PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

Managing the duality of IHRM: unravelling the strategy and perceptions of key actors in South Korean MNCs

This research aims to extend our understanding of the duality between global integration and local responsiveness in multinational corporations (MNCs) by exploring the perceptions of corporate HR actors regarding the intra-organisational factors that alter the balance between these pressures. It examines the perceptions and actions of key actors in the context of two Korean MNCs. The study shows the importance attributed to a range of socio-procedural factors by corporate actors and which, therefore, inform the practical management of the dual forces, notably: HR expertise, social ties, trustworthy relationships and co-involvement in decision processes.

Investigating task difficulty: learners’ and teachers’ perceptions

This paper presents an investigation into learners’ and teachers’ perceptions of and criteria for task difficulty. Ten second language learners performed four oral narrative tasks and were retrospectively interviewed about which tasks they perceived as difficult, what factors affected this difficulty and how they identified and defined this task difficulty. Ten EFL/ESOL teachers were given the same tasks and asked to consider the difficulty of the tasks for their learners, and were invited to discuss the factors they believed contributed to this difficulty. Qualitative analysis of the data revealed that, although there were some differences between the two groups’ perceptions of task difficulty, there was substantial similarity between them in terms of the criteria they considered in identifying and defining task difficulty. The findings of this study lend support to the tenets of a cognitive approach to task-based language learning, and demonstrate which aspects of two models of task difficulty reflect the teachers’ and learners’ perceptions and perspectives.

Translation practices in political institutions: a comparison of national, supranational, and non-governmental organisations

This paper explores the settings and practices of translation at three types of political institutions, i.e. national, supranational, and non-governmental organisations. The three institutions are the translation service of the German Foreign Office, the translation department of the European Central Bank, and translation provision by the non-governmental organisation Amnesty International. The three case studies describe the specific translation practices in place at these institutions and illustrate some characteristic translation strategies. In this way, we reflect on how different translation practices can impact on translation agency and how these practices in turn are influenced by the type of institution and its organisational structure. The article also aims to explore to which extent the characteristics of collectivity, anonymity and standardisation, and of institutional translation as self-translation are applicable to the institutions under discussion.

Conflicting language ideologies and contradictory language practices in Singaporean bilingual families

Informed by family language policy (FLP) as the theoretical framework, I illustrate in this paper how language ideologies can be incongruous and language policies can be conflicting through three multilingual families in Singapore representing three major ethnic groups – Chinese, Malay and Indian. By studying their family language audits, observing their language practices, and engaging in conversations about their language ideologies, I look at what these families do and do not do and what they claim to do and not to do. Data were collected over a period of 6 months with more than 700 minutes of recording of actual interactions. Analysis of the data reveals that language ideologies are ‘power-inflected’ and tend to become the source of educational and social tensions which in turn shape family language practices. In Singapore these tensions are illustrated by the bilingual policy recognising mother tongues (MTs) and English as official languages, and its educational policy establishing English as the medium of instruction. The view of English as having instrumental values and MTs as having cultural functions reveals that language choices and practices in family domains are value-laden in everyday interactions and explicitly negotiated and established through FLP.

A case study of the Tatweer school system in Saudi Arabia: the perceptions of leaders and teachers

School reform is a major concern in many countries that seek to improve their educational systems and enhance their performances. In consequence, many global schemes, theories, studies, attempts, and programmes have been introduced to promote education in recent years. Saudi Arabia is one of these countries that implemented educational change by introducing many initiatives. The Tatweer Programme is one of these initiatives and is considered as a major recent reform. The main purpose of this study is to investigate this reform in depth by examining the perceptions and experiences of the Tatweer leaders and teachers to find out which extent they have been enabled to be innovative, and to examine the types of leadership and decision-making that have been undertaken by such schools. This study adopted a qualitative case study that employed interviews, focus groups and documentary analysis. The design of the study has been divided into two phases; the first phase was the feasibility study and the second phase was the main study. The research sample of the feasibility study was head teachers, educational experts and Tatweer Unit’s members. The sample of the main study was three Tatweer schools, Tatweer Unit members and one official of Tatweer Project in Riyadh. The findings of this study identified the level of autonomy in managing the school; the Tatweer schools’ system is semi-autonomous when it comes to the internal management, but it lacks autonomy when it comes to staff appointment, student assessment, and curriculum development. In addition, the managerial work has been distributed through teams and members; the Excellence Team plays a critical role in school effectiveness leading an efficient change. Moreover, Professional Learning Communities have been used to enhance the work within Tatweer schools. Finally the findings show that there have been major shifts in the Tatweer schools’ system; the shifting from centralisation to semi-decentralisation; from the culture of the individual to the culture of community; from the traditional school to one focused on self-evaluation and planning; from management to leadership; and from an isolated school being open to society. These shifts have impacted positively on the attitudes of students, parents and staff.

