Medication incident reporting in residential aged care facilities: Limitations and risks to residents' safety

Background Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs. Methods The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach. Results The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs. Conclusions This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

Understanding the information dynamics of medication administration in residential aged care facilities (RACFs): A prerequisite for design of effective ICT systems

Medication information is a critical part of the information required to ensure residents' safety in the highly collaborative care context of RACFs. Studies report poor medication information as a barrier to improve medication management in RACFs. Research exploring medication work practices in aged care settings remains limited. This study aimed to identify contextual and work practice factors contributing to breakdowns in medication information exchange in RACFs in relation to the medication administration process. We employed non-participant observations and semi-structured interviews to explore information practices in three Australian RACFs. Findings identified inefficiencies due to lack of information timeliness, manual stock management, multiple data transcriptions, inadequate design of essential documents such as administration sheets and a reliance on manual auditing procedures. Technological solutions such as electronic medication administration records offer opportunities to overcome some of the identified problems. However these interventions need to be designed to align with the collaborative team based processes they intend to support.

Design challenges for electronic medication administration record systems in residential aged care facilities: A formative evaluation

Introduction Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements. Methods A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system. Results The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues.We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows. Discussion Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.

Coping with information silos: An examination of the medication management process in residential aged care facilities (RACFs)

The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in silos can negatively impact the quality of medication management processes in RACF settings. The implementation of commercial software applications like electronic medication charts need to be appropriately integrated to satisfy the collaborative information requirements of the RACF medication process.

Electronic Building Passport - Final Report: Project 2 National Energy Efficient Building Project Phase 2

The National Energy Efficient Building Project (NEEBP) Phase One report, published in December 2014, investigated “process issues and systemic failures” in the administration of the energy performance requirements in the National Construction Code. It found that most stakeholders believed that under-compliance with these requirements is widespread across Australia, with similar issues being reported in all states and territories. The report found that many different factors were contributing to this outcome and, as a result, many recommendations were offered that together would be expected to remedy the systemic issues reported. To follow up on this Phase 1 report, three additional projects were commissioned as part of Phase 2 of the overall NEEBP project. This Report deals with the development and piloting of an Electronic Building Passport (EBP) tool – a project undertaken jointly by pitt&sherry and a team at the Queensland University of Technology (QUT) led by Dr Wendy Miller. The other Phase 2 projects cover audits of Class 1 buildings and issues relating to building alterations and additions. The passport concept aims to provide all stakeholders with (controlled) access to the key documentation and information that they need to verify the energy performance of buildings. This trial project deals with residential buildings but in principle could apply to any building type. Nine councils were recruited to help develop and test a pilot electronic building passport tool. The participation of these councils – across all states – enabled an assessment of the extent to which these councils are currently utilising documentation; to track the compliance of residential buildings with the energy performance requirements in the National Construction Code (NCC). Overall we found that none of the participating councils are currently compiling all of the energy performance-related documentation that would demonstrate code compliance. The key reasons for this include: a major lack of clarity on precisely what documentation should be collected; cost and budget pressures; low public/stakeholder demand for the documentation; and a pragmatic judgement that non-compliance with any regulated documentation requirements represents a relatively low risk for them. Some councils reported producing documentation, such as certificates of final completion, only on demand, for example. Only three of the nine council participants reported regularly conducting compliance assessments or audits utilising this documentation and/or inspections. Overall we formed the view that documentation and information tracking processes operating within the building standards and compliance system are not working to assure compliance with the Code’s energy performance requirements. In other words the Code, and its implementation under state and territory regulatory processes, is falling short as a ‘quality assurance’ system for consumers. As a result it is likely that the new housing stock is under-performing relative to policy expectations, consuming unnecessary amounts of energy, imposing unnecessarily high energy bills on occupants, and generating unnecessary greenhouse gas emissions. At the same time, Councils noted that the demand for documentation relating to building energy performance was low. All the participant councils in the EBP pilot agreed that documentation and information processes need to work more effectively if the potential regulatory and market drivers towards energy efficient homes are to be harnessed. These findings are fully consistent with the Phase 1 NEEBP report. It was also agreed that an EBP system could potentially play an important role in improving documentation and information processes. However, only one of the participant councils indicated that they might adopt such a system on a voluntary basis. The majority felt that such a system would only be taken up if it were: - A nationally agreed system, imposed as a mandatory requirement under state or national regulation; - Capable of being used by multiple parties including councils, private certifiers, building regulators, builders and energy assessors in particular; and - Fully integrated into their existing document management systems, or at least seamlessly compatible rather than a separate, unlinked tool. Further, we note that the value of an EBP in capturing statistical information relating to the energy performance of buildings would be much greater if an EBP were adopted on a nationally consistent basis. Councils were clear that a key impediment to the take up of an EBP system is that they are facing very considerable budget and staffing challenges. They report that they are often unable to meet all community demands from the resources available to them. Therefore they are unlikely to provide resources to support the roll out of an EBP system on a voluntary basis. Overall, we conclude from this pilot that the public good would be well served if the Australian, state and territory governments continued to develop and implement an Electronic Building Passport system in a cost-efficient and effective manner. This development should occur with detailed input from building regulators, the Australian Building Codes Board (ABCB), councils and private certifiers in the first instance. This report provides a suite of recommendations (Section 7.2) designed to advance the development and guide the implementation of a national EBP system.

