Australian Teaching Hospital Research Articles

Outpatient parenteral antibiotic therapy in a suburban tertiary referral centre in Australia over 10years.

Outpatient parenteral antibiotic therapy (OPAT) is a widely accepted and safe therapeutic option for carefully selected patients. This study reviewed the practice of an OPAT service in a large Australian tertiary teaching hospital in Western Sydney over a 10-year period. Data were retrieved from a prospectively maintained electronic database which included information on patient demographics, clinical diagnosis, microbiological identity, antimicrobial therapy, complications and readmissions. Data were analysed using descriptive statistics. There were 3435 referrals made to the service between January 2004 and June 2014, amounting to 25,289 antibiotic days. The most frequent referral was for Skin and Soft Tissue Infections (SSTIs), 61.28%, followed by Bone and Joint Infections (BJIs), 15.30%. The most common organism identified was methicillin-sensitive Staphylococcus aureus. Readmission was uncommon (5.15%), with the highest rate of readmission noted for Cardiovascular System Infections (16.67%) followed by BJIs (10.31%). Line infection, aseptic thrombophlebitis and drug hypersensitivity or reaction were the cause of 68.55% of all complications. There was a decline in line-related complications throughout the study period. OPAT service is in increasing demand in Australia, providing a significant relief in in-hospital days. Growth in referrals was seen not only with SSTIs and BJIs, but also a diverse range of other infective entities with limited literature in its treatment in an OPAT setting. This study highlights the need to improve data collection, develop risk stratification strategies and standardisation of OPAT services in Australia.

The benefits of sensory modulation on levels of distress for consumers in a mental health emergency setting.

This paper reports a pilot study exploring the benefits of offering sensory modulation within a mental health emergency setting for consumers experiencing distress during a psychiatric presentation. Seventy-four consumers with a mental health presentation reported on their sensory modulation use experiences during their stay in a South Australian tertiary teaching hospital emergency department. An evaluation form was used to document use of items, self-reported distress pre and post sensory modulation use, and other consumer experiences. Consumers used between one and six sensory items for a median duration of 45 min. There was a statistically significant reduction ( t(73) = 15.83, p < .001) in self-reported distress post sensory modulation use, and consumers also reported that use was helpful, distracting, calming and assisted in managing negative emotions and thoughts. The results demonstrate the potential value of sensory-based interventions in reducing behavioural and emotional dysregulation in an emergency setting whilst also promoting consumer self-management strategies.

Distribution of potential eye and tissue donors within an Australian teaching hospital.

Eye and Tissue donation has the capacity to transform lives, yet the vast majority of potential in-hospital donors are not recognised. Studies which describe the relative importance of specific units or wards in determining the size of the donor pool are limited. The aim of this study was to map the distribution of potential Eye and Tissue donors within the study hospital. A 12-month retrospective analysis of all patient deaths at the study hospital was undertaken. The ability to donate corneal, heart valve, bone and skin tissue was investigated. Patients were classified as potential donors if they met specific age criteria and had an absence of contraindications based on electronic database search. There were 985 deaths during the study period. Deaths occurred under the care of 26 separate clinical units, and within 28 unique wards and treatment spaces. Four hundred and forty nine (45.6%) patients were identified as potential eye or tissue donors. The majority of potential donors occurred in ICU, Emergency and palliative care units. Of the subset of 328 deaths≤70years, the frequency of potential tissue donors was 55% (n=181). ED and ICU had significantly higher frequencies of potential donor than other wards (86 and 77%, p<0.01). The current study has identified the ED, ICU and PCUs are being important sites for potential Eye and Tissue Donors within our hospital. These will provide an important focus for future interventions to improve the rate of eye and tissue donation.

Percutaneous endoscopic gastrostomy (PEG) versus radiologically inserted gastrostomy (RIG): A comparison of outcomes at an Australian teaching hospital

