The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study

Objectives: To assess the impact of a closed-loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Design, setting and participants: Before-and-after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Intervention: Closed-loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Main outcome measures: Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Results: Prescribing errors were identified in 3.8% of 2450 medication orders pre-intervention and 2.0% of 2353 orders afterwards (p<0.001; χ2 test). MAEs occurred in 7.0% of 1473 non-intravenous doses pre-intervention and 4.3% of 1139 afterwards (p = 0.005; χ2 test). Patient identity was not checked for 82.6% of 1344 doses pre-intervention and 18.9% of 1291 afterwards (p<0.001; χ2 test). Medical staff required 15 s to prescribe a regular inpatient drug pre-intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre-intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; χ2 test). Conclusions: A closed-loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication-related tasks increased.

The impact of a closed-loop electronic prescribing and automated dispensing system on the ward pharmacist’s time and activities

Objective To assess the impact of a closed-loop electronic prescribing and automated dispensing system on the time spent providing a ward pharmacy service and the activities carried out. Setting Surgical ward, London teaching hospital. Method All data were collected two months pre- and one year post-intervention. First, the ward pharmacist recorded the time taken each day for four weeks. Second, an observational study was conducted over 10 weekdays, using two-dimensional work sampling, to identify the ward pharmacist's activities. Finally, medication orders were examined to identify pharmacists' endorsements that should have been, and were actually, made. Key findings Mean time to provide a weekday ward pharmacy service increased from 1 h 8 min to 1 h 38 min per day (P = 0.001; unpaired t-test). There were significant increases in time spent prescription monitoring, recommending changes in therapy/monitoring, giving advice or information, and non-productive time. There were decreases for supply, looking for charts and checking patients' own drugs. There was an increase in the amount of time spent with medical and pharmacy staff, and with 'self'. Seventy-eight per cent of patients' medication records could be assessed for endorsements pre- and 100% post-intervention. Endorsements were required for 390 (50%) of 787 medication orders pre-intervention and 190 (21%) of 897 afterwards (P < 0.0001; chi-square test). Endorsements were made for 214 (55%) of endorsement opportunities pre-intervention and 57 (30%) afterwards (P < 0.0001; chi-square test). Conclusion The intervention increased the overall time required to provide a ward pharmacy service and changed the types of activity undertaken. Contact time with medical and pharmacy staff increased. There was no significant change in time spent with patients. Fewer pharmacy endorsements were required post-intervention, but a lower percentage were actually made. The findings have important implications for the design, introduction and use of similar systems.

Developments in the Doha Round and WTO dispute settlement: some implications for EU agricultural policy

Progress in the Doha Round is assessed against the changes to the common agricultural policy (CAP) brought about by the Fischler reforms of 2003-2004, and that proposed for sugar. An elimination of export subsidies could place EU exports of processed foods at a competitive disadvantage because of high sugar and milk prices. Provided the single payment scheme falls within the green box, the likely new limits on domestic support should not be problematic for the post-Fischler CAP. However, an ambitious market access package could open up EU markets and bring pressure for further reform. If there is no Doha agreement, existing provisions will continue to apply, but without the protection of the Peace Clause; and increased litigation is likely. Further CAP reform is to be expected.

Black stem rust "...two blighted ears of wheat, which few persons would have thought it worthwhile to carry with them round the world..."

A brief survey of the history of this most severe pathogen of wheat and our developing understanding of it.

Effects of urban density on carbon dioxide exchanges: observations of dense urban, suburban and woodland areas of southern England

Anthropogenic and biogenic controls on the surface–atmosphere exchange of CO2 are explored for three different environments. Similarities are seen between suburban and woodland sites during summer, when photosynthesis and respiration determine the diurnal pattern of the CO2 flux. In winter, emissions from human activities dominate urban and suburban fluxes; building emissions increase during cold weather, while traffic is a major component of CO2 emissions all year round. Observed CO2 fluxes reflect diurnal traffic patterns (busy throughout the day (urban); rush-hour peaks (suburban)) and vary between working days and non-working days, except at the woodland site. Suburban vegetation offsets some anthropogenic emissions, but 24-h CO2 fluxes are usually positive even during summer. Observations are compared to estimated emissions from simple models and inventories. Annual CO2 exchanges are significantly different between sites, demonstrating the impacts of increasing urban density (and decreasing vegetation fraction) on the CO2 flux to the atmosphere.