Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe Study

Aim: To determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. Methods: 1) Systematic reviews; 2) Retrospective review of unique medication items prescribed over a 12 month period to a 2% sample of patients from 15 general practices in England; 3) Interviews with 34 prescribers regarding 70 potential errors; 15 root cause analyses, and six focus groups involving 46 primary health care team members Results: The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for one in eight patients, involving around one in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with one in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology. Conclusion: Prescribing errors in general practices are common, although severe errors are unusual. Many factors increase the risk of error. Strategies for reducing the prevalence of error should focus on GP training, continuing professional development for GPs, clinical governance, effective use of clinical computer systems, and improving safety systems within general practices and at the interface with secondary care.

Private industrial project management: a systems-based case study

The technique of linear responsibility analysis is used for a retrospective case study of a private industrial development consisting of an extension to existing buildings to provide a warehouse, services block and packing line. The organizational structure adopted on the project is analysed using concepts from systems theory which are included in Walker's theoretical model of the structure of building project organizations (Walker, 1981). This model proposes that the process of building provision can be viewed as systems and subsystems which are differentiated from each other at decision points. Further to this, the subsystems can be viewed as the interaction of managing system and operating system. Using Walker's model, a systematic analysis of the relationships between the contributors gives a quantitative assessment of the efficacy of the organizational structure used. The causes of the client's dissatisfaction with the outcome of the project were lack of integration and complexity of the managing system. However, there was a high level of satisfaction with the completed project and this is reflected by the way in which the organization structure corresponded to the model's propositions.

Experiences with sustainability indicators and stakeholder participation: A case study relating to a 'Blue Plan' project in Malta

The practical application of systemic sustainability analysis (SSA; Bell and Morse, 1999) as applied in-a project instigated and managed by 'Blue Plan', one of the regional activity centres of the Mediterranean Action Plan, is set out and explained in this paper. The context in which SSA was applied and adapted to SPSA (systemic and prospective sustainability analysis). is described in the Mediterranean, primarily in Malta. The SSA process is summarized, its extension and linkage to the prospective approach is described and the comments of stakeholders in the context are added. Some preliminary outcomes are suggested. The pauticular focus of the paper is on the lessons learned from doing SSA/SPSA within a classic blueprint project framework. It is-not assumed that SSA/SPSA is 'finished' or 'definitive'. Rather, we suggest that it is a developing and changing approach that practitioners can adapt and change to meet the specific needs of the circumstances that confront them. Copyright (C) 2004 John Wiley & Sons, Ltd and ERP Environment.

A conventionally managed project: a systems based case study

The technique of linear responsibility analysis is used for a retrospective case study of a private development consisting of an extension to an existing building to provide a wholesale butchery facility. The project used a conventionally organized management process. The organization structure adopted on the project is analysed using concepts from the systems theory, which are included in Walkers theoretical model of the structure of building project organizations. This model proposes that the process of building provision can be viewed as systems and sub-systems that are differentiated from each other at decision points. Further to this, the sub-systems can be viewed as the interaction of managing system and operating system. Using Walkers model, a systematic analysis of the relationships between the contributors gives a quantitative assessment of the efficiency of the organizational structure used. The project's organization structure diverged from the models propositions resulting in delay to the project's completion and cost overrun but the client was satisfied with the project functionally.

A project managed by a multi disciplinary practice: a systems based case study.

The technique of linear responsibility analysis is used for a retrospective case study of a private industrial development consisting of an engineering factory and offices. A multi-disciplinary professional practice was used to manage and design the project. The organizational structure adopted on the project is analysed using concepts from systems theory which are included in Walker's theoretical model of the structure of building project organizations (Walker, 1981). This model proposes that the process of buildings provision can be viewed as systems and sub-systems which are differentiated form each other at decision points. Further to this, the sub-systematic analysis of the relationship between the contributors gives a quantitative assessment of the efficiency of the organizational structure used. There was a high level of satisfaction with the completed project and this is reflected by the way in which the organization structure corresponded to the model's proposition. However, the project was subject to string environmental forces which the project organization was not capable of entirely overcoming.

