10/18/24, 9:17 PM Module 5

Module 5

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Module 5 Study Guide and Deliverables

Readings: Lecture Topics:

Lecture 09: The Renal, Urinary, and Reproductive Systems
Lecture 10: Cancer

Case study:

D1 Case Study Amata Chapter 06 pdf

Recommended Reading:

Anatomy and Physiology (Biga et. al., 2019)

Chapter 25: The Urinary System

Chapter 26: Fluid, Electrolyte, and Acid/Base Balance

Hacking Healthcare (Trotter and Uhlman, 2011)

Chapter 7 Human Errors

Health informatics and drug adverse reactions:

Lecture material:
L3 Adler JPtSaf 1208 2 pdf
L4 Classen HealthAff 2011 pdf
L5 Goldman Adverse Event Reporting 1996 pdf
L6 Kass RIA1 2001 pdf
Additional Materials:
NIH What is Cancer?
NIH About Cancer

Discussions: Discussion 5

Initial posts due by Saturday, October 5 at 11:59 PM ET

Comments on other students' posts due by Tuesday, October 8 at 6:00 PM
ET

Assignments: Assignment 5 due Tuesday, October 8 at 6:00 PM ET

Assessments: Graded Quiz 5 due Tuesday, October 15 at 6:00 PM ET

Live Classroom: Tuesday, October 1 from 7:00-8:30 pm ET
Friday, October 4 from 7:00-8:30 pm ET

Module Overview

The urinary and reproductive systems are usually grouped together as the genitourinary system. This grouping is an accident of common tissue origin, similar anatomical
location and the sharing of some structural elements for both urinary excretion and the process of germ cells production and fertilization. In this module, an overview will be
provided of the structure, function and basic physiology of the renal and genitourinary systems.

The word cancer strikes fear into many; nevertheless, the advances in diagnosis and treatment over the last 40 years have made it a much more manageable process
prolonging not only life but the quality of life for survivors. We will address the differences between benign and malignant tumors; how diagnoses may be made; how therapies

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may be targeted, and how normal tissue may also be damaged. Additionally, we will address how the tissue origin of a tumor may preserve some of the functionality of the
originating tissue with profound consequences for physiological homeostasis. The contribution of immunity and infectious disease to cancer will also be addressed. Not only
can viral infection be associated with subsequent tumor development, but the immune system itself helps eradicate potential cancerous cells from the body. Much like
endocrine pathologies, neoplastic disease has metabolic consequences often far beyond the original insult, thus efficient and accurate information transfer between specialist
members of a team dealing with a particular patient places a heavy responsibility upon the IT infrastructure. Case studies will be used to exemplify this issue.

Learning Objectives

After completing this module, you will cover the basics of the physiology of human renal, urinary, and reproductive systems. You will also understand the key concepts related
to safety of patients, focusing on medication errors and adverse drug reactions. You will develop understanding of specific points:

The structure, function and basic physiology of the renal, urinary, and reproductive systems
The means to measure and image function in these systems
Therapies available and possible medical interventions
How tumors arise: disposition and multi‐step insults to the cell
Common diagnostic methods, treatments, and procedures associated with these disorders
Imaging techniques to aid differentiation of normal tissue from neoplastic tissue
Adverse drug reactions and adverse drug events

The Renal, Urinary, and Reproductive Systems

The Renal, Urinary, and Reproductive Systems

Components of the urinary and reproductive systems exist in relatively close proximity. The male urethra (see next section) is a component of both the urinary system and the
male reproductive system.

Functions of the urinary system include waste and electrolyte excretion. Water is excreted by the urinary system. Normal kidney function includes the ability to concentrate the
urine. The degree of concentration of the urine can be varied depending on body needs.

The male and female reproductive systems function in procreation. Not only do these systems have different anatomy, these systems have different common disorders. As
such, common diagnostic and treatment procedures differ as well.

Physicians of many different specialties may be involved in the treatment of patients with disorders of the urinary system, female reproductive system, or male reproductive
system. Some of these specialties are nephrology, urology, and gynecology. A physician that specializes in diagnosis and treatment of disorders of the kidney is known as a
nephrologist. A surgeon that specializes in diagnosis and treatment of disorders of the urinary tract and the male reproductive system is known as a urologist. A physician that
specializes in the diagnosis and treatment of disorders of the female reproductive system is known as a gynecologist. A physician that specializes in taking care of women
during pregnancy and childbirth is known as an obstetrician.

Basic Urinary System Anatomy

The urinary system consists of two kidneys, two ureters, one bladder, and one urethra.

Components of the Urinary System

(NCI, n.d.)

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The kidneys are bean shaped organs located in the retroperitoneal area of the abdominal cavity. As you may recall from lecture 4, retroperitoneal is behind the area of the
abdominal cavity surrounded by the tissue membrane known as the peritoneum. There is normally one kidney on each side of midline (left and right).

Blood flows from the aorta toward each kidney through a renal artery. Blood flowing from each kidney travels through a renal vein to the inferior vena cava.

The basic functional unit of the kidney is the nephron. There are approximately one million nephrons in a normal kidney.

A ureter runs from each of the kidneys to the bladder. The bladder holds urine and can expand to some degree as the amount of urine contained increases. The wall of the
bladder contains a muscular layer known as the detrusor muscle.

Urine exits the bladder and the body through the urethra. In males, the urethra runs through the penis. In females, the urinary meatus or external opening of the urethra, is just
anterior to the external opening of the vagina.

There is an internal urethral sphincter and an external urethral sphincter. The internal urethral sphincter contains smooth muscles. The external urethral sphincter contains
skeletal or striated muscle.

Something to think about

Does the muscle composition of the internal and external urethral sphincter remind you of the anal
sphincter mentioned in module 2?

Basic Urinary System Physiology

Blood flows to the kidneys and is filtered at the nephrons. The result of this filtering that occurs at the glomerulus is known as glomerular filtrate. A number of relatively complex
processes occur in the renal tubules that alter the glomerular filtrate. These processes include reabsorption and secretion of glucose and electrolytes and reabsorption of
water.

The altered glomerular filtrate leaves the kidneys as urine through the ureters. The urine travels through the ureters to the bladder.

Urine is stored in the bladder. Normally, an amount of stored urine is reached that causes a person to feel that they have the need to urinate or void. The internal urethral
sphincter normally relaxes involuntarily, while the external urethral sphincter is normally relaxed voluntarily to allow urination.

