Physicians' perceptions, attitudes and expectations regarding the role of hospital-based pharmacists in the West Bank, Palestine

Objective - To evaluate the perceptions, expectations and experiences of physicians with regard to hospital-based pharmacists in the West Bank, Palestine. Methods - A self-administered questionnaire was distributed to 250 physicians practising in four general hospitals in the West Bank, Palestine. The main sections of the questionnaire comprised a series of statements pertaining to physicians' perceptions, expectations and experiences with pharmacists. Key findings - One hundred and fifty seven questionnaires were completed and returned (response rate, 62.8%). The majority of respondents were most comfortable with pharmacists detecting and preventing prescription errors (76.4%; 95% confidence interval (CI) 69.5–81.2%) and patient education (57.9%; CI 51.2–63.4%) but they were not comfortable with pharmacists suggesting the use of prescription medications to patients (56.7%; CI 49.8–62.4%). Most physicians (62.4%; CI 56.8–69.1%) expected the pharmacist to educate their patients about the safe and appropriate use of their medication. However, approximately one-third (31.7%; CI 26.0–39.6%) did not expect pharmacists to be available for consultation during rounds. Physicians' experiences with pharmacists were less favourable; whereas 77% (CI 70.2–81.5%) of the physicians agreed that pharmacists were always a reliable source of information, only 11.5% (CI 6.2–16.4%) agreed that pharmacists appeared to be willing to take responsibility for solving any drug-related problems. Conclusion -The present study showed that hospital physicians are more likely to accept traditional pharmacy services than newer clinical services for hospital-based pharmacists in the West Bank, Palestine. Pharmacists should therefore interact more positively and more frequently with physicians. This will close the gap between the physicians' commonly held perceptions of what they expect pharmacists to do and what pharmacists can actually do, and gain support for an extended role of hospital-based pharmacists in future patient therapy management.

Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

General bounds on Bayes errors for regression with Gaussian processes

Based on a simple convexity lemma, we develop bounds for different types of Bayesian prediction errors for regression with Gaussian processes. The basic bounds are formulated for a fixed training set. Simpler expressions are obtained for sampling from an input distribution which equals the weight function of the covariance kernel, yielding asymptotically tight results. The results are compared with numerical experiments.

Operator-induced errors in Hartmann-Shack wavefront sensing:model eye study

Purpose: To evaluate the effects of instrument realignment and angular misalignment during the clinical determination of wavefront aberrations by simulation in model eyes. Setting: Aston Academy of Life Sciences, Aston University, Birmingham, United Kingdom. Methods: Six model eyes were examined with wavefront-aberration-supported cornea ablation (WASCA) (Carl Zeiss Meditec) in 4 sessions of 10 measurements each: sessions 1 and 2, consecutive repeated measures without realignment; session 3, realignment of the instrument between readings; session 4, measurements without realignment but with the model eye shifted 6 degrees angularly. Intersession repeatability and the effects of realignment and misalignment were obtained by comparing the measurements in the various sessions for coma, spherical aberration, and higher-order aberrations (HOAs). Results: The mean differences between the 2 sessions without realignment of the instrument were 0.020 μm ± 0.076 (SD) for Z3 - 1(P = .551), 0.009 ± 0.139 μm for Z3 1(P = .877), 0.004 ± 0.037 μm for Z4 0 (P = .820), and 0.005 ± 0.01 μm for HO root mean square (RMS) (P = .301). Differences between the nonrealigned and realigned instruments were -0.017 ± 0.026 μm for Z3 - 1(P = .159), 0.009 ± 0.028 μm for Z3 1 (P = .475), 0.007 ± 0.014 μm for Z4 0(P = .296), and 0.002 ± 0.007 μm for HO RMS (P = 0.529; differences between centered and misaligned instruments were -0.355 ± 0.149 μm for Z3 - 1 (P = .002), 0.007 ± 0.034 μm for Z3 1(P = .620), -0.005 ± 0.081 μm for Z4 0(P = .885), and 0.012 ± 0.020 μm for HO RMS (P = .195). Realignment increased the standard deviation by a factor of 3 compared with the first session without realignment. Conclusions: Repeatability of the WASCA was excellent in all situations tested. Realignment substantially increased the variance of the measurements. Angular misalignment can result in significant errors, particularly in the determination of coma. These findings are important when assessing highly aberrated eyes during follow-up or before surgery. © 2007 ASCRS and ESCRS.

