Bakgrund: Läkemedel är den vanligaste behandlingsformen inom sjukvården och samtidigt det är det bästa och mest effektiva alternativet, så är användningen av läkemedel förenat med risker och bieffekter. Dessa bieffekter är en av de ledande anledningarna till dödsfall i de flesta länder. Upp till 60 % av läkemedelsrelaterade problem skulle kunna undvikas. Det kan vara ett fel som kommer att skada, eller har potential att skada patienten, även kallad undvikbar läkemedelsavvikelse, som kan förekomma i läkemedelskedjan. I SVerige avlider 3150 personer per år av sådana skador. Syfte: Syftet med studien är att beskriva de undvikbara läkemedelsavvikelser som har rapporterats inom Synergi i Landstinget i Östergötland under 2011. Metod: Genomgång av landstinget avvikelserapporteringssystem Synergi med rapporter relaterade till läkemedel. Utifrån beskrivningen i fritexten bedömdes det som det handlade om en undvikbar läkemedelsavvikelse. Resultat: Under 2011 inkom 2750 rapporter varav 2320 klassades som undvikbara läkemedelsavvikelser och 6,7 % (n=155) av dessa ledde till skador. En patient avled till följd av en undvikbar läkemedelsavvikelse. Den vanligaste typen av fel var brist i rutin (n=1255) och vanligaste konsekvensen var uteblivna doser (n=604). Warfarin var det läkemedel som förekom i flest rapporter (n=140), medan uteblivna/för låga doser av heparin ledde till flest allvarliga skador (n=3). Slutenvården stod för 52 % (n=1211) av alla rapporter och även 80 % (n=125) av skadorna. Slutsats: Bristande rutiner kan vara en vanlig orsak till läkemedelsavvikelser. Därför behöver den svenska sjukvården satsa på att förbättra och förenkla sina rutiner, både mellan avdelningar och enskilt för att förbättra patientsäkerheten. Den har kommit en bit på väg, men behöver tydligare riktlinjer och mer utbildning och information till både avdelningar och de enskilda personer som arbetar inom sjukvården. / Background: Drugs are the most common way to treat illnesses in healthcare and the best and most efficient alternative. At the same time you must keep i mind that the use of drugs is always associated with risks and side effects. These side effects or adverse drug reactions are among the leading causes of death in many countries. At least 60 % of adverse drug reactions are preventable. A preventable drug reation is called a medication error. A medication error occurs when a failure in the treatment leads to harm to the patient, or has the potential to lead to harm to the patient. The treatment process is a chain of several events, from the diagnosis of an illness and the choice of drugs, to monitoring the administration. There are many steps from start to the end that all have the potential to lead to mistakes. Medication errors can lead to great costs for healthcare, poor quality of life for the patient or even death. In Sweden it is estimated that 3150 patients die annually caused by medication errors. Purpose: The purpose of this study was to describe medication errors in Landstinget i Östergötland (the County Council of Östergötland) in 2011. Method: Search was done through the error report system, Synergi, with medication error as a priority. From the description in the primary text judge if the report described a medication error. Results: During 2011 2750 reports were submitted to Synergi, and 2320 of these were identified as medication errors. 6,7 % (n=155) of these medication errors had caused harm to the patient, one of them died due to medication error. The most common type of failure was some sort lack of routine (n=1255) and it usually lead to errors of omission; whern a dose that should have been given was not (n=604). Warfarin, an anticoagulantia, was the most frequent drug in the reports (n=140), while a low dose/missed dose of heparin, another anticoagulantia, lead to harm that was classified as serious, to the patients (n=3). MOre than halfr of the reports were fro inpatient care, 52 % (n=1211) and also 80 % (n=125) of medication errors that caused harm to the patients. Conclusion: Lack of routine can be a major cause of medication errors and therefore Swedish healthcare needs to improve routines and even simplify them for easier and faster access for the staff. The cooperation between members of the staff in hospitals, health centers and community home care sholud be better to improve the safety of patients. The healthcare needs more guidance and education to overcome the lack of routines and even more resources for a labor intensive activity where the need for healthcare is increasing

Class of 2014 Abstract / Specific Aims: To assess if the use of three targeted open ended questions elicited more adverse drug reactions (ADRs) and allergies than found in the electronic medical record. Subjects: Inpatients at the University of Arizona Medical Center (UAMC) in Tucson, AZ that were 18 years or older and agreed to participate in the study. Methods: Data was collected using a verbal questionnaire. Each patient was asked the exact same three open ended questions in the same order by the one student to determine the number of ADRs the patient has had. The patient’s electronic medical record at UAMC was used to determine the number of ADRs documented. The number of ADRs elicited by the two methods were documented and compared using statistical analysis. No demographic variables were collected in this study. Main Results: A total of 58 patients at UAMC agreed to participate in our study by answering three targeted open ended questions. Overall the use of the three open ended question did elicit more ADRs (mean = 1.12) than listed on their electronic medical record which were elicited by asking one closed ended question (mean = 0.91). However, the results were not statistically significant (p-value = 0.57). Conclusion: The use of three targeted open ended questions appears to elicit a similar number of ADRs compared to the number of ADRs listed in the patient’s electronic medical record.

