cost. The results obtained further support the modification of surface glycan composition resulting from down-regulation of the genes coding for oligosaccharyltransferases as a general resistance mechanism in response to prolonged exposure to carbohydrate-binding agents.     

Plasmodium vivax Diversity and Population Structure across Four Continents

Plasmodium vivax is the geographically most widespread human malaria parasite. To analyze patterns of microsatellite diversity and population structure across countries of different transmission intensity, genotyping data from 11 microsatellite markers was either generated or compiled from 841 isolates from four continents collected in 1999–2008. Diversity was highest in South-East Asia (mean allelic richness 10.0–12.8), intermediate in the South Pacific (8.1–9.9) Madagascar and Sudan (7.9–8.4), and lowest in South America and Central Asia (5.5–7.2). A reduced panel of only 3 markers was sufficient to identify approx. 90% of all haplotypes in South Pacific, African and SE-Asian populations, but only 60–80% in Latin American populations, suggesting that typing of 2–6 markers, depending on the level of endemicity, is sufficient for epidemiological studies. Clustering analysis showed distinct clusters in Peru and Brazil, but little sub-structuring was observed within Africa, SE-Asia or the South Pacific. Isolates from Uzbekistan were exceptional, as a near-clonal parasite population was observed that was clearly separated from all other populations (F _ST>0.2). Outside Central Asia F _ST values were highest (0.11–0.16) between South American and all other populations, and lowest (0.04–0.07) between populations from South-East Asia and the South Pacific. These comparisons between P. vivax populations from four continents indicated that not only transmission intensity, but also geographical isolation affect diversity and population structure. However, the high effective population size results in slow changes of these parameters. This persistency must be taken into account when assessing the impact of control programs on the genetic structure of parasite populations.     

Bed Net Durability Assessments: Exploring a Composite Measure of Net Damage

Background

The durability of Long Lasting Insecticidal Nets (LLINs) in field conditions is of great importance for malaria prevention and control efforts; however, the physical integrity of the net fabric is not well understood making it challenging to determine overall effectiveness of nets as they age. The 2011 World Health Organization Pesticide Evaluation Scheme (WHOPES) guidelines provide a simple, standardized method using a proportional hole index (PHI) for assessing net damage with the intent to provide national malaria control programs with guidelines to assess the useful life of LLINS and estimate the rate of replacement.

Methods

We evaluated the utility of the PHI measure using 409 LLINs collected over three years in Nampula Province, Mozambique following a mass distribution campaign in 2008. For each LLIN the diameter and distance from the bottom of the net were recorded for every hole. Holes were classified into four size categories and a PHI was calculated following WHOPES guidelines. We investigate how the size, shape, and location of holes influence the PHI. The areas of the WHOPES defined categories were compared to circular and elliptical areas based on approximate shape and actual measured axes of each hole and the PHI was compared to cumulative damaged surface area of the LLIN.

Results

The damaged area of small, medium, large, and extra-large holes was overestimated using the WHOPES categories compared to elliptical areas using the actual measured axes. Similar results were found when comparing to circular areas except for extra-large holes which were underestimated. (Wilcoxon signed rank test of differences p< 0.0001 for all sizes). Approximating holes as circular overestimated hole surface area by 1.5 to 2 times or more. There was a significant difference in the mean number of holes < 0.5 cm by brand and there were more holes of all sizes on the bottom of nets than the top. For a range of hypothetical PHI thresholds used to designate a “failed LLIN”, roughly 75 to 80% of failed LLINs were detected by considering large and extra-large holes alone, but sensitivity varied by brand.

Conclusions

Future studies may refine the PHI to better approximate overall damaged surface area. Furthermore, research is needed to identify whether or not appropriate PHI thresholds can be used to deem a net no longer protective. Once a cutoff is selected, simpler methods of determining the effective lifespan of LLINs can help guide replacement strategies for malaria control programs.     

The role of nurses in physician-assisted deaths in Belgium

Background

Belgium’s law on euthanasia allows only physicians to perform the act. We investigated the involvement of nurses in the decision-making and in the preparation and administration of life-ending drugs with a patient’s explicit request (euthanasia) or without an explicit request. We also examined factors associated with these deaths.

Methods

In 2007, we surveyed 1678 nurses who, in an earlier survey, had reported caring for one or more patients who received a potential life-ending decision within the year before the survey. Eligible nurses were surveyed about their most recent case.

Results

The response rate was 76%. Overall, 128 nurses reported having cared for a patient who received euthanasia and 120 for a patient who received life-ending drugs without his or her explicit request. Respectively, 64% (75/117) and 69% (81/118) of these nurses were involved in the physician’s decision-making process. More often this entailed an exchange of information on the patient’s condition or the patient’s or relatives’ wishes (45% [34/117] and 51% [41/118]) than sharing in the decision-making (24% [18/117] and 31% [25/118]). The life-ending drugs were administered by the nurse in 12% of the cases of euthanasia, as compared with 45% of the cases of assisted death without an explicit request. In both types of assisted death, the nurses acted on the physician’s orders but mostly in the physician’s absence. Factors significantly associated with a nurse administering the life-ending drugs included being a male nurse working in a hospital (odds ratio [OR] 40.07, 95% confidence interval [CI] 7.37–217.79) and the patient being over 80 years old (OR 5.57, 95% CI 1.98–15.70).

