Inappropriate Omission Research Articles

Application of generative language models to orthopaedic practice

ObjectiveTo explore whether large language models (LLMs) Generated Pre-trained Transformer (GPT)-3 and ChatGPT can write clinical letters and predict management plans for common orthopaedic scenarios.DesignFifteen scenarios were generated and ChatGPT...

Procedure-Level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention

The objective of this study was to quantify prophylaxis misutilization to identify high-priority procedures for improved stewardship and SSI prevention. This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database. 9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colorectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%). A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. Retrospective Cohort. III.

743: EVALUATION OF REGULAR INSULIN 10 UNITS VERSUS 5 UNITS FOR THE TREATMENT OF HYPERKALEMIA

Introduction: Hyperkalemia is a common problem faced in the intensive care unit (ICU) and emergency department. Traditionally, regular insulin 10 units IV has been used in combination with dextrose to shift potassium intracellularly to prevent cardiac abnormalities. Available literature supports the use of different insulin regimens based on a patient’s weight, renal function, and diabetes status. Currently, our institution has a hyperkalemia order set that includes varying regular insulin doses, dextrose, and scheduled lab draws for potassium and glucose. The purpose of this study was to compare the efficacy and safety of regular insulin 5 units and 10 units for the treatment of hyperkalemia. Methods: This was a single-center, retrospective, cohort study of ICU and emergency department patients who received regular insulin 10 units or 5 units IV push for hyperkalemia treatment. The primary outcome was the decrease in potassium in mmol/L after insulin administration. Secondary outcomes included the incidence of hypoglycemia, rate of order set utilization, and incidence of inappropriate omission of dextrose. Results: Forty-three patients were included in the study, with 21 receiving 10 units and 22 receiving 5 units. Patients who received 5 units of insulin had worse renal function (serum creatinine 5.6 mg/dL vs 3.5 mg/dL) and lower glucose values prior to insulin (glucose 133.7 mg/dL vs 184.8 mg/dL) compared to those who received 10 units. Both groups had similar potassium levels upon presentation, 6.19 mmol/L in insulin 5 unit group compared to 6.20 mmol/L in the 10 unit group. Average decrease in potassium levels was 1.1 mmol/L with 5 units and 1.0 mmol/L with 10 units. Two patients in each group experienced hypoglycemia after insulin administration. Both groups had similar rates of dextrose orders omitted and need for additional units of insulin within 24 hours. Conclusions: The potassium lowering effects were not different between groups based on the units of insulin received. Regular insulin 10 units did not result in a higher incidence of hypoglycemia or a need for less additional insulin orders. This study demonstrated that the use of regular insulin 5 units had similar outcomes compared to the use of 10 units for the treatment of hyperkalemia.

Impact of a policy to improve the management of oral medications when patients are fasting before a procedure: an interrupted time series analysis.

BackgroundManaging medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure.MethodsThe policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications.The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions.The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression.ResultsPre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions.In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions.ConclusionsDistinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.

Reducing omission of eye drops during hospital admission.

Chronic ophthalmic conditions, such as glaucoma and dry eye disease, are frequently encountered debilitating eye conditions that can lead to substantial reduction in vision and quality of life. However, there is ongoing evidence to suggest that topical ophthalmic therapy is inappropriately omitted on admission to hospital. The primary aim of this audit was to investigate the trust adherence to the National Institute for Health and Care Excellence guideline on the prescribing standard of eye drops during hospital admission. The secondary aim was to raise awareness and ensure successful compliance with national standards to reduce unintentional omission of eye drops on admission and subsequent complications. Electronic medical records of all medical and surgical adult inpatients were studied prospectively on two different occasions. The quality of documentation of eye drops in clerking notes, the length of time taken between the admission and prescription of eye drops, and the accuracy of the prescription were examined. Following the initial audit, interventions focusing on clinician education were implemented. This includes highlighting the importance of eye drops in all departmental mandatory introductory sessions and putting up posters on all the wards as prompts. The same data collection method was used in the reaudit. In the initial audit, 64 (mean age 81.8±8.9 years) patients with regular prescriptions for eye drops were identified; 38 (59.4%) patients had eye drops for dry eye disease only, 20 (31.3%) patients had eye drops for glaucoma only, and six (9.4%) patients had eye drops for both. In the reaudit, 57 (mean age 76.7±15.3 years) patients were identified; 42 (73.7%) patients had eye drops for dry eye disease only, 10 (17.5%) patients had eye drops for glaucoma only, and five (8.8%) patients had eye drops for both. Following the intervention, there was a significant improvement in documentation of ocular diagnosis and eye drops on clerking notes from 41% to 65% (P=0.008), and eye drop reconciliation within 24 hours of admission improved from 45% to 75% (P=0.0008). All patients (100%) received the correct eye drop prescription before and after the intervention. Education is effective in promoting adherence to national guidelines and reducing the incidence of inappropriate omission of eye drops on admission to hospital.