Magister Pharmaceuticae - MPharm / South Africa faces a huge Human Immunodeficiency Virus (HIV) burden with more than 400,000 children currently on antiretroviral therapy (ART). Studies on lipid and haematological profile changes in paediatrics are of particular interest since these children are exposed to ART in the course of a developmentally significant period and will possibly have longer collective exposure to ART. As such, monitoring for adverse effects, including lipid and haematological abnormalities, is essential for curtailing morbidity and mortality rates of children on ART. There is a dearth of studies assessing lipid and haematological abnormalities in the South African paediatric population on ART where genetic differences, co-morbidities, malnutrition and use of traditional medicines, all influence the safety profile of a drug. The goal of this study was twofold: Firstly to identify a suitable parameter for assessing lipid and haematological abnormalities in paediatrics on Antiretroviral (ARV) treatment using available secondary data and secondly, to assess prescriber adherence to routine monitoring tests in the ART guidelines. This study was a retrospective review of secondary data obtained from 168 patient clinical records at a Community Health Centre in the Cape Metropole, Western Cape and corresponding laboratory data from the National Health Laboratory Service (NHLS) database. Appropriate cholesterol, triglyceride, haemoglobin and neutrophil test results were compared against the standard reference ranges/values. The Chi-Squared test identified associations between total cholesterol (TC) /triglycerides and haemoglobin (Hb)/neutrophil and other independent variables. Evaluation of health care provider adherence to routine monitoring tests was assessed against relevant national ARV management guidelines. There was a paucity of baseline data for all laboratory markers and infrequent follow-up tests were ordered by healthcare providers. This precluded the measurement of changing lipid and haematological levels and an alternative parameter, viz., the highest available laboratory test value for each marker per patient, was assessed against reference values/ranges. Only nine out of the 36 (25%) patients on an AZT regimen had any Hb or neutrophil laboratory tests performed and 23 and two out of 97 (24% and 2%) patients, respectively, on a protease inhibitor (PI) had a TC and triglyceride laboratory test performed. Anaemia was detected in 45.5 % of children below five years of age, in 21.7% between ages of six and 11 and in 65.5 % between 12 and 14 years of age. Neutropenia was detected in 25.6% of children below five years of age and in 50% aged between six and 11. Hypercholesterolemia was found in 13.1% of patients. The only statistically statistical associations were found between the TC and CD4 count in children aged six to 14 years (χ2=5.000; p=0.025) and between neutrophil counts and viral load in children aged six to 14 years (χ2=6.4532; p=0.0240). A significant association was also found between Hb levels and viral load (χ2=7.000; p=0.008). In the absence of baseline test results and routine monitoring of haematological and lipid profiles, this study presents a potential alternative marker for assessing lipid and haematological abnormalities using the highest level of neutrophil, Hb, TC and triglycerides recorded for each patient.

