Prevalence of errors in a pediatric hospital medication system: implications for error proofing

The purpose of this study was to determine the prevalence of errors in the medication system of a pediatric teaching hospital. Error was defined broadly to capture all deviations in the process from medication order through administration of the dose. The long-term goal was to provide direction to efforts to error-proof the system. The sample was 3,312 medication orders written during 669 patient-days for which a total of 11,978 doses were passed. Errors were categorized as intercepted errors (intercepted through the normal processes of the medication system) or administration errors (errors that involve the patient with or without adverse sequelae). Errors were also categorized as errors in primary activities (e.g., prescribing or preparing the medication for administration) or supporting activity (e.g., transferring the order to another record). A total of 784 errors were identified; 98% were intercepted and 2% were administration errors. More errors (71%) occurred in supporting activities than in primary activities. Medication systems are complex processes. Errors are imbedded in the medication system and are typically intercepted before patients are involved. Intercepting errors involves additional work that adds to an already cumbersome process. Error proofing will be different for errors in primary activities and for supporting activities.

An update on "special stain" histochemistry with emphasis on automation

For nearly 100 years, pathologists have utilized "special histochemical stains" to assist in tissue-based diagnosis. As illustrated in Figures 1 and 2, histochemical stains have been used to identify infectious microorganisms (e.g., Mycobacterium tuberculosis with acid-fast bacillus (AFB) stain), to detail inflammatory stromal or structural alterations (e.g., fibrosis in liver cirrhosis with Masson trichrome), to identify microanatomic sites of disease (e.g., basement membrane in glomerulonephritis with Jones methenamine silver), to identify abnormal chemical deposits (e.g., iron in hemochromatosis with Prussian blue stain), or abnormal immune deposits (e.g., amyloid via Congo red stain). The current surgical pathology laboratory may employ a repertoire of 20 to 25 "special stains" to ensure the full diagnostic complement. While the diagnostic repertoire and the biochemical recipes for the stains are now a well-established, codified part of surgical pathology, there is an ever-moving, leading edge of new developments including new reagents, applications, and methods. This review seeks to update the reader on some of the new applications including both new reagents and methods. Particular emphasis will be placed on the recent technologic advance of automating special stains in kinetic-mode (1-4). The authors consider in turn: 1. In brief, the "news" (recent literature review) of new staining applications; 2. In greater detail, two new applications for detection of Microsporidia and Helicobacer pylori; 3. The new technologic advancement of kinetic mode automation of special stains.

Normal transitions in synthesis of replacement histones H2A.Z and H3.3 during differentiation of dystrophic myotube cells. A brief note

We previously reported that differentiating G0 myotube cells cultured from normal chicken embryos exhibit a histone synthesis pattern that is highlighted by transitions in the expression of the minor replacement variants H3.3 and perhaps H2A.Z (Wunsch and Lough, Dev. Biol. 119 (1987) 94-99). Because these proteins may be synthesized to maintain chromatin structure during the differentiation and maturation of the skeletal muscle fiber, it was of interest to determine whether they are made at normal levels during the differentiation of dystrophic muscle. To this end, the synthesis of histone proteins in cultured myoblasts and myotubes from normal and dystrophic avian embryos has been characterized by two-dimensional polyacrylamide gel electrophoresis and fluorography. Proliferating myoblasts (day 1) as well as two stages of differentiating myotubes (days 3, 4) exhibited histone synthesis patterns that were indistinguishable when comparing normal and dystrophic cells. It is noteworthy that this study also revealed that, in both cell types, the change in H2A.Z synthesis during the myoblast/myotube transition was remarkable, increasing from approximately 20% of the non-ubiquitinated H2As in myoblasts to 80% in myotubes. Also, gel staining patterns and immunoblotting detected no differences in the degree of histone ubiquitination between normal and dystrophic cells. These findings indicate that, up to this point in dystrophic differentiation, neither the synthesis nor ubiquitination of histones are perturbed.

[Distribution of manganese and its modification by magnesium and cobalt in the guinea pig]

Five groups of 8 guinea-pigs each had been treated by manganese, magnesium, cobalt or their combination over a period of 26 days. The concentration of the metals administered had been determined in the liver, pancreas, kidney, adrenal gland, spleen and brain and been compared with the adequate rates of a sample group of 8 animals. Mutual influences could be stated. Statements on the interaction mechanisms could not be derived.

[Ion pair-HPLC of some aromatic amino- and hydroxycarboxylic acids]

Various factors influencing the ion-pair-HPLC separation of some aromatic amino- and hydroxycarbon acids were described and discussed. Distinct effects of the ion pair formation of organic acids with quarternary alkylammonium salts (CTAB) are recognized on condition that the carboxylic group is not blocked by intramolecular H-bonding or partial betain structure. If the carboxylic group is unconnected the retention time increases depending on the pka of the acid with increasing pH if no complete ionization exists. In order to separate similar compounds at low retention time with distinct resolution an organic modifier of suitable strength and high selectivity have to be added to the mobile phase.