Gastrostomy tubes for enteral nutrition are most commonly inserted via percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG) techniques. The current study aimed to compare clinical outcomes and complication rates in patients who underwent PEG and RIG procedures at a tertiary teaching hospital in Australia. A retrospective review was conducted on patients who underwent PEG or RIG tube insertion between February 2013 and February 2015at Flinders Medical Centre, Australia. The primary outcome studied was the tube dislodgement rate. Secondary outcomes measured included hospital length of stay, 30 day and 1 year mortality and peri- and post-procedural complications such as hypoxia, bleeding, stoma site infection and haematoma. Baseline comparisons were conducted using the Mann-Whitney test and chi square test. 137 patients (PEG=85, RIG=52) underwent gastrostomy tube insertion. Indications for insertion were head and neck cancer (PEG=30, RIG=21), stroke (PEG=27, RIG=11), post-trauma (PEG=6, RIG=3) and neuromuscular pathologies (PEG=9, RIG=0). There was a significantly higher tube dislodgement rate in RIG (26.5%) compared to PEG (2.4%), p<0.001. The 1-year mortality was also significantly higher after RIG (46.2%) compared to the PEG group (16.7%), p<0.05. No differences were seen in other peri- and post-procedural complications. Although both PEG and RIG insertion techniques compare favourably in terms of the majority of peri and post procedural complications, the rates of tube dislodgement were significantly higher in the RIG group. The higher mortality rate at 1 year after RIG placement may be related to patient selection particularly as no differences were seen at 30 days.

Two-year audit of outcomes of pituitary surgery at an Australian teaching hospital.

There is evidence that cure rates and complications are influenced by the caseload in neurosurgical centres performing transsphenoidal pituitary surgery. Although Australian centres may perform relatively small numbers of these procedures, there have been few published audits of their performance. To conduct an audit of surgery for pituitary tumours between 2012 and 2014 in the only public hospital neurosurgical unit in the state of Western Australia. A retrospective chart review was conducted, with standardised extraction of data relating to indications for surgery, tumour type, procedure and postoperative endocrinological and other outcomes. Of 53 patients identified, most (91%) underwent transsphenoidal surgery. Most tumours were non-functioning (71.7%), and most of these extended outside the sella turcica (86.8 vs 73.3% of functioning tumours). There was complete removal in 43.4% of patients and evidence of biochemical cure in 33.3% of functioning tumours, but readmission for further surgery was infrequent (5.7%). Persistent cerebrospinal fluid leakage, photophobia and deep venous thrombosis occurred in <4% of patients. There were no deaths. There was a relatively high rate of permanent diabetes insipidus (DI) (13.2 vs <5% in published series), while the frequency of new postoperative anterior pituitary dysfunction (9.4%) was within the range reported in the literature (3-14%). The outcomes of pituitary surgery in this audit were largely comparable to those reported from other neurosurgical units in Australia and other countries. The increased risk of permanent postoperative DI may reflect the high proportion of non-functioning tumours with extension outside the sella turcica.

What Factors Determine the Use of an Electronic Test Result Acknowledgement System? - A Qualitative Study Across Two EDs.

Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part in determining the nature of change that an electronic result acknowledgement system is likely to produce.

Sustained improvement in vancomycin dosing and monitoring post-implementation of guidelines: Results of a three-year follow-up after a multifaceted intervention in an Australian teaching hospital.

Despite vancomycin being in use for over half-a-century, it is still not dosed or monitored appropriately in many centers around the world. The objective of this study was to determine the effectiveness of a multifaceted intervention to implement a vancomycin dosing and monitoring guideline across multiple medical and surgical units over time. This was an observational before-and-after interventional cohort study. The pre-intervention period was August to December 2010-2011 and the post-intervention period was September to November 2012-2014. The implementation strategy comprised: face-to-face education, online continuing medical education, dissemination of pocket guideline and email reminder. Outcome measures included: appropriate prescribing of loading and maintenance doses, therapeutic drug monitoring, time to attain target range and nephrotoxicity. Post-implementation prescribing of loading doses increased (10.4%-43.6%, P=<0.001), guideline adherent first maintenance dose (44%-68.4% P=0.04), correct dose adjustment from (53.1%-72.2%, P=0.009). Beneficial effects pre and post-implementation were observed for adherent timing of initial concentration (43.2%-51.9%, P=0.01), concentrations in target range (32.6%-44.1%, P=0.001), time to target range (median 6-4 days, P=<0.001), potentially nephrotoxic concentrations (30.7%-20.9%, P=<0.001) and nephrotoxicity (10.4%-6.8%, P=<0.001). A multifaceted intervention to implement a vancomycin dosing and monitoring guideline significantly improved prescribing, monitoring, pharmacokinetic and safety outcomes for patients treated with vancomycin over an extended period. However, increased guideline adoption by clinicians is required to maximize and prolong the utility of this important agent.

Counting the cost of over-the-counter codeine containing analgesic misuse: A retrospective review of hospital admissions over a 5 year period.