Magister Public Health - MPH / Background: Adverse Drug Reactions (ADRs) contribute to potentially expensive hospital admissions and are regarded as a major public health priority. ADRs in South Africa are mainly detected by a spontaneous reporting system but it is plagued by under-reporting. Previous records indicated under-reporting of ADRs in the Cape Winelands District amongst healthcare workers. Pharmacists, in particular, did not report ADRs compared to other healthcare cadres whilst they are generally considered to be the custodians of medicines. Study Aim: This study aimed to explore and describe the perceptions and experiences of rural public sector pharmacists’ reporting of ADRs and to understand why pharmacists in this rural health district under-reported ADRs. Study Design: A qualitative study design was appropriate for this research question as the researcher wanted to gain an in-depth understanding of human behavior related to the phenomena of under-reporting. Study Population and Sampling: The primary study population consisted of 24 public sector pharmacists in the Cape Winelands District. A purposive sampling strategy enabled the selection of 16 pharmacists ranging in gender, age, experience and rank. Eight pharmacists were supervisor pharmacists while the rest were production pharmacists, including a community service pharmacist and an intern pharmacist. Supervisor pharmacists are more involved with managerial tasks and the attendance of meetings compared to production pharmacists that focus on patient care and dispensing of medication. Two key informants involved in the Western Cape Pharmacovigilance System were included in the study. One key stakeholder was a policy specialist pharmacist working at Directorate: Pharmacy Services and primarily involved with the Provincial Pharmacy and Therapeutics Committee. The other key policy stakeholder, at the time of the study, was the manager of the Medicines Information Centre which forms part of the University of Cape Town’s (UCT) Pharmacology Division. Both were highly experienced pharmacists familiar with the pharmacovigilance system. Data Collection: In-depth interviews were conducted using a semi-structured interview guide consisting of open- ended questions. The semi-structured interview guide was tested on a participant outside the primary study population. Interviews were conducted in English and Afrikaans. Interviews were tape-recorded and the interviewers made field notes to supplement the data recorded. Two researchers with experience in qualitative data collection, briefed by the investigator, interviewed the pharmacists who worked in the district and the investigator interviewed the two key stakeholders. Data Analysis: The tape recordings were translated, where applicable, and all were transcribed verbatim by the investigator. The transcribed recordings were analyzed by the investigator by assigning codes to material on an Excel spreadsheet. This approach enabled the identification of themes which aided the understanding of the research phenomena. Ethics: Ethical approval was obtained from the University of the Western Cape Senate Research Committee and permission from the Western Cape Department of Health Research Committee. Written informed consent (See Appendix 1, page 73) was obtained from each participant prior to conducting the interviews and interviewees were assured of confidentiality throughout the research. Key Results and Discussion: Pharmacists in the study strongly acknowledged the importance of ADR reporting which is linked with pharmacists seeing themselves as the custodians of medication. Pharmacists in the study associated the reporting of ADRs with medication safety and felt responsible for ensuring it. In spite of this acknowledgement of the importance of ADR reporting, pharmacists rarely reported an ADR themselves. This finding was in line with previous research conducted and linked with barriers pharmacists faced in practice. The study revealed that pharmacists identified ADR reporting opportunities during their normal clinical work and enabled other health care professionals (HCPs) to confirm the occurrence of an ADR and report it. Pharmacists primarily identified ADRs when they scanned patient folders for clues that could indicate that an ADR had occurred. Other research conducted confirmed that the use of patient records could be used in the identification of ADRs. This finding was important to inform future training workshops to promote reporting of ADRs. Some pharmacists in the study associated an ADR with a therapeutic or clinical intervention. In general, therapeutic interventions usually involved a clinical action more closely associated with medical officers and were viewed by pharmacists in the study as being outside their legal and clinical scope of practice. A clinical intervention could include a change of medication, change of dose, and other prescription changes or might involve the medical officer referring the patient to a higher level of care depending on the severity of the suspected ADR experienced. A clinical intervention could include performing complex diagnostic tests, observations and laboratory investigations. Pharmacists’ association of an ADR experience with a clinical intervention was an important factor limiting their reporting of ADRs. The implication of this belief is that patients were referred from the pharmacy back to medical officers for the clinical intervention. In this way, although pharmacists do not directly report an ADR, their referral to medical officers would help improve reporting of ADRs. An unexpected and contrasting finding compared to previous research was the strong belief of some pharmacists in this study that