Training pharmacists to deliver a complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis

Objective: To describe the training undertaken by pharmacists employed in a pharmacist-led information technology-based intervention study to reduce medication errors in primary care (PINCER Trial), evaluate pharmacists’ assessment of the training, and the time implications of undertaking the training. Methods: Six pharmacists received training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation forms were entered onto a Microsoft Excel spreadsheet, independently checked and the summary of results further verified. Frequencies were calculated for responses to the three-point Likert scale questions. Free-text comments from the evaluation forms and pharmacists’ diaries were analysed thematically. Key findings: All six pharmacists received 22 hours of training over five sessions. In four out of the five sessions, the pharmacists who completed an evaluation form (27 out of 30 were completed) stated they were satisfied or very satisfied with the various elements of the training package. Analysis of free-text comments and the pharmacists’ diaries showed that the principles of root cause analysis and educational outreach were viewed as useful tools to help pharmacists conduct pharmaceutical interventions in both the study and other pharmacy roles that they undertook. The opportunity to undertake role play was a valuable part of the training received. Conclusions: Findings presented in this paper suggest that providing the PINCER pharmacists with training in root cause analysis and educational outreach contributed to the successful delivery of PINCER interventions and could potentially be utilised by other pharmacists based in general practice to deliver pharmaceutical interventions to improve patient safety.

Can France really stop them? : A study grounded on the realist perspective about the French foreign policy towards Syria as the root cause of the Phenomenon of French Foreign Fighters

During the Syrian conflict the number of European Foreign Fighters has increased exponentially and has become an ever-growing concern for European policymakers. This phenomenon presents host of major security challenges for European policymakers and governments. Among European countries, France provides the highest number of citizens who have gone to Syria to fight against Assad´s regime. The French authorities have estimated that by mid-2014, over 700 French citizens have left France and travelled to Syria to fight. Historically France has had a relationship with Syria which started with its role as a border-drawing colonial power. Grounded in a framework of realism, that emphasizes nation-states as the primary actor within the international system, the analysis concentrates on the role of France´s foreign policy on the Syria as push factor for terrorism and radicalization. This paper attempts to determinate a specific correlation between the policy that France has been conducting towards Syria between 2000 and 2015, and the phenomenon of French Foreign Fighters. Findings suggest that France´s foreign policy towards Syria is the main root cause of the French Foreign Fighters phenomenon.

Uncovering the root cause of ethnic difference in ability testing:differential test functioning, test familiarity and trait optimism as explanations of ethnic group differences

The present research represents a coherent approach to understanding the root causes of ethnic group differences in ability test performance. Two studies were conducted, each of which was designed to address a key knowledge gap in the ethnic bias literature. In Study 1, both the LR Method of Differential Item Functioning (DIF) detection and Mixture Latent Variable Modelling were used to investigate the degree to which Differential Test Functioning (DTF) could explain ethnic group test performance differences in a large, previously unpublished dataset. Though mean test score differences were observed between a number of ethnic groups, neither technique was able to identify ethnic DTF. This calls into question the practical application of DTF to understanding these group differences. Study 2 investigated whether a number of non-cognitive factors might explain ethnic group test performance differences on a variety of ability tests. Two factors – test familiarity and trait optimism – were able to explain a large proportion of ethnic group test score differences. Furthermore, test familiarity was found to mediate the relationship between socio-economic factors – particularly participant educational level and familial social status – and test performance, suggesting that test familiarity develops over time through the mechanism of exposure to ability testing in other contexts. These findings represent a substantial contribution to the field’s understanding of two key issues surrounding ethnic test performance differences. The author calls for a new line of research into these performance facilitating and debilitating factors, before recommendations are offered for practitioners to ensure fairer deployment of ability testing in high-stakes selection processes.

Root cause analysis applied to a finite element model's refinement of a negative stiffness structure

Negative Stiffness Structures are mechanical systems that require a decrease in the applied force to generate an increase in displacement. They are structures that possess special characteristics such as snap-through and bi-stability. All of these features make them particularly suitable for different applications, such as shock-absorption, vibration isolation and damping. From this point of view, they have risen awareness of their characteristics and, in order to match them to the application needed, a numerical simulation is of great interest. In this regard, this thesis is a continuation of previous studies in a circular negative stiffness structure and aims at refine the numerical model by presenting a new solution. To that end, an investigation procedure is needed. Amongst all of the methods available, root cause analysis was the chosen one to perform the investigation since it provides a clear view of the problem under analysis and a categorization of all the causes behind it. As a result of the cause-effect analysis, the main causes that have influence on the numerical results were obtained. Once all of the causes were listed, solutions to them were proposed and it led to a new numerical model. The numerical model proposed was of nonlinear type of analysis with hexagonal elements and a hyperelastic material model. The results were analyzed through force-displacement curves, allowing for the visualization of the structure’s energy recovery. When compared to the results obtained from the experimental part, it is evident that the trend is similar and the negative stiffness behaviour is present.

