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Introduction of computer assisted control of oral anticoagulation in general practice purchase 400mg flagyl overnight delivery. Healthcare informatics : the business magazine for information and communication systems 2009;26(9):30-3 discount flagyl 500 mg on line. The push to share data electronically--both inside and outside of the hospital walls--is forcing patient identification to the forefront. Primary care clinician attitudes towards ambulatory computerized physician order entry. The concordance of self-report with other measures of medication adherence: a summary of the literature. A meta-model of chemotherapy planning in the multi­ hospital/multi-trial-center-environment of pediatric oncology. Critical pathway for the management of acute heart failure at the veterans affairs san diego healthcare system: Transforming performance measures into cardiac care. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. Implementation of a computerized physician order entry system at a 500 bed community hospital: case for pharmacist involvement. Clinical pharmacy in a geriatric unit: Impacts of clinical pharmacy interventions prior to medical order. The effects of computerized medical records on provider efficiency and quality of care. Massachusetts Technology Collaborative and New England Healthcare Institute; 2006. Collaborative improvement in the order and delivery process of intravenous infusion medications in the neonatal intensive care unit to decrease errors and utilize technology. Centralized information system for general practitioners and out-patient medical services: Conception of realization. Building man-man-machine synergies: experiences from the Vanderbilt and Geneva clinical information systems. The impact of computerised physician order entry systems on pathology services: A systematic review. Computer-supported weight-based drug infusion concentrations in the neonatal intensive care unit. Home infusion therapy trial of a multitherapy remotely programmable ambulatory pump. Multi-tasking in practice: coordinated activities in the computer supported doctor-patient consultation. Methods, architecture, evaluation and usability of a case- based antibiotics advisor. Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Identifying medication-use system variances associated with computerized provider order entry. Healthcare financial management : journal of the Healthcare Financial Management Association 2009;63(11):38-41. Improving recognition of drug interactions: benefits and barriers to using automated drug alerts. The utility of adding retrospective medication profiling to computerized provider order entry in an ambulatory care population. Online prospective drug utilization review in community practice: Clinical and economic impact. Is health information technology associated with patient safety in the United States? The evolution and implementation of a pediatric computerized order entry system: a case study. Development of a mini computer program to identify medication orders requiring modification based on patient-specific renal function. Using an Internet comanagement module to improve the quality of chronic disease care. A continuous-improvement approach for reducing the number of chemotherapy-related medication errors. Translating research into practice: Organizational issues in implementing automated decision support for hypertension in three medical centers. Integration of an automated dispensing device into a computerized unit dose hospital pharmacy. Development of a guideline-based decision support system with explanation facilities for outpatient therapy.

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Unused units can be added to the general donor blood inventory Blood bank/Apply knowledge of standard operating procedures/Autologous donation/2 4 order 200mg flagyl overnight delivery. An autologous unit of whole blood was collected Answers to Questions 18–20 on a 33-year-old woman in preparation for a knee replacement procedure in 3 weeks buy generic flagyl 200mg on-line. D This is a common scenario with women who have blood unit had her hyphenated last name, first recently married, and have not changed their license name, and last four digits of her social security or other form of identification given to the collection number for identification. Checking that other demographic information system, however, only had her married name and matches is sufficient if approved by the medical first name, medical record number, and social director, because an autologous unit is very difficult security number. C Vaccines developed by recombinant technology admissions make the correction in the carry no deferral period. Ensure that social security numbers match, confirm the name with donor and have admissions make the correction in the computer system with the medical director’s approval, then make the unit available for transfusion Blood bank/Standard operating procedures/Autologous donation/3 19. Perform an elution on the cord cells the cells of an Rh-positive baby Blood bank/Select course of action/Hemolytic disease of D. A fetal screen yielded negative results on a mother baby’s red cells if they did not contain the K antigen; who is O negative and infant who is O positive. B If the fetal screen or rosette test is negative, indicating the fetal maternal blood is negligible in a possible B. Issue one full dose of RhIg RhIg candidate, standard practice is to issue one dose C. Perform an antibody screen on the mother Blood bank/Select course of action/Hemolytic disease of 3. A The identification of the antibody is very important the newborn/Rosette test/3 at this stage of the pregnancy. What should be done when a woman who is may determine the strength of the antibody and 24 weeks pregnant has a positive antibody screen? No need to do anything until 30 weeks gestation who already has an antibody might cause a C. Administer Rh immune globulin (RhIg) transfusion reaction and/or evoke an even stronger D. Adsorb the antibody onto antigen-positive cells antibody response, possibly causing more harm to the fetus. Blood bank/Apply knowledge of standard operating procedures/Hemolytic disease of the newborn/Antibody 5. A If the cord cells contain excessive Wharton’s jelly, testing/2 then further washing or obtaining another cord sample will not solve the problem. Early induction of labor Blood bank/Apply knowledge of