The kidney has other functions besides the production of urine. One of these is the production of the hormone erythropoietin. Erythropoietin stimulates the production of red
blood cells or erythrocytes.

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Common Urinary System Pathophysiology

A common disorder of the urinary system is infection. A bacterial infection of the bladder or cystitis may be referred to as a urinary tract infection or simply as a “UTI”. These are
more common in women than men. The urethra (path from outside the body to the bladder) is much shorter in women than men.

A urinary tract infection may also involve the kidney. This is referred to as pyelonephritis.

Sexually transmitted infection of the urethra may occur. Organisms that can cause this include Neisseria gonorrhoeae and Chlamydia trachomatis. Infections with these
organisms are commonly referred to as gonorrhea and chlamydia respectively. Patients that have infections of the urethra caused by these organisms may experience dysuria.
Dysuria is pain or difficulty with urination. Infections with these organisms may be symptomatic or asymptomatic.

Kidney stones form from solids that precipitate from urine in the urinary system. Most kidney stones contain calcium, but there are other types. The condition of having kidney
stones is referred to as nephrolithiasis. It is common for a patient with a kidney stone to have pain and blood in the urine. A kidney stone may cause obstruction in the urinary
system.

Chronic renal failure and end-stage renal disease are conditions of long-term kidney function decline or complete failure. There are multiple causes of end-stage renal disease
including high blood pressure and diabetes mellitus. Patients with end-stage renal disease will die if not treated.

Common Urinary System Diagnostic Tests

A urinalysis is a test that is commonly ordered during evaluation and treatment of a patient. It is commonly a group of tests that involves the use of a strip with multiple small
squares on it that is dipped into urine. The squares can change color according to the presence and/or amount of a substance. You may hear the strip referred to as a
“dipstick”.

Blood urea nitrogen, commonly referred to as “BUN”, and creatinine are commonly ordered blood tests that are used to estimate kidney functioning. Urea is produced during
protein metabolism. Creatinine is formed through metabolism of creatine, which is found in muscle. Measurements of both of these may be expected to increase in cases of
declining kidney function. You may hear the condition of having an elevated blood urea nitrogen referred to as azotemia. Other conditions or factors may influence the results
of these tests. Dehydration may cause the proportion of blood urea nitrogen to creatinine to increase.

Common components of a urinalysis include protein and glucose. A urinalysis that is “positive” for glucose (test results consistent with glucose in the urine) may occur when
the urine of a patient with diabetes mellitus is tested. There may be limitations to urinalysis testing. For example, a urinalysis protein test may not detect certain proteins. Urine
is also commonly evaluated under a microscope.

Not all kidney stones are visible on X-ray films. A procedure known as intravenous pyelography has been used commonly in the past to help diagnose kidney stones. You may
hear this procedure referred to as an “IVP”. Radiopaque dye is administered intravenously to a patient for an intravenous pyelogram. The dye is excreted through the urinary
system. X-rays are taken while the dye is in the urinary system. This procedure may show evidence of a kidney stone in a ureter. CT scan can now be used to help diagnose
kidney stones.

Intravenous Pyelogram

(Wikipedia, 2015a)

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Common Urinary System Treatment

Infections of the urinary system may be treated with antibiotics. Factors that may influence specific antibiotic regimen selection include the infecting organism and the condition
of the patient. A female patient with cystitis may be treated with antibiotic pills taken for three days. A patient with pyelonephritis may be admitted to the hospital and treated
with intravenous antibiotics.

A kidney stone may pass through the urinary system and leave the body with the urine without specific treatment. Sometimes more complex or invasive treatment is indicated
to remove or destroy a kidney stone. One such treatment is extracorporeal shock wave lithotripsy. This involves the use of shock waves directed towards the stone through a
water medium. Treatment aimed at preventing future stones may include dietary changes and/or medication.

Kidney stone fragments after lithotripsy

(Wikipedia, 2015)

Patients with end-stage renal disease may be treated with dialysis. Dialysis may be thought of as trying to duplicate the function of the kidney through artificial or partially
artificial means.

Hemodialysis involves passing the patient’s blood through a dialysis machine. A hemodialysis machine contains semipermeable membrane. A fluid known as dialysate is used
in hemodialysis. In concept, the dialysate is functionally similar to urine. It is common for a patient undergoing hemodialysis to have a surgically introduced connection between
an artery and a vein in their arm.

Peritoneal dialysis involves infusing fluid into the abdominal cavity so that it comes in contact with the peritoneal membrane. The fluid is retained for a period of time then
drained out. The infused fluid may be thought of as similar in function to the dialysate in hemodialysis. The peritoneal membrane may be thought of as similar in function to
semipermeable membrane used in hemodialysis.

Some patients with end-stage renal disease are treated with a kidney transplant. The transplanted kidney may be from a living or deceased donor.

Basic Female Reproductive System Anatomy

The female reproductive system includes two ovaries, two fallopian tubes, one uterus, and one vagina. Due to the related role of infant nutrition, the female breasts will be
included in this section.

The external female genitalia are known as the vulva. This is the location of the external opening of the vagina. The vagina extends internally between the bladder and the
rectum.

Female External Genitalia

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(NCI, n.d.a)

The cervix, which is part of the uterus, is located at the internal end of the vagina. There is an opening in the cervix known as the external os. This opening leads to the inner
cavity or uterine cavity of the uterus. The internal layer of the uterus is known as the endometrium.

Organs of the Female Reproductive System

(NCI, n.d.a)

Extending laterally from either side of the uterus is a fallopian or uterine tube. There are finger-like structures around the end of the fallopian tubes called fimbriae. Each ovary
is attached to the uterus by an ovarian ligament.

Uterus and Uterine Tubes

(NCI, n.d.a)

The breasts lie on the anterior chest and contain adipose, or fat, tissue and a system of ducts. Ducts run from lobules of the breast to the nipple.

The Breast and its Structures

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(Rice, 2003).

Basic Female Reproductive System Physiology

The menstrual cycle occurs during childbearing years in females. Gonadotropin-releasing hormone (GnRH) is secreted by the hypothalamus and influences the secretion
of Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH) by the anterior pituitary gland. LH and FSH influence the ovaries, which secrete estrogen and
progesterone.