Adherence to Clinical Quidelines on Preoperative Assessment and Correction of Cardiovascular Risk in Non-cardiac Surgery

Surgical care is associated with a high risk of complications. In 2014 the updated joint ESC/ESA guidelines on preoperative assessment and perioperative management of patients were published to improve patient safety in non-cardiac surgery. The increase in the adherence to clinical guidelines promotes the improving of the healthcare quality and safety improvement.Aim. To study physicians' level of adherence to ESC/ESA clinical guidelines for preoperative assessment and perioperative management of patients.Material and methods. A retrospective observational study included 102 patients admitted to Moscow general hospital from 01.03.2019 to 30.06.2018 for elective surgery. All of them underwent preoperative examination in outpatient department of the hospital and had at least one concomitant disease requiring drug therapy. The medical records data on the preoperative examination and perioperative treatment with beta-blockers, HMG CoA reductase inhibitors and angiotensin-converting-enzyme (ACE) inhibitors/ angiotensin receptor blockers (ARBs) were analyzed for compliance with the ESC/ESA guidelines.Results. A standardized cardiac risks assessment was not documented in the results of preoperative examination. Electrocardiography (ECG), echocardiography and non-invasive stress tests were performed according to clinical guidelines in 100%, 77.8% and 25% of cases, respectively. Unnecessary ECG and echocardiography were prescribed in 50.5% and 72% of cases, respectively. Appropriate correction of ACE inhibitors/ARBs therapy was performed in 66.7% patients with congestive heart failure and only in 2.7% with arterial hypertension. In 19 patients with ischemic cardiac disease, 13 (84.2%) patients received HMG CoA reductase inhibitors and 16 (68.4%) ones received beta-blockers during hospitalization. Inappropriate omission of statins, beta-blockers and ACE inhibitors (ARBs) during hospitalization was registered in 22.2%, 11% and 4.9% patients, respectively.Conclusion. The number of inappropriate ECGs and echocardiographies, as well as incorrect treatment with beta-blockers, HMG CoA reductase inhibitors and ACE inhibitors (ARBs) in perioperative period evidence that the adherence of physicians to the clinical guidelines on preoperative assessment and perioperative management of patients remains low.It is reasonably to develop risk-based interdisciplinary protocols for preoperative examination, algorithms for interdisciplinary communication and interaction between specialists and the healthcare levels, as well as physicians' education for better adherence to clinical guidelines.

Comparison of Local Recurrence Risk Estimates After Breast-Conserving Surgery for DCIS: DCIS Nomogram Versus Refined Oncotype DX Breast DCIS Score.