[Osteomyelitis of the sacrum]

In the axial skeleton, osteomyelitis of the os sacrum is rare, although it occurs more frequently than tuberculosis of the sacrum. Secondary osteomyelitis as a complication of tumours, metastases or inflammatory processes of the adjacent areas is seen more often than primary sacral osteomyelitis.

[A method for the determination of the osmotic fragility of erythrocytes]

A method for registration of the haemolysis of erythrocytes as a measure for their osmotic resistance is presented. The technical realization is performed by means of a cuvette head-piece for holding a filter, which separates the investigation material from water. A cuvette insertion guarantees the regular construction of a haemoglobin gradient, serving as a measure for haemolysis, which is photometrically measured in the Spekol (VEB Carl Zeiss JENA) and registered by means of the compensation tape writer G 1 B 1 (VEB Carl Zeiss JENA). 0.3-0.4 ml investigation material are used. The expenditure of time amounts to about 20 minutes.

[Interaction of solvent effects on the plasma membrane]

The combined effect of trichloroethylene and butanol on the behaviour of human erythrocytes during haemolysis in hypotensive milieu was investigated in comparison to the individual effects of solvents. In these cases, among others, appeared statistically significant quantitative changes of the maximum of stability. In a common influence of trichloroethylene and butanol and additional stabilisation of the membrane may be the result, which is traced back to various places of effect of the solvents. When 150 mmol/l butanol are used the haemolysis is suppressed by trichloroethylene in its concentration region of 8-10 mmol/l. This effect can be explained by additional inclusion of trichloroethylene in butanol-free lipid classes. When 200 mmol/l butanol are given the haemolysis much increases already at an application of 4 mmol/l trichloroethylene. Here trichloroethylene cannot infiltrate into other still butanol-free lipid classes, in order to evoke an additional stabilisation. On the contrary, in cooperation the decomposition of the crystal structure of the lipids (emulsification) and thus the haemolysis develops. These results refer to the fact that combined effects of solvents are not always to be valuated additively.

[Cancer-like x-ray findings in the esophagus caused by blood clot-hemorrhage due to coagulopathy]

The case demonstrated here shows that filling defects in the oesophagus do not prove the existence of a tumour. In diffuse haemorrhages of the oesophageal mucosa the blood may not be swallowed completely or vomited; it may coagulate in the oesophagus, adhere to the wall and produce a tumor-like pattern.

The radiological residua of healed diabetic arthropathies

Diabetic arthropathy is a relatively rare manifestation of neuropathic disease, occurring in fewer than 5% of cases. Abnormalities of this type are confined largely to the small joints of the feet, although the larger joints of the lower limbs and the spine occasionally are affected. Some lesions, particularly in the feet, repair spontaneously, leaving radiological residua sufficiently characteristic to prompt suspicion of an unrecognised diabetic state. These include deformity of the head of the second metatarsal (akin to a Freiberg lesion), shortening of the great toe, painless deforming arthrosis of the knee, and ankylosis of interphalangeal joints. In the presence of these signs the patient should be interrogated concerning diabetes and blood sugar estimates, with provocation of necessary, obtained. Should such a diagnosis be sustained, appropriate protective measures may be undertaken to avoid a relapse of the arthropathy.

[Hypervascularisation in diabetic patients shown by angiography (author's transl)]

Two diabetic patients are described who showed widened and tortuous arteries, increased blood flow and increased filling of small arteries, with simultaneous filling of arteries and veins (increased flow through arterio-venous anastomoses). In one patient, during an observation period of four years, occlusion of both common iliacs developed, as well as a block of one femoral artery and mural changes in the other. Inthe second patient, areas of occlusion and hypervascularisation co-existed. The first patient showed osteolytic changes, also involving the joints, whereas the second patient developed diffuse rarefaction of the bones in the leg and foot. Ischaemic necroses developed inthe soft tissues in both patients and leg amputation was therefore carried out. The angiographic and skeletal findings, however, suggest that the soft tissues suffered trophic changes which should be regarded as a secondary complication of the ischaemia.

[Radiological appearances in the near-drowned (author's transl)]

Three patients unconscious when rescued from drowning had radiographic studies of their lungs carried out after several hours, or on the following day. The findings had to be interpreted as pulmonary oedema. The most seriously affected patient showed the picture of massive acute interstitial oedema on the second day. After initial regression, coarse shadows developed, indicating the alveolar form of pulmonary oedema. The sputum contained candida, but there was no evidence of pulmonary candidiasis. In two patients there were transient signs of limited atelectases. Two patients were re-examined after five years. There were no features which could be interpreted as a consequence of the drowning episode. The radiographic appearances showed minor changes which could be due to mild pulmonary fibrosis.