JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT, Tuesday, March 8, 2005)
JAMA NEWS RELEASES
COMPUTERIZED ORDER ENTRY SYSTEMS CAN INCREASE RISK OF MEDICATION ERRORS
MANY CHILDREN ARE UNDERVACCINATED OR HAVE DELAYED VACCINATIONS IN THEIR FIRST 2 YEARS OF LIFE
PRELIMINARY STUDY SUGGESTS SMOKING WHILE PREGNANT MAY INCREASE CHROMOSOMAL ABNORMALITIES IN FETAL CELLS
JAMA REPORT (VIDEO NEWS RELEASE SCRIPT)
A THIRD OF U.S. TWO-YEAR OLDS NOT RECEIVING VACCINES ON TIME
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.
TV Note: This week's JAMA video news release is on the timeliness of childhood vaccinations in the U.S. The release will be fed Tuesday, March 8, from 9:00 - 9:30 a.m. ET on Intelsat America 6 (formerly Telstar 6), Transponder 11 (C-Band) and from 2:00 - 2:30 p.m. ET on Intelsat America 6, Transponder 11 (C-Band). For more information, call 312/464-JAMA (5262).
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Embargoed for Release: 3 p.m. CT, TUESDAY, March 8, 2005
Media Advisory: To contact Ross Koppel, Ph.D., call Rebecca Harmon at 215-349-5660.
To contact editorialist Robert L. Wears, M.D., M.S., call Pat McGhee at 904-244-5523.
COMPUTERIZED ORDER ENTRY SYSTEMS CAN INCREASE RISK OF MEDICATION ERRORS
CHICAGO—A new study suggests that computerized order entry systems which are implemented in part to reduce prescribing errors can actually increase the risk of medication errors in certain situations, according to a study in the March 9 issue of JAMA.
Adverse drug events (ADEs) are estimated to injure or kill more than 770,000 patients in hospitals annually, according to background information on the article. Prescribing errors are the largest identified source of preventable hospital medical error. Computerized physician order entry (CPOE) systems are widely viewed as crucial for reducing prescribing errors and potentially saving hundreds of billions in annual costs. Published studies have indicated that CPOE reduces medication errors up to 81 percent. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.
Ross Koppel, Ph.D., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues conducted a study of CPOE-related factors that enhance risk of prescription errors. The researchers performed a qualitative and quantitative study of house staff interaction with a CPOE system at a teaching hospital. They surveyed house staff (N = 261; 88 percent of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders .
The researchers found that the CPOE system they studied facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three-quarters of the house staff reported observing each of these errors risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction.
"The literature on CPOE, with few exceptions, is enthusiastic. Our findings, however, reveal that CPOE systems can facilitate error risks in addition to reducing them. Without studies of the advantages and disadvantages of CPOE systems, researchers are looking at only one edge of the sword. This limitation is especially noteworthy because many problems we identified are easily corrected," the authors write.
The researchers make several recommendations on how to reduce medication errors. "(1) Focus primarily on the organization of work; not on technology; CPOE must determine clinical actions only if they improve, or at least do not deteriorate, patient care. (2) Aggressively examine the technology in use; problems are obscured by workarounds, the medical problem-solving ethos, and low house staff status. (3) Aggressively fix technology when it is shown to be counterproductive because failure to do so engenders alienation and dangerous workarounds in addition to persistent errors; substitution of technology for people is a misunderstanding of both. (4) Pursue errors' 'second stories' and multiple causations to surmount the following barriers enhanced by episodic and incomplete error reporting, which is standard, and management belief in these reports, which obfuscates and compounds problems. (5) Plan for continuous revisions and quality improvement, recognizing that all changes generate new error risks," the researchers write.
"As CPOE systems are implemented, clinicians and hospitals must attend to the errors they cause, in addition to the errors they prevent."
(JAMA. 2005;293:1197-1203. Available post-embargo at jama.com)
Editor's Note: This research was supported by a grant from the Agency for Healthcare Research and Quality, Improving Patient Safety Through Reduction in Medication Errors. Co-author Dr. Metlay is also supported through an Advanced Research Career Development Award from the Health Services Research and Development Service of the Department of Veterans Affairs.