Combination analgesics containing codeine (CACC) are currently available over-the-counter (OTC) in many countries following a pharmacist's advice. Published case reports detail life-threatening morbidities associated with OTC-CACC misuse, although the cost of treating such patients has not been quantified. This study aims to: (i) identify and detail patients admitted to an Australian tertiary teaching hospital over a 5 year period with sequelae of OTC-CACC misuse; and (ii) estimate the costs of identified hospital admissions. Using International Classification of Diseases (10th revision) diagnostic codes, a structured search was performed to identify admissions to a tertiary teaching hospital, relating to CACC misuse, over the defined period. A retrospective case note review provided data detailing patient characteristics, presenting morbidities and resultant interventions, and an approximate cost was calculated for identified admissions. Ninety-nine OTC-CACC-related admissions (for 30 individual patients) were identified. Most related to gastrointestinal morbidities secondary to ibuprofen/codeine misuse. Mean length of stay per admission was 5.9 days, with 10.1% of admissions requiring intensive care. Patients consumed a daily mean of 28 OTC-CACC tablets for a mean of 606 days prior to admission. These 99 admissions were estimated to cost the health system AU$1 008 082 with a mean cost per admission of AU$10 183. The outcomes of OTC-CACC misuse are serious and come at a significant cost to patient health and the Australian health-care system. Identification and management of this cohort appears sub-optimal with delays in diagnosis and high readmission rates.

Knowledge of proprietary and generic drug names among hospital prescribers: time to mandate generic prescribing?

Although medical students are taught clinical pharmacology using generic drug names, prescribing in hospitals often uses brand names. As a result, junior doctors may be prescribing drugs without knowing their nature or mode of action. We carried out a knowledge survey of 81 medical students and doctors at a 650-bed Australian teaching hospital to assess their knowledge of common drugs when given the brand name. We identified 20 commonly prescribed drugs and their brand names based on current hospital inpatients. No participant was able to provide the generic name, class or mode of action for all 20 drugs, with an average of 8.3 of 20 and 6.3 of the 10 most common drug names correctly identified. These data support calls to mandate prescribing using generic rather than brand names of drugs in hospitals.

Patient and clinician perspectives of an integrated electronic medication prescribing and dispensing system: A qualitative study at a multisite Australian hospital network

While clinician attitudes towards electronic prescribing (e-prescribing) systems have been widely studied, little is known about the perspectives of patients, despite being the primary beneficiaries of these systems. The objective of this study is to explore and compare patient and clinician attitudes towards an integrated e-prescribing and dispensing system, in order to guide improvements in system implementation, service delivery and enhancements to system functionality. A cross-sectional survey was developed and administered to patients and multidisciplinary clinicians at a multisite Australian metropolitan teaching hospital network in all areas where e-prescribing was fully implemented. Participants' views on perceived impact and valued features of the e-prescribing system were elucidated. Overall, 783 participants (400 patients and 383 clinicians) completed the survey. Although 98% of clinicians were aware of the transition to e-prescriptions, only 36% of patients were aware prior to the study. Over 80% of patients and clinicians perceived improvements in prescribing and dispensing safety and clinician workflow; 90% of patients were comfortable with information privacy associated with e-prescriptions; and 86% of patients preferred e-prescriptions to handwritten prescriptions. Although over 80% of patients valued features that improved access to information and medication safety, clinicians were more discerning about valued system features. The majority of patients and clinicians reported a positive impact of e-prescribing on safety and efficiency. Both groups valued safe and effective use of medicines, although differences existed in the importance placed on key system features. A greater focus on patient engagement and communication is needed to optimise the delivery of patient-centred care.

Quantitative Retinal Vascular Changes in Obstructive Sleep Apnea

To examine the relationship between both static and dynamic retinal vascular caliber and the severity of obstructive sleep apnea (OSA). Prospective cross-sectional study. Adult patients undergoing diagnostic polysomnography studies at a private Australian university teaching hospital were recruited. OSA severity was defined by the apnea-hypopnea index (AHI): severe >30, moderate >15-30, mild 5-15, and controls <5. Of 115 patients recruited (73 male; mean age 58 ± 13 years), there were 41 severe, 35 moderate, and 25 mild OSA patients and 14 controls. Static retinal vascular caliber was measured as the average diameter of retinal arterioles (CRAE) and venules (CRVE), and summarized as the arteriovenous ratio (AVR). Dynamic retinal vascular caliber was evaluated as the average pulsation amplitude of retinal arterioles (SRAP) and venules (SRVP). Comparisons across groups were performed using multivariate linear regression analysis. All results were adjusted for age, body mass index, and mean arterial pressure. Increasing AHI was significantly associated with decreasing AVR (P= .008) and CRAE (P= .016). A significant relationship was demonstrated between increasing AHI and attenuated retinal vascular pulsation amplitude (arterioles P= .028; venules P < .0001). Increasing OSA severity is independently associated with retinal arteriolar narrowing and attenuated vascular pulsation amplitude. The retinal vasculature is easily imaged, and may be a surrogate biomarker of cerebral and systemic vascular risk in patients with OSA requiring further comprehensive investigation.

Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) protocol: testing the effectiveness of a facilitation intervention in a pragmatic, cluster-randomised trial with an embedded process evaluation and cost analysis

BackgroundVital signs are the primary indicator of physiological status and for determining the need for urgent clinical treatment. Yet, if physiological signs of deterioration are missed, misinterpreted or mismanaged, then critical illness, unplanned intensive care admissions, cardiac arrest and death may ensue. Although evidence demonstrates the benefit of early recognition and management of deteriorating patients, failure to escalate care and manage deteriorating patients remains a relatively frequent occurrence in hospitals.Methods/designA pragmatic cluster-randomised controlled trial design will be used to measure clinical effectiveness and cost of a facilitation intervention to improve nurses’ vital sign measurement, interpretation, treatment and escalation of care for patients with abnormal vital signs. A cost consequence analysis will evaluate the intervention cost and effectiveness, and a process evaluation will determine how the implementation of the intervention contributes to outcomes. We will compare clinical outcomes and costs from standard implementation of clinical practice guidelines (CPGs) to facilitated implementation of CPGs. The primary outcome will be adherence to the CPGs by nurses, as measured by escalation of care as per organisational policy. The study will be conducted in four Australian major metropolitan teaching hospitals. In each hospital, eight to ten wards will be randomly allocated to intervention and control groups. Control wards will receive standard implementation of CPGs, while intervention wards will receive standard CPG implementation plus facilitation, using facilitation methods and processes tailored to the ward context. The intervention will be administered to all nursing staff at the ward level for 6 months. At each hospital, two types of facilitators will be provided: a hospital-level facilitator as the lead; and two ward-level facilitators for each ward.DiscussionThis study uses an innovative, networked approach to facilitation to enable uptake of CPGs. Findings will inform the intervention utility and knowledge translation measurement approaches. If successful, the study methodology and intervention has potential for translation to other health care standards.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12616000544471p

Junior doctors' preparedness to prescribe, monitor, and treat patients with the antibiotic vancomycin in an Australian teaching hospital.

PurposeWe aimed to assess the preparedness of junior doctors to use vancomycin, and to determine whether attending an educational session and being provided pocket guidelines were associated with self-reported confidence and objective knowledge.MethodsThis was a 2-component cross-sectional study. A 60-minute educational session was implemented and pocket guidelines were provided. Preparedness was evaluated by a self-reported confidence survey in the early and late stages of each training year, and by continuing medical education (CME) knowledge scores.ResultsSelf-confidence was higher among those later in the training year (n=75) than in those earlier (n=120) in the year for all questions. In the late group, vancomycin education was associated with higher self-confidence regarding the frequency of therapeutic drug monitoring (P=0.02) and dose amendment (P=0.05); however, the confidence for initial monitoring was lower (P<0.05). Those with pocket guidelines were more confident treating patients with vancomycin (P<0.001), choosing initial (P=0.01) and maintenance doses (P<0.001), and knowing the monitoring frequency (P=0.03). The 85 respondents who completed the knowledge assessment scored a mean±standard deviation of 8.55±1.55 on 10 questions, and the interventions had no significant effect.ConclusionAttending an educational session and possessing pocket guidelines were associated with preparedness, as measured by higher self-reported confidence using vancomycin. High knowledge scores were attained following CME; however attending an educational session or possessing pocket guidelines did not significantly increase the knowledge scores. Our findings support providing educational sessions and pocket guidelines to increase self-confidence in prescribing vancomycin, yet also highlight the importance of evaluating content, format, and delivery when seeking to improve preparedness to use vancomycin through education.

Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: An ethnographic study.