The menstrual cycle lasts an average of 28 days. Variations in hormone levels occur during this cycle. Ovulation occurs roughly in the middle of the cycle. An oocyte (immature
female egg) is released from an ovary. Normally the oocyte would enter the fallopian tube and travel to the uterus. If fertilization does not occur, there is bleeding and discharge

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of endometrial tissue out of the uterus and through the vagina. This is known as menstruation. If fertilization does occur, this typically takes place in the fallopian tube.

Normal pregnancy involves fertilization, and implantation in the uterus. Ovulation and menstruation cease and there is breast tissue growth. A hormone known as human
chorionic gonadotropin is produced by the placenta.

The duration of a normal pregnancy is approximately 38 weeks from the time of fertilization. During and after birth, oxytocin is released from the posterior pituitary gland.
Oxytocin plays a role in delivery and breast feeding of the baby.

Menstruation ceases with menopause. The age of onset of menopause varies, but it typically occurs somewhere about age 50.

Common Female Reproductive System Pathophysiology

Breast cancer is the most common cancer in American women (CDC, 2015). Breast cancer occurs primarily in women, but can occur in men. Breast cancer has been
associated with certain genes. The staging of breast cancer typically involves assessment of axillary lymph nodes on the side of the body that the breast cancer is found.
These lymph nodes lie in or near the armpit area.

Annual deaths due to cervical cancer in the U.S. have decreased. This can be attributed to screening. Cervical cancer has been associated with certain types of a virus
called human papilloma virus (HPV).

It is possible for pregnancy to occur with implantation outside of the uterus. This is known as ectopic pregnancy. Most of these occur in a fallopian tube. An ectopic pregnancy
may cause life-threatening bleeding.

Infertility is a term that may be used to describe a situation in which regular intercourse and insemination (ejaculation of the male semen in the reproductive tube of the female)
for an extended period of time has not resulted in pregnancy. Significant resources have been applied to the diagnosis and treatment of infertility.

Common Female Reproductive System Diagnostic Tests

Pregnancy tests may help in “diagnosing” pregnancy. It is common to test for a subunit of human chorionic gonadotropin (hCG). Urine or blood may be tested. Home urine
pregnancy tests are currently available.

A mammogram is an x-ray study of the breast. Mammography can be used to screen for breast cancer. It may also be helpful in diagnosing breast cancer. One might think of
the difference between screening and diagnosing as follows: screening is done on a population that does not have any complaints or findings to suggest the presence of what
you are looking for, while diagnosing is done on someone that has a finding or complaint that suggests the possibility of what you are looking for.

Normal Mammogram

(Rice, 2003).

A Papanicolaou smear or Pap smear is used as a screening technique to look for evidence of cervical cancer or abnormal conditions that could lead to cervical cancer. The
procedure involves using an instrument inserted into the vagina to obtain a cell sample.

Common Female Reproductive System Treatments

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Surgery may be part of the treatment of breast cancer. There are different surgical procedures that may be used. Both the stage of the tumor and patient preference may play
a role in determining a surgical procedure that is used in treating a patient with breast cancer. A lumpectomy is removal of a tumor with some surrounding breast tissue.
Removal of an entire breast would be considered a mastectomy.

Treatment of breast cancer may also consist of or include chemotherapy, radiation, hormonal therapy or antibody therapy. Some breast cancer tumors test positive for certain
receptors. An example of this would be estrogen receptors. Patients with a breast cancer tumor that tests positive for estrogen receptors may be treated with a medication
called tamoxifen. A simple way that one might think of the action of tamoxifen is that it prevents estrogen from attaching to breast cancer tissue and stimulating its growth.

The treatment of cervical cancer generally depends primarily on the stage at diagnosis. Treatment may include surgery, chemotherapy, and/or radiation.

Vaccination against certain types of human papilloma virus (HPV) is available. This vaccination is thought to lower risk of cervical cancer.

In vitro fertilization may be used in cases of infertility. This involves removal of oocytes and fertilization outside of the body. A resulting embryo or embryos are transferred to the
uterus of the patient.

Basic Male Reproductive System Anatomy

One might think of the purpose or function of the male reproductive system as delivering sperms to the female reproductive system. Sperms are the male counterparts to
female eggs and both are known as gametes, with a spermatozoon being needed for the fertilization of an ovulated egg . In order to understand the male reproductive system,
it might be helpful to trace the path taken by spermatozoa within the male reproductive system.

Spermatogenesis, or formation of spermatozoa, occurs in the testes. A normal male has two testes that lie within the scrotum.

Male Reproductive System

(NCI, n.d.d)

Spermatozoa move from the testes to the epididymis. Normally there is an epididymis adjacent to each testis.

From the epididymis, spermatozoa enter a relatively narrow tube-like structure known as the vas deferens. A vas deferens runs from each epididymis.

There are two seminal vesicles. Each located near the prostate and bladder. A duct from the seminal vesicle joins the vas deferens to form the ejaculatory duct. Each
ejaculatory duct joins the urethra within the prostate gland. (The urethra passes through the prostate gland.)

Spermatozoa travel through the vas deferens and the ejaculatory duct to continue in the urethra. From there, spermatozoa follow the same path as urine to leave the penis.

Basic Male Reproductive System Physiology

Gonadotropin-releasing hormone (GnRH) is secreted by the hypothalamus and influences the secretion of Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH) by
the anterior pituitary gland. LH and FSH influence the testes.

The testes secrete testosterone and dihydrotestosterone. These hormones are part of a group of hormones known as androgens. Androgens are associated with male
secondary sexual characteristics. Athletes have used this type of “steroid” to enhance athletic performance.

There is no monthly cycle of fertility for human males. Spermatozoa from the testis are contained in the epididymis. Increased amount of blood flow in the penis causes
erection and an increase in the size of the penis results. Erection occurs during sexual arousal. During sexual intercourse, the friction with the vaginal wall after consecutive
intromissions stimulates the very sensitive nerve endings on the surface of the penis and normally leading to ejaculation of the semen . The ejaculation results in spermatozoa
along with the semen components to be from the penis into the female reproductive tube. The seminal vesicles produce fluid that is ejaculated along with spermatozoa.