EDITORIAL: COMPUTER TECHNOLOGY AND CLINICAL WORK
In an accompanying editorial, Robert L. Wears, M.D., M.S., of the University of Florida, Jacksonville, and Marc Berg, M.A., M.D., Ph.D., of Erasmus University, Rotterdam, the Netherlands, discuss the findings by Koppel et al and a review article in this issue by Garg et al which examined computerized clinical decision support systems.
"These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. Clearly, there is no reason to expect health care, which is from an organizational standpoint probably the most complex enterprise in modern society, to be immune to them. Taken together, these 2 studies suggest that important lessons about introducing new technologies into complex work seem to have been missed."
"For a small but important example, it has been long established in software engineering that systems cannot be adequately evaluated by their developers, a principle that seems to be commonly overlooked in health care. Since roughly 75 percent of all large IT projects in health care fail, inattention to these lessons is, at best, wasteful of time and resources and, at worst, harmful to patients and clinicians.
"To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around," the authors write. "In short, rather than framing the problem as 'not developing the systems right,' these failures demonstrate 'not developing the right systems' due to widespread but misleading theories about both technology and clinical work."
"... an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail," the authors write.
(JAMA. 2005;293:1261-1263. Available post-embargo at jama.com)
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3 p.m. CT, TUESDAY, March 8, 2005
Media Advisory: To contact Elizabeth T. Luman, Ph.D., call Curtis Allen at 404-639-8487.
MANY CHILDREN ARE UNDERVACCINATED OR HAVE DELAYED VACCINATIONS IN THEIR FIRST 2 YEARS OF LIFE
CHICAGO—Approximately one-third of U.S. children were undervaccinated for more than six months and one-fourth experienced delays in receiving many of the recommended vaccinations during their first 24 months of life, according to a study in the March 9 issue of JAMA.
Remaining appropriately vaccinated at all times decreases a child's risk of contracting vaccine-preventable diseases and prevents disease outbreaks, according to background information in the article. Yet a previous study found that only 18 percent of children in the U.S. received all vaccinations at the recommended ages or acceptably early (i.e., within minimum age allowances) and only 9 percent at the recommended ages.
Elizabeth T. Luman, Ph.D., of the Centers for Disease Control and Prevention, Atlanta, and colleagues examined the timeliness of receipt of vaccination among a nationally representative sample of children in the United States for each recommended vaccine and for all vaccines combined. The study consisted of the 2003 National Immunization Survey, conducted by random-digit dialing of households and mailing to vaccination providers to estimate vaccination coverage rates for U.S. children aged 19 to 35 months. Data for this study were limited to 14,810 children aged 24 to 35 months. The researchers wanted to determine the cumulative days children were undervaccinated during the first 24 months of life for each of 6 vaccines (diphtheria and tetanus toxoids and acellular pertussis; poliovirus; measles, mumps, and rubella; Haemophilus influenzae type b; hepatitis B; and varicella) and all vaccines combined, number of late vaccines, and risk factors for severe delay of vaccination.
The researchers found that children were undervaccinated an average of 172 days for all vaccines combined during their first 24 months of life. Approximately 34 percent were undervaccinated for less than 1 month and 29 percent for 1 to 6 months, while 37 percent were undervaccinated for more than 6 months. Vaccine-specific undervaccination of more than 6 months ranged from 9 percent for poliovirus vaccine to 21 percent for Haemophilus influenzae type b vaccine. An estimated 25 percent of children had delays in receipt of 4 or more of the 6 vaccines. Approximately 21 percent of children were severely delayed (undervaccinated for more than 6 months and for 4 or more vaccines).
Factors associated with severe delay included having a mother who was unmarried or who did not have a college degree, living in a household with 2 or more children, being non-Hispanic black, having 2 or more vaccination providers, and using public vaccination provider(s).
"Interventions must be focused on plans that could best address the needs of these mothers, such as extended office hours for women who have difficulty taking time away from work, using appropriate education-level information regarding safety and benefits of vaccination, and ensuring availability of sibling child care in the workplace," the researchers write.
