Computerized provider order entry (CPOE) has been shown to improve patient safety by reducing medication errors and subsequent adverse drug events (ADEs). Studies demonstrating these benefits have ...been conducted primarily in the inpatient setting, with fewer in the ambulatory setting. The objective was to evaluate the effect of a basic, ambulatory CPOE system on medication errors and associated ADEs.
This quasiexperimental, pretest-post-test study was conducted in a community-based, multispecialty health system not affiliated with an academic medical center. The intervention was a basic CPOE system with limited clinical decision support capabilities.
Comparison of prescriptions written before (n=5016 handwritten) to after (n=5153 electronically prescribed) implementation of the CPOE system. The primary outcome was the occurrence of error(s); secondary outcomes were types and severity of errors.
Frequency of errors declined from 18.2% to 8.2%-a reduction in adjusted odds of 70% (OR: 0.30; 95% CI 0.23 to 0.40). The largest reductions were seen in adjusted odds of errors of illegibility (97%), use of inappropriate abbreviations (94%) and missing information (85%). There was a 57% reduction in adjusted odds of errors that did not cause harm (potential ADEs) (OR 0.43; 95% CI 0.38 to 0.49). The reduction in the number of errors that caused harm (preventable ADEs) was not statistically significant, perhaps due to few errors in this category.
A basic CPOE system in a community setting was associated with a significant reduction in medication errors of most types and severity levels.
To (1) describe the role of clinical pharmacists in providing population-based pharmaceutical care as employees of a physician group practice, (2) describe the strategies used by pharmacists to ...optimize medication use, (3) quantify improvements in care, and (4) illustrate the calculations used to quantify cost savings.
Community-based, multispecialty, physician group practice located in the north Puget Sound area between 2003 and 2007.
Using four cornerstones (evidence-based medicine, therapeutic interchange, academic detailing, and a local pharmacy and therapeutics committee), the pharmacists provided population-based pharmaceutical care, leading generic switches, target drug programs, and prescription to over-the-counter medication switches. They also led disease management programs, managed drug recalls, implemented electronic health records, negotiated budgets with health plans, and led patient assistance programs and prior authorization programs to improve patient satisfaction.
Implementing these strategies from the vantage point of a physician group presents a seldom-realized employment opportunity for pharmacists.
The impact of these strategies is measured by process, use, and clinical outcomes metrics. These, in turn, are linked to incentive payments in the pay-for-performance environment or to a lowered per member, per month cost in the capitated environment.
In 2006-2007, 71% of our hypertensive patients received generic agents compared with a network average for receiving generic agents of 43%, while the proportion of patients with controlled blood pressure increased from 45% to 60%. We saved $450,000 in inpatient costs for deep venous thrombosis.
Clinical pharmacists employed in a physician group practice can optimize medication use, improve care, and reduce costs.
Despite some success in secondary brain metastases, targeted or immune-based therapies have shown limited efficacy against primary brain malignancies such as glioblastoma (GBM). Although the ...intratumoral heterogeneity of GBM is implicated in treatment resistance, it remains unclear whether this diversity is observed within brain metastases and to what extent cancer cell-intrinsic heterogeneity sculpts the local immune microenvironment. Here, we profiled the immunogenomic state of 93 spatially distinct regions from 30 malignant brain tumors through whole-exome, RNA, and T-cell receptor sequencing. Our analyses identified differences between primary and secondary malignancies, with gliomas displaying more spatial heterogeneity at the genomic and neoantigen levels. In addition, this spatial diversity was recapitulated in the distribution of T-cell clones in which some gliomas harbored highly expanded but spatially restricted clonotypes. This study defines the immunogenomic landscape across a cohort of malignant brain tumors and contains implications for the design of targeted and immune-based therapies against intracranial malignancies. SIGNIFICANCE: This study describes the impact of spatial heterogeneity on genomic and immunologic characteristics of gliomas and brain metastases. The results suggest that gliomas harbor significantly greater intratumoral heterogeneity of genomic alterations, neoantigens, and T-cell clones than brain metastases, indicating the importance of multisector analysis for clinical or translational studies.
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Despite some success in secondary brain metastases, targeted or immune-based therapies have shown limited efficacy against primary brain malignancies such as glioblastoma (GBM). While the ...intratumoral heterogeneity of GBM is implicated in treatment resistance, it remains unclear whether this diversity is observed within brain metastases and to what extent cancer-cell intrinsic heterogeneity sculpts the local immune microenvironment. Here, we profiled the immunogenomic state of 93 spatially distinct regions from 30 malignant brain tumors through whole exome, RNA, and TCR-sequencing. Our analyses identified differences between primary and secondary malignancies with gliomas displaying more spatial heterogeneity at the genomic and neoantigen level. Additionally, this spatial diversity was recapitulated in the distribution of T cell clones where some gliomas harbored highly expanded but spatially restricted clonotypes. This study defines the immunogenomic landscape across a cohort of malignant brain tumors and contains implications for the design of targeted and immune-based therapies against intracranial malignancies.
A computer simulation model of non-Darcy flow is used along with field experiments to study the performance of subslab ventilation systems, using different types of aggregates, for mitigation of ...indoor radon.
We have measured the magnetic field dependence of the paramagnetic to the
field-induced high temperature antiferroquadrupolar magnetically ordered phase
transition is CeB6 from 0 to 60 T using a ...variety of techniques. It is found
that the field-dependent phase separation line becomes re-entrant above 35 T
and below 10 K. Measurements of resonant ultra-sound, specific heat and neutron
diffraction show conclusively that the zero-field temperature-dependent phase
transition is to a state with no ordered dipole moments, but with second order
transition signatures in both sound attenuation and specific heat.
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