common ADRs should be reported. Pharmacists believed that by reporting common ADRs en masse, authorities might decide to remove the problematic medication from the approved public sector formulary. This was in contrast to previous research where pharmacists either acknowledged that authorities only want novel or serious ADRs from newly marketed medication or believed that reporting well-known ADRs was a waste of time. Pharmacists reported that they faced several barriers in reporting ADRs. The main barriers that were mentioned were a lack of adequate feedback, heavy workload and time constraints, uncertainty in identifying the cause of an ADR and issues pharmacists had with the reporting process. These barriers were consistent with previous research conducted. Finally, pharmacists suggested various means of facilitating ADR reporting including use of electronic reporting aids, creating increased awareness amongst healthcare professionals, conducting continuous training and making amendments to the reporting form, some of which were in line with previous research conducted. Conclusion: Exploring the perceptions and experiences of pharmacists with respect to the under-reporting of ADRs revealed key knowledge about the spontaneous reporting system that could be applied to strengthen the current reporting system and enable more reporting. Whilst it was clear that pharmacists play an important role as the gatekeepers and drivers of the reporting process enabling other HCPs to report ADRs, more should be done to empower pharmacists in managing ADR reporting opportunities. This could benefit the healthcare system in ensuring that more ADRs are reported, as well as decrease the waiting time of patients and the workload of medical officers. In addition, engaging with pharmacists and HCPs to overcome barriers to reporting would facilitate increased ADR reporting. Recommendations: Several recommendations emerged from the study. Future circulars, training workshops and awareness posters about the ADR reporting process should inform all HCPs to report any medication suspected of being the cause of an ADR and not waste time in trying to identify the medication that caused it. A training workshop should be conducted with pharmacists to improve their skills in terms of identifying ADRs, how and what to report and of the appropriate referral of patients to the medical officers. An annual assessment on the availability of reporting forms in all health facilities should be conducted. In addition, the MIC should conduct a survey on the user-friendliness of the reporting form and enable HCPs to provide recommendations to help improve the reporting form template. Pharmacovigilance should be a standing item on the agendas of sub-district PTC meetings at which supervisor pharmacists should give quarterly updates to sub-district management on ADRs reported. As this study focused primarily on the experiences and perceptions of pharmacists in a rural health district, a follow-up study should explore perceptions and knowledge of medical officers and nurses of ADR reporting, specifically on the availability and complexity of the reporting form. Finally, the MIC should explore the development of a basic ADR causality assessment tool that could assist pharmacists and other HCPs in identifying a possible ADR and improve confidence amongst pharmacists and HCPs in reporting ADRs.

Objectives: This thesis included 6 manuscripts which focused on the analysis of adverse events following immunization (AEFIs), including general health services utilization (emergency room (ER) visits and hospital admissions) and specific diagnoses (e.g. febrile convulsions). The main objectives of this research were: 1) To demonstrate the utility of the self-controlled case series (SCCS) design coupled with health administrative data for studying the safety of vaccines; 2) Introducing an innovative approach using relative incidence ratios (RIRs) within an SCCS analysis to identify risk factors for AEFIs and to overcome the healthy vaccinee bias; and 3) To demonstrate how SCCS and RIR analyses of health services outcomes in health administrative data can provide important insights into underlying physiological and behavioural mechanisms. Data Sources: This work utilized Ontario health administrative data housed at the Institute for Clinical Evaluative Sciences (ICES). The study included all children born in Ontario, Canada between 2002 and 2011 (over 1 million children). Vaccinations were identified using OHIP fee for service billing codes for general vaccination. Admissions and ER visits for any reason were identified in the Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS). Primary reasons for admissions and ER visits were investigated using ICD-10-CA codes reported in the DAD and NACRS databases. Statistical Methods: The self-controlled case series design (SCCS) was used to calculate the relative incidence of admissions, ER visits and other AEFIs. To investigate relative incidence for AEFIs across risk groups of interest, as well as addressing the healthy vaccinee effect bias, RIRs were calculated. RIRs are the ratio of incidence ratios in a subgroup of interest relative to a designated reference group. Results and Conclusions: The combined approach of using the SCCS design and RIRs to identify risk factors and overcome the healthy vaccinee bias proved to be a powerful approach to studying vaccine safety. Future work will be important to characterize the performance and validity of the SCCS + RIR approach in the presence of increasing levels of confounding and differing manifestations of the healthy vaccinee bias, as well as to elucidate the biological and behavioural mechanisms underlying our findings.