Erections occur during sleep in normal males and that is because of the increase of nitric oxide that cause vaso dilatation, this process is involuntary. Constriction of the blood
vessels of the penis limits blood flow and reverses erection. Cold water or ice causes constriction of the vessels, other medication that produce the same results as a side

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effect and lead to what is known as erectile dysfunction. Nocturnal penile tumescence refers to erections that occur during sleep.

Common Male Reproductive System Pathophysiology

Benign prostatic hyperplasia (BPH) is a nonmalignant increase in size of the prostate gland. This is a common condition in older men.

Benign prostatic hyperplasia may cause symptoms by obstructing urine flow. Complaints of a patient with benign prostatic hyperplasia may include difficulty starting a urine
stream and urinating frequently at night.

Benign Prostatic Hyperplasia

(NCI Visuals Online, 2008)

Cancer of the prostate is a common cancer in men. It is typically diagnosed in older men. Prostate cancer may cause death. Prostate cancer may not cause any problems in a
particular patient. Physicians’ decisions regarding screening for and treatment of prostate cancer may not be an easy one .

Erectile dysfunction (ED) is the inability to attain or maintain an erection sufficient for sexual intercourse. The incidence of erectile dysfunction increases in males with
advancing age. There are multiple factors that may cause or contribute to erectile dysfunction. Significant resources have been applied to the treatment of erectile dysfunction.

Common Male Reproductive System Diagnostic Tests

A physician may detect enlargement of the prostate gland on physical examination. Abnormalities of the prostate gland may be found on digital rectal examination.

Digital Rectal Exam

(NCI Visuals Online, 2008a)

The measurement of prostate specific antigen, commonly referred to as “PSA”, is a test that may be helpful in diagnosing prostate cancer. A rise in prostate specific antigen
may be due to other causes besides cancer. For example, an elevation in prostate specific antigen may accompany benign prostatic hyperplasia.

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A biopsy of the prostate may be performed when prostate cancer is suspected. This can be guided by transrectal ultrasound (TRUS), which involves placing an ultrasound
probe in the rectum. Biopsy can be performed by needle through the rectum or by inserting a metal tube through the penis and all the way to the prostate gland (a very painful
procedure).

Transrectal Ultrasound with prostate biopsy

(NIDDK, 2012)

The clinical evaluation for erectile dysfunction could include a number of tests. One of these tests is a serum prolactin level. You may recall from lecture eight that a
prolactinoma secretes prolactin without being inhibited by the normal regulatory mechanism. A prolactinoma could cause or contribute to erectile dysfunction. Other testing
could include evaluating or monitoring for nocturnal penile tumescence.

Common Male Reproductive System Treatments

Treatment possibilities for erectile dysfunction now include oral medications. Another treatment possibility involves the surgical implantation of a penile prosthesis. There are a
number of other treatment possibilities.

Surgical Implant

(NIDDK, 2012a)

Treatment possibilities for benign prostatic hyperplasia include the use of oral medication aimed at shrinking the prostate. Another treatment possibility is transurethral
resection of the prostate (TURP). This involves inserting an instrument into the urethra and removing prostate tissue. There are a number of other treatment possibilities.

TURP

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(NIDDK, 2012a)

Treatment possibilities for prostate cancer include observation, surgery, radiation, and hormone therapy. Treatment of prostate cancer may result in significant complications or
problems for a patient. One of these is impotence or loss of erectile function.

References

CDC (2015) Breast cancer. Retrieved 8/20/2015 from http://www.cdc.gov/cancer/breast/.

Genetics Home Reference (2015) What is DNA? Retrieved 8/20/2015 from http://ghr.nlm.nih.gov/handbook/basics/dna.

NCI (n.d.) Components of the urinary system. Retrieved 8/20/2015 from http://training.seer.cancer.gov/anatomy/urinary/components/.

NCI (n.d.a) External genitalia. Retrieved 8/20/2015 from http://training.seer.cancer.gov/anatomy/reproductive/female/genitalia.html

NCI (n.d.b) Female reproductive system. Retrieved 8/20/2015 from http://training.seer.cancer.gov/anatomy/reproductive/female/.

NCI (n.d.c) Genital tract. Retrieved 8/20/2015 from http://training.seer.cancer.gov/anatomy/reproductive/female/tract.html.

NCI (n.d.d) Male reproductive system. Retrieved 8/20/2015 from http://training.seer.cancer.gov/anatomy/reproductive/male/.

NCI Visuals Online (2008) Benign prostatic hyperplasia. Retrieved 8/9/2022 from https://visualsonline.cancer.gov/details.cfm?imageid=7137.

NCI Visuals Online (2008a) Digital rectal exam. Retrieved 8/9/2022 from https://visualsonline.cancer.gov/details.cfm?imageid=7136.

NIDDK (2012) Imaging of the Urinary Tract. Retrieved 8/20/2015 from https://www.niddk.nih.gov/health-information/diagnostic-tests/urinary-tract-imaging.

NIDDK (2012a) Erectile Dysfunction. Retrieved 8/20/2015 from https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/.

NIDDK (2012b) What I need to know about Prostate Problems. Retrieved 8/20/2015 from https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems.

Rice, J. (2003) The terminology of health & medicine (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.

Wikipedia (2015) Extracorporeal shock wave lithotripsy. Retrieved 8/20/2015 from https://en.wikipedia.org/wiki/Extracorporeal_shock_wave_lithotripsy.

Wikipedia (2015a) Intravenous pyelogram. Retrieved 8/20/2015 from https://en.wikipedia.org/wiki/Intravenous_pyelogram.

Cancer

Cancer

What is Cancer? Are all Cancers the same? Why still we do not have a cure for cancer despite the amount of money invested? These and many other questions are valid and
will be discussed throughout the lecture to give an understandable approach to the Neoplasic disease (Cancer).

The relevance of Cancer (Neoplasic Disease) is huge if we take into account that the National Cancer Institute spends around 5 billion dollars annually in research and
treatment. According to data from 2008 – and figures have changed very slightly since then- Breast Cancer is the most funded research (around 10-12% of the total funds).
The runner up is Prostate Cancer receiving 6.5% of the funds and Colon Cancer is the third target with 6% of the overall budget. The Uterine Cancer is the research with fewer
funding, receiving only around 0.3% of the funds.