An analysis of the management of a public sector project: a systems-based case study

The management of a public sector project is analysed using a model developed from systems theory. Linear responsibility analysis is used to identify the primary and key decision structure of the project and to generate quantitative data regarding differentiation and integration of the operating system, the managing system and the client/project team. The environmental context of the project is identified. Conclusions are drawn regarding the project organization structure's ability to cope with the prevailing environmental conditions. It is found that the complexity of the managing system imposed on the project was unable to achieve this and created serious deficiencies in the outcome of the project.

e-learning in project management using simulation models: a case study based on the replication of an experiment

Current e-learning systems are increasing their importance in higher education. However, the state of the art of e-learning applications, besides the state of the practice, does not achieve the level of interactivity that current learning theories advocate. In this paper, the possibility of enhancing e-learning systems to achieve deep learning has been studied by replicating an experiment in which students had to learn basic software engineering principles. One group learned these principles using a static approach, while the other group learned the same principles using a system-dynamics-based approach, which provided interactivity and feedback. The results show that, quantitatively, the latter group achieved a better understanding of the principles; furthermore, qualitatively, they enjoyed the learning experience

The use of public participation and economic appraisal for public involvement in large-scale hydropower projects: Case study of the Nam Theun 2 Hydropower Project

Gaining public acceptance is one of the main issues with large-scale low-carbon projects such as hydropower development. It has been recommended by the World Commission on Dams that to gain public acceptance, publicinvolvement is necessary in the decision-making process (WCD, 2000). As financially-significant actors in the planning and implementation of large-scale hydropowerprojects in developing country contexts, the paper examines the ways in which publicinvolvement may be influenced by international financial institutions. Using the casestudy of the NamTheun2HydropowerProject in Laos, the paper analyses how publicinvolvement facilitated by the Asian Development Bank had a bearing on procedural and distributional justice. The paper analyses the extent of publicparticipation and the assessment of full social and environmental costs of the project in the Cost-Benefit Analysis conducted during the projectappraisal stage. It is argued that while efforts were made to involve the public, there were several factors that influenced procedural and distributional justice: the late contribution of the Asian Development Bank in the projectappraisal stage; and the issue of non-market values and discount rate to calculate the full social and environmental costs.

Implementing ‘Site BIM’: a case study of ICT innovation on a large hospital project

Numerous Building Information Modelling (BIM) tools are well established and potentially beneficial in certain uses. However, issues of adoption and implementation persist, particularly for on-site use of BIM tools in the construction phase. We describe an empirical case-study of the implementation of an innovative ‘Site BIM’ system on a major hospital construction project. The main contractor on the project developed BIM-enabled tools to allow site workers using mobile tablet personal computers to access design information and to capture work quality and progress data on-site. Accounts show that ‘Site BIM’, while judged to be successful and actively supporting users, was delivered through an exploratory and emergent development process of informal prototyping. Technical IT skills were adopted into the construction project through personal relationships and arrangements rather than formal processes. Implementation was driven by construction project employees rather than controlled centrally by the corporate IT function.

Change management in practice: an ethnographic study of changes to contract requirements on a hospital project

Changes to client requirements are inevitable during construction. Industry discourse is concerned with minimizing and controlling changes. However, accounts of practices involved in making changes are rare. In response to calls for more research into working practices, an ethnographic study of a live hospital project was undertaken to explore how changes are made. A vignette of a meeting exploring the investigation of changes illustrates the issues. This represents an example from the ethnographic fieldwork, which produced many observations. There was a strong emphasis on using change management procedures contained within the contract to investigate changes, even when it was known that the change was not required. For the practitioners, this was a way of demonstrating best practice, transparent and accountable decision-making regarding changes. Hence, concerns for following procedures sometimes overshadowed considerations about whether or not a change was required to improve the functionality of the building. However, the procedures acted as boundary objects between the communities of practice involved on the project by coordinating the work of managing changes. Insights suggest how contract procedures facilitate and impede the making of changes, which can inform policy guidance and contract drafting.

Application of dried blood spots to determine vitamin D status in a large nutritional study with unsupervised sampling: the Food4Me project

An efficient and robust method to measure vitamin D (25-hydroxy vitamin D3 (25(OH)D3) and 25-hydroxy vitamin D2 in dried blood spots (DBS) has been developed and applied in the pan-European multi-centre, internet-based, personalised nutrition intervention study Food4Me. The method includes calibration with blood containing endogenous 25(OH)D3, spotted as DBS and corrected for haematocrit content. The methodology was validated following international standards. The performance characteristics did not reach those of the current gold standard liquid chromatography-MS/MS in plasma for all parameters, but were found to be very suitable for status-level determination under field conditions. DBS sample quality was very high, and 3778 measurements of 25(OH)D3 were obtained from 1465 participants. The study centre and the season within the study centre were very good predictors of 25(OH)D3 levels (P<0·001 for each case). Seasonal effects were modelled by fitting a sine function with a minimum 25(OH)D3 level on 20 January and a maximum on 21 July. The seasonal amplitude varied from centre to centre. The largest difference between winter and summer levels was found in Germany and the smallest in Poland. The model was cross-validated to determine the consistency of the predictions and the performance of the DBS method. The Pearson's correlation between the measured values and the predicted values was r 0·65, and the sd of their differences was 21·2 nmol/l. This includes the analytical variation and the biological variation within subjects. Overall, DBS obtained by unsupervised sampling of the participants at home was a viable methodology for obtaining vitamin D status information in a large nutritional study.