"Assessing days undervaccinated reveals weaknesses in childhood vaccination programs. Physicians are in the best position to assess the needs of their patients to determine reasons for delay. Evidence-based solutions exist for many of these needs, such as reminder-recall systems, extended office hours, expanding availability of pediatric care, and education regarding the importance and safety of vaccinations. Minimizing the time spent incompletely protected from vaccine-preventable diseases is important to the health of individuals and to public health and should be given greater emphasis by public health programs and vaccination providers," the authors write.
"These results confirm that opportunity exists for improvement in vaccine administration in the United States to ensure that all children remain fully vaccinated and optimally protected from vaccine-preventable diseases throughout early childhood-the time when children are most at risk for illness and severe complications from many vaccine-preventable diseases," the researchers write.
(JAMA. 2005;293:1204-1211. Available post-embargo at jama.com)
Editor's Note: This research and the National Immunization Survey were conducted through funding by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3 p.m. CT, TUESDAY, March 8, 2005
Media Advisory: To contact corresponding author Josep Egozcue, M.D., email: 5518jec{at}comb.es or call 011-34-93-330-78-20. To contact editorialist David M. DeMarini, Ph.D., call Ann Brown at 919-541-7818.
PRELIMINARY STUDY SUGGESTS SMOKING WHILE PREGNANT MAY INCREASE CHROMOSOMAL ABNORMALITIES IN FETAL CELLS
CHICAGO—A preliminary report suggests that maternal smoking during pregnancy is associated with increased chromosomal abnormalities in fetal cells, according to a study in the March 9 issue of JAMA.
Maternal smoking during pregnancy has many consequences during and after pregnancy, such as infertility, coagulation problems, obstetric complications such as extrauterine pregnancy and placenta previa, and intrauterine growth retardation, according to background information in the article. However, only indirect data have been published on a possible genotoxic (effect of damaging DNA, possibly causing genetic mutation) effect on pregnancy in humans.
Rosa Ana de la Chica, M.Sc., of the Universitat Autònoma de Barcelona, Bellaterra, Spain, and colleagues conducted a study to determine whether maternal smoking has a genotoxic effect on amniotic cells, expressed as an increased chromosomal instability, and analyzed whether any chromosomal regions are especially affected by exposure to tobacco. Fetal amniocytes (cells of fetal origin in the amniotic fluid) were obtained by routine amniocentesis for prenatal diagnosis from 25 controls and 25 women who smoke (10 or more cigarettes/d for 10 or more years). The women were asked to fill out a smoking questionnaire concerning their smoking habits.
The researchers found that when comparing genetic data between smokers and nonsmokers (controls) there were important differences for the proportion of structural chromosomal abnormalities (smokers: 12.1 percent; controls: 3.5 percent) and to a lesser degree for the proportion of metaphases (a phase of cell division) with chromosomal instability (smokers: 10.5 percent; controls: 8.0 percent), and for the proportion of chromosomal lesions (smokers: 15.7 percent; controls: 10.1 percent). Statistical analysis found a certain chromosomal region was most affected by tobacco, and noted that this region has been implicated in hematopoietic (pertaining to the formation of blood or blood cells) malignancies.
"It has been suggested that the increase of chromosomal lesions and structural abnormalities or the very existence of an increased chromosomal instability resulting from the genotoxic effect of tobacco could be indicative of an increased cancer risk and that fragile sites could be responsible for the chromosomal instability observed in cancer cells," the authors write. "Moreover, an increase of chromosomal instability is associated with an increase in the risk of cancer, especially childhood malignancies."
(JAMA. 2005;293:1212-1222. Available post-embargo at jama.com)
Editor's Note: Financial support for this study was provided by the Comissionat per a Universitats i Recerca.
EDITORIAL: SMOKING WHILE PREGNANT
In an accompanying editorial, David M. DeMarini, Ph.D., and R. Julian Preston, Ph.D., of the U.S. Environmental Protection Agency, Research Triangle Park, N.C., discuss the findings in the study which examines the affects of smoking while pregnant.
"The findings of de la Chica et al represent the first report of tobacco smoke-associated genotoxic damage in fetal epithelial (membranous cellular tissue) cells from mothers who smoke. As such, these data add to the set of related and indirect data that have implicated tobacco smoke as a transplacental mutagen to the developing fetus."