Evaluation of tomato production systems at Bowen in mitigating the risk of fruit fly infestation: a systems approach for market access

Queensland fruit flies Bactrocera tryoni and B. neohumeralis are considered major quarantine pests of tomato, a major crop in the horticultural production district around Bowen, North Queensland, Australia. Preharvest and/or postharvest treatments are required to meet the market access requirements of both domestic and international trading partners. The suspension from use of dimethoate and fenthion, the two insecticides used for fruit fly control, has resulted in the loss of both pre and postharvest uses in fresh tomato. Research undertaken quantitatively at Bowen evaluated the effectiveness of pre-harvest production systems without specific fruit fly controls and postharvest mitigation measures in reducing the risk of fruit fly infestation in tomato. A district-wide trapping using cue-lure baited traps was undertaken to determine fruit fly seasonal patterns in relation to the cropping seasons. A total of 17,626 field-harvested and 11,755 pack-house tomatoes were sampled from ten farms over three cropping seasons (2006-2009). The fruit were incubated and examined for fruit fly infestation. No fruit fly infested fruit were recorded over the three seasons in either the field or the pack-house samples. Statistical analyses showed that upper infestation levels were extremely low (between 0.025 and 0.062%) at the 95% confidence level. The trap catches showed a seasonal pattern in fruit fly activity, with low numbers during the autumn and winter months, rising slightly in spring and peaking in summer. This seasonal pattern was similar over the four seasons. The main two species of fruit fly caught were B. tryoni and B. neohumeralis. Based on the results, it is clear that the risk of fruit fly infestation is extremely low under the current production systems in the Bowen region.

Accounting for risk: The advent of capped conveyancing title insurance

Title insurance companies originating from America, have, in the past 15 years become part of the Australian conveyancing landscape. However for most residential freehold owners, their activities would be a mystery. A purchaser does not routinely obtain title insurance, with the companies presently focussing on servicing the mortgagee sector. While the lack of penetration in the residential purchaser market may be attributed to the consumer’s lack of knowledge, evidence from Ontario and New Zealand illustrates that title insurance is likely to become an additional cost in the conveyancing process in Australia. In this article we highlight the reasons why, and demonstrate how title insurers have, by working with the legal profession been able to subtly move the risk of responsibility for compensation for loss, (at least in the first instance) from the state to the insurer, but with the added benefit for the state and the conveyancing agents that the cost of the insurance is ultimately borne by the consumer. In New Zealand this development is being accelerated by the introduction of capped conveyancing title insurance. Whether title insurance will become part of the conveyancing process is no longer the relevant question for Australia, (it undoubtedly will), but the unknown issue is just how title insurance companies will work with conveyancing agents to infiltrate the market, and what response this infiltration will have in terms of the state’s view as to their continued role in the provision of assurance. We suggest that developments from New Zealand in relation to capped conveyancing insurance are likely to be replicated in Australia in the near future, and that the state’s role in providing an assurance fund will continue, though the state may seek to expand the areas in which the right to compensation is restricted.

Antecedents of SME export intensity in a Latin American market

Small and medium-sized enterprises (SMEs) from emerging markets in Latin America are increasingly engaging in export-related activities. Nevertheless, limited research exists into the export behavior of such firms. This study proposes and tests a conceptual model that includes the main drivers and inhibitors of export intensity for SMEs from Chile. The model uses confirmatory factor analysis (CFA) to develop the underlying multi-item constructs and structural equation modeling (SEM) to test the model. Results show that manager’s export commitment as well as managerial and organizational resources and capabilities are drivers of export intensity. In addition, the results show that managerial perceptions of internal barriers, such as a manager’s lack of international experience and knowledge, act as significant barriers to developing exports. However, unlike previous findings from developed countries no evidence exists of external cost barriers having a significant impact on export intensity, which is possibly an indication of a competitive business environment in Chile.

Studies on Wage Differentials and Labour Market Transitions

This thesis consists of four studies. The first study examines wage differentials between women and men in the Finnish manufacturing sector. A matched employer-employee data set is used to decompose the overall gender wage gap into the contributions of sex differences in human capital, labour market segregation, and residual within-job wage differentials. The topic of the second study is the relationship between the extended unemployment benefits and labour market transitions of older workers. The analysis exploits a quasi-experimental setting caused by a change in the law that raised the eligibility age of workers benefiting from extended benefits. Roughly half of the unemployed workers with extended benefits are estimated to be effectively withdrawn from labour market search. The risk of unemployment declined and the re-employment probability increased among the age groups directly affected by the reform. The third study provides an empirical analysis of a structural equilibrium search model. Estimation results from various model specifications are compared and discussed. The last study is a methodological study where the difficulties of interpreting the results of competing risks hazard models are discussed and a solution for a particular class of models is proposed. It is argued that a common practice of reporting the results of qualitative response models in terms of marginal effects is also useful in the context of competing risks duration models.

