Errors associated with the preparation of aseptic products in UK hospital pharmacies: lessons from the national aseptic error reporting scheme

Background Pharmacy aseptic units prepare and supply injectables to minimise risks. The UK National Aseptic Error Reporting Scheme has been collecting data on pharmacy compounding errors, including near-misses, since 2003. Objectives The cumulative reports from January 2004 to December 2007, inclusive, were analysed. Methods The different variables of product types, error types, staff making and detecting errors, stage errors detected, perceived contributory factors, and potential or actual outcomes were presented by cross-tabulation of data. Results A total of 4691 reports were submitted against an estimated 958 532 items made, returning 0.49% as the overall error rate. Most of the errors were detected before reaching patients, with only 24 detected during or after administration. The highest number of reports related to adult cytotoxic preparations (40%) and the most frequently recorded error was a labelling error (34.2%). Errors were mostly detected at first check in assembly area (46.6%). Individual staff error contributed most (78.1%) to overall errors, while errors with paediatric parenteral nutrition appeared to be blamed on low staff levels more than other products were. The majority of errors (68.6%) had no potential patient outcomes attached, while it appeared that paediatric cytotoxic products and paediatric parenteral nutrition were associated with greater levels of perceived patient harm. Conclusions The majority of reports were related to near-misses, and this study highlights scope for examining current arrangements for checking and releasing products, certainly for paediatric cytotoxic and paediatric parenteral nutrition preparations within aseptic units, but in the context of resource and capacity constraints.

Space-efficient Indexing of Chess Endgame Tables

Chess endgame tables should provide efficiently the value and depth of any required position during play. The indexing of an endgame’s positions is crucial to meeting this objective. This paper updates Heinz’ previous review of approaches to indexing and describes the latest approach by the first and third authors. Heinz’ and Nalimov’s endgame tables (EGTs) encompass the en passant rule and have the most compact index schemes to date. Nalimov’s EGTs, to the Distance-to-Mate (DTM) metric, require only 30.6 × 10^9 elements in total for all the 3-to-5-man endgames and are individually more compact than previous tables. His new index scheme has proved itself while generating the tables and in the 1999 World Computer Chess Championship where many of the top programs used the new suite of EGTs.

Space-efficient indexing of endgame tables for chess

Chess endgame tables should provide efficiently the value and depth of any required position during play. The indexing of an endgame’s positions is crucial to meeting this objective. This paper updates Heinz’ previous review of approaches to indexing and describes the latest approach by the first and third authors. Heinz’ and Nalimov’s endgame tables (EGTs) encompass the en passant rule and have the most compact index schemes to date. Nalimov’s EGTs, to the Distance-to-Mate (DTM) metric, require only 30.6 × 109 elements in total for all the 3-to-5-man endgames and are individually more compact than previous tables. His new index scheme has proved itself while generating the tables and in the 1999 World Computer Chess Championship where many of the top programs used the new suite of EGTs.

The bond scheme

Under the bond scheme, a pre-determined series of payments would compensate farmers for lost revenues resulting from policy change. Unlike the Single Payment Scheme, payments would be fully decoupled: recipients would not have to retain farmland, or remain in agriculture. If vested in a paper asset, the guaranteed, unencumbered, income stream would be similar to that from a government bond. Recipients could exchange this for a capital sum reflecting the net present value of future payments, and reinvest in other business ventures, either on- or offfarm.With a finite, declining flow of payments, budget expenditure would reduce, releasing funds for other uses.

A comparison of conservative upwind difference schemes for the Euler equations

Numerical results are presented and compared for three conservative upwind difference schemes for the Euler equations when applied to two standard test problems. This includes consideration of the effect of treating part of the flux balance as a source, and a comparison of different averaging of the flow variables. Two of the schemes are also shown to be equivalent in their implementation, while being different in construction and having different approximate Jacobians. (C) 2006 Elsevier Ltd. All rights reserved.

An adaptive finite element water column model using the Mellor-Yamada level 2.5 turbulence closure scheme

A one-dimensional water column model using the Mellor and Yamada level 2.5 parameterization of vertical turbulent fluxes is presented. The model equations are discretized with a mixed finite element scheme. Details of the finite element discrete equations are given and adaptive mesh refinement strategies are presented. The refinement criterion is an "a posteriori" error estimator based on stratification, shear and distance to surface. The model performances are assessed by studying the stress driven penetration of a turbulent layer into a stratified fluid. This example illustrates the ability of the presented model to follow some internal structures of the flow and paves the way for truly generalized vertical coordinates. (c) 2005 Elsevier Ltd. All rights reserved.