Children are particularly vulnerable to experiencing medication incidents in hospitals. Making sound medication decisions is therefore of paramount importance. Prior research has principally described pharmacists' role in reducing medication errors. There is a dearth of information about pharmacists' interactions with pediatric hospital staff across disciplines in resolving medication issues. The aim of this study was to examine interdisciplinary medication decision making by pharmacists in pediatric hospital settings. An ethnographic design was undertaken comprising observations, semi-structured interviews and focus groups. Audio-recorded data were analyzed thematically. The study was conducted in three wards of an Australian pediatric tertiary teaching hospital, comprising general surgical, gastroenterology, endocrinology, neurology, adolescent and rehabilitation settings. Pharmacists, registered nurses and doctors were recruited from diverse clinical wards following information sessions. Pharmacists were central to complex pediatric medication decision making, intervening about dosage, administration, drug interactions and authorities. Pharmacists proactively contacted doctors and nurses about prescribing issues; conversely, staff routinely approached pharmacists for medication advice. Pharmacists were perceived as medication experts, their extensive knowledge valued in resolving complex issues: when off-label medications were prescribed, when protocols were absent or ambiguous, where tension existed between protocol adherence and patient safety, and where patients on multiple medications were at risk of medication error. Pharmacists had strong relationships with doctors and nurses, which had a bearing on pharmacists' input in interventions. Furthermore, pharmacists identified prescribing errors through strategies, such as case note review and medication reconciliation, although the lack of emergency department pharmacists and limited after-hours staffing posed challenges to both strategies. Pharmacists made a substantial and highly valued contribution to pediatric inter-professional medication decision making. These results provide new knowledge that informs theoretical developments of pharmacists' role in decision making.

Appropriateness of surgical antibiotic prophylaxis for breast surgery procedures.

Background Guidelines for the appropriate use of antibiotic prophylaxis are provided in the Therapeutic Guidelines: Antibiotics (eTG) in Australia. Inappropriate use of antibiotics is problematic. Objective To examine adherence with therapeutic guidelines (eTG) in breast surgery and trends in non-adherence dependent on the type of breast surgery performed. Setting Major Western Australian teaching hospital. Method A retrospective cross-sectional study reviewed a random sample of 150 from 1049 eligible medical records of patients who underwent a breast surgical procedure in 2013 or 2014. Main outcome measure Adherence to the eTG. Results Antibiotic prophylaxis was prescribed for 139 (92.7%) operations. Adherence to the eTG occurred in 20 (13.3%) operations, whilst 11 (7.3%) did not adhere to any element of the eTG. Appropriate timing was the main factor not adhered to. Postoperative antibiotics were prescribed following 35 (23.3%) operations, with 32 (91.4%) administered beyond 24h. Length of stay was significantly different (p=0.0036) between surgical groups. There was a tendency for risk of an infection to be decreased with adherence (odds ratio: 0.23; 95% CI: 0.05, 1.07; p=0.06). Conclusion Adherence to the eTG was low (13.3%), despite a decreased risk of SSI when guidelines were followed.

Social cohesion: The missing factor required for a successful hand hygiene program.

There are limited explorations into hospital staff reactions to automated hand hygiene surveillance or hand hygiene interventions. An automated surveillance system with daily feedback and a behavioral intervention component was trialed in 2 wards in an Australian tertiary teaching hospital. After 9 months, 12 clinicians from each ward were interviewed prior to the completion of the trial to explore satisfaction with the system and behavioral component of nudging each other with a reminder to comply. Only on completion of the trial were transcripts analyzed for themes. Staff from the ward with improved compliance described a socially cohesive team with a well-liked nurse unit manager who accessed daily compliance rates and worked with staff to set goals. This contrasted with the ward without improvement in compliance, whose staff described their great reluctance and discomfort to nudge each other to comply and distrust of the authenticity of the rates established from the automated system. Interventions for improving compliance are more likely to be successful in a ward with a social cohesive team. Patient safety interventions, in the first instance, may benefit from purposeful selection of wards with cohesive teams and skilled leaders who can transform clinicians into early adopters of the program.

Medication Safety: Experiential Learning for Pharmacy Students and Staff in a Hospital Setting.

