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.

A normative method to analyse workarounds in a healthcare environment: motivations, consequences, and constraints

Healthcare information systems have the potential to enhance productivity, lower costs, and reduce medication errors by automating business processes. However, various issues such as system complexity and system abilities in a relation to user requirements as well as rapid changes in business needs have an impact on the use of these systems. In many cases failure of a system to meet business process needs has pushed users to develop alternative work processes (workarounds) to fill this gap. Some research has been undertaken on why users are motivated to perform and create workarounds. However, very little research has assessed the consequences on patient safety. Moreover, the impact of performing these workarounds on the organisation and how to quantify risks and benefits is not well analysed. Generally, there is a lack of rigorous understanding and qualitative and quantitative studies on healthcare IS workarounds and their outcomes. This project applies A Normative Approach for Modelling Workarounds to develop A Model of Motivation, Constraints, and Consequences. It aims to understand the phenomenon in-depth and provide guidelines to organisations on how to deal with workarounds. Finally the method is demonstrated on a case study example and its relative merits discussed.

Supporting Computer-supported collaborative work (CSCW) in conceptual design

In order to gain a better understanding of online conceptual collaborative design processes this paper investigates how student designers make use of a shared virtual synchronous environment when engaged in conceptual design. The software enables users to talk to each other and share sketches when they are remotely located. The paper describes a novel methodology for observing and analysing collaborative design processes by adapting the concepts of grounded theory. Rather than concentrating on narrow aspects of the final artefacts, emerging “themes” are generated that provide a broader picture of collaborative design process and context descriptions. Findings on the themes of “grounding – mutual understanding” and “support creativity” complement findings from other research, while important themes associated with “near-synchrony” have not been emphasised in other research. From the study, a series of design recommendations are made for the development of tools to support online computer-supported collaborative work in design using a shared virtual environment.

Design for design: support for creative practice in computer-supported collaborative work (CSCW) in design

This paper describes a novel methodology for observing and analysing collaborative design by using the concepts of cognitive dimensions related to concept-based misfit analysis. The study aims at gaining an insight into support for creative practice of graphical communication in collaborative design processes of designers while sketching within a shared white board and audio conferencing environment. Empirical data on design processes have been obtained from observation of groups of student designers solving an interior space-planning problem of a lounge-diner in a shared virtual environment. The results of the study provide recommendations for the design and development of interactive systems to support such collaborative design activities.

From activity to active learning: drawing and dialogue interaction in virtual learning environments for computer-supported collaborative work in design.

Virtual learning environments (VLEs) would appear to be particular effective in computer-supported collaborative work (CSCW) for active learning. Most research studies looking at computer-supported collaborative design have focused on either synchronous or asynchronous modes of communication, but near-synchronous working has received relatively little attention. Yet it could be argued that near-synchronous communication encourages creative, rhetorical and critical exchanges of ideas, building on each other’s contributions. Furthermore, although many researchers have carried out studies on collaborative design protocol, argumentation and constructive interaction, little is known about the interaction between drawing and dialogue in near-synchronous collaborative design. The paper reports the first stage of an investigation into the requirements for the design and development of interactive systems to support the learning of collaborative design activities. The aim of the study is to understand the collaborative design processes while sketching in a shared white board and audio conferencing media. Empirical data on design processes have been obtained from observation of seven sessions with groups of design students solving an interior space-planning problem of a lounge-diner in a virtual learning environment, Lyceum, an in-house software developed by the Open University to support its students in collaborative learning.

Insights into processes and deposits of hazardous vulcanian explosions at Soufrière Hills Volcano during 2008 and 2009 (Montserrat, West Indies)

During the Soufrière Hills eruption, vulcanian explosions have generally occurred 1) in episodic cycles; 2) isolated during pauses in extrusion, and 3) after major collapses of the dome. In a different eruptive context, significant vulcanian explosions occurred on 29 July 2008, 3 December 2008, and 3 January 2009. Deposits are pumiceous except for the 3 December event. We reconstructed the dispersal pattern of the deposits and their textural characteristics to evaluate erupted volume and vesicularity of the magma at fragmentation. We discuss the implications of these explosions in terms of eruptive processes and chronology, and the hazards posed by their sudden and often unheralded occurrence. We suggest that overpressurization of the conduit can develop over time-scales of months to weeks by a process of self-sealing of conduit walls and/or the cooling dome by silica polymorphs. This work provides new insights for understanding the generation of hazardous vulcanian explosions at andesitic volcanoes.