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For a better scope and understanding, below there is a list of the most frequent cancer type in the USA per gender, incidence (new cases diagnosed per year), and mortality
rate ( Deaths of a certain cause –in this case cancer- / Population)x 100,000) as for 2010:

Table 1. Twelve Most Frequent Cancer Types in USA 2010

Type of cancer Incidence (new cases per year) Estimated Mortality Rate(per 100,000 habitants)

Lung and bronchus 222,520 50.7

Prostate 217,730 10.3

Breast (only females) 207,090 12.9

Colon and Rectal 142,570 16.6

Bladder 70,530 4.7

Melanoma 68,130 2.8

Non-Hodgkin lymphoma 65,540 6.5

Kidney 53,581 3.9

Thyroid 44,670 0.5

Endometrial 43,470 2.6

Pancreatic 43,140 11.9

Leukemia 43,050 7.0

Total 1,222,021 130.46

Therefore, we can understand that the stakes are high.

More information can be found in

http://surveillance.cancer.gov/about/
http://www.cdc.gov/
http://www.cancer.gov/

The Basis of Cancer

The Stages of Tumor Development

(NIH Office of Science Education, n.d.)

Organ development and repair are based on cell growth and maturation. Both are normal events that happen constantly in all our different tissues, organs and systems.
However, both, cell growth and maturation, must follow a specific pace, order and are controlled by complex regulating systems. If these regulation systems do not act at
specific moments during cell growth and maturation, cell growth will be not stopped and cells will also not mature as they should, therefore, not being able to maintain their
normal and desired function.

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In general, under the term of Cancer or Neoplasia there are enclosed a spectrum of diseases characterized by abnormal cell growth, certain degree of invasion, and certain
degree of cell immaturity. The different cancer types are classified according to their primary original tissue (where they are formed initially), as well as sub divided according to
different characteristics the cells have, the degree of invasion (local or with distant metastasis: cancer cells that have migrated from the original anatomic location to any other
part of the body, through the lymphatic system or the circulatory system, and start growing cancer in those other areas), and genetic information.

Basic Genetics of Cancer

Normal cells have an inner part called nucle us where the genetic material (DNA) which is condensed as euro-chromatin and heterochromatin. During cell division the cell
condense its chromatin material into chromosomes to ensure the proper and equal error-less transmission of the genetic material from the mother cell to the daughter cells.
Humans have 46 chromosomes, 44 chromosomes are called autosomal chromosomes and 2 chromosomes are known as sex chromosomes. The two sex chromosomes in
females are called XX where as in males are known as XY, where Y is a shorter chromosome but carries sex determining genes which once expressed switch the
development of the embryo from female to male. The chromosomes are just a spatial configuration to compact and compress the information located in the DNA. Therefore,
the chromosomes are made of DNA and some structures (proteins) that help to fold it properly.

DNA is nothing else but “the Code.” Genes are DNA sequences that differ in length and the order of the four chemical compounds called nucleic bases. These four bases
are Adenine (A), Cytosine (C), Guanine (G), and Thymine (T). A gene has coding regions (exons) and non-coding regions (introns). Getting from the code in DNA to the final
product, protein, is a complicated process. First, genes are transcribed (copied) to messenger RNA strands that travel from the nucleus to the cytoplasm of the cell. The RNA
code is read and translated to make the protein, which is synthesized with the help of two other forms of RNA—ribosomal RNA and transfer RNA.

DNA is a double helix formed by base pairs attached to a

sugar-phosphate backbone.
(Genetics Home Reference, 2015)

When cells divide, the DNA—chromosomes—should be divided too. In order to do that there are several very well specified steps in which the chromosomes should unfold
themselves, let special proteins replicate the sequence of DNA, and fold themselves again. During the replication phase (S-phase of the cells cycle), a preparatory step before
the process of cell division “Mitosis”—the DNA is more exposed and less protected than when it is condensed as the chromosomes. If something affects the cells at that
moment in time—toxins, radiation, cigarette’s smoke, etc. , there are chances that the DNA will be affected (mutated) and changes in one or more bases may be copied in the
other cell. Although DNA damage is very common and there are mechanisms to repair it, there are moments in which these damages are either too extended and/or in a
critical position. When the DNA damage is either too long and/or in a specific coding location, cells can only have one “dignifying” solution: induced self death —it is
called apoptosis: programmed cell death; it also happens when cells “get old” and do have to be replaced like skin cells that replicate very often—and thus, not propagate the
DNA damage to the next generation. However, sometimes cells do not undergo apoptosis because the genes regulating apoptosis are mutated, or the cells express apoptosis
inhibitory proteins and proliferation inducing proteins leading to a n inhibited growth, replicate and inconsistently mature in an anarchical way, leading to what is known
as Neoplasia or Cancer.

There are specific genes—parts of DNA coding—that have a specific relationship with Neoplasia. They are called Proto-oncogenes and Suppressor genes. As we have
mentioned before, DNA can be damaged easily, and in fact this is what happens. We have in place a set of proteins that recognize and repair DNA damages to avoid aberrant
cells. Despite the names, Proto-oncogenes and Suppressor genes, the function of many of these is still unknown and not very well explained. They have many interrelations
with different pathways. The expression of these genes (if they are activated or not; like a switch, on/off) is also dependent on many complex factors. What is important to know
about them is that these special types of genes play a major role in controlling DNA damages, and that when they change their functional status (e. g. from “on” to “off” or
partially activated) these changes may translate to a cascade of events and differences in protein action that could eventually lead to Neoplasia.

Finally, it is important that all the mechanisms in cell replication—mitosis—growth and apoptosis are mediated by a complex system of intrinsic factors—from inside of the cell
working as a “clock” indicating the moment in which cells should replicate or die—as well as a combination of extrinsic factors like toxins or chemical compounds in the blood.
They generate a cascade of events that involve what is called pathways with different outcomes. Those pathways are a set of interrelated chemical changes in different

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proteins and compounds in the cells that lead to a desired outcome: mitosis or apoptosis in this case. Current drug developments target these specific intermediate proteins in
a cascade of a pathway to either block mitosis or induce apoptosis in cancer cells while avoiding damaging “normal” cells to a certain extent.

Classifying Neoplasia

The general agreement in classifying a neoplasia is based on the origin of the tumor (let’s say, from the digestive tube, like Colon cancer), as well as the extent of the disease
itself (located in a single point or with metastasis). Other classifications regarding cell type and cell origin are not intended to be discussed in this course.