Determine Initial Cause for Current Premature Portland Cement Concrete Pavement Deterioration Final Report, 2000

A detailed investigation has been conducted on core samples taken from 17 portland cement concrete pavements located in Iowa. The goal of the investigation was to help to clarify the root cause of the premature deterioration problem that has become evident since the early 1990s. Laboratory experiments were also conducted to evaluate how cement composition, mixing time, and admixtures could have influenced the occurrence of premature deterioration. The cements used in this study were selected in an attempt to cover the main compositional parameters pertinent to the construction industry in Iowa. The hardened air content determinations conducted during this study indicated that the pavements that exhibited premature deterioration often contained poor to marginal entrained-air void systems. In addition, petrographic studies indicated that sometimes the entrained-air void system had been marginal after mixing and placement of the pavement slab, while in other instances a marginal to adequate entrained-air void system had been filled with ettringite. The filling was most probably accelerated because of shrinkage cracking at the surface of the concrete pavements. The results of this study suggest that the durability—more sciecifically, the frost resistance—of the concrete pavements should be less than anticipated during the design stage of the pavements. Construction practices played a significant role in the premature deterioration problem. The pavements that exhibited premature distress also exhibited features that suggested poor mixing and poor control of aggregate grading. Segregation was very common in the cores extracted from the pavements that exhibited premature distress. This suggests that the vibrators on the paver were used to overcome a workability problem. Entrained-air voids formed in concrete mixtures experiencing these types of problems normally tend to be extremely coarse, and hence they can easily be lost during the paving process. This tends to leave the pavement with a low air content and a poor distribution of air voids. All of these features were consistent with a premature stiffening problem that drastically influenced the ability of the contractor to place the concrete mixture. Laboratory studies conducted during this project indicated that most premature stiffening problems can be directly attributed to the portland cement used on the project. The admixtures (class C fly ash and water reducer) tended to have only a minor influence on the premature stiffening problem when they were used at the dosage rates described in this study.

Application of multivariate statistical process control to fuel cell manufacturing

Univariate statistical control charts, such as the Shewhart chart, do not satisfy the requirements for process monitoring on a high volume automated fuel cell manufacturing line. This is because of the number of variables that require monitoring. The risk of elevated false alarms, due to the nature of the process being high volume, can present problems if univariate methods are used. Multivariate statistical methods are discussed as an alternative for process monitoring and control. The research presented is conducted on a manufacturing line which evaluates the performance of a fuel cell. It has three stages of production assembly that contribute to the final end product performance. The product performance is assessed by power and energy measurements, taken at various time points throughout the discharge testing of the fuel cell. The literature review performed on these multivariate techniques are evaluated using individual and batch observations. Modern techniques using multivariate control charts on Hotellings T2 are compared to other multivariate methods, such as Principal Components Analysis (PCA). The latter, PCA, was identified as the most suitable method. Control charts such as, scores, T2 and DModX charts, are constructed from the PCA model. Diagnostic procedures, using Contribution plots, for out of control points that are detected using these control charts, are also discussed. These plots enable the investigator to perform root cause analysis. Multivariate batch techniques are compared to individual observations typically seen on continuous processes. Recommendations, for the introduction of multivariate techniques that would be appropriate for most high volume processes, are also covered.

The Rise of democracy in Europe and the fight against mass poverty in Latin America: the implications for marxist thought of some recent mainstream papers

Recently a number of mainstream papers have treated the rise of democracy in 19th century Europe and its instability in Latin America in an eminently Marxist fashion. This paper sets out their implications for Marxist thought. With respect to Europe, Marx's emphasis on political action backed by the threat of violence is vindicated but his justification for socialism is not. With respect to Latin America, the unequal distribution of wealth is the cause of political instability that is, in turn, the root cause of mass poverty. In addition it is possible to explain some of the paradoxical characteristics of neo-liberalism and to make a weak argument for socialism in spite of its rejection in Europe.