Work performance, productivity and indoor air

Temperature, relative humidity, and air quality all affect the sensory system via thermo receptors in the skin and the olfactory system. Air quality is mainly defined by the contaminants in the air. However, the most persistent memory of any space is often its odor. Strong, emotional, and past experiences are awakened by the olfactory sense. Odors can also influence cognitive processes that affect creative task performance, as well as personal memories and moods. Besides nitrogen and oxygen, the air contains particles and many chemicals that affect the efficiency of the oxygenation process in the blood, and ultimately the air breathed affects thinking and concentration. It is important to show clients the value of spending more capital on high-quality buildings that promote good ventilation. The process of achieving indoor-air quality is a continual one throughout the design, construction, commissioning, and facilities management processes. This paper reviews the evidence.

A comparison of two editions of the RIBA plan of work

The RIBA Plan of Work describes the way a construction process should be organized. Although not officially approved by the RIBA council, a new plan of work was published in 2000 with the intention of replacing the RIBA Plan of Work, so it is useful to analyse both in terms of the organizational structure they impose upon construction projects. Using analytical principles from organizational theory, both plans are analysed by converting them into organizational matrices and assessing their relative complexities, the load on participants, decentralization of responsibility, number of interfaces and the extent to which they provide for co-ordination and control. This demonstrates first, that the analysis of organizational structure is an appropriate approach for undertaking comparisons of such documents; and second, that while both plans of work are of roughly equal complexity, the new one is more demanding on the participants; produces a higher number of interfaces between processes, and provides for more co-ordination than the old one. Neither plan deals with controlling the output of individuals, leaving it as an internal matter for each participating organization.

Student-teachers' perspectives on positive and negative social processes in schools

In recent years, the Standards for Qualified Teacher Status in England have placed new emphasis on student-teachers' ability to become integrated into the 'corporate life of the school' and to work with other professionals. Little research, however, has been carried out into how student-teachers perceive the social processes and interactions that are central to such integration during their initial teacher education school placements. This study aims to shed light on these perceptions. The data, gathered from 23 student-teachers through interviews and reflective writing, illustrate the extent to which the participants perceived such social processes as supporting or obstructing their development as teachers. Signals of inclusion, the degree of match or mismatch in students' and school colleagues' role expectations, and the social awareness of both school and student-teacher emerged as crucial factors in this respect. The student-teachers' accounts show their social interactions with school staff to be meaningful in developing their 'teacher self' and to be profoundly emotionally charged. The implications for mentor and student-teacher role preparation are discussed in this article.

The eMinerals project: developing the concept of the virtual organisation to support collaborative work on molecular-scale environmental simulations

The eMinerals project has established an integrated compute and data minigrid infrastructure together with a set of collaborative tools,. The infrastructure is designed to support molecular simulation scientists working together as a virtual organisation aiming to understand a number of strategic processes in environmental science. The eMinerals virtual organisation is now working towards applying this infrastructure to tackle a new generation of scientific problems. This paper describes the achievements of the eMinerals virtual organisation to date, and describes ongoing applications of the virtual organisation infrastructure.

Multi-microprocessor control of processes with pure time delay

In 1967 a novel scheme was proposed for controlling processes with large pure time delay (Fellgett et al, 1967) and some of the constituent parts of the scheme were investigated (Swann, 1970; Atkinson et al, 1973). At that time the available computational facilities were inadequate for the scheme to be implemented practically, but with the advent of modern microcomputers the scheme becomes feasible. This paper describes recent work (Mitchell, 1987) in implementing the scheme in a new multi-microprocessor configuration and shows the improved performance it provides compared with conventional three-term controllers.

