Errors associated with the preparation of aseptic products in UK hospital pharmacies: lessons from the national aseptic error reporting scheme

Background Pharmacy aseptic units prepare and supply injectables to minimise risks. The UK National Aseptic Error Reporting Scheme has been collecting data on pharmacy compounding errors, including near-misses, since 2003. Objectives The cumulative reports from January 2004 to December 2007, inclusive, were analysed. Methods The different variables of product types, error types, staff making and detecting errors, stage errors detected, perceived contributory factors, and potential or actual outcomes were presented by cross-tabulation of data. Results A total of 4691 reports were submitted against an estimated 958 532 items made, returning 0.49% as the overall error rate. Most of the errors were detected before reaching patients, with only 24 detected during or after administration. The highest number of reports related to adult cytotoxic preparations (40%) and the most frequently recorded error was a labelling error (34.2%). Errors were mostly detected at first check in assembly area (46.6%). Individual staff error contributed most (78.1%) to overall errors, while errors with paediatric parenteral nutrition appeared to be blamed on low staff levels more than other products were. The majority of errors (68.6%) had no potential patient outcomes attached, while it appeared that paediatric cytotoxic products and paediatric parenteral nutrition were associated with greater levels of perceived patient harm. Conclusions The majority of reports were related to near-misses, and this study highlights scope for examining current arrangements for checking and releasing products, certainly for paediatric cytotoxic and paediatric parenteral nutrition preparations within aseptic units, but in the context of resource and capacity constraints.

Characterising errors in airborne laser altimetry data to extract soil roughness

Airborne laser altimetry has the potential to make frequent detailed observations that are important for many aspects of studying land surface processes. However, the uncertainties inherent in airborne laser altimetry data have rarely been well measured. Uncertainty is often specified as generally as 20cm in elevation, and 40cm planimetric. To better constrain these uncertainties, we present an analysis of several datasets acquired specifically to study the temporal consistency of laser altimetry data, and thus assess its operational value. The error budget has three main components, each with a time regime. For measurements acquired less than 50ms apart, elevations have a local standard deviation in height of 3.5cm, enabling the local measurement of surface roughness of the order of 5cm. Points acquired seconds apart acquire an additional random error due to Differential Geographic Positioning System (DGPS) fluctuation. Measurements made up to an hour apart show an elevation drift of 7cm over a half hour. Over months, this drift gives rise to a random elevation offset between swathes, with an average of 6.4cm. The RMS planimetric error in point location was derived as 37.4cm. We conclude by considering the consequences of these uncertainties on the principle application of laser altimetry in the UK, intertidal zone monitoring.

A singular vector perspective of 4DVAR: The spatial structure and evolution of baroclinic weather systems

The extent to which the four-dimensional variational data assimilation (4DVAR) is able to use information about the time evolution of the atmosphere to infer the vertical spatial structure of baroclinic weather systems is investigated. The singular value decomposition (SVD) of the 4DVAR observability matrix is introduced as a novel technique to examine the spatial structure of analysis increments. Specific results are illustrated using 4DVAR analyses and SVD within an idealized 2D Eady model setting. Three different aspects are investigated. The first aspect considers correcting errors that result in normal-mode growth or decay. The results show that 4DVAR performs well at correcting growing errors but not decaying errors. Although it is possible for 4DVAR to correct decaying errors, the assimilation of observations can be detrimental to a forecast because 4DVAR is likely to add growing errors instead of correcting decaying errors. The second aspect shows that the singular values of the observability matrix are a useful tool to identify the optimal spatial and temporal locations for the observations. The results show that the ability to extract the time-evolution information can be maximized by placing the observations far apart in time. The third aspect considers correcting errors that result in nonmodal rapid growth. 4DVAR is able to use the model dynamics to infer some of the vertical structure. However, the specification of the case-dependent background error variances plays a crucial role.

Predictability and skill of boreal winter forecasts made with the ECMWF Seasonal Forecasting System II

The performance of boreal winter forecasts made with the European Centre for Medium-Range Weather Forecasts (ECMWF) System 11 Seasonal Forecasting System is investigated through analyses of ensemble hindcasts for the period 1987-2001. The predictability, or signal-to-noise ratio, associated with the forecasts, and the forecast skill are examined. On average, forecasts of 500 hPa geopotential height (GPH) have skill in most of the Tropics and in a few regions of the extratropics. There is broad, but not perfect, agreement between regions of high predictability and regions of high skill. However, model errors are also identified, in particular regions where the forecast ensemble spread appears too small. For individual winters the information provided by t-values, a simple measure of the forecast signal-to-noise ratio, is investigated. For 2 m surface air temperature (T2m), highest t-values are found in the Tropics but there is considerable interannual variability, and in the tropical Atlantic and Indian basins this variability is not directly tied to the El Nino Southern Oscillation. For GPH there is also large interannual variability in t-values, but these variations cannot easily be predicted from the strength of the tropical sea-surface-temperature anomalies. It is argued that the t-values for 500 hPa GPH can give valuable insight into the oceanic forcing of the atmosphere that generates predictable signals in the model. Consequently, t-values may be a useful tool for understanding, at a mechanistic level, forecast successes and failures. Lastly, the extent to which t-values are useful as a predictor of forecast skill is investigated. For T2m, t-values provide a useful predictor of forecast skill in both the Tropics and extratropics. Except in the equatorial east Pacific, most of the information in t-values is associated with interannual variability of the ensemble-mean forecast rather than interannual variability of the ensemble spread. For GPH, however, t-values provide a useful predictor of forecast skill only in the tropical Pacific region.