standard operating procedures/Hemolytic disease of the newborn/Clinical interventions/2 158 4. O-negative mother; A-positive baby; second fetus pregnancy; no anti-D in mother D. Yes, if the baby’s type is Rh negative anti-K, she will be monitored to determine if the C. Yes, if the baby’s type is Rh positive antibody level and signs of fetal distress necessitate D. C RhIg is immune anti-D and is given to Rh-negative Blood bank/Correlate clinical and laboratory data/ mothers who give birth to Rh-positive babies and Hemolytic disease of the newborn/RhIg/3 who do not have anti-D already formed from 8. Should an A-negative woman who has just had a previous pregnancies or transfusion. Yes, but only if she does not have evidence of the fetus is unknown, termination of a pregnancy active Anti-D from any cause presents a situation in which an B. Yes, but only a minidose regardless of trimester is used if the pregnancy is terminated in the first D. The on a woman who is 6 weeks pregnant with woman is weak D positive, and, therefore, is not a vaginal bleeding as O negative. Typically, a test for weak D is not tells the emergency department physician she is done as part of the obstetric workup. Is A-positive baby and has no anti-D formed from a this woman a candidate for RhIg? Yes, based upon the Provue results immunization typically has a titer >4, compared with passive administration of anti-D, which has a Blood bank/Correlate clinical and laboratory results/ titer <4. All of the following are routinely performed on a 40 fetal cells in 2,000 maternal red cells. Divide this number by 30 to arrive at the Blood bank/Apply knowledge of biological principles/ number of doses. When the number to the right of Hemolytic disease of the newborn/1 the decimal point is less than 5, round down and add one dose of RhIg.

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The outcomes discount 500 mg flagyl with visa, most often measures of efficiency and changing work patterns purchase 500mg flagyl otc, were usually reported as being positive. The main unit of analysis in 12 of the 16 studies was prescriptions, orders, and medications. The main unit of 552,578 580 574 analysis for the other four studies were patients, pharmacists, and clinicians. The 578 patients were of geriatric age (65 years or greater) or adults (45 to 64 years), or geriatric 552 alone. One article described decreases in prescribing of contraindicated drug-drug combinations in 577 ambulatory settings. Another looked at the agreement between pharmacists and family physicians (need for clarification of prescriptions) with and without e-Transmission of 575 prescriptions, again in the ambulatory setting. All other process changes that were the main focus of the order communication articles dealt with errors and efficiencies. Two studies showed improvements in prescribing with increased interaction 552,577 between pharmacists and physicians (Table 9). Five hospital-based studies sought to change response times (Table 576,578,581,584 9). Another found an increased time to checking the prescription with an e-Prescribing system compared with a paper 575 based system (11 vs. For example, a decrease from 115 minutes to 5 minutes for verification of a prescription in a study by 584 Wielthrolter and colleagues. Ekeldahl and colleagues showed that the rate of picking up 579 prescriptions did not change with the introduction of an e-Prescribing system. Most of the process evaluations show improvements, often in efficiency related to times and changing work patterns (Table 9). Nine studies were 438,507,552,574,585,586,588-590 identified as evaluating dispensing (Appendix C, Evidence Table 3). In addition, many of these studies evaluated technologies that were older, no longer available, or only available in Europe. Raebel and colleagues and Halkin and colleagues reported data based on patients as the unit of study. All others reported data on medications or prescribing events as their unit of analysis. Aspirin for patients with diabetes was studied, and two others targeted 507,552 groups of medications with high potential for interactions. Efficiency, monitoring, and preventive care outcomes were not reported in the nine studies. Evidence on other outcomes or technologies in 11 dispensing was found to be lacking or inconclusive. For pharmacists who were prompted electronically to suggest aspirin to patients with diabetes when they were filling other prescriptions, the use of aspirin 588 increased. Four of the four ambulatory studies demonstrated statistically significant improvements in what drugs were dispensed. Refill utilization was improved and aspirin use increased 29 while pharmacists were being prompted to include aspirin use when dispensing medications for 588 patients with diabetes. Murray and colleagues showed changes in workflow for pharmacists (more time interacting and problem solving) and who they interacted with (more time interacting with peers and physicians). Workflow was also changed in another study using a pharmacy 574 information system. Nilsson and colleagues showed that acute prescriptions were picked up more often for an e-Prescribing system compared with a paper-based system (91 percent vs. Administering Summary of the Findings for Process Changes Nineteen studies measured changes in process associated with the administering phase of medication management (Appendix C, Evidence Table 4). This nonintegration was especially true for older studies—most of the more recent studies show medication administering systems that are integrated. Three studies included pharmacists, and 465,592,593,596 four discussed physicians. The main focus of the study was medications or 34,438,439,465,581,589,592-595,598,599,601,602 597,600 12 prescriptions, nurses and patients: infants and those 596 whose ages were unspecified. Medications were not limited to a specific drug or class of drugs 596 592 except for one study of the need for antibiotics and one study of aspirin use. All of the studies but one were set in hospitals: acute care or tertiary, 602 12,593-595 438,465 34,438 critical care units, pediatric standalone hospitals, general hospitals, other 465,581 597 specialty hospitals, and the emergency department. Eight studies had major endpoints that were found to be positive in reporting decreased 438,439,465,581,589,594,601,602 errors. The relative risk reduction in many of the studies was high and often approximately 40 to 50 percent.