Improving patient safety: how and why incidences occur in nursing care

The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU) in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

The role of WNT and mTOR in human memory T cell formation

Cancer is one of the world's leading causes of death with a rising trend in incidence. These epidemiologic observations underline the need for novel treatment strategies. In this regard, a promising approach takes advantage of the adaptive effector mechanisms of the immune system, using T lymphocytes to specifically target and destroy tumour cells. However, whereas current approaches mainly depend on short-lived, terminally differentiated effector T cells, increasing evidence suggests that long lasting and maximum efficient immune responses are mediated by low differentiated memory T cells. These memory T cells should display characteristics of stem cells, such as longevity, self-renewal capacity and the ability to continuously give rise to further differentiated effectors. These stem celllike memory T (TSCM) cells are thought to be of key therapeutic value as they might not only attack differentiated tumour cells, but also eradicate the root cause of cancer, the cancer stem cells themselves. Thus, efforts are made to characterize TSCM cells and to identify the signalling pathways which mediate their induction. Recently, a human TSCM cell subset was described and the activation of the Wnt-ß-catenin signalling pathway by the drug TWS119 during naive CD8+ T (TN) cell priming was suggested to mediate their induction. However, a precise deciphering of the signalling pathways leading to TSCM cell induction and an in-depth characterization of in vitro induced and in vivo occurring TSCM cells remain to be performed. Here, evidence is presented that the induction of human and mouse CD8+ and CD4+ TSCM cells may be triggered by inhibition of mechanistic/mammalian target of rapamycin (mTOR) complex 1 with simultaneously active mTOR complex 2. This molecular mechanism arrests a fraction of activated TN cells in a stem cell-like differentiation state independently of the Wnt-ß-catenin signalling pathway. Of note, TWS119 was found to also inhibit mTORCl, thereby mediating the induction of TSCM cells. Suggesting an immunostimulatory effect, the acquired data broaden the therapeutic range of mTORCl inhibitors like rapamycin, which are, at present, exclusively used due to their immunosuppressive function. Furthermore, by performing broad metabolic analyses, a well-orchestrated interplay between intracellular signalling pathways and the T cells' metabolic programmes could be identified as important regulator of the T cells' differentiation fate. Moreover, in vitro induced CD4+ TSCM cells possess superior functional capacities and share fate-determining key factors with their naturally occurring counterparts, assessed by a first-time full transcriptome analysis of in vivo occurring CD4+ TN cell, TSCM cells and central memory (TCM) cells and in vitro induced CD4+ TSCM cells. Of interest, a group of 56 genes, with a unique expression profile in TSCM cells could be identified. Thus, a pharmacological mechanism allowing to confer sternness to activated TN cells has been found which might be highly relevant for the design of novel T cell-based cancer immunotherapies.

Construction and Evaluation of Submerged Vanes for Stream Control, HR-274, 1988

The objective of this study was to determine the practicality and effectiveness of using submerged vanes ("Iowa Vanes") to control bank erosion in a bend of East Nishnabotna River, Iowa. The vane system was constructed during the summer of 1985. It functions by eliminating, or reducing, the centrifugally induced helical motion of the flow in the bend, which is the root cause of bank undermining. The system was monitored over a 2-year period, from September 1985 to October 1987. Two surveys were conducted in the spring of 1986 in which data were taken of depths and velocities throughout the bend and of water-surface slope. The movement of the bank was determined from aerial photos and from repeated measurements of the vane-to-bank distance. The bankfull scour depths and velocities along the bank have been reduced significantly; and the movement of the bank has been stopped or considerably reduced. The improvements were obtained without changing the energy slope of the channel. Areas of design improvements were identified.

Estudi comparatiu: errors de les infermeres en la preparació i l'administració de la medicació segons dos sistemes de distribució