Therefore, thanks to the description above, we can understand that Colon cancer belongs to the digestive tube, Thyroid cancer to the thyroid gland, breast cancer to breast
and so on. Also, hematologic neoplasms are malignant cells coming from the cells of the blood: platelets, red corpuscles and white or lymphocytic cells, as well as some
structures called lymph. Basically, depending on the origin of the tumor cell, we will have cancer in one or all of these cells. The importance for this is that those cells will no
longer have their normal function, and for example, their initial symptoms will be: a) anemia and tiredness with a problem in the red cells, b) infections, fever, and tiredness with
a problem with the white cells, c) problems in coagulation if platelets are affected.

The common names for these type of cancers are: lymphoma (Hodgkin and non-Hodgkin lymphoma), leukemia (chronic or acute). There are many subtypes and classification
in every one of them, but what is relevant is that most of them have common issues, as well as there are some of them that occur due to very specific and concrete mutations
in DNA. These specific mutations could eventually be solved in the future with what is called genetic therapy—where you try to replace the “erroneous” genetic code with a
non-malignant one—as well as being able to work with stem cells.

Common Treatment in Neoplasia

As is widely known, chemotherapy and radiation are the two most common treatments for most of the cancers, as well as surgical removal of the tumor when possible.

Chemotherapy aims to kill malignant cells by poisoning. This is introducing chemical factors in the cells and trying to cause apoptosis. The usual mechanisms of delivery are
either oral, or by injecting this type of chemical in the blood. These chemicals substances mostly attack cells with higher rate of mitosis (proliferation) and thus, mostly attack
malignant cells. However, this type of therapy also kills “normal proliferating cells like lymphocytes and hair follicles” or non-malignant cells, thus showing the side effects
mostly associated with the use of chemotherapy. Current drug development tries to better differentiate malignant from non-malignant cells by using chemicals that specifically
targets some proteins that are almost concentrated in the malignant cells. However, this new line of chemotherapy, although a great advance, is still not totally safe or without
side effects too.

Radiation’s approach is different. It basically aims to “burn” a specific part of the body, in that case, the cancer. Therefore, it is not always possible to use and most of the time
relies on physical contact (although radiation is mostly used in brain tumors and without direct physical contact).

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In general, the medical approach is to be as aggressive as possible with the tumor and probably using different kinds of chemotherapy at the same time, or even combinations
of radiation and chemotherapy to rapidly kill the tumor, avoid spread and give the rest of the body a chance to recover. Also, there are certain protocols that use a combination
of chemotherapy and/or radiation pre or post-surgical removal of the tumor, either to shrink the tumor before operating and making easier to remove, or later, to kill any
remaining microscopic cells in the site.

Epidemiology

Epidemiology is a science that includes the study of patterns of disease process occurrence. You may hear the term used in reference to the science in general, applied to a
research project, or applied to a specific disease process.

Knowledge of a pattern of disease process occurrence may lead to identification of a cause or contributing factor of that disease process. This may lead to control of that
disease process.

The following figure shows information related to occurrence of Rocky Mountain Spotted Fever. This is an infectious disease spread by ticks.

Percent of RMSF Cases Reported each Month, 1993–2008

Proportion of RMSF cases reported to CDC by month of onset 2008,

Epidemiology Figure 4
(CDC, 2013)

Something to think about

What do you think is the explanation for the pattern seen in the previous diagram?

Associated IT: Cancer

There are many vendors supplying applications/systems for healthcare environments that range from small practices to big hospitals. However, no matter if the
application/system is a generic EHR/EMR or a system designed for a specific medical unit, there are still some business/healthcare functions that will not be covered by these
applications/systems. If the healthcare organization performs some kind of specialty function, it is uncommon for these giant applications to completely cover all aspects of the
specialty function. An example of this may be a cancer treatment facility or a pediatric cancer treatment facility. In such cases, the specialty center or facility may have a
custom system developed. Below is a screen shot for a chemotherapy treatment plan template that is taken from a system for chemotherapy.

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Chemotherapy treatment plan sample

Custom applications for other functions or specialties such as billing, immunization, anesthesia, or cardiology could be developed. There could be more than 250 custom
applications in a big hospital. A new technology may evolve from these customizations at large hospitals. MUMPS language is an example of such an occurrence. MUMPS
(Massachusetts General Hospital Utility Multi-Programming System), or just M, is a programming language developed at Mass General hospital in the 1960s. The following is
another screen shot taken from a custom system for billing.

Screen capture from sample billing system

Immunization is another example of a medical function that may not be covered in enterprise wide applications. A sample report generated from a custom application is shown
below. Schools in Massachusetts need this report.

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School report

Screen capture from immunization tracking application

Case Study: Cancer

A 30 year old male presented to the emergency department for sudden onset of left flank pain and nausea. The patient was in his usual state of health until 3 days ago when
he developed new onset diarrhea. The patient reported that the diarrhea lasted about 2 days and then got better. The patient also reported that his daughter had diarrhea
about 5 days ago and her friend had diarrhea last week. The patient reported that he was starting to feel better from his diarrhea when he developed sudden onset left side
flank pain. He stated that the pain sometimes feels like it is going to his groin. The patient reports that he feels like he is going to vomit, but has not done so. The pain started
about two hours prior to coming to emergency department. The patient has no other significant past medical history.

On examination, the patient appeared to be in significant distress and holding his left side. There was no fever and no abdominal tenderness.

The patient’s white blood cell count was normal and he was not anemic. His BUN was mildly elevated. Creatinine was normal. The patient’s urinalysis was positive for
hematuria or blood in the urine.

The patient was initially treated with intravenous fluid and pain medication. A CT scan was ordered for the patient.

The patient waited some time before he was taken to get the CT scan. The patient waited some time after having the CT scan for the study to be interpreted. Findings on the
CT scan were consistent with a kidney stone in the left ureter.

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When the emergency department physician went to see the patient with the results of the CT scan, the patient informed the emergency department physician that he was
feeling much better. The pain and nausea had completely resolved.

The patient was seen by his own physician at a follow-up visit and reported no complaints or problems.

IT Workflow: Cancer

The IT Workflow for evaluation and management in the hospital emergency department would be similar to that outlined for the case study in lecture 3. The IT Workflow for the
CT Scan would be similar to that outlined for an MRI in lecture 7.