Evaluation of quality of surgical care begins with the Donabedian triad focusing on structure, process, and outcomes. Outcomes, which are inherently patient-centered, are most easily and commonly measured, and are indeed fundamental to evaluating the quality of surgical care. Specifically, post-operative adverse events (AEs) remain the most frequently measured and reported outcomes, as they represent harm to the patient; and thus, are often used as a means for comparing institutional, as well as, individual surgeon performance. The importance of rigorous recording of clearly defined AEs, although widely recognized, is poorly performed in practice. In previous work, created in accordance to the Clavien-Dindo classification, we developed and integrated a classification of Thoracic Morbidity & Mortality (TM&M) within The Ottawa Hospital’s Division of Thoracic Surgery allowing objective and standardized assessment of all post-operative AEs following all surgeries. In this thesis, the complementary studies that were conducted surrounding the continued clinical application and critical appraisal of the TM&M classification system as a means toward quality improvement are described. Using standardized reporting of both incidence and severity of post-operative complications, we first provide an overview of the burden and distribution that the two most pervasive post-operative AEs have on the thoracic surgical patient population, including prolonged alveolar air leak and atrial fibrillation (Chapter I and II). Next, we explore the inter-system reliability of reported AEs following thoracic surgery from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), which is widely considered the most prominent surgical quality improvement effort, and the TM&M classification system in order to better understand to what extent the methods used to collect data may be impacting results (Chapter III). The disparity between the two systems and the duplicate participation indicates distinct value to the two quality reporting systems. An absence of evidence in the literature regarding individual surgeon outcome reporting and its impact on the quality of care prompted us to create risk-adjusted, surgeon-specific outcome reports to enable individualized performance measurement and feedback (Chapter IV). A priority for the division has been to ensure such measurement translates into reproducible improvements in surgical performance. To do so, we implemented complementary continuous quality improvement seminars to provide an additional forum for discussion regarding collective results, utilizing positive deviance, to unmask best performers as a catalyst for discussing practice measures to improve specific AEs. Lastly, an evolutionary understanding of the heterogeneity of TM&M data was considered as a critical next step to following improvements in care (Chapter V). Recognizing that software was necessary to efficiently record and review TM&M data, iterative development led to an evolution of a real-time, web-based, point-of-care Thoracic Surgery Quality monitoring, Information management, and Clinical documentation (TSQIC) software system. The TSQIC system has enabled bedside data recording and storage, and automated dynamic analysis and reporting of surgical volume and quality. We observe that measurement of TM&M data alone, while necessary, is not sufficient for quality improvement. We suggest that in addition to implementing a complementary point-of-care, interactive, web-based quality monitoring system, key factors for improving quality and patient safety include a combination of temporal analyses of AEs, effective surgeon-specific feedback mechanisms, actionable information based on best practice measures, standardization of case reviews, and a unit-based approach conducive of team-work and safety culture, led by open and collegial dialogue.

Cette thèse propose d'étudier le rôle du secteur privé dans la fourniture des biens et services publics dans le cadre du récent contrat de Partenariat Public-Privé (PPP). Le premier chapitre de cette thèse a pour but de comparer l'efficacité du PPP à sa forme plus ancienne, le contrat de Délégation de Service Public (DSP). Le PPP permet au gouvernement de déléguer à un opérateur privé à la fois la construction d'une infrastructure publique et son exploitation. Cela revient à lui confier de plus grandes responsabilités comparées à ce qu'elles sont dans la DSP et lui confère également une dimension de long terme. L'efficacité du PPP devient alors dépendante des engagements pris par le gouvernement à l'étape de construction, qui peuvent ne pas être honorés à celle d'exploitation. A l'inverse, le contrat de DSP ne souffre pas de cet éventuel opportunisme du fait que les deux tâches relatives à la fourniture de services publics sont réalisées par deux firmes différentes. Nous montrons dans ce chapitre que l'efficacité du PPP est endommagée par l'opportunisme du gouvernement, mais pas suffisamment pour recommander la DSP. Nous concluons que, contrairement à l'opinion générale, l'engagement du gouvernement n'est pas un facteur clés du succès du contrat PPP. Le deuxième chapitre contribue au débat sur l'efficacité de la fourniture du service de l'eau par le secteur privé. Pour cela, nous menons une étude empirique en France, pays pionnier en matière de gestion privée de l'eau. Dans ce chapitre, nous évaluons l'impact du choix de gestion de l'eau sur les prix de l'eau, en prenant soin de corriger le biais de sélection dont souffre cette évaluation. Pour cela, nous estimons un modèle