An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital

Aims: To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. Method: A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Results: Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patient's medication history. Parents/carers provided the most accurate details of a patient's medication history in 81% of cases. Conclusions: This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Synthesis and evaluation of novel ligands for quantum dot stabilisation and polymerisation studies

This thesis describes the design and synthesis of a variety of functionalised phosphine oxides and sulfides, based on the structure of trioctylphosphine oxide, synthesised for the purpose of surface modification of quantum dots. The ability of the ligands to modify the surface chemistry via displacement of the original hexadecylamine capping layer of quantum dots was evaluated. Finally the surface modified quantum dots were investigated for enhancement in their inherent properties and improved compatibility with the various applications for which they were initially designed. Upon the commencement of research involving quantum dots it became apparent that more information on their behaviour and interaction with the environment was required. The limits of the inherent stability of hexadecylamine capped quantum dots were investigated by exposure to a number of different environments. The effect upon the stability of the quantum dots was monitored by changes in the photoluminescence ability of their cores. Subtle differences between different batches of quantum dots were observed and the necessity to account for these in future applications noted. Lastly the displacement of the original hexadecylamine coating with the "designer" functionalised ligands was evaluated to produce a set of conditions that would result in the best possible surface modification. A general procedure was elucidated however it was discovered that each displacement still required slight adjustment by consideration of the other factors such as the difference in ligand structure and the individuality of the various batches of quantum dots. This thesis also describes a procedure for the addition of a protective layer to the surface of quantum dots by cross-linking the functionalised ligands bound to the surface via an acyclic diene metathesis polymerisation. A detailed description of the problems encountered in the analysis of these materials combined with the use of novel techniques such as diffusion ordered spectroscopy is provided as a means to overcome the limitations encountered. Finally a demonstration of the superior stability, upon exposure to a range of aggressive environments of these protected materials compared with those before cross-linking provided physical proof of the cross-linking process and the advantages of the cross-linking modification. Finally this thesis includes the presentation of initial work into the production of luminescent nanocrystal encoded resin beads for the specific use in solid phase combinatorial chemistry. Demonstration of the successful covalent incorporation of quantum dots into the polymeric matrices of non-functionalised and functionalised resin beads is described. Finally by preliminary work to address and overcome the possible limitations that may be encountered in the production and general employment of these materials in combinatorial techniques is given.

Intellectual property law

A firm favourite with students and lecturers alike, Intellectual Property can be trusted to equip you with the best possible basis for study of this dynamic subject. Providing an unrivalled account of the law in this area, this book also examines the ethical and policy influences which have shaped its development providing you with a solid basis for further exploration of the subject.

Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study):a cluster randomised controlled trial

Background - Delivery of high-quality, evidence-based health care to deprived sectors of the community is a major goal for society. We investigated the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes. Methods - In this cluster randomised controlled trial, 21 inner-city practices in the UK were assigned by simple randomisation to intervention (enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse [nine practices; n=868]) or control (standard care [12 practices; n=618]) groups. All adult patients of south Asian origin with type 2 diabetes were eligible. Prescribing algorithms with clearly defined targets were provided for all practices. Primary outcomes were changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years. Analysis was by intention to treat. This trial is registered, number ISRCTN 38297969. Findings - We recorded significant differences between treatment groups in diastolic blood pressure (1·91 [95% CI -2·88 to -0·94] mm?Hg, p=0·0001) and mean arterial pressure (1·36 [-2·49 to -0·23] mm?Hg, p=0·0180), after adjustment for confounders and clustering. We noted no significant differences between groups for total cholesterol (0·03 [-0·04 to 0·11] mmol/L), systolic blood pressure (-0·33 [-2·41 to 1·75] mm?Hg), or HbA1c (-0·15% [-0·33 to 0·03]). Economic analysis suggests that the nurse-led intervention was not cost effective (incremental cost-effectiveness ratio £28?933 per QALY gained). Across the whole study population over the 2 years of the trial, systolic blood pressure, diastolic blood pressure, and cholesterol decreased significantly by 4·9 (95% CI 4·0–5·9) mm?Hg, 3·8 (3·2–4·4) mm?Hg, and 0·45 (0·40–0·51) mmol/L, respectively, and we recorded a small and non-significant increase for haemoglobin A1c (0·04% [-0·04 to 0·13]), p=0·290). Interpretation - We recorded additional, although small, benefits from our culturally tailored care package that were greater than the secular changes achieved in the UK in recent years. Stricter targets in general practice and further measures to motivate patients are needed to achieve best possible health-care outcomes in south Asian patients with diabetes. Funding - Pfizer, Sanofi-Aventis, Servier Laboratories UK, Merck Sharp & Dohme/Schering-Plough, Takeda UK, Roche, Merck Pharma, Daiichi-Sankyo UK, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Bristol-Myers Squibb, Solvay Health Care, and Assurance Medical Society UK.