Essays on Labor Market Frictions, Technological Change and Macroeconomic Fluctuations

The dissertation consists of an introductory chapter and three essays that apply search-matching theory to study the interaction of labor market frictions, technological change and macroeconomic fluctuations. The first essay studies the impact of capital-embodied growth on equilibrium unemployment by extending a vintage capital/search model to incorporate vintage human capital. In addition to the capital obsolescence (or creative destruction) effect that tends to raise unemployment, vintage human capital introduces a skill obsolescence effect of faster growth that has the opposite sign. Faster skill obsolescence reduces the value of unemployment, hence wages and leads to more job creation and less job destruction, unambiguously reducing unemployment. The second essay studies the effect of skill biased technological change on skill mismatch and the allocation of workers and firms in the labor market. By allowing workers to invest in education, we extend a matching model with two-sided heterogeneity to incorporate an endogenous distribution of high and low skill workers. We consider various possibilities for the cost of acquiring skills and show that while unemployment increases in most scenarios, the effect on the distribution of vacancy and worker types varies according to the structure of skill costs. When the model is extended to incorporate endogenous labor market participation, we show that the unemployment rate becomes less informative of the state of the labor market as the participation margin absorbs employment effects. The third essay studies the effects of labor taxes on equilibrium labor market outcomes and macroeconomic dynamics in a New Keynesian model with matching frictions. Three policy instruments are considered: a marginal tax and a tax subsidy to produce tax progression schemes, and a replacement ratio to account for variability in outside options. In equilibrium, the marginal tax rate and replacement ratio dampen economic activity whereas tax subsidies boost the economy. The marginal tax rate and replacement ratio amplify shock responses whereas employment subsidies weaken them. The tax instruments affect the degree to which the wage absorbs shocks. We show that increasing tax progression when taxation is initially progressive is harmful for steady state employment and output, and amplifies the sensitivity of macroeconomic variables to shocks. When taxation is initially proportional, increasing progression is beneficial for output and employment and dampens shock responses.

Tibetan Market Participation in China

Since the Chinese government began implementing economic reforms in the late 1970s, China has experienced profound economic change and growth. Like other parts of China, Tibetan areas of China have also experienced wide-ranging economic change with growth even higher than the China-wide average in certain years. Though China s strategic policy of developing the West provided many opportunities for economic and business activities, Tibetans have proven poorly equipped to respond to and take advantage of these opportunities. This study is about people, about market participation and specifically about why Tibetans do not effectively participate in the market in the context of China s economic development process. Many political, social, cultural and environmental factors explain the difficulties met by Tibetan communities. However, this study focuses on three factors: the social and culture context, government policy and education. The Buddhistic nature of Tibetan communities, particularly the political and economic system in traditional Tibetan society, explains this, especially after implementation of new national economic policies. An inclusive economic development policy that promotes local people s participation in the market demands serious consideration of local conditions. Unfortunately, such considerations often ignore local Tibetan realities. The economic development policy in Tibetan areas in China is nearly always an attempt to replicate the inland model and open up markets, even though economic and sociopolitical conditions in Tibet are markedly unlike much of China. A consequence of these policies is increasing numbers of non-Tibetan migrants flowing into Tibetan areas with the ensuing marginalization of Tibetans in the marketplace. Poor quality education is another factor contributing to Tibetan inability to effectively participate in the market. Vocational and business education targeting Tibetans is of very low quality and reflective of government failing to consider local circumstances when implementing education policy. The relatively few Tibetans who do receive education are nearly always unable to compete with non-Tibetan migrants in commercial activity. Encouraging and promoting Tibetan participation in business development and access to quality education are crucial for a sustainable and prosperous society in the long term. Particularly, a localized development policy that considers local environmental conditions and production as well as local culture is crucial. Tibet s economic development should be based on local environmental and production conditions, while utilizing Tibetan culture for the benefit of creating a sustainable economy. Such a localized approach best promotes Tibetan market participation. Keywords: Tibet cultural policy education market participation

Impact of wildfires and floods on property values: A before and after analysis

One of the most evident casualties of a natural disaster is the property market. The private and social costs from such events run into millions of dollars. In this paper, we use a unique dataset to examine the impact on residential house prices affected by natural disasters using a hedonic property (HP) values approach. For this purpose, we use data before and after a wildfire and floods from Rockhampton in central Queensland, Australia. The data is unique because one suburb was affected by wildfires and another was affected by floods. For the analysis, three suburbs namely Frenchville, Park Avenue and Norman Gardens are used. Frenchville was significantly affected by wildfires in the latter part of 2009 and to a lesser extent in 2012, while Park Avenue was affected by floods at the end of 2010, January 2011–2013. Norman Gardens, which was relatively unaffected, is used as a control site. This enables us to examine the before and after effects on property values in the three suburbs. The results confirm that soon after a natural disaster property prices in affected areas decrease even though the large majority of individual houses remain unaffected. Furthermore, the results indicate that the largely unaffected suburb may gain immediately after a natural disaster but this gain may disappear if natural disasters continue to occur in the area/region due to the stigma created. The results have several important policy decision and welfare implications which are briefly discussed in the paper.