Introducció: Els errors de medicació són definits com qualsevol incident prevenible que pot causar dany al pacient o donar lloc a una utilització inapropiada dels medicaments, quan aquests estan sota el control dels professionals sanitaris o del pacient. Els errors en la preparació i l’administració de medicació són els més comuns de l’àrea hospitalària i, tot i la llarga cadena per la qual passa el fàrmac, el professional d’infermeria és el últim responsable de l’acció, tenint així, un paper molt important en la seguretat del pacient. Les infermeres dediquen el 40% del temps de la seva jornada laboral en tasques relacionades amb la medicació. Objectiu: Determinar si les infermeres produeixen més errors si treballen amb sistemes de distribució de medicació de stock o en sistemes de distribució unidosis de medicació. Metodologia: Estudi quantitatiu, observacional i descriptiu, on la notificació d’errors (o oportunitats d’error) realitzats per la infermera, en les fases de preparació i administració de medicació, es farà mitjançant un qüestionari autoelaborat. Els elements a identificar seran: el tipus d’error, les causes que poden haver--‐lo produït, la seva potencial gravetat i qui l’ha pogut evitar; així com el tipus de professional que l’ha produït. Altres dades rellevants són: el medicament implicat junt amb la dosis i la via d’administració i el sistema de distribució utilitzat. Mostreig i mostra: El mostreig serà no probabilístic i per conveniència. S’escolliran aquelles infermeres que l’investigador consideri amb les característiques necessàries per participar en l’estudi, així que la mostra estarà formada per les infermeres les quals treballen a la unitat 40 de l’Hospital del Mar i utilitzen un sistema de distribució de medicació de dosis unitàries i les infermeres que treballen a urgències (concretament a l’àrea de nivell dos) de l’Hospital del Mar les quals treballen amb un sistema de distribució de medicació de stock.

Field Instrumentation, Testing, and Long-Term Monitoring of High-Mast Lighting Towers in the State of Iowa, TR-518, 2006

As a result of the collapse of a 140 foot high-mast lighting tower in Sioux City, Iowa in November of 2003, a thorough investigation into the behavior and design of these tall, yet relatively flexible structures was undertaken. Extensive work regarding the root cause of this failure was carried out by Robert Dexter of The University of Minnesota. Furthermore, a statewide inspection of all the high-mast towers in Iowa revealed fatigue cracks and loose anchor bolts on other existing structures. The current study was proposed to examine the static and dynamic behavior of a variety of towers in the State of Iowa utilizing field testing, specifically long-term monitoring and load testing. This report presents the results and conclusions from this project. The field work for this project was divided into two phases. Phase 1 of the project was conducted in October 2004 and focused on the dynamic properties of ten different towers in Clear Lake, Ames, and Des Moines, Iowa. Of those ten, two were also instrumented to obtain stress distributions at various details and were included in a 12 month long-term monitoring study. Phase 2 of this investigation was conducted in May of 2005, in Sioux City, Iowa, and focused on determining the static and dynamic behavior of a tower similar to the one that collapsed in November 2003. Identical tests were performed on a similar tower which was retrofitted with a more substantial replacement bottom section in order to assess the effect of the retrofit. A third tower with different details was dynamically load tested to determine its dynamic characteristics, similar to the Phase 1 testing. Based on the dynamic load tests, the modal frequencies of the towers fall within the same range. Also, the damping ratios are significantly lower in the higher modes than the values suggested in the AASHTO and CAN/CSA specifications. The comparatively higher damping ratios in the first mode may be due to aerodynamic damping. These low damping ratios in combination with poor fatigue details contribute to the accumulation of a large number of damage-causing cycles. As predicted, the stresses in the original Sioux City tower are much greater than the stresses in the retrofitted towers at Sioux City. Additionally, it was found that poor installation practices which often lead to loose anchor bolts and out-of-level leveling nuts can cause high localized stresses in the towers, which can accelerate fatigue damage.

Service Management for Service Desk

Palvelunhallinnan kehittäminen Service Desk ympäristöön johtaa parempaan työnkulun hallintaan. Service Deskin päätehtävänä on toimia ainoana yhteyspisteenä asiakkaalta tietohallinto-osastolle. Jokainen yhteydenottopitää kirjata ja se pitäisi olla jäljitettävissä. Tapahtumien eli insidenttien kirjaaminen tapahtuu pääasiassa Service Desk -funktiossa, joka omistaa niistä jokaisen. Tapahtumien hallintaprosessin tehtävänä on etsiä loppukäyttäjän tai IT-infrastruktuurin monitorointityökalun ilmoittamalle insidentille mahdollisimman nopea ratkaisu. Insidentit saattavat johtaa ongelmiin, jotka käsitellään erillisessä prosessissa. Ongelmien hallintaprosessi yrittää etsiä vikatilanteen pohjimmaisen syyn. Kun pohjimmaisin syy on löytynyt, prosessi lähettää muutospyynnön muutosten hallintaprosessille. Jotta päästään mahdollisimman hyvään tehokkuuteen, pitää määrittää asiakasrajapinta sekä mittarit. ITIL-malli tarjoaa prosessit IT-palvelunhallinnan kehittämiselle. Kansainvälisesti tunnettuna 'de factO' standardina sitä voidaan soveltaa globaaleissa yrityksissä. Tässä työssä keskitytään erään lääkkeiden jakelussa toimivan yrityksen tietohallinto-osaston Help Deskin nykytilan määrittämiseen. Työssä myös kuvataan tietohallinto-osaston tavoitetila, jossa keskitytään Service Deskin IT palvelunhallinnan kehittämiseen. Muut prosessit ja mittarit on kuvattu niiltä osin, jotka tulee huomioida Service Deskin seuraamisen ja ohjaamisen kannalta.

