The prevalence and nature of prescribing and monitoring errors in English general practice – a retrospective case note review

Objective To determine the prevalence and nature of prescribing and monitoring errors in general practices in England. Design Retrospective case note review of unique medication items prescribed over a 12 month period to a 2% random sample of patients. Mixed effects logistic regression was used to analyse the data. Setting Fifteen general practices across three primary care trusts in England. Data sources Examination of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients. Main outcome measures Prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions. Results Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval 4.4 - 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age less than 15 (Odds Ratio (OR) 1.87, 1.19 to 2.94, p=0.006) or greater than 64 years (OR 1.68, 1.04 to 2.73, p=0.035), and higher numbers of unique medication items prescribed (OR 1.16, 1.12 to 1.19, p<0.001). Conclusion Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed based on the study findings.

The causes of prescribing errors in English general practices: a qualitative study

Aim: To examine the causes of prescribing and monitoring errors in English general practices and provide recommendations for how they may be overcome. Design: Qualitative interview and focus group study with purposive sampling and thematic analysis informed by Reason’s accident causation model. Participants: General practice staff participated in a combination of semi-structured interviews (n=34) and six focus groups (n=46). Setting: Fifteen general practices across three primary care trusts in England. Results: We identified seven categories of high-level error-producing conditions: the prescriber, the patient, the team, the task, the working environment, the computer system, and the primary-secondary care interface. Each of these was further broken down to reveal various error-producing conditions. The prescriber’s therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health, were all identified as possible causes. The patient’s characteristics and the complexity of the individual clinical case were also found to have contributed to prescribing errors. The importance of feeling comfortable within the practice team was highlighted, as well as the safety of general practitioners (GPs) in signing prescriptions generated by nurses when they had not seen the patient for themselves. The working environment with its high workload, time pressures, and interruptions, and computer related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts, were all highlighted as possible causes of prescribing errors and often interconnected. Conclusion: This study has highlighted the complex underlying causes of prescribing and monitoring errors in general practices, several of which are amenable to intervention.

Reverse knowledge transfer: evidence from General Motors in the UK and Poland

This paper explores the concept of a reverse diffusion of knowledge, that is, the transfer flowing from a company’s subsidiary to its home plant. The article presents the empirical evidence gathered in General Motors UK and Poland, where the reverse diffusion of a concept of the built-in quality took place. Lastly, the implications of our findings for future research are discussed.

Student and Faculty Perceptions of Technology’s Usefulness in Community College General Education Courses

Educational institutions of all levels invest large amounts of time and resources into instructional technology, with the goal of enhancing the educational effectiveness of the learning environment. The decisions made by instructors and institutions regarding the implementation of technology are guided by perceptions of usefulness held by those who are in control. The primary objective of this mixed methods study was to examine the student and faculty perceptions of technology being used in general education courses at a community college. This study builds upon and challenges the assertions of writers such as Prensky (2001a, 2001b) and Tapscott (1998) who claim that a vast difference in technology perception exists between generational groups, resulting in a diminished usefulness of technology in instruction. In this study, data were gathered through student surveys and interviews, and through faculty surveys and interviews. Analysis of the data used Kendall’s Tau test for correlation between various student and faculty variables in various groupings, and also typological analysis of the transcribed interview data. The analysis of the quantitative data revealed no relationship between age and perception of technology’s usefulness. A positive relationship was found to exist between the perception of the frequency of technology use and the perception of technology’s effectiveness, suggesting that both faculty members and students believed that the more technology is used, the more useful it is in instruction. The analysis of the qualitative data revealed that both faculty and students perceive technology to be useful, and that the most significant barriers to technology’s usefulness include faulty hardware and software systems,lack of user support, and lack of training for faculty. The results of the study suggest that the differences in perception of technology between generations that are proposed by Prensky may not exist when comparing adults from the younger generation with adults from the older generation. Further, the study suggests that institutions continue to invest in instructional technology, with a focus on high levels of support and training for faculty, and more universal availability of specific technologies, including web access, in class video, and presentation software. Adviser: Ronald Joekel

Health risk appraisal for older people 4: case finding for hypertension, hyperlipidaemia and diabetes mellitus in older people in English general practice before the introduction of the Quality and Outcomes Framework

Early intervention can help to reduce the burden of disability in the older population, but many do not access preventive care. There is uncertainty over what factors influence case finding in older patients in general practice.