Interpretation

By administering the life-ending drugs in some of the cases of euthanasia, and in almost half of the cases without an explicit request from the patient, the nurses in our study operated beyond the legal margins of their profession.Medical end-of-life decisions with a possible or certain life-shortening effect occur often in end-of-life care.^1–5 The most controversial and ethically debated medical practice is that in which drugs are administered with the intention of ending the patient’s life, whether at the patient’s explicit request (euthanasia) or not. The debate focuses mainly on the role and responsibilities of the physician.⁶ However, physicians worldwide have reported that nurses are also involved in these medical practices, mostly in the decision-making and sometimes in the administration of the life-ending drugs.^1–3,7–9 Critical care,¹⁰ oncology¹¹ and palliative care nurses^12,13 have confirmed this by reporting their own involvement, particularly in cases of euthanasia.^14,15In Belgium, the law permits physicians to perform euthanasia under strict requirements of due care, one of which is that they must discuss the request with the nurses involved.¹⁶ There are no further explicit stipulations determining the role of nurses in euthanasia. Physician-assisted death is legally regulated in some other countries as well (e.g., the Netherlands, Luxemburg and the US states of Oregon and Washington State), without specifying the role of nurses. Reports from nurses in these jurisdictions are scarce, apart from some that are limited to particular settings, or lack details about their involvement.^13,14We conducted this study to investigate the involvement of nurses in Flanders, Belgium, in the decision-making and in the preparation and administration of life-ending drugs with, or without, a patient’s explicit request. We also examined patient- and nurse-related factors associated with the involvement of nurses in these deaths. In a related research article, Chambaere and colleagues describe the findings from a survey of physicians in Flanders about the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient.¹⁷     

A Combination of Fertility Signals and Aggression Regulates Reproduction in the Ant <Emphasis Type="Italic">Gnamptogenys striatula</Emphasis>

Approximately 150 ant species are facultatively or obligately queenless whereby mated workers assume the role of the queen. In many of these species a reproductive dominance hierarchy is established by way of aggressive interactions. Top-ranking workers, which are typically the most fecund, acquire a characteristic cuticular hydrocarbon profile. We studied the temporal dynamics of this chemical change and associated interplay with observed aggressive interactions in an experimentally orphaned colony of the facultatively queenless ant Gnamptogenys striatula. Our observations and chemical analyses demonstrate that chemical fertility signals played a major role in the establishment of a dominance hierarchy and aggression settled dominance relationships only when ants had identical hydrocarbon profiles. Moreover, individuals with a higher potential fertility, in this experiment reflected in a higher ovariole number, are shown to have a better chance of becoming a reproductive.     

Adeno-associated virus: a key to the human genome?

Adeno-associated viruses (AAV) are widely spread throughout the human population, yet no pathology has been associated with infection. This fact, together with the availability of simple molecular techniques to alter the packaged viral genome, has made AAV a serious contender in the search for an ideal gene therapy delivery vehicle. However, our understanding of the intriguing features of this virus is far from exhausted and it is likely that the mechanisms underlying the viral lifestyle will reveal possible novel strategies that can be employed in future clinical approaches. One such aspect is the unique approach AAV has evolved in order to establish latency. In the absence of a cellular milieu that will support productive viral replication, wild-type AAV can integrate its genome site specifically into a locus on human chromosome 19 (termed AAVS1), where it resides without apparent effects on the host cell until cellular conditions are changed by outside influences, such as adenovirus super-infection, which will lead to the rescue of the viral genome and productive replication. This article will introduce the biology of AAV, the unique viral strategy of targeted genome integration and address relevant questions within the context of attempts to establish therapeutic approaches that will utilize targeted gene addition to the human genome.     

Inagina: The Last House of Iron

Inagina: The Last House of Iron. 1998. 52 minutes, color. video by Eric Huyesecom and Bernard Augustoni in French and English. For more information contact Documentary Educational Resources, 101 Morse Street, Watertown, MA 02172, Tel. (617) 926-0491, Fax (617) 926-9519; http://anthropologie.unige.ch/inagina .     

Localization and topogenesis studies of cytoplasmic and vacuolar homologs of the Galanthus nivalis agglutinin

The Galanthus nivalis agglutinin (GNA) is synthesized as a preproprotein. To corroborate the role of the different targeting peptides in the topogenesis of GNA and related proteins, different constructs were made whereby both the complete original GNA gene and different truncated sequences were coupled to the enhanced green fluorescent protein (EGFP). In addition, a GNA ortholog from rice that lacks the signal peptide and C-terminal propeptide sequence was fused to EGFP. These fusion constructs were expressed in tobacco BY-2 cells and their localization analyzed by confocal fluorescence microscopy. We observed that the processed preproprotein of GNA was directed towards the vacuolar compartment, whereas both the truncated forms of GNA corresponding to the mature lectin polypeptide and the rice ortholog of GNA were located in the nucleus and the cytoplasm. It can be concluded, therefore, that removal of the C-terminal propeptide and the signal peptide is sufficient to change the subcellular targeting of a normally vacuolar protein to the nuclear/cytoplasmic compartment of the BY-2 cells. These findings support the proposed hypothesis that cytoplasmic/nuclear GNA-like proteins and their vacuolar homologs are evolutionarily related and that the classical GNA-related lectins might have evolved from cytoplasmic orthologs through an evolutionary event involving the insertion of a signal peptide and a C-terminal propeptide.