Inhimillisten virheiden tarkastelu ydinvoimalaitosten käyttökokemusten hyödyntämisessä

Tässä työssä on kuvattu ydinvoimalaitosten käyttökokemusten tutkimusta keskittyen erityisesti inhimillisten toimintojen tarkasteluun. Työssä on kerrottu kansainvälisistä vaatimuksista ja järjestöistä sekä yleisesti käyttökokemusten tutkimuksessa käytössä olevista menetelmistä keskittyen perussyyanalyysimenetelmiin. Suomen osalta työssä on käsitelty lainsäädännön asettamia velvoitteita ja muita vaatimuksia, jotka ydinvoima-alalla koostuvat lähinnä Säteilyturvakeskuksen YVL-ohjeista. Viranomaisena toimivan Säteilyturvakeskuksen, alan tutkimusta suorittavan Valtion teknillisen tutkimuskeskuksen ja Teollisuuden Voima Oy:n käyttökokemusten tutkimiseen liittyvät organisaatiot ja menettelytavat on esitelty. Fortum Power and Heat Oy:n omistaman ja käyttämän Loviisan ydinvoimalaitoksen käyttökokemusten hyödyntäminen on käsitelty tarkemmin. Loviisan voimalaitoksen organisaatio ja käyttökokemusten sekä inhimillisten virheiden käsittelymenetelmiä on esitelty ja analysoitu. Työn alkuvaiheessa Loviisan voimalaitoksella inhimillisistä virheistä kerätystä tiedosta koottu tietokanta järjesteltiin kuntoon. Järjestelyn jälkeen tietoa analysoitiin ja analysoinnin tulokset on esitetty tässä työssä. Sekä järjestelyn että analysoinnin aikana havaitut kehityskohteet kirjattiin muistiin. Pienet toimenpiteet suoritettiin heti ja suuremmat kirjattiin tämän työn toimenpide-ehdotuksiin. Kehittämiskeinoja on ehdotettu virheiden luokittelumenetelmään ja käyttökokemusten käsittelymenetelmiin.

Perussyyanalyysien käyttö ydinvoimalaitosten tapahtumien tutkinnassa

Tämä diplomityö käsittelee perussyyanalyysien käyttöä Loviisan voimalaitoksella tapahtumien tutkinnassa. Diplomityössä käydään läpi erilaisia maailmalla käytössä olevia perussyyanalyysimenetelmiä. Nykyään Loviisan voimalaitoksella ei ole ohjeessa määritelty miten perussyyanalyysit tulee tehdä, joten diplomityön tulosten perusteella on tarkoitus valita Loviisan voimalaitokselle sopiva menetelmä. Diplomityössä tehdään eräs perussyyanalyysi kahdella eri menetelmällä, jotka tuntuivat sopivilta menetelmiltä Loviisan voimalaitoksille. Perussyyanalyysimenetelmät, joita käytetään, ovat Loviisassa käytetty sovellettu HPES-menetelmä ja yhdysvaltalaisten ydinvoimaviranomaisten kehittämä HPIP-menetelmä. Perussyyanalyysien valmistuttua ja tuloksia vertaillessa tultiin siihen lopputulokseen, ettei Loviisan voimalaitoksella ole tarvetta vaihtaa nykyisin käytössä olevaa mutta ohjeistamatonta menetelmää. Loviisan voimalaitokselle tehtävään uuteen perussyyanalyysiohjeeseen liitetään menetelmäkuvaus sovelletusta HPES-menetelmästä. Menetelmäkuvauksessa kuvataan miten HPES-menetelmää käytetään perussyyanalyysien tekoon Loviisan voimalaitoksella.