The IT workflow associated with treating two different patients may be very similar, even if those patients have very different medical problems. The IT workflow associated with
treating two different patients may vary more depending on the unit(s) or location(s) of a patient’s treatment, whether treatment is inpatient or outpatient, and if any specialized
technology that utilizes unique IT systems is used in evaluation or treatment of the patient.

Another aspect of IT workflow is billing and collection. This involves the use of coding which is further discussed in Module 6. An EHR system may assign codes based on
physician input completed during or after evaluation of the patient.

Billing is now typically done electronically. As previously mentioned, this process may be initiated automatically following a physician’s input regarding evaluation and
management of a patient. Electronic billing typically involves the use of a standard referred to as X12.

Cases presented in this course have been relatively simple and straightforward. A patient could be hospitalized for months and experience multiple aspects of disease
manifestations and complications following treatment. Care of a patient may involve multiple units of a facility or multiple facilities. Examples of this are transfer to another
hospital and transfer to a rehabilitation facility. Transfer of information regarding a patient’s previous care to another healthcare facility may be accomplished manually or
electronically.

Introduction: IT in Diagnostic Imaging

Diagnostic imaging plays an important role in modern medicine. The electronic storage of medical images is now quite common in the U.S. Hence, it has become important to
provide a system that can easily store images digitally and make them available whenever needed with minimal effort.

Digital medical images consist of machine generated data which is non-structured. (The data does not consist of rows and columns.) Also the understanding of the data is
based upon human and/or machine interpretation. Image management may vary from database to database.

Database Systems

A database is an application/system used to store data and make it available. Database systems can vary from simple to very complex based on the features an organization
needs. Almost every application needs some kind of a database. The database could be a simple indexed organized file system, a relational database, a hierarchical database,
a network database, or an object-relational database. The majority of database systems are relational, but hierarchical is also used.

Oracle, DB2, SQL Server, MySQL, PostgreSQL are examples of relational databases. IBM IMS (Information Management System) is a hierarchical database. Cache is
example of an object oriented database. CouchDB and Mongo are other kinds of object oriented databases.

Some database are built for specific needs. For example TeraData, Netezza, and Greenplum are designed for data warehousing needs; while Timesten and VoltDB are
memory resident database systems.

Relational databases store and manage data in a structure called a table. A table contains data arranged in rows and columns.

In the example above emp_id and emp_name are columns. There are five records or rows in the table. A database for an application may have from a few tables to thousands
of tables.

Object oriented databases may store images in native file systems. Relational database may store images as large object data types.

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PACS

Digital diagnostic image storage requires PACS. PACS stands for Picture Archiving and Communication System. PACS consists of image and data acquisition, storage, and a
retrieval system. It can range from a simple film digitizer with a small database to very complex enterprise system. The main components of the PACS are imaging modalities
or devices, interface, host computers, storage devices, network, and display systems.

PACS Components and Data Flow

Simple PACS components. HIS – Hospital Information System, RIS – Radiology Information System. The
application servers are used for education, research, and other clinical usage.

As digital images require larger storage sizes, it may be necessary to compress the image files for transmission and storage purposes. In general there are two types of image
compression methods; lossless and lossy. A lossless scheme can compress the image files in a ratio of 3:1. In this method, the original image can be recovered from the
compressed images. On the other hand, in the lost method, the images can be compressed in a ratio of up to 50:1 or more. In such cases, the image quality gets degraded.
Another type of compression is clinical image compression, which stores only certain useful images and discards others.

Fig: Image Compression.

Image Compression

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The decoding procedure is performed in opposite fashion to encoding procedure. Quantization determines the compression ratio.

Typical Size of the Images

The size of an image in an imaging study series varies based on the procedure, device resolution, compression factor, redundancy of the images, and BSA (body surface
area). However, this table provides a general idea of how big an image in a series could be.

Procedure # of images in the series Size of an Image

Plain Film 1 to 10 images 2MB-2.5MB

MRI Typically 100 or more images 150KB-200KB

UltraSound 15 to 100 images 120KB-150KB

CT Scan A series could have 1000 or more images. 200KB-500KB

Datatypes and Structures

Databases may provide some special data types and structures for dealing with images or unstructured data. These may be handled similarly to structured data in storage,
indexing, processing, and manipulations. For example, oracle provides PL/SQL packages, procedures, and functions for multimedia or DICOM (Digital Imaging and
Communication in Medicine) data along with an increased range of features such as partition, support of 3-D data, point clouds, and terrain models. The GeoRaster data type
handles significantly larger data sets with improved performance and greater simplicity. Oracle Multimedia (interMedia) provides good storage, management, and processing
for images and other corporate data. Oracle Multimedia also supports SecureFiles. This makes a very good combination to improve performance, and content management
capabilities. A BLOB (a large object datatype) of up to 128 TB can be stored and retrieved easily.

Along with faster and better image data storage and retrieval, current database technologies also provide supporting image attributes including height, width, compression,
resolution, and structured data for image identification.

DICOM (Digital Communication and Imaging in Medicine)

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Having so many vendors for applications, systems, diagnostic modalities, it becomes necessary to have standards for data and image communications. Interfacing diagnostic
imaging systems or components requires two things: a common data format and a communication protocol. HL7 is a standard format for data and DICOM (Digial Imaging and
Communication in Medicine) is a data and communication protocol. Using the DICOM standard, heterogeneous modalities (from different manufacturers) can be interfaced to
form an integrated healthcare system.
There are two components of DICOM: The information object class and the service class.

1. The object class defines the contents of the images and their relationship: Patients, Study, Results, Storage resources, and Image annotations are normalized DICOM
information object classes. Computed radiograph, Computed tomogram, Digitized film image, Digital subtraction image, MR image, Nuclear medicine image, Ultrasound
image, Displayable image, and Graphics are composite DICOM information object classes.
2. The service class defines what to do with these objects: Image storage, query, retrieval, and print are DICOM service classes. DICOM files start with file meta-
information, then data set, then image pixel data.

Fig: DICOM Communication. This figure shows the steps required to move the images from a scanner to the workstation. The steps are generalized into four steps. A step that
occurs within a device is called service, and a protocol occurs between devices.

CT scanner encodes images into DICOM objects

Scanner calls DIMSEs (DICOM message service elements) to move the image objects down to the physical layer.
The workstation calls the counter set of DIMSEs to receive the object and to convert it to a certain level.
The workstation decodes the DICOM objects.