Adaptive congestion control of DSRC vehicle networks for collaborative road safety applications

Congestion control is critical for the provisioning of quality of services (QoS) over dedicated short range communications (DSRC) vehicle networks for road safety applications. In this paper we propose a congestion control method for DSRC vehicle networks at road intersection, with the aims of providing high availability and low latency channels for high priority emergency safety applications while maximizing channel utilization for low priority routine safety applications. In this method a offline simulation based approach is used to find out the best possible configurations of message rate and MAC layer backoff exponent (BE) for a given number of vehicles equipped with DSRC radios. The identified best configurations are then used online by an roadside access point (AP) for system operation. Simulation results demonstrated that this adaptive method significantly outperforms the fixed control method under varying number of vehicles. The impact of estimation error on the number of vehicles in the network on system level performance is also investigated.

QoS guarantee with adaptive transmit power and message rate control for DSRC vehicle network based road safety applications

Quality of services (QoS) support is critical for dedicated short range communications (DSRC) vehicle networks based collaborative road safety applications. In this paper we propose an adaptive power and message rate control method for DSRC vehicle networks at road intersections. The design objective is to provide high availability and low latency channels for high priority emergency safety applications while maximizing channel utilization for low priority routine safety applications. In this method an offline simulation based approach is used to find out the best possible configurations of transmit power and message rate for given numbers of vehicles in the network. The identified best configurations are then used online by roadside access points (AP) according to estimated number of vehicles. Simulation results show that this adaptive method significantly outperforms a fixed control method. © 2011 Springer-Verlag.

Experiences of patients with age-related macular degeneration receiving anti-vascular endothelial growth factor therapy:a qualitative study

The societal cost for the average health authority in the United Kingdom for the care of wet age-related macular degeneration (AMD) has been suggested to be around £7.4 million. It is vital that the best possible care based on the best available evidence is provided to reduce the impact of AMD on patients' lives and the financial cost to the health-care system. This study explored the experiences of AMD patients treated with intravitreal ranibizumab injections. Three semistructured interviews were conducted with seven participants over the course of 18 months. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified four themes: preparing for treatment, the treatment process, patient-provider communication, and results of treatment. Patient experiences highlighted the need to move away from the reliance on letters for information provision, and the need for clearer guidelines about when to cease AMD treatment. Interviews highlighted the need for the inclusion of rigorous qualitative evidence with experiential data in future good clinical practice guideline development for AMD. © The Author(s) 2013.

Human resource management:strategic and international perspectives

With a strong focus on employability, this new text treats international, strategic and contemporary issues as central to the study and practice of Human Resource Management. Covering the core curriculum, this book provides all the knowledge and tools you need to get the best possible grades and achieve great career success after university. Key Features •Skills and employability focus will help you to secure a job in the tough economic climate whether as an HRM specialist or as a line manager. •Debating HRM boxes will develop your critical thinking skills, valued by examiners and employers alike. •International and cross-cultural perspectives are woven into discussion and case studies to prepare you for the realities of the global workplace. •Contemporary and strategic issues such as ethics, justice and CSR are introduced early on to underpin and enhance your understanding of the core HRM functions. •Unique final part will ensure that your skills can be applied in a range of organisational settings including SMEs and the not-for-profit and voluntary sectors. •Mapped to the CIPD’s learning outcomes but with an emphasis on the role of line managers throughout. •Companion website includes full text journal articles, glossary and chapter podcasts

Intellectual property asset management:how to identify, protect, manage and exploit intellectual property within the business environment