The social relations of business representation and devolved governance in the United Kingdom

The reform of regional governance in the United Kingdom has been, in part, premised on the notion that regions provide new territories of action in which cooperative networks between business communities and state-agencies can be established. Promoting business interests is seen as one mechanism for enhancing the economic competitiveness and performance of 'laggard' regions. Yet, within this context of change, business agendas and capacities are often assumed to exist 'out there, as a resource waiting to be tapped by state institutions. There is little recognition that business organisations' involvement in networks of governance owes much to historical patterns and practices of business representation, to the types of activities that exist within the business sector, and to interpretations of their own role and position within wider policymaking and implementation networks. This paper, drawing on a study of business agendas in post-devolution Scotland, demonstrates that in practice business agendas are highly complex. Their formation in any particular place depends on the actions of reflexive agents, whose perspectives and capacities are shaped by the social, economic, and political contexts within which they are operating. As such, any understanding of business agendas needs to identify the social relations of business as a whole, rather than assuming away such complexities.

What is the new medicines use review ‘patient survey’ attempting to capture in the context of existing patient satisfaction with pharmacy questionnaires and a new conceptual framework?

The community pharmacy service medicines use review (MUR) was introduced in 2005 ‘to improve patient knowledge, concordance and use of medicines’ through a private patient–pharmacist consultation. The MUR presents a fundamental change in community pharmacy service provision. While traditionally pharmacists are dispensers of medicines and providers of medicines advice, and patients as recipients, the MUR considers pharmacists providing consultation-type activities and patients as active participants. The MUR facilitates a two-way discussion about medicines use. Traditional patient–pharmacist behaviours transform into a new set of behaviours involving the booking of appointments, consultation processes and form completion, and the physical environment of the patient–pharmacist interaction moves from the traditional setting of the dispensary and medicines counter to a private consultation room. Thus, the new service challenges traditional identities and behaviours of the patient and the pharmacist as well as the environment in which the interaction takes place. In 2008, the UK government concluded there is at present too much emphasis on the quantity of MURs rather than on their quality.[1] A number of plans to remedy the perceived imbalance included a suggestion to reward ‘health outcomes’ achieved, with calls for a more focussed and scientific approach to the evaluation of pharmacy services using outcomes research. Specifically, the UK government set out the main principal research areas for the evaluation of pharmacy services to include ‘patient and public perceptions and satisfaction’as well as ‘impact on care and outcomes’. A limited number of ‘patient satisfaction with pharmacy services’ type questionnaires are available, of varying quality, measuring dimensions relating to pharmacists’ technical competence, behavioural impressions and general satisfaction. For example, an often cited paper by Larson[2] uses two factors to measure satisfaction, namely ‘friendly explanation’ and ‘managing therapy’; the factors are highly interrelated and the questions somewhat awkwardly phrased, but more importantly, we believe the questionnaire excludes some specific domains unique to the MUR. By conducting patient interviews with recent MUR recipients, we have been working to identify relevant concepts and develop a conceptual framework to inform item development for a Patient Reported Outcome Measure questionnaire bespoke to the MUR. We note with interest the recent launch of a multidisciplinary audit template by the Royal Pharmaceutical Society of Great Britain (RPSGB) in an attempt to review the effectiveness of MURs and improve their quality.[3] This template includes an MUR ‘patient survey’. We will discuss this ‘patient survey’ in light of our work and existing patient satisfaction with pharmacy questionnaires, outlining a new conceptual framework as a basis for measuring patient satisfaction with the MUR. Ethical approval for the study was obtained from the NHS Surrey Research Ethics Committee on 2 June 2008. References 1. Department of Health (2008). Pharmacy in England: Building on Strengths – Delivering the Future. London: HMSO. www. official-documents.gov.uk/document/cm73/7341/7341.pdf (accessed 29 September 2009). 2. Larson LN et al. Patient satisfaction with pharmaceutical care: update of a validated instrument. JAmPharmAssoc 2002; 42: 44–50. 3. Royal Pharmaceutical Society of Great Britain (2009). Pharmacy Medicines Use Review – Patient Audit. London: RPSGB. http:// qi4pd.org.uk/index.php/Medicines-Use-Review-Patient-Audit. html (accessed 29 September 2009).

