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.

Primality-testing Mersenne numbers

Report of a systematic review of Mersenne numbers 2^p-1 for p < 62982.

Mersenne numbers

These notes have been issued on a small scale in 1983 and 1987 and on request at other times. This issue follows two items of news. First, WaIter Colquitt and Luther Welsh found the 'missed' Mersenne prime M110503 and advanced the frontier of complete Mp-testing to 139,267. In so doing, they terminated Slowinski's significant string of four consecutive Mersenne primes. Secondly, a team of five established a non-Mersenne number as the largest known prime. This result terminated the 1952-89 reign of Mersenne primes. All the original Mersenne numbers with p < 258 were factorised some time ago. The Sandia Laboratories team of Davis, Holdridge & Simmons with some little assistance from a CRAY machine cracked M211 in 1983 and M251 in 1984. They contributed their results to the 'Cunningham Project', care of Sam Wagstaff. That project is now moving apace thanks to developments in technology, factorisation and primality testing. New levels of computer power and new computer architectures motivated by the open-ended promise of parallelism are now available. Once again, the suppliers may be offering free buildings with the computer. However, the Sandia '84 CRAY-l implementation of the quadratic-sieve method is now outpowered by the number-field sieve technique. This is deployed on either purpose-built hardware or large syndicates, even distributed world-wide, of collaborating standard processors. New factorisation techniques of both special and general applicability have been defined and deployed. The elliptic-curve method finds large factors with helpful properties while the number-field sieve approach is breaking down composites with over one hundred digits. The material is updated on an occasional basis to follow the latest developments in primality-testing large Mp and factorising smaller Mp; all dates derive from the published literature or