A ductal carcinoma in situ (DCIS) Nomogram integrating 10 clinicopathologic/treatment factors and a Refined DCIS Score (RDS) that incorporates a genomic assay and three clinicopathologic factors (Oncotype DX DCIS Score) are available to estimate DCIS 10-year local recurrence risk (LRR). This study compared these estimates. Patients 50years of age or older with DCIS size 2.5cm or smaller and a genomic assay available were identified. An RDS within 1-2% of the range of Nomogram LRR estimates obtained by assuming use and non-use of endocrine therapy (Nomogram ± ET) was defined as concordant. Assuming a 10-year risk threshold of 10% for recommending radiation, Nomogram ± ET and RDS estimates were compared, and threshold concordance was determined. For 54 (92%) of 59 patients, the RDS and Nomogram ± ET LRR estimates were concordant. For the remaining 5 (8%) of the 59 patients, the RDS LRR estimates were lower than the Nomogram+ET estimates, with an absolute difference of 3-8%, and thus were discordant. For these five patients, the RDS estimates of 10-year LRR were lower than 10% (range 5-8%) and the Nomogram + ET estimates were 10% or higher (range 11-14%). These five patients with both discordant and threshold-discordant estimates all had close margins (≤ 2mm). Among 92% of women 50years of age or older with DCIS size 2.5cm or smaller, free-of-charge online Nomogram 10-year LRR estimates were concordant with those obtained using the commercially available RDS (> $4600). Among the 8% with discordant risk estimates, the RDS appeared to underestimate the LRR and may lead to inappropriate omission of radiotherapy. Unless other data show a clinically significant advantage of the RDS (Oncotype DX DCIS Score), the study data suggest that for women 50years of age or older with DCIS size 2.5cm or smaller, its use is not warranted.

A review and study of aspirin utilization for the primary prevention of cardiovascular events in a psychiatric population.

In April 2016, the US Preventive Service Task Force (USPSTF) updated the aspirin guidelines for the primary prevention of cardiovascular disease (CVD) and colorectal cancer. This review assesses the importance of appropriate use of aspirin for the primary prevention of CVD and, specifically, how individuals with psychiatric disorders may benefit from such use. This study examined how current prescribing practices of aspirin in a state psychiatric hospital align with these new guidelines and how inappropriate prescribing may jeopardize patient safety. A retrospective chart review of 93 patients was performed to evaluate whether aspirin therapy would be recommended for primary prevention of CVD based on the new USPSTF guidelines. A secondary analysis of these data was performed using the 2009 USPSTF recommendations to strengthen the assumption that practitioners were no longer using the old guidelines. Drug interactions between aspirin and concurrently prescribed pharmacotherapy were classified based on of severity, and the past events of bleeding were quantified. Based on the 2016 guidelines, 25 of the 93 patients included in this study were identified as potential candidates who would benefit from aspirin use for the primary prevention of CVD; of whom 22 (88%) were not prescribed aspirin. The remaining 68 patients did not meet the criteria for aspirin use for primary prevention, although 11 (16.2%) of these patients were taking low-dose aspirin. Based on the 2009 guidelines, 49 of the 93 patients included in our study would have been identified as potential candidates who would benefit from the use of aspirin for the primary prevention of CVD; 41 (83.7%) of whom were not prescribed aspirin. The remaining 44 patients did not meet the previous criteria for aspirin use for primary prevention, although six (13.6%) of these individuals were taking low-dose aspirin daily. The results above indicate a difference between prescribing practices of aspirin use for the primary prevention of CVD. We identified a similar rate of underuse; however, there was a slight increase in the appropriate prescribing according to the 2016 guidelines compared with the 2009 guidelines (88 vs. 83.7%, respectively). Also, there was a higher incidence of unnecessary prescribing (overutilization) of aspirin for the primary prevention of CVD in 2016 compared with 2009 despite the more restrictive criteria (and smaller candidate pool) published in these newer guidelines. There were 47 drug interactions identified when patients' aspirin and concurrent medication regimens were reviewed for our entire sample population. These interactions could potentially lead to an adverse drug reaction in the future. Our safety analysis revealed that none of the patients who were prescribed aspirin had any bleeding events while on therapy within the period of this study. Inappropriate omission of aspirin (underutilization) was more prevalent in our psychiatric institution than overutilization; however, the overall percentage of both underuse and overuse were greater when patients were evaluated according to the 2016 guidelines and then compared with the 2009 statistics. Overutilization did not pose a serious risk for those on aspirin therapy in this sample, as there were no major episodes of bleeding. However, future harm from aspirin still exists based on the significant number of major and moderate potential drug interactions with aspirin and the increased risk of decreased adherence to critical psychiatric medications due to increased pill burden and regimen complexity. Our findings demonstrate that there is an opportunity to educate prescribers on the updated 2016 USPSTF guidelines to improve preventive care and patient safety, which include harm reduction by initiating aspirin in those who are at a risk of cardiovascular events, continuing aspirin in those who are currently receiving aspirin appropriately, and discontinuing aspirin in those who are not considered to be at a high risk of CVD and who may also be at a risk of experiencing an increased risk of bleeding.