Testing strategies and follow-up for coeliac disease in a general internal medicine outpatient department from 2000 to 2005

PRINCIPLES: Coeliac disease (gluten sensitive enteropathy) is a genetically determined disorder with an incidence in the general population that is comparable to type 2 diabetes mellitus. Awareness of this fact and of the often atypical and oligosymptomatic manifestations is only now gaining ground in the medical profession. A high index of suspicion is important in order to minimise diagnostic and therapeutic delay. METHODS: Testing patterns and follow-up for coeliac disease in our institution have been analysed retrospectively for the past five years. The current literature was reviewed with respect to recommendations for clinical practice. RESULTS: A total of 271 patients were tested for coeliac disease over a period of five years. Only in 24 patients were positive results found; after further work-up, the final number of cases with certain or presumed coeliac disease was four. Followup was often difficult, many patients being lost after a single visit. CONCLUSIONS: This study showed that the number of tests ordered in our institution, more often for abdominal than atypical symptoms, has started to increase in the past two years. It also showed that screening tests have found their place in general clinical practice, while the final choice of tests needs to be determined in accordance with available guidelines and local resources. Upper endoscopy with small bowel biopsy remains the gold standard for diagnosis, but its place in follow-up is less certain. Coeliac disease is a disorder for which there is a definite treatment (gluten free diet); if it is left untreated diminished quality of life and potentially serious complications may ensue. Further education of the medical profession regarding coeliac disease, its incidence, presentation and treatment, is clearly indicated..

Emotional processing in a ten-session general psychiatric treatment for borderline personality disorder: a case study

This study examines the effects of a borderline-specific treatment, called general psychiatric management, on emotional change, outcome and therapeutic alliance of an outpatient presenting with borderline personality disorder. Based on the sequential model of emotional processing, emotional states were assessed in a 10-session setting. The case showed an increase in expressions of distress and no change in therapeutic alliance and tended towards general deterioration. Results suggest emotional processing may play a lesser role in general psychiatric management in early phase treatment than previously hypothezised.

Juvenile–adult tree associations in a continental Mediterranean ecosystem: no evidence for sustained and general facilitation at increased aridity

Question: How do tree species identity, microhabitat and water availability affect inter- and intra-specific interactions between juvenile and adult woody plants? Location: Continental Mediterranean forests in Alto Tajo Natural Park, Guadalajara, Spain. Methods: A total of 2066 juveniles and adults of four co-occurring tree species were mapped in 17 plots. The frequency of juveniles at different microhabitats and water availability levels was analysed using log-linear models. We used nearest-neighbour contingency table analysis of spatial segregation and J-functions to describe the spatial patterns. Results: We found a complex spatial pattern that varied according to species identity and microhabitat. Recruitment was more frequent in gaps for Quercus ilex, while the other three species recruited preferentially under shrubs or trees depending on the water availability level. Juveniles were not spatially associated to conspecific adults, experiencing segregation from them inmany cases. Spatial associations, both positive and negative, were more common at higher water availability levels. Conclusions: Our results do not agree with expectations from the stressgradient hypothesis, suggesting that positive interactions do not increase in importance with increasing aridity in the study ecosystem. Regeneration patterns are species-specific and depend on microhabitat characteristics and dispersal strategies. In general, juveniles do not look for conspecific adult protection. This work contributes to the understanding of species co-existence, proving the importance of considering a multispecies approach at several plots to overcome limitations of simple pair-wise comparisons in a limited number of sites.

Identifying asthma and chronic obstructive pulmonary disease in patients with persistent cough presenting to general practitioners: descriptive study

Objective: To determine the prevalence of asthma and chronic obstructive pulmonary disease in patients not known to have these disorders, who present in general practice with persistent cough, and to ascertain criteria to help general practitioners in diagnosis.

The impact on general practitioners of the changing balance of care for elderly people living in institutions

Objectives: To describe utilisation of general practitioners by elderly people resident in communal establishments; to examine variations in general practitioner utilisation and estimate the likely impact of the “downsizing” of long stay provision in NHS hospitals.

Effects of special educator peer coaching on general educator effectiveness in inclusive classroom settings

This dissertation investigated the effects of a peer coaching relationship between a special education teacher and two general education teachers. More specifically, a two-tier multiple baseline design across subjects was used to evaluate the effects of peer coaching on the general education teachers' use of effective instructional practices (EIPs) and subsequent effects on the engagement rate and academic performance of students with and without disabilities. The peer coaching process included modeling, direct support, and feedback on the use of effective instructional practices including getting student attention, giving specific directions, asking specific questions with wait time, contingent positive reinforcement, positive error correction, precorrection, prompting, and proximity control. A 30-second partial interval recording procedure was used to observe the general education teachers' use of effective instructional practices and student engagement rates. Student participants' academic performance was measured using weekly quizzes. ^ Peer coaching resulted in an overall increase in the teachers' use of EIPs. One general education teacher had a 30% increase in average EIP use from 46% during the baseline phase to 76% during intervention. Student engagement for her two student participants with and without disabilities indicated an increase from 54% to 69% and from 47% to 65% respectively. Results for the second general education teacher indicated a 34% increase in average EIP use from 55% during the baseline to 89% during intervention. Student engagement for the two student participants with and without disabilities in her class increased from 48% to 83% and from 29% to 71% respectively. Student academic performance showed a small increase. In follow-up observations, the effects of peer coaching on teacher use of EIPs and student engagement and academic performance were maintained. ^ The results of this study suggest that using peer coaching to support general education teachers can be an effective method to improve the educational outcomes of students with and without disabilities in general education. Further research is needed to investigate the effects of peer coaching with other special and general educator partnerships and other student participants. ^

The effects of self-monitoring on homework completion and accuracy rates of students with disabilities in an inclusive general education classroom