d'effet de traitement à l'aide d'un modèle à variable latente empruntant ainsi la méthodologie de Carpentier et al. (2006). L'effet moyen de la délégation et celui sur une municipalité ayant choisie la gestion privée de l'eau sont examinés. Contrairement aux études empiriques précédentes, nous montrons qu'il n'y a pas de différences significatives de prix de l'eau selon le mode de gestion de l'eau choisi. Le troisième chapitre examine la fourniture de biens publics lorsque ces derniers sont soumis à un risque d'interruption. Afin de pallier ce risque, une autorité publique peut adopter une politique de dédoublement des sources approvisionnement. Au lieu de confier toute la fourniture d'un bien public à une seule et même source, elle peut la confier à deux distinctes. De cette manière, si l'une est interrompue, l'autre peut prendre le relais. Dédoubler les sources approvisionnement permet d'assurer la continuité du bien public mais engendre des coûts, une source plus coûteuse pouvant prendre le relais. C'est ainsi que l'autorité publique fait face à un dilemme entre confier l'approvisionnement du bien public à une ou deux sources. Dans ce chapitre, nous étudions tout d'abord le choix d'approvisionnement avant de nous intéresser au partage respectif de la fourniture du bien public entre les deux sources en cas de dédoublement. Nous analysons également le choix de l'autorité publique en matière d'approvisionnement lorsqu'elle est susceptible d'être influencée par des groupes d'intérêt. / This thesis investigates three questions related to the role of private sector involvement in the provision of public goods or services. The State withdrawal from such provision has led to the use of partnerships between the public and the private sectors. They take place through a variety of contracts from the traditional form of public procurement to the modern form, Public-Private Partnership (PPP). The first chapter analyzes the contracting out of public services through Public-Private Partnerships (PPP) subject to government opportunism. The construction of a public infrastructure and its operation are carried out by a private sector firm. Due to bundling of these two tasks, the PPP efficiency is affected by government's commitment power, contrarily to the traditional procurement, in which the two tasks are contracted out separately. We find that the PPP cost efficiency is damaged by the government opportunism but not sufficiently to recommend the use of TP contract. PPP contract should still be preferred by the government. We conclude that, contrarily to the widespread view, government commitment is not the key factor determining the success of PPP. The second chapter offers an empirical study to contribute to the debate over the efficiency of private provision of water services, looking at the main policy lessons that can be drawn from recent French experience. The purpose of this paper is to accurately evaluate the impact of private management on water prices after taking into account the selection bias. To do so, we use a treatment effect approach in a latent variable framework following the Carpentier et al. (2006) methodology. Two specific treatment parameters are reexamined: the Average Treatment Effect (ATE) and the effect of Treatment on the Treated (ATT). Contrary to the previous empirical findings, we show that private management does not have a significant impact on water prices. The third chapter examines the provision of a public good subject to a risk of disruption in a dynamic setting. To hedge against this risk, a public authority may use a dual sourcing policy. Instead of awarding the entire production to one firm (sole sourcing), he may split production among two firms (dual sourcing). If the production of one firm is disrupted, the other firm may take over. However, ensuring the continuity of production increases the procurement cost since a less efficient firm may be awarded part of the production. The public authority thus faces a trade-off when deciding upon the procurement policy. We first examine the optimal choice between sole and dual sourcing. Then, we determine the optimal share of production awarded to each firm in case of dual sourcing. We also consider how asymmetry of information on the secondary firm's efficiency affects the optimal procurement policy since an informational rent is given up to this firm. Finally, we extend our model to consider the influence of lobbying on the public authority's choice of procurement policy.

A national sample of attorneys (N = 134) was surveyed to investigate how characteristics of a rejected applicant’s claim would affect subsequent claimant outcomes and appraisals. Equal Employment Opportunity Commission (EEOC) merit determinations positively influenced attorney representation decisions and confidence in favorable claimant outcomes. Attorneys found rejected applicant claims more credible when the claimant perceived the selection procedure to be unrelated to the target position and when the applicant was a racial minority. Attorney course of legal action was dependent on the interaction of both EEOC decision and applicant perceptions of job relatedness, such that more claimant supportive actions were observed when the EEOC found merit and the applicant perceived the selection procedures to be job unrelated. The impact of organizational efforts in validation, scoring procedures, and adverse impact reduction were explored in regard to settlement and litigation outcomes. Exploratory analyses identified best practices in regard to these issues.