Effects of syllabic complexity in predicting accuracy of repetition and direction of errors in patients with articulatory and phonological difficulties

The purpose of this paper is to demonstrate the existence of a strong and significant effect of complexity in aphasia independent from other variables including length. Complexity was found to be a strong and significant predictor of accurate repetition in a group of 13 Italian aphasic patients when it was entered in a regression equation either simultaneously or after a large number of other variables. Significant effects were found both when complexity was measured in terms of number of complex onsets (as in a recent paper by Nickels & Howard, 2004) and when it was measured in a more comprehensive way. Significant complexity effects were also found with matched lists contrasting simple and complex words and in analyses of errors. Effects of complexity, however, were restricted to patients with articulatory difficulties. Reasons for this association and for the lack of significant results in Nickels and Howard (2004) are discussed. © 2005 Psychology Press Ltd.

Patterns of phonological errors as a function of a phonological versus an articulatory locus of impairment

WWe present the case of two aphasic patients: one with fluent speech, MM, and one with dysfluent speech, DB. Both patients make similar proportions of phonological errors in speech production and the errors have similar characteristics. A closer analysis, however, shows a number of differences. DB's phonological errors involve, for the most part, simplifications of syllabic structure; they affect consonants more than vowels; and, among vowels, they show effects of sonority/complexity. This error pattern may reflect articulatory difficulties. MM's errors, instead, show little effect of syllable structure, affect vowels at least as much as consonants and, and affect all different vowels to a similar extent. This pattern is consistent with a more central impairment involving the selection of the right phoneme among competing alternatives. We propose that, at this level, vowel selection may be more difficult than consonant selection because vowels belong to a smaller set of repeatedly activated units.

Source coded image data in the presence of channel errors

The growth and advances made in computer technology have led to the present interest in picture processing techniques. When considering image data compression the tendency is towards trans-form source coding of the image data. This method of source coding has reached a stage where very high reductions in the number of bits representing the data can be made while still preserving image fidelity. The point has thus been reached where channel errors need to be considered, as these will be inherent in any image comnunication system. The thesis first describes general source coding of images with the emphasis almost totally on transform coding. The transform technique adopted is the Discrete Cosine Transform (DCT) which becomes common to both transform coders. Hereafter the techniques of source coding differ substantially i.e. one tech­nique involves zonal coding, the other involves threshold coding. Having outlined the theory and methods of implementation of the two source coders, their performances are then assessed first in the absence, and then in the presence, of channel errors. These tests provide a foundation on which to base methods of protection against channel errors. Six different protection schemes are then proposed. Results obtained, from each particular, combined, source and channel error protection scheme, which are described in full are then presented. Comparisons are made between each scheme and indicate the best one to use given a particular channel error rate.

Phonological–lexical activation:a lexical component or anoutput buffer? Evidence from aphasic errors

Single word production requires that phoneme activation is maintained while articulatory conversion is taking place. Word serial recall, connected speech and non-word production (repetition and spelling) are all assumed to involve a phonological output buffer. A crucial question is whether the same memory resources are also involved in single word production. We investigate this question by assessing length and positional effects in the single word repetition and reading of six aphasic patients. We expect a damaged buffer to result in error rates per phoneme which increase with word length and in position effects. Although our patients had trouble with phoneme activation (they made mainly errors of phoneme selection), they did not show the effects expected from a buffer impairment. These results show that phoneme activation cannot be automatically equated with a buffer. We hypothesize that the phonemes of existing words are kept active though permanent links to the word node. Thus, the sustained activation needed for their articulation will come from the lexicon and will have different characteristics from the activation needed for the short-term retention of an unbound set of units. We conclude that there is no need and no evidence for a phonological buffer in single word production.

Medication errors in older people with mental health problems:a review

Objective - To review and summarise published data on medication errors in older people with mental health problems. Methods - A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance. Results - Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious. Conclusions - Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors.

Measuring the assessment and counselling provided with the supply of non-prescription asthma reliever medication: a simulated patient study

BACKGROUND: Over one quarter of asthma reliever medications are provided without prescription by community pharmacies in Australia. Evidence that community pharmacies provide these medications with sufficient patient assessment and medication counseling to ensure compliance with the government's Quality Use of Medicines principles is currently lacking. OBJECTIVE: To assess current practice when asthma reliever medication is provided in the community pharmacy setting and to identify factors that correlate with assessment of asthma control. METHODS: Researchers posing as patients visited a sample of Perth metropolitan community pharmacies in May 2007. During the visit, the simulated patient enacted a standardized scenario of someone with moderately controlled asthma who wished to purchase a salbutamol (albuterol) inhaler without prescription. Results of the encounter were recorded immediately after the visit. Regression analysis was performed, with medication use frequency (a marker of asthma control) as the dependent variable. RESULTS: One hundred sixty community pharmacies in the Perth metropolitan area were visited in May 2007. Pharmacists and/or pharmacy assistants provided some form of assessment in 84% of the visits. Counseling was provided to the simulated patients in 24% of the visits. Only 4 pharmacy staff members asked whether the simulated patient knew how to use the inhaler. Significant correlation was found between assessment and/or counseling of reliever use frequency and 3 independent variables: visit length (p < 0.001), number of assessment questions asked (p < 0.001), and the simulated patient who conducted the visit (p < 0.02). CONCLUSIONS: Both patient assessment and medication counseling were suboptimal compared with recommended practice when nonprescription asthma reliever medication was supplied in the community pharmacy setting. Pharmacy and pharmacist demographic variables do not appear to affect assessment of asthma control. This research indicates the need for substantial improvements in practice in order to provide reliever medication in line with Quality Use of Medication principles of ensuring safe and effective use of medication.