Food scares and trust: A European study

The complex interactions between the determinants of food purchase under risk are explored using the SPARTA model, based on the theory of planned behaviour, and estimated through a combination of multivariate statistical techniques. The application investigates chicken consumption choices in two scenarios: ( a) a 'standard' purchasing situation; and (b) following a hypothetical Salmonella scare. The data are from a nationally representative survey of 2,725 respondents from five European countries: France, Germany, Italy, the Netherlands and the United Kingdom. Results show that the effects and interactions of behavioural determinants vary significantly within Europe. Only in the case of a food scare do risk perceptions and trust come into play. The policy priority should be on building and maintaining trust in food and health authorities and research institutions, while food chain actors could mitigate the consequences of a food scare through public trust. No relationship is found between socio-demographic variables and consumer trust in food safety information.

Trust and governance of global value chains: The case of a Brazilian beef processor

Purpose - The purpose of this paper is to offer an exploratory case study comparing one Brazilian beef processor's relationships supplying two different distribution channels, an EU importer and an EU retail chain operating in Brazil. Design/methodology/approach - The paper begins with a short review of global value chains and the recent literature on trust. It gives the background to the Brazilian beef chain and presents data obtained through in-depth interviews, annual reports and direct observation with the Brazilian beef processor, the EU importer and the retailer. The interviews were conducted with individual firms, but the analysis places them in a chain context, identifying the links and relationships between the agents of the chains and aiming to describe each distribution channel. Findings - Executive chain governance exercised by the domestic retailer stimulates technical upgrading and transferring of best practices to local. suppliers. Consequently, this kind of relationship results in more trust within the global value chain. Practical implications - There are difficulties and challenges facing this Brazilian beef processor that are party related to the need to comply with increasingly complex and demanding food safety and food quality standards. There is still a gap between practices adopted for the export market and practices adopted locally. The strategies of transnational retailers in offering differentiated beef should be taken in account. Originality/value - The research outlines an interdisciplinary framework able to explain chain relationships and the kind of trust that emerges in relationships between EU importer/retail and a developing country supplier.

Key performance indicators (KPIs) and priority setting in using the multi-attribute approach for assessing sustainable intelligent buildings

The main objectives of this paper are to: firstly, identify key issues related to sustainable intelligent buildings (environmental, social, economic and technological factors); develop a conceptual model for the selection of the appropriate KPIs; secondly, test critically stakeholder's perceptions and values of selected KPIs intelligent buildings; and thirdly develop a new model for measuring the level of sustainability for sustainable intelligent buildings. This paper uses a consensus-based model (Sustainable Built Environment Tool- SuBETool), which is analysed using the analytical hierarchical process (AHP) for multi-criteria decision-making. The use of the multi-attribute model for priority setting in the sustainability assessment of intelligent buildings is introduced. The paper commences by reviewing the literature on sustainable intelligent buildings research and presents a pilot-study investigating the problems of complexity and subjectivity. This study is based upon a survey perceptions held by selected stakeholders and the value they attribute to selected KPIs. It is argued that the benefit of the new proposed model (SuBETool) is a ‘tool’ for ‘comparative’ rather than an absolute measurement. It has the potential to provide useful lessons from current sustainability assessment methods for strategic future of sustainable intelligent buildings in order to improve a building's performance and to deliver objective outcomes. Findings of this survey enrich the field of intelligent buildings in two ways. Firstly, it gives a detailed insight into the selection of sustainable building indicators, as well as their degree of importance. Secondly, it tesst critically stakeholder's perceptions and values of selected KPIs intelligent buildings. It is concluded that the priority levels for selected criteria is largely dependent on the integrated design team, which includes the client, architects, engineers and facilities managers.