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Twenty-three percent (23%; 49/211) of ciprofloxacin patients used post- therapy antimicrobials compared to 29% (66/231) of comparator patients discount flagyl 500mg mastercard. The two most common antimicrobials used were cephalexin (5% [10/211] ciprofloxacin versus 8% [18/231] comparator) and nitrofurantoin (6% [13/211] ciprofloxacin versus 8% [17/231] comparator) generic flagyl 250 mg. Escherichia coli was the most frequently isolated pre-therapy infection-causing organism. Patients less than or equal to 5 years comprised 51% (108/211) of patients in the ciprofloxacin group and 43% (99/231) of patients in the comparator group. No substantial differences in demographics or baseline disease characteristics were noted between the treatment groups. Clinical cure in patients valid for efficacy was 96% [202/211] in the ciprofloxacin group and 93% [214/231] in the comparator group. The p-value from the Breslow-Day test for treatment by disease stratum/treatment type interaction was 0. The bacteriological eradication rate at the test of cure visit in patients valid for efficacy was 84% [178/211] in the ciprofloxacin group and 78% [181/231] in the comparator group. Clinical cure rates and bacteriological eradication rates were not substantially impacted by age, race, or sex. For 5 patients (2 in the ciprofloxacin group and 3 in the comparator group), it could not be confirmed whether study drug was taken. Patients less than or equal to 5 years comprised 48% (160/335) of patients in the ciprofloxacin group and 46% (159/349) of patients in the comparator group. The following table was compiled by the applicant using information recorded in the pharmacy log at each investigator site. Due to changes and clarifications of patient data, these patients were removed by the applicant. Clinical Reviewer’s Comment: The reviewer agrees with the applicant’s removal of these 4 patients from the arthropathy algorithm, as they do not appear to be true arthropathies, as defined by the protocol. An additional 21 patients were identified by the applicant that had not already been identified by the algorithm at the end of the study (i. A break down of cases by treatment received can be found in Tables 20 and 21 in Appendix 1. There were 46 cases of arthropathy in the ciprofloxacin arm and 33 in the comparator arm by one year of follow-up. The p-value from the Breslow-Day test for treatment by treatment route interaction was marginally statistically significant at 0. Clinical Reviewer’s Comment: The one year arthropathy rates by treatment type/disease stratum do not show a statistically significant result (p-value 0. Therefore, the clinical significance of this statistical result is felt to be minimal by the reviewer. Tables 24 and 25 in Appendix 1 detail the ciprofloxacin and comparator cases of arthropathy, respectively, that occurred by Day +42 of follow-up. Clinical Reviewer’s Comment: Tables 24 and 25 in Appendix 1 were created by the reviewer. In the reviewer’s assessment, there were 30 patients who experienced adverse events by Day +42. The reviewer moved one ciprofloxacin patient from the Day +42 to one year grouping based on a reassessment of when the event occurred. In the comparator arm, 21 patients experienced events before Day +42 and 1 also experienced another event after Day +42. Table 26 summarizes arthropathy by Day +42 follow-up by selected baseline characteristics in patients valid for safety. There was a much bigger difference between treatment group arthropathy rates in the United States (21% ciprofloxacin versus 11% comparator) than in the overall rates. The arthropathy rate was higher than the overall rate in Caucasians (14% ciprofloxacin versus 10% comparator) and lower than the overall rate in Hispanics (8% ciprofloxacin versus 3% comparator) and the “uncodable” race group (5% ciprofloxacin versus 3% comparator). The arthropathy rates were quite similar between males and females and consistent between treatment groups. Differences between treatment groups in the arthropathy rate by Day +42 were fairly consistent with the overall rate in the different age groups, and the arthropathy rate in both treatment groups increased with age. The highest arthropathy rate was seen in the ≥12 year to <17 year age group, where the rate was 22% for ciprofloxacin patients and 14% for comparator patients. Theoretical reasons for this difference posed by the applicant for explaining the higher rate in the older patients are: greater physical activity, more accurate ability to report pain, and greater weight across weight-bearing joints of adolescents versus younger children. Theoretical reasons proposed by the applicant for these differences could be differences in concomitant medications, in age, in pre-existing joint problems, in infection-associated arthropathy and in duration of infection. All proposed reasons are potentially valid, but it is not possible to identify the true cause of the differences, due to the nature of the data collection and because many of the variables are correlated with each other. Of these, 5/21 ciprofloxacin patients and 1/13 comparator patients had an event(s) occurring by Day +42 as well as an event(s) occurring between Day +42 and one year.