"Although consistent with ...previous reports, the study by de la Chica et al contains several limitations that urge caution and suggest that their findings should be viewed as highly preliminary. One limitation is lack of a direct or indirect exposure assessment, such as urinary cotinine measurements of the mother and DNA or protein adduct measurements of both maternal and fetal tissues," they write.
"That so few studies have examined the genotoxic effects of maternal smoking on the fetus reflects the difficulty of such studies in terms of screening and selecting study participants, obtaining fetal cells for analysis, and the limited availability of assays and end points that have been available for use. Although obtaining suitable patients and cells may continue to be problematic, the development of new methods and end points, especially genomic methods, offers hope for progress in this important area of public health. A definitive demonstration of transplacental mutagenesis of fetal epithelial cells by maternal smoking requires further studies that take into account the concerns outlined here. In the meantime, the message to women based on the published literature remains clear: smoking during pregnancy can be hazardous for both the fetus and the mother," the authors conclude.
(JAMA. 2005;293:1264-1265. Available post-embargo at jama.com)
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
A THIRD OF U.S. TWO-YEAR OLDS NOT RECEIVING VACCINES ON TIME
VIDEO:
NAT SOT UP FULL FOR :03
Sarah talking as baby puts block in her mouth
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"No, not in the mouth... please."
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Sarah and Sloane playing with toys on the floor
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SARA HENCHOCK DOESN'T WANT HER DAUGHTER SLOANE PUTTING GERMS IN HER MOUTH. SHE WANTS TO PROTECT HER FROM ILLNESS. THAT'S ALSO WHY SHE HAS SLOANE IMMUNIZED.
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Super: Sara Henchock
Mother
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"The diseases such as whopping cough and measles, for her to be immunized against them is so important."
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Nurse injecting vaccine in baby's leg
Different baby receiving vaccine
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THOSE ARE JUST A FEW OF THE DISEASES BABIES ARE VACCINATED AGAINST. DURING THE FIRST YEAR AND A HALF OF LIFE, A CHILD NEEDS 15 TO 18 DOSES OF VACCINES.
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Super: Elizabeth Luman, Ph.D.
National Immunization Program
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"And these doses need to be given at certain times, at 2 months, 4 months, 6 months, etc. So you can see why it's difficult for parents to make sure they get all their vaccinations on time."
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Dr. Luman and colleagues going over data at desk in office
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DR. ELIZABETH LUMAN (loo-man), FROM THE NATIONAL IMMUNIZATION PROGRAM AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION, LED A STUDY TO FIND OUT HOW MANY CHILDREN FALL BEHIND IN THEIR IMMUNIZATIONS.
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Elizabeth Luman, Ph.D.
National Immunization Program
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"We analyzed data collected in 2003 on over 14,000 2-year old children in the United States."
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GFX/JAMA COVER
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THEIR FINDINGS APPEAR IN JAMA, THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
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Elizabeth Luman, Ph.D.
National Immunization Program
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"We found that more than a third of children were behind in their vaccinations for more than 6 months during their first two years of life."
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Needle going into white baby's thigh
Baby crying
Different white baby getting immunized
African American baby getting immunized
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IT'S IMPORTANT THAT CHILDREN RECEIVE THEIR VACCINATIONS ON TIME DURING THE FIRST TWO YEARS, BECAUSE THIS IS WHEN CHILDREN ARE AT HIGHEST RISK OF MANY SERIOUS DISEASES. CERTAIN GROUPS OF CHILDREN WERE MORE LIKELY TO BE DELAYED IN THEIR VACCINATIONS.
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Elizabeth Luman, Ph.D.
National Immunization Program
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"Children whose mothers are unmarried or have less than a college education and also children who live in households with more than one child and are African American and children who have public vaccination providers and who visit more than one vaccination provider."
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Sara reading book with Sloane
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SARA SAYS HAVING THE SAME PROVIDER SINCE SLOANE WAS BORN IS A BIG HELP.
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Sara Henchock
Mother
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"I think it would be very difficult to keep up with all the vaccinations she needs and when she gets them if I didn't have the pediatrician to handle that for us."
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Sara covering sleeping Sloane with blanket
C/U of Sloane's sleeping face
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SHE'S LUCKY. SHE CAN REST EASY THAT SLOANE HAS ALL THE VACCINATIONS SHE NEEDS. THIS IS MAVIS PRALL REPORTING.