Medication Safety has been an established pharmacy specialty in Australian hospitals since the early 2000s and is now one of the ten Australian hospital accreditation standards. Although advances have occurred, medication-related patient harm has not been eradicated. Victorian undergraduate pharmacy programs include some aspects of medication safety, however clinical pharmacy experience, along with interpersonal and project management skills, are required to prepare pharmacists to be confident medication safety practitioners. This article outlines the range of medication safety-related training offered at an Australian tertiary teaching hospital, including; on-site tutorial for undergraduate students, experiential placement for pharmacy interns, orientation for pharmacy staff and resources for credentialing pharmacists for extended roles. Improvements continue to be made, such as electronic medication management systems, which increase the safe use of medications and facilitate patient care. Implementation and evaluation of these systems require medication safety expertise. Patients’ engaging in their own care is an acknowledged safety improvement strategy and is enhanced by pharmacist facilitation. Building educator skills and integrating experiential teaching with university curricula should ensure pharmacists have both the knowledge and experience early in their careers, in order to have a leading role in future medication management.

Trunnion Corrosion and Early Failure in Monolithic Metal-on-Polyethylene TMZF Femoral Components: A Case Series

We describe four patients who were treated with primary total hip arthroplasty (THA) at two tertiary academic Australian teaching hospitals that experienced premature failure of head-neck trunnions through dissociation of the head-neck taper junction. This retrospective case series have similar clinical presentations and macroscopic pathology with severe head-neck taper junction loss of material, corrosion and early catastrophic failure. It is proposed that the accelerated wear is related to use of varus offset neck in a proprietary beta titanium alloy (Ti-12Mo-6Zr-2Fe or TMZFÒ Stryker Osteonics, Mahwah NJ, USA) TMZF femoral stem, longer head-neck combination in a relatively active, older, male patient population. In this limited case series presentation was on average 80 months (range 53-92) following index procedure. In three of the four patients, a prodromal period of groin or buttock pain was reported for between 1 week and 2 months prior to acute presentation. Significant metallosis and local tissue damage including gluteal muscle insufficiency was evident. Each stem revised was well fixed. An extended trochanteric osteotomy was required in two of the four cases for stem extraction. We recommend caution and further evaluation on the relationship between TMZF metal alloy and its longevity in higher demand patients with high neck offset, varus stem geometry and large CoCr bearing heads.

The extent of medication errors and adverse drug reactions throughout the patient journey in acute care in Australia.

To provide an estimate of the numbers of medication errors and adverse drug reactions that occur along a person's journey through their hospital stay in Australia. A search of databases and online resources was undertaken to identify published literature on medication safety in the acute care setting in Australia from 2008 to 2013. Data on the rates of adverse drug reactions and medication errors associated with hospitalization was extracted from the published studies. This evidence was synthesized with evidence from previous reviews of medication safety in the acute care setting in Australia conducted in 2002 and 2008. Findings from the Australian literature across the two previous reviews of medication safety and the present review indicate the proportion of all hospital admissions that are medication-related is between 2 and 3%. Studies assessing medication errors on admission to hospital suggest there may be an overall rate of two errors for every three patients at the time of admission to hospital. Large studies examining the rates of prescribing errors in major Australian teaching hospitals give insight into the rates of prescription error and suggest that prescription error rates of up to one error per patient occur in the hospital system. The best available evidence from more recent research suggests that errors (excluding errors of timing) occur in around 9% of medication administrations in hospital. At hospital discharge, errors in medication documentation in discharge summaries may occur at a rate of up to two errors per patient. Medication safety in the various stages of the patient journey through acute care in Australia continues to be a significant problem. However, the extent of medication-related problems in acute care needs to be interpreted within the context of increasingly complex health care. There are an estimated 230 000 medication-related hospital admissions occurring per year. This suggests an annual cost of medication-related admissions of AU$1.2 billion.

What Would Women Choose When Given a Choice in Breast Reconstruction?

Background:Reconstruction after mastectomy is an important milestone for many women treated for breast cancer. However, because many surgeons only offer their preferred method of reconstruction, it is not clear which approach women would choose if offered a genuine choice.Methods:Between 1998 and 2010, the breast reconstruction service at a major Australian teaching hospital was staffed by a single plastic surgeon trained in both prosthetic and autologous breast reconstruction techniques. The choices of all 837 women who underwent reconstruction were compared across time for publicly and privately funded patients using binary logistic regression.Results:Overall, women chose prosthetic over autologous reconstruction at a ratio of 4.7:1. This ratio increasingly favored prosthetic reconstruction over time, though less strongly for private patients who did not face a 3-year waiting list for autologous reconstruction.Conclusions:Financial constraints affected these women’s reconstruction choices. Nevertheless, and in contrast to the situation in the United States, these women clearly favored prosthetic over autologous reconstruction.