Medical Errors

A health information system has three main components: hardware, software, and people. In addition to that it contains several additional components: clinical guidelines,
medical terminology dictionaries, interfaces to diagnostic devices, and interfaces to various databases. These databases may include laboratory, pharmacy, diagnostic
imaging, research, and specialist registry databases.
Upgrades to central hardware and software are relatively easy to identify, design, and implement. Upgrades to additional components may be more challenging because of
knowledge-based content and technological dependencies that need to be addressed. Upgrades to people (technology adoption, education, change of process, replacements,
and expansion of teams) producers and users of health information are the most difficult. The upgrades to health information systems need to be done with exceptional care—
a replacement of a hardware component may affect other participating components ranging from software and databases, to any of the steps in clinical process. Testing of an
upgrade does not involve checking the replaced component, but also a detailed analysis of possible ripple effects throughout clinical process.
Major types of health information systems include:

Electronic Medical Records Systems that stores patient data acquired during encounters
Computerized provider order entry (CPOE) that support ordering diagnostic tests and therapy plans
Medication administration systems (MAS) that support medication dispensation that typically use bar coding.
Clinical decision support systems that assist healthcare professionals to make decisions of clinical relevance such as diagnosis or therapy.
Telemedicine systems that transfer health data at distance.

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Electronic error reporting systems where various institutions report errors that occurred during health care delivery.
Insurance and Claims Systems

Health information systems enable access to information that can be used to improve both the outcomes of health care and patient safety. The Agency for Healthcare
Research and Quality (AHQR) of the Department of Health and Human Services has defined quality indicators for improving performance of hospitals (see the AHRQ Quality
Indicators Toolkit for Hospitals document).
WHO’s definition of an adverse drug reaction (ADR), which has been in use for more than 40 years, is “a response to a drug that is noxious and unintended and occurs at
doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification of physiological function” (WHO, 1972). ADRs happen in situations where
the drugs are in-appropriately used. While most preventable drug related injuries suffered by patients as a result of errors in drug use (Bates et al., 1997). An adverse event is
defined as an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of
discharge, or both (Brennan et al., 1991). Adverse drug events (ADE), a subset of adverse events, are injuries resulting from medical intervention related to drugs. They are
more comprehensive and clinically significant than ADRs (Bates et al., 1997).
The main types of adverse drug reactions (ADRs) and their prevalence are shown in Figure 1. The bodily systems most commonly affected by ADRs include heart, stomach
and intestines, central nervous system, kidneys, and vascular system. It is very difficult to predict patients who will suffer from ADRs or a drug that is likely to cause an ADR.
The best current predictor is known history of ADRs that can be retrieved from the EHR. Other than known history, patient characteristics are usually not useful predictors of an
ADR. The factors like older age, intensity of treatment, severity of illness, and multiple medications are increasing the risk of ADRs, but these factors do not show cause and
effect relationship that is known to exist between patients who suffer ADEs and these factors. The intensive care unit patients are at increased risk for severe ADRs than other
patients.

Figure 1. Prevalence of different types of ADRs. These results represent the averages from
four reported studies
Classen et al., 1997; Jha et al., 1998; Bates et al., 1997; Leape et al., 1991

Patient injuries resulting from ADEs significantly increase the cost of health care and represent a major opportunity for hospitals to reduce costs. More than 770,000 injuries
and deaths happen each year in the US (Kass, 2001). Direct hospitals expenses from treating ADEs during hospitalization are estimated to be between 1.5 and 5.5 billion
dollars annually. These estimates exclude costs for new hospital admissions due to ADEs, and costs for litigation, malpractice, and settlement for injuries. The 2001 statistics
by the AHRQ in 2001 dollars include:

ADEs in hospitalized patients resulted in 8-12 days longer hospitalization adding $16,000 - $24,000 to hospital cost.
Estimated 28 – 95% of ADEs are preventable - medication errors can be prevented through use of computerized monitoring systems.
More than 84% of errors (dose, frequency, and route mistakes) can be prevented through the use of computerized medication order entry.
Computerized systems alone can help save up to $500,000 annually in direct costs in each hospital.
Reduction medical errors can be achieved through integration of best practices, education of hospital staff, and information technology.

Medication administration process involves four major steps: ordering (typically by the physician), transcription (entering into medication sheets), dispensing (by pharmacist),
and administration (typically by the nurse). Medication errors may occur at any of the steps, but most commonly they happen during ordering and administration. Medication
Errors are a frequent cause of ADEs. The most common medication errors include (Kass, 2001):

Dose error
Known allergies
Wrong drug given to a patient
Wrong route of drug administration (e.g. orally, intradermally, IV)
Wrong frequency of drug administration
Missed dose
Wrong techniques
Illegible orders
Duplicate therapy
Adverse drug-drug interaction
Equipment failure
Inadequate monitoring

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Preparation errors

Figure 2 shows the percent for selected types of errors that were commonly associated with ADEs.

Figure 2. Commonly studies medication errors as causes of ADEs: percent of ADEs for each cause
(Kass, 2001).

The research of medication error indicated that the reduction of incidence of ADEs involves information technology for minimization of medication errors. Examples of these
improvements include better detection (using expert systems), better prevention (using CPOEs), understanding the causes of ADEs (making system changes), and
improvement of quality (using CPOEs and information technology). Some factors, however, such as genetic predisposition are known risk factors. The improvement of
medication administration can be facilitated through:

Integration of safety information from FDA's MedWatch program into hospital information systems. The MedWatch is accessible at www.fda.gov/medwatch.
Improving and streamlining incident reporting and analysis systems. For example formal implementation of the “Global Trigger Tool” has shown that 90% of ADEs are
not reported if AHRQ Quality Indicators Toolkit is used (Classen et al., 2011). The detailed implementation of Global Trigger Tool is described in (Adler et al.2008).
The process of error reporting must be based on trust with no fear of repercussions or punishment and automated system of error reporting may help improve the
situation.
Stronger involvement of pharmacists in educating and advising physicians who prescribe medications.
Improvement of medication administration and monitoring systems using reliable bar coding, alerts, and warning systems, additional warnings when potential for harm is
high (e.g. administration of insulin, narcotics and opiates, or anticoagulants).

References

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