In the new ‘knowledge-intensive economies’ Intellectual assets increasingly play a key part on balance sheets. There is an increasing global awareness that in order to promote innovation and the growth of the economy, businesses must fully recognise and exploit their intellectual assets. A company’s ability to innovate rapidly and successfully is now regarded as essential and most breakthroughs are made by Small and Medium-sized Enterprises (SMEs), usually with no in-house legal professionals to help them. It is essential that those working with or creating intellectual property rights (IPR) are aware of the basics of Intellectual Property Law. Intellectual Property Asset Management provides business and management students at all levels with an accessible-straight-forward explanation of what the main Intellectual Property rights are and how these rights are protected. Locating the subject squarely in a business context and using case studies and examples throughout drawn from a wide range of business organisations, it explains how an organisation can exploit their rights through licensing, franchising and other means in order to make the best possible use of their IP assets. This book will provide students with: • the basic Intellectual Property law knowledge needed to identify a potential IP issue • the tools and understanding to assess an IP breach • the ability to identify where the problem cannot be solved in house and where expert legal assistance is required • the knowledge required to work effectively with lawyers and other legal professionals to achieve the desired outcome

Adaptive power and rate control for QoS guarantee of DSRC based collaborative road safety applications

In this paper we propose an adaptive power and message rate control method for safety applications at road intersections. The design objectives are to firstly provide guaranteed QoS support to both high priority emergency safety applications and low priority routine safety applications and secondly maximize channel utilization. We use an offline simulation based approach to find out the best possible configurations of transmit power and message rate for given numbers of vehicles in the network with certain safety QoS requirements. The identified configurations are then used online by roadside access points (AP) adaptively according to estimated number of vehicles. Simulation results show that this adaptive method could provide required QoS support to safety applications and it significantly outperforms a fixed control method. © 2013 International Information Institute.

Introduction to performance improvement management software (PIM-DEA)

This chapter provides information on the use of Performance Improvement Management Software (PIMDEA). This advanced DEA software enables users to make the best possible analysis of the data, using the latest theoretical developments in Data Envelopment Analysis (DEA). PIM-DEA software gives full capacity to assess efficiency and productivity, set targets, identify benchmarks, and much more, allowing users to truly manage the performance of organizational units. PIM-DEA is easy to use and powerful, and it has an extensive range of the most up-to-date DEA models and which can handle large sets of data.

Ultra-long range distributed fibre sensing using virtually transparent propagation

Distributed fibre sensors provide unique capabilities for monitoring large infrastructures with high resolution. Practically, all these sensors are based on some kind of backscattering interaction. A pulsed activating signal is launched on one side of the sensing fibre and the backscattered signal is read as a function of the time of flight of the pulse along the fibre. A key limitation in the measurement range of all these sensors is introduced by fibre attenuation. As the pulse travels along the fibre, the losses in the fibre cause a drop of signal contrast and consequently a growth in the measurement uncertainty. In typical single-mode fibres, attenuation imposes a range limit of less than 30km, for resolutions in the order of 1-2 meters. An interesting improvement in this performance can be considered by using distributed amplification along the fibre [1]. Distributed amplification allows having a more homogeneous signal power along the sensing fibre, which also enables reducing the signal power at the input and therefore avoiding nonlinearities. However, in long structures (≥ 50 km), plain distributed amplification does not perfectly compensate the losses and significant power variations along the fibre are to be expected, leading to inevitable limitations in the measurements. From this perspective, it is simple to understand intuitively that the best possible solution for distributed sensors would be offered by a virtually transparent fibre, i.e. a fibre exhibiting effectively zero attenuation in the spectral region of the pulse. In addition, it can be shown that lossless transmission is the working point that allows the minimization of the amplified spontaneous emission (ASE) noise build-up. © 2011 IEEE.

The clinical significance of medicines reconciliation in children admitted to hospital