Correcting errors in optical data transmission using neural networks

Optical data communication systems are prone to a variety of processes that modify the transmitted signal, and contribute errors in the determination of 1s from 0s. This is a difficult, and commercially important, problem to solve. Errors must be detected and corrected at high speed, and the classifier must be very accurate; ideally it should also be tunable to the characteristics of individual communication links. We show that simple single layer neural networks may be used to address these problems, and examine how different input representations affect the accuracy of bit error correction. Our results lead us to conclude that a system based on these principles can perform at least as well as an existing non-trainable error correction system, whilst being tunable to suit the individual characteristics of different communication links.

Advancing age and bleeding risk are the strongest barriers to anticoagulant prescription in atrial fibrillation

In clinical practice many patients with atrial fibrillation (AF) at high thromboembolic risk fail to receive adequate oral anticoagulation (OAC) [1]. The complex management of anticoagulant therapy [frequent international normalised ratio (INR) monitoring because of narrow therapeutic window, interaction with food and alcohol, concomitant medications and comorbities], the overestimation of bleeding risk and the underestimation of stroke risk, may partially explain physicians' reluctance to prescribe anticoagulation. In the current issue of Age and Ageing, Pugh and Mead [2] report a systematic review on physicians' attitudes concerning anticoagulant treatment among AF patients. Through surveys (questionnaire, clinical vignette and interview) on hypothetical case scenarios, they have identified the barriers to effective anticoagulant prescription, as follows: increasing age, bleeding risk or previous bleeding, fall risk, co-morbidities (e.g. chronic alcoholism or cognitive impairment) and lack of compliance. In particular, advanced age has been reported as the most striking reason for with-holding anticoagulation, while risk of falls and previous bleeding are also disproportionate barriers to warfarin prescription.

'He was like a zombie':off-label prescription of antipsychotic drugs in dementia

This paper explores the legal position of the off-label prescription of antipsychotic medications to people with dementia who experience behavioural and psychological symptoms of dementia (BPSD). Dementia is a challenging illness, and BPSD can be very difficult for carers to manage, with evidence that this contributes to carer strain and can result in the early institutionalisation of people with dementia. As a result, the prescription of antipsychotic and other neuroleptic medications to treat BPSD has become commonplace, in spite of these drugs being untested and unlicensed for use to treat older people with dementia. In recent years, it has become apparent through clinical trials that antipsychotic drugs increase the risk of cerebrovascular accident (stroke) and death in people with dementia. In addition, these types of medication also have other risk factors for people with dementia, including over-sedation and worsening of cognitive function. Drawing on recent questionnaire (n = 185), focus group (n = 15), and interview (n = 11) data with carers of people with dementia, this paper explores the law relating to off-label prescription, and the applicability of medical negligence law to cases where adverse events follow the use of antipsychotic medication. It is argued that the practice of off-label prescribing requires regulatory intervention in order to protect vulnerable patients. © The Author [2012]. Published by Oxford University Press; all rights reserved.

Managers' perceptual errors revisited:the role of knowledge calibration

Insights from the stream of research on knowledge calibration, which refers to the correspondence between accuracy and confidence in knowledge, enable a better understanding of consequences of inaccurate perceptions of managers. This paper examines the consequences of inaccurate managerial knowledge through the lens of knowledge calibration. Specifically, the paper examines the antecedent role of miscalibration of knowledge in strategy formation. It is postulated that miscalibrated managers who overestimate external factors and display a high level of confidence in their estimates are likely to enact strategies that are relatively more evolutionary and incremental in nature, whereas miscalibrated managers who overestimate internal factors and display a high level of confidence in their estimates are likely to enact strategies that are relatively more discontinuous and disruptive in nature. Perspectives from social cognitive theory provide support for the underlying processes. The paper, in part, explains the paradox of the prevalence of inaccurate managerial perceptions and efficacious performance. It also advances the literature on strategy formation through the application of the construct of knowledge calibration.