Planning for the reuse of redundant defence estate: disposal processes, policy frameworks and development impacts

This paper reviews recent research and other literature concerning the planning and development of redundant defence estate. It concentrates on UK sources but includes reference to material from Europe and the North America were it is relevant for comparative purposes. It introduces the topic by providing a brief review of the recent restructuring of the UK defence estate and then proceeds to examine the various planning policy issues generated by this process; the policy frameworks used to guide it; comparable approaches to surplus land disposal and the appraisal of impacts; and ending the main body of the review with an analyse of the economic, social and environmental impacts of military base closure and redevelopment. It concludes that there is a significant body of work focusing on the reuse and redevelopment of redundant defence estate in the UK and abroad, but that much of this work is based on limited research or on personal experience. One particular weakness of the current literature is that it does not fully reflect the institutional difficulties posed by the disposal process and the day-to-day pressures which MOD personnel have to deal with. In doing this, it also under-emphasises the embedded cultures of individuals and professional groups who are required to operationalise the policies, procedures and practices for planning and redeveloping redundant defence estate.

Professionalism in digitally-mediated project work

Fieldwork in a major construction programme is used to examine what is meant by professionalism where large integrated digital systems are used to design, deliver, and maintain buildings and infrastructure. The increasing ‘professionalization’ of the client is found to change other professional roles and interactions in project delivery. New technologies for approvals and workflow monitoring are associated with new occupational groups; new kinds of professional accountability; and a greater integration across professional roles. Further conflicts also arise, where occupational groups have different understandings of project deliverables and how they are competently achieved. The preliminary findings are important for an increasing policy focus on shareable data, in order for building owners and operators to improve the cost, value, handover and operation of complex buildings. However, it will also have an impact on wider public decision-making processes, professional autonomy, expertise and interdependence. These findings are considered in relation to extant literatures, which problematize the idea of professionalism; and the shift from drawings to shareable data as deliverables. The implications for ethics in established professions and other occupational groups are discussed; directions are suggested for further scholarship on professionalism in digitally mediated project work to improve practices which will better serve society.

Building networks to work: an ethnographic study of informal routes into the UK construction industry and pathways for migrant up-skilling

The UK construction industry labour market is characterised by high levels of self-employment, sub-contracting, informality and flexibility. A corollary of this, and a sign of the increasing globalisation of construction, has been an increasing reliance on migrant labour, particularly that from the Eastern European Accession states. Yet, little is known about how their experiences within and outside of work shape their work in the construction sector. In this context better qualitative understandings of the social and communication networks through which migrant workers gain employment, create routes through the sector and develop their role/career are needed. We draw on two examples from a short-term ethnographic study of migrant construction worker employment experiences and practices in the town of Crewe in Cheshire, UK, to demonstrate how informal networks intersect with formal elements of the sector to facilitate both recruitment and up-skilling. Such research knowledge, we argue, offers new evidence of the importance of attending to migrant worker’s own experiences in the development of more transparent recruitment processes.

The competition–performance relation: a meta-analytic review and test of the opposing processes model of competition and performance

What is the relation between competition and performance? The present research addresses this important multidisciplinary question by conducting a meta-analysis of existing empirical work and by proposing a new conceptual model—the opposing processes model of competition and performance. This model was tested by conducting an additional meta-analysis and 3 new empirical studies. The first meta-analysis revealed that there is no noteworthy relation between competition and performance. The second meta-analysis showed, in accord with the opposing processes model, that the absence of a direct effect is the result of inconsistent mediation via achievement goals: Competition prompts performance-approach goals which, in turn, facilitate performance; and competition also prompts performance-avoidance goals which, in turn, undermine performance. These same direct and mediational findings were also observed in the 3 new empirical studies (using 3 different conceptualizations of competition and attending to numerous control variables). Our findings provide both interpretational clarity regarding past research and conceptual guidance regarding future research on the competition–performance relation.