Aims and Objectives: The NICE/NPSA guidance on Medicines Reconciliation in adults upon hospital admission excludes children under the age of 16.1 Hence the primary aim and objective of this study was to use medicines reconciliation to primarily identify if discrepancies occur upon hospital admission. Secondary objectives were to clinically assess for harm discrepancies that were identified in paediatric patients on long term medications at four hospitals across the UK. Method: Medicines reconciliation is a procedure where the current medication history of a patient prior to hospital admission would be taken and verifying the medication orders made at hospital admission against this history, addressing any discrepancies identified. Medicines reconciliation was carried out prospectively for 244 paediatric patients on chronic medication across four UK hospitals (Birmingham, London, Leeds and North Staffordshire) between January – May 2011. Medicines reconciliation was conducted by a clinical pharmacist using the following sources of information: 1) the patient's Pre-Admission Medication (PAM) from the patient's general practitioner 2) examination of the Patient's Own Medications brought into hospital, 3) a semi-structured interview with the parent-carers and 4) identification of admission medication orders written on the drug chart prior to clinical pharmacy input (Drug Chart). Discrepancies between the PAM and Drug Chart were documented and classified as intentional or unintentional. Intentional discrepancies were defined as changes that were made knowingly by the prescriber and confirmed. Unintentional discrepancies were assessed for clinical significance by an expert panel and assigned a significance score based on the likelihood of causing potential discomfort or clinical deterioration: class 1 unlikely, class 2 moderate and class 3 severe.2 Results: 1004 medication regimens were included from the 244 patients across the four sites. 588 of the 1004 (59%) medicines, had discrepancies between the PAM and Drug Chart; of these 36% (n = 209) were unintentional and included for clinically assessment. 189 drug discrepancies 30% were classified as class 1, 47% were class 2 and 23% were class 3 discrepancies. The remaining 20 discrepancies were cases where deviating from the PAM would have been the right thing to do, which might suggest that an intentional but undocumented discrepancy by the prescriber writing up the admission order may have occurred. Conclusion: The results suggest that medication discrepancies in paediatric patients do occur upon hospital admission, which do have a potential to cause harm and that medicines reconciliation is a potential solution to preventing such discrepancies. References: 1. National Institute for Health and Clinical Excellence. National Patient Safety Agency. PSG001. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: NICE; 2007. 2. Cornish, P. L., Knowles, S. R., Marchesano, et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Archives of Internal Medicine 2005; 165:424–429

Medication -related adverse events in older people with dementia:causes and possible solutions

This submission for a PhD by previously published work is based upon six publications in peer reviewed journals, reflecting a 9-year research programme. My research has shown, in a coherent and original way, the difficulty in treating people with dementia with safe and effective medication whilst providing research-founded guidance to develop mechanisms to optimise medication choice and minimise iatrogenic events. A wide range of methods, including systematic reviews, meta-analysis, randomised controlled trials (RCTs), quantitative research and mixed methods were used to generate the data, which supported the exploration of three themes. The first theme, to understand the incidence and causes of medication errors in dementia services, identified that people with dementia may be more susceptible to medication-related iatrogenic disease partly due to inherent disease-related characteristics. One particular area of concern is the use of anti-psychotics to treat the Behavioural and Psychological Symptoms of Dementia (BPSD). The second and third themes, respectively, investigated a novel pharmacological and health services intervention to limit anti-psychotic usage. The second phase found that whilst the glutamate receptor blocker memantine showed some promise, further research was clearly required. The third phase found that anti-psychotic usage in dementia may be higher than official figures suggest and that medication review linking primary and secondary care can limit such usage. My work has been widely cited, reflecting a substantial contribution to the field, in terms of our understanding of the causes of, and possible solutions to limit, medication-related adverse events in people with dementia. More importantly, this work has already informed clinical practice, patients, carers and policy makers by its demonstrable impact on health policy. In particular my research has identified key lines of enquiry for future work and for the development of my own personal research programme to reduce the risk associated with medication in this vulnerable population.

History and symptom taking in contact lens fitting and aftercare

Aim: To appraise history and symptom taking for contact lens consultations, to determine current practice and to make recommendations for best practice. Method: The peer reviewed academic literature was reviewed and the results informed a survey completed by 256 eye care practitioners (ECPs) on their current practice and influences. Results: The last eye-test date, last contact lens aftercare (for existing wearers) and reason for visit are key questions for most ECPs. Detailed use of contact lens questions are more commonly applied in aftercares than when refitting patients who have previously discontinued wear (87% vs 56% use), whereas questions on ocular and general history, medication and lifestyle were generally more commonly utilised for new patients than in aftercares (72% vs 50%). 75% of ECPs requested patients bring a list of their medication to appointments. Differential diagnosis questioning was thorough in most ECPs (87% of relevant questions asked). Attempts to optimise compliance included oral instruction (95% always) and written patient instructions (95% at least sometimes). Abbreviations were used by 39% of respondents (26% used ones provided by a professional body). Conclusion: There is scope for more consistency in history and symptom taking for contact lens consultations and recommendations are made.