Adverse childhood experiences (ACEs) have long been linked to poor physical, mental, and behavioral outcomes in adulthood. Individuals with exposure to more types of ACEs are at greater risk of engaging in delinquent and criminal offending and also are relatedly more likely to be involved in the criminal justice system. The high prevalence of ACEs and other co-morbid risk factors in forensic populations calls for further investigation into how differential exposure to adversities influence the onset and nature of offending behaviors. Additionally, there are few studies investigating structural elements that precede offending behaviors (e.g., social and economic factors) in varied communities. Thus, the present study aims to examine the role of individual adversities and community factors on the development of nonsexual delinquent behaviors and juvenile justice involvement in a treatment sample of male adolescents. Data for the present study were derived from two sources. First, data were collected from archival records at a private nonprofit facility in rural Appalachia that provides treatment to adolescents who have engaged in sexually abusive behavior. Variables of interest include exposure to ACEs, indicators of sexual boundary problems within the home of origin (exposure to pornography by adult in home, witnessing sexual behaviors between others), and lifetime arrest history. Second, county-level secondary data were downloaded and delineated by county from the County Health Rankings & Roadmaps (CHR&R) program website, which provides publicly available data compiled by the University of Wisconsin Population Health Institute in collaboration with the Robert Wood Johnson Foundation. The CHR&R data has been published annually since 2010 and includes county-level markers of overall health and various factors that impact the health of counties. A standardized z-score was calculated to indicate social and economic environment compared to other counties in the state. Participants were assigned a z-score based on documented zip code of origin. To test the hypothesized model, confirmatory factor analysis was used, first examining indicators of individual adverse experiences and exposure to sexual behaviors in the home of origin. A three-factor model emerged: Factor 1 represented emotional abuse, physical abuse, and neglect; Factor 2 included indicators of household dysfunction; and Factor 3 included sexual abuse and more passive indicators of sexual boundary concerns in the home. Next, structural equation modeling revealed the association between individual experiences of adversity, county-level social/economic environment, and nonsexual delinquent behaviors with socioecological influences as a moderator. Results reveal varying relationships between exposures to adversity and arrest-related outcome variables. Additional discussion regarding findings, implications, and areas for future research will be explored.

Persons exposed to adverse childhood experiences (ACEs) are at increased risk of developing long-term negative health consequences. ACEs have a cumulative negative impact on mental health outcomes in particular. Evidence suggests that those in forensic psychiatric settings are disproportionally exposed to ACEs, lending to potentially greater complexity in the relationship between ACEs, psychiatric comorbidity, and behavioral problems. Additionally, within this population a common intervention for mental health symptomology includes pharmacology, particularly as health issues compound. As a medication regimen becomes more complex, the risk for negative consequences – including drug interactions, side effects, and even death – increases. Limited empirical research describing associations between ACEs, mental health outcomes, and polypharmacy is available. Furthermore, no published studies to date have examined these relationships in forensic inpatient mental health populations, despite the evidence that these populations are disproportionately exposed to maltreatment and household dysfunction in childhood, frequently have higher rates of physical and mental health problems, and are usually treated with multiple forms of medications in response to health and behavioral needs. To address gaps in existing research, the relationship between ACEs, mental health outcomes, and prescription practices will be examined within a forensic inpatient sample. The current study seeks to investigate the impact of ACEs on mental health outcomes and the relationship to polypharmacy practices within a forensic psychiatric setting. A total of 182 patients residing in a secure forensic psychiatric hospital were selected. The sample is predominantly male (80.8%, n=147) and majority Caucasian (55.5%, n=101) or African American (40.1%, n=73), with a mean age of 43.5 (SD=13.2). Participants range from persons with at least one mental health disorder (100%, n=182) to persons with at least one chronic illness (74.5%, n=132). It is expected that greater experiences of childhood maltreatment and household dysfunction will result in greater negative mental health outcomes and associated behaviors. This relationship is expected to contribute to polypharmacy practices among prescribing physicians. Because high rates of polypharmacy yield a potential for increased aversive health outcomes, understanding the association between ACEs and other predictive factors and polypharmacy practice has valuable implications for the treatment and rehabilitation of persons in forensic mental health settings.