This study investigated the effects of self-monitoring on the homework completion and accuracy rates of four, fourth-grade students with disabilities in an inclusive general education classroom. A multiple baseline across subjects design was utilized to examine four dependent variables: completion of spelling homework, accuracy of spelling homework, completion of math homework, accuracy of math homework. Data were collected and analyzed during baseline, three phases of intervention, and maintenance. ^ Throughout baseline and all phases, participants followed typical classroom procedures, brought their homework to school each day and gave it to the general education teacher. During Phase I of the intervention, participants self-monitored with a daily sheet at home and on the computer at school in the morning using KidTools (Fitzgerald & Koury, 2003); a student friendly, self-monitoring program. They also participated in brief daily conferences to review their self-monitoring sheets with the investigator, their special education teacher. Phase II followed the same steps except conferencing was reduced to two days a week, which were randomly selected by the researcher and Phase III conferencing was one random day a week. Maintenance data were taken over a two-to-three week period subsequent to the end of the intervention. ^ Results of this study demonstrated self-monitoring substantially improved spelling and math homework completion and accuracy rates of students with disabilities in an inclusive, general education classroom. On average, completion and accuracy rates were highest over baseline in Phase III. Self-monitoring led to higher percentages of completion and accuracy during each phase of the intervention compared to baseline, group percentages also rose slightly during maintenance. Therefore, results suggest self-monitoring leads to short-term maintenance in spelling and math homework completion and accuracy. ^ This study adds to the existing literature by investigating the effects of self-monitoring of homework for students with disabilities included in general education classrooms. Future research should consider selecting participants with other demographic characteristics, using peers for conferencing instead of the teacher, and the use of self-monitoring with other academic subjects (e.g., science, history). Additionally, future research could investigate the effects of each of the two self-monitoring components used alone, with or without the conferencing.^

An analysis of the attitudes of dental patients attending general dental practice in Galway

Aim: To describe the patterns of dental attendance and attitudes towards tooth loss of general dental practice patients in Galway. Objectives: 1. To determine the pattern of adult dental attendance in general practices in Galway; and, 2. To examine the oral health attitudes of these patients. Method: Questionnaires were distributed to 311 consecutive adult patients in the waiting rooms of ten general dental practices in Galway, which were randomly selected from the telephone directory. Results: A total of 254 of the 311 questionnaires distributed were fully completed, returned and included in the results, giving a response rate of 81.7%. A total of 59% of dentate participants attended their dentist for annual or biannual examinations compared to 23% of edentate patients. Some 10.5% of medical card holders and 0.5% of non-medical card holders were edentulous. Conclusions: The data from the survey indicated that medical card holders in Galway were more likely to be edentulous than nonmedical card holders. Edentate patients were less likely to be regular dental attenders than dentate patients.

A Soft Computing Approach to Quality Evaluation of General Chemistry Learning in Higher Education

In contemporary societies higher education must shape individuals able to solve problems in a workable and simpler manner and, therefore, a multidisciplinary view of the problems, with insights in disciplines like psychology, mathematics or computer science becomes mandatory. Undeniably, the great challenge for teachers is to provide a comprehensive training in General Chemistry with high standards of quality, and aiming not only at the promotion of the student’s academic success, but also at the understanding of the competences/skills required to their future doings. Thus, this work will be focused on the development of an intelligent system to assess the Quality-of-General-Chemistry-Learning, based on factors related with subject, teachers and students.

Characterization of ENSO changes under idealised radiative forcing in an intermediate complexity general circulation model

Intermediate-complexity general circulation models are a fundamental tool to investigate the role of internal and external variability within the general circulation of the atmosphere and ocean. The model used in this thesis is an intermediate complexity atmospheric general circulation model (SPEEDY) coupled to a state-of-the-art modelling framework for the ocean (NEMO). We assess to which extent the model allows a realistic simulation of the most prominent natural mode of variability at interannual time scales: El-Niño Southern Oscillation (ENSO). To a good approximation, the model represents the ENSO-induced Sea Surface Temperature (SST) pattern in the equatorial Pacific, despite a cold tongue-like bias. The model underestimates (overestimates) the typical ENSO spatial variability during the winter (summer) seasons. The mid-latitude response to ENSO reveals that the typical poleward stationary Rossby wave train is reasonably well represented. The spectral decomposition of ENSO features a spectrum that lacks periodicity at high frequencies and is overly periodic at interannual timescales. We then implemented an idealised transient mean state change in the SPEEDY model. A warmer climate is simulated by an alteration of the parametrized radiative fluxes that corresponds to doubled carbon dioxide absorptivity. Results indicate that the globally averaged surface air temperature increases of 0.76 K. Regionally, the induced signal on the SST field features a significant warming over the central-western Pacific and an El-Niño-like warming in the subtropics. In general, the model features a weakening of the tropical Walker circulation and a poleward expansion of the local Hadley cell. This response is also detected in a poleward rearrangement of the tropical convective rainfall pattern. The model setting that has been here implemented provides a valid theoretical support for future studies on climate sensitivity and forced modes of variability under mean state changes.