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.

The F test for comparing two normal variances: correct and incorrect calculation of the two-sided p-value?

This article illustrates that not all statistical software packages are correctly calculating a p-value for the classical F test comparison of two independent Normal variances. This is illustrated with a simple example, and the reasons why are discussed. Eight different software packages are considered.

Shaping literacy in the secondary school: policy, practice and agency in the age of the national literacy strategy

This article examines the definitions of literacy in operation in secondary schools, and the relationship between official literacy policy and the practices of the agents responsible for implementing this policy. We trace the history of national policy back to the Language Across the Curriculum movement of the 1970s as it provides an illustrative point of comparison with the first five years of the National Literacy Strategy. Drawing on empirical data which illuminate the views, perceptions and practices of key agents on a number of levels, we critically review the concept of 'school literacy' promoted in government policy, defining it as 'school-centric literacy' and question its ability to facilitate participation in the practices associated with the media and technological literacies which are increasingly a feature of school life. There is evidence of some unplanned effects of the current national policy but also that levels of agency, for literacy teachers in particular, may be rapidly diminishing.