Medication errors in residential aged care facilities: A distributed cognition analysis of the information exchange process

Background Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. Methods The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May–September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. Results The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Conclusions Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents’ safety.

Bayesian Analysis of a Superimposed Renewal Process

Stochastic behavior of an aero-engine failure/repair process has been analyzed from a Bayesian perspective. Number of failures/repairs in the component-sockets of this multi-component system are assumed to follow independent renewal processes with Weibull inter-arrival times. Based on the field failure/repair data of a large number of such engines and independent Gamma priors on the scale parameters and log-concave priors on the shape parameters, an exact method of sampling from the resulting posterior distributions of the parameters has been proposed. These generated parameter values are next utilised in obtaining the posteriors of the expected number of system repairs, system failure rate, and the conditional intensity function, which are computed using a recursive formula.

Internal defect and process parameter analysis during friction stir welding of Al 6061 sheets

Welding parameters like welding speed, rotation speed, plunge depth, shoulder diameter etc., influence the weld zone properties, microstructure of friction stir welds, and forming behavior of welded sheets in a synergistic fashion. The main aims of the present work are to (1) analyze the effect of welding speed, rotation speed, plunge depth, and shoulder diameter on the formation of internal defects during friction stir welding (FSW), (2) study the effect on axial force and torque during welding, (c) optimize the welding parameters for producing internal defect-free welds, and (d) propose and validate a simple criterion to identify defect-free weld formation. The base material used for FSW throughout the work is Al 6061T6 having a thickness value of 2.1 mm. Only butt welding of sheets is aimed in the present work. It is observed from the present analysis that higher welding speed, higher rotation speed, and higher plunge depth are preferred for producing a weld without internal defects. All the shoulder diameters used for FSW in the present work produced defect-free welds. The axial force and torque are not constant and a large variation is seen with respect to FSW parameters that produced defective welds. In the case of defect-free weld formation, the axial force and torque are relatively constant. A simple criterion, (a,tau/a,p)(defective) > (a,tau/a,p)(defect free) and (a,F/a,p)(defective) > (a,F/a,p)(defect free), is proposed with this observation for identifying the onset of defect-free weld formation. Here F is axial force, tau is torque, and p is welding speed or tool rotation speed or plunge depth. The same criterion is validated with respect to Al 5xxx base material. Even in this case, the axial force and torque remained constant while producing defect-free welds.

Analysis of the modulation process in advanced bus-clamping PWM techniques

Advanced bus-clamping pulse width modulation (ABCPWM) techniques are advantageous in terms of line current distortion and inverter switching loss in voltage source inverter-fed applications. However, the PWM waveforms corresponding to these techniques are not amenable to carrier-based generation. The modulation process in ABCPWM methods is analyzed here from a “per-phase” perspective. It is shown that three sets of descendant modulating functions (or modified modulating functions) can be generated from the three-phase sinusoidal signals. Each set of the modified modulating functions can be used to produce the PWM waveform of a given phase in a computationally efficient manner. Theoretical results and experimental investigations on a 5hp motor drive are presented

Moment Tensor Analysis of the Acoustic Emission Source in the Rock Damage Process

To further investigate the mechanism of acoustic emission (AE) in the rock fracture experiment, moment tensor analysis was carried out. The AE sources characterized by crack sizes, orientations and fracture modes, are represented by a time-dependent momen

Analysis of the legislative framework in the Brazilian policymaking process

Analisa os aspectos da estrutura política brasileira que contribuem para falhas nos processos decisórios e ineficácia nos resultados finais de políticas de governo, com ênfase nos problemas institucionais do poder legislativo. Aborda os seguintes tópicos: fragmentação do sistema partidário, infidelidade partidária, modelo de federalismo, preenchimento de cargos públicos, larga utilização de medidas provisórias, disfunções do processo legislativo.

Learning and management skills: the internationalization of Grupo Arcor. Analysis from a process-based approach

This paper analyzes the path of the international expansion of Grupo Arcor, an Argentine multinational company specializing in confectionery. The objective is to entify corporate strategies and business learning that led this Latin American firm to establish itself as one of the leading manufacturers in confectionery industry ,particularly in the 21st Century. The analysis is primarily qualitative in order to identify the economic dimension as a determinant in the internationalization process; a processbased approach from the Uppsala Model is used for this. However, the study is also complemented with a regression analysis to test if the firm was driven to expand internationally by the expectations on the degree of globalization of the industry and the accumulation of experience in foreign markets, and if the company was influenced by psychic distance in choosing the location of its investment; given the influence of these variables in Grupo Arcor business strategies. Our findings suggest that Grupo Arcor, was able to become global due to strategies such as vertical integration, diversification of products and geographical markets (based on psychic distance) and indeed some strategies were consequence of the globalization of the sector and the accumulation of experience in foreign markets.