Health system costs of potentially inappropriate prescribing in Ontario, Canada: a protocol for a population-based cohort study

IntroductionAdverse drug events (ADEs) are common in older persons and contribute significantly to emergency department visits, hospitalisations and mortality. ADEs are often due to potentially inappropriate prescriptions (PIP) or potentially...

Adherence to Surgical Antibiotic Prophylaxis Guidelines in New South Wales, Australia: Identifying Deficiencies and Regression Analysis of Contributing Factors.

Surgical antibiotic prophylaxis is frequently reported in the literature to be suboptimal, a finding having both clinical and public health implications. This study aimed to calculate rates and patterns of adherence to guidelines at two sites and identify extrinsic contributing factors. A retrospective analysis was conducted over two 12-mo periods during 2013-2014 at the metropolitan Blacktown Hospital and regional Lismore Base Hospital, New South Wales, Australia. A group of 400 patients undergoing abdominal general surgery was selected via simple random sampling (n = 200 per site). Medical records were reviewed, and prophylactic antibiotic regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v. 14) with respect to drug choice, dosage, timing of administration, and duration of administration. The overall rate of adherence to the guidelines was 16.5% at Blacktown Hospital and 19.5% at Lismore Base Hospital. At each site, prophylaxis was administered to more than 95% of patients and was inappropriately withheld in 4%. Drug choice was the most frequent error type, specifically involving inappropriate omission of metronidazole and use of newer-generation cephalosporins. Errors in the timing of administration also were frequent, with prophylaxis typically occurring excessively early. Logistic regression identified emergency surgery as independently associated with prophylactic errors in both the Blacktown Hospital (p < 0.001) and the Lismore Base Hospital cohorts (p = 0.020). Adherence to antibiotic prophylactic guidelines was poor at both the metropolitan and regional sites. Choice of antibiotic and timing of administration were identified as major error types. Consideration should be given to multidisciplinary involvement of anesthetists, implementation of focused interventions with an emphasis on emergency settings, and further research correlating antibiotic use with clinical significance.

SAT0466 The “table-1 P value” issue; baseline group comparison is inappropriately omitted in non-randomized studies

BackgroundGuidelines on reporting randomized controlled trials advise against performing baseline comparison in randomized groups (1). Such comparison is considered futile as any difference will be by chance by definition (2)....

Recurrent Obstetric Management Mistakes Identified by Simulation

Simulation-based drills offer a partial solution to the problem of providing hands-on clinical experience in emergency medicine. They permit repeated practice and aid the acquisition of skills in managing conditions that are not amenable to traditional bedside teaching. The investigators developed a simulation-based curricular unit for hands-on training using mannequins in 4 obstetrical emergencies: eclamptic seizures, postpartum hemorrhage, shoulder dystocia, and breech presentation. The obstetrical teams consisted of at least 1 resident in the first 3 years of a 6-year program and 2 midwives; the midwives had a mean delivery room experience of 2.5 years. Sixty residents and 88 midwives took the course, and 42 labor and delivery teams completed all 4 sessions. Sessions were videotaped from several angles, and tutors observing the sessions completed checklists of required actions and noted whether each action was done correctly according to predefined criteria. The commonest management errors were: Delayed transport of a bleeding patient to the operating room (82%). Lack of familiarity with administering prostaglandin to reverse uterine atony (82%). Poor cardiopulmonary resuscitation technique (80%). Inadequate documentation of shoulder dystocia (80%). Delayed administration of blood products to reverse consumption coagulopathy (66%). Inappropriate omission of episiotomy in cases of shoulder dystocia and breech extraction (32%). Eighteen residents were asked to repeat their training day 6 months or longer after simulation-based training. Their scores were significantly higher in the repeat sessions than in the initial hands-on course. Among the areas in which improvement was most evident were in team organization and mission assignment, knowing how much of commonly used drugs to deliver and how to administer them, and early transfer to the operating room of patients with postpartum bleeding. More than 90% of all trainees expressed great interest in hands-on practice. More than 80% of those who initially were confident in their ability to perform well in these situations acknowledged a change of heart when responding to the concluding feedback questionnaire. The authors believe that simulation-based training in obstetrical emergencies should have a prominent role in the ongoing medical education of labor and delivery teams.