The impact of ICT on the work patterns of managers and their organisations

Purpose – The main aim of this paper is to present the results of a study examining managers' attitudes towards the deployment and use of information and communications technology (ICT) in their organisations. The study comes at a time when ICT is being recognised as a major enabler of innovation and new business models, which have the potential to have major impact on western economies and jobs. Design/methodology/approach – A questionnaire was specially designed to collect data relating to three research questions. The questionnaire also included a number of open-ended questions. A total of 181 managers from a wide range of industries across a number of countries participated in the electronic survey. The quantitative responses to the survey were analysed using SPSS. Exploratory factor analysis using Varimax rotation was used and ANOVA to compare responses by different groups. Findings – The survey showed that many of the respondents appeared equipped to work “any place, any time”. However, it also highlighted the challenges managers face in working in a connected operation. Also, the data suggested that many managers were less than confident about their companies' policies and practices in relation to information management. Originality/value – A next step from this exploratory research could be the development of a model exploring the impact of ICT on management and organisational performance in terms of personal characteristics of the manager, the role performed, the context and the ICT provision. Also, further research could focus on examining in more detail differences between management levels.

A review of the use of demonstration projects to achieve widespread adoption of innovative practices

The UK construction industry has embarked on one of the largest experiments in the implementation of innovative technologies and practices in its history. Following Rethinking Construction[1], generally known as the Egan Report, the Movement for Innovation was established with the aim of using demonstration projects as practical examples of innovation in order to encourage others to follow the example. The number of demonstration projects has exceeded the original plans and more are being added. This paper reviews the approach in terms of the practice of using demonstration projects to achieve widespread take up of innovation, the modifications to the programme and its management and considers future developments to improve its, effectiveness.

Trees outside forests and rural livelihoods: a study of Chitwan District, Nepal

Trees outside forests (TOF) in Nepal’s Terai have significantly increased over the past decade. The Chitwan District was one of the focus districts in the Terai Community Forestry Development Project that promoted a tree seedling distribution program. This paper examines the current position of tree integration on farmland and its contribution to livelihoods of rural households in this district. Interviews with local key informants, government and non-government agencies and woodbased industries, as well as an in-depth study of 32 households were used to describe the constraints faced by the households in management of trees on farmland. Most households cited disease, poor growth, lack of preferred tree species, lack of technical support, an uncertain tree market, and lack of financial support as constraints. Despite the important role of trees in subsistence and marketbased rural livelihood diversification, and the consequent reduction in pressure on national forests from on-farm trees, current government policies and practices fail to recognise the value of these trees. It is argued that there is substantial potential for improving on-farm trees to enhance rural livelihoods. A responsive service mechanism centred on tree growing households would help the management of tree resources on the farmland.

Emerging hybrid practices in construction design work: role of mixed media

Information technologies are used across all stages of the construction process, and are crucial in the delivery of large projects. Drawing on detailed research on a construction megaproject, we take a practice-based approach to examining the practical and theoretical tensions between existing ways of working and the introduction of new coordination tools in this paper. We analyze the new hybrid practices that emerge, using insights from actor-network theory to articulate the delegation of actions to material and digital objects within ecologies of practice. The three vignettes that we discuss highlight this delegation of actions, the “plugging” and “patching” of ecologies occurring across media and the continual iterations of working practices between different types of media. By shifting the focus from tools to these wider ecologies of practice, the approach has important managerial mplications for the stabilization of new technologies and practices and for managing technological change on large construction projects. We conclude with a discussion of new directions for research, oriented to further elaborating on the importance of the material in understanding change.