Posición de garante de los miembros de la fuerza pública

&lt;span&gt;En los medios de comunicación de Colombia aparecen continuas informaciones relacionadas con la ocurrencia de hechos de violencia en nuestro país que principalmente afectan a la población civil por la acción de grupos al margen de la ley, por los cuales se viene atribuyendo responsabilidad al Estado y consecuencias penales y disciplinarias por comisión por omisión contra miembros de la Fuerza Pública. Todo parte de "la posición de garante" de las Fuerzas Militares en relación con la defensa nacional y de la Policía sobre la seguridad nacional que obliga a todos sus miembros a proteger la vida y los demás derechos fundamentales relacionados con este de todos los residentes en Colombia. Precisamente el artículo 25 de la Ley 522 de 1999 se encarga de regular la posición de garante en Colombia y el tema adquiere mayor importancia cuando se trata de juzgar conductas de miembros de la Fuerza Pública debido a que la imputación de la omisión se origina precisamente en la delimitación de los ámbitos de competencia de estas instituciones. Sin embargo, la experiencia del conflicto armado nos indica que no existen fronteras perfectamente delimitadas entre las funciones de defensa y seguridad nacional y en el caso de la misma omisión impropia y la posición de garante hay posiciones doctrinales divergentes que no ofrecen ninguna seguridad al asunto y que dificultan la aplicación de esta figura tal como lo reseñamos a lo largo del trabajo y como los destacan importantes autores nacionales y extranjeros. Todo lo anterior viene afectando el desarrollo de las causas penales y a ello se suman las deficiencias del sistema judicial de Colombia particularmente el cuestionamiento nacional e internacional de la jurisdicción penal militar y las sanciones adoptadas por la Corte Interamericana de Derechos Humanos contra el Estado Colombiano. Así mismo, el "concepto de relación con el servicio" del artículo 221 de la carta Política nos parece que merece un análisis particular por que en los análisis que realizaron dentro del trabajo de investigación estos nos indican que su comportamiento en la omisión impropia es distinto al de la acción por cuanto el "servicio que presta la Fuerza Pública" es a su vez la base y el fundamento de la posición de garante y en consecuencia, el eje central de la imputación penal y disciplinaria. El trabajo se orientó a demostrar el estado actual de la cuestión por esta razón nos parece oportuno dar a conocer los resultados obtenidos respecto de la "posición de garante" con la idea de iniciar la discusión académica que merece esta figura jurídica.&lt;/span&gt;

The Effect of Inappropriate Omissions on Formula Scores: A Simulation Study

Responses to a 50‐item, four‐choice test were simulated for 1,000 examinees under conventional formula‐scoring instructions. One hundred ninety‐two simulation runs reflected variations in the average level o f item difficulty, the extent to which examinees tended to omit inappropriately (when the formulascoring directions recommended guessing), the extent to which they were misinformed (classified correct answers as distractors), the extent to which they guessed contrary to the formula‐scoring instructions, the extent to which examinee ability and tendency to omit inappropriately were correlated, the examinee ability level at which misinformation was most prevalent, and the extent to which item difficulty was related to the probability that an examinee would be misinformed. For each examinee, formula scores and expected formula scores were determined allowing and not allowing inappropriate omissions. Under certain conditions, failure to guess as recommended by the formula‐scoring instructions produced nontrivial proportions o f examinees with expected score losses o f one or more points. These conditions were a test o f at least moderate difficulty, a low level for the tendency to be misinformed, and at least a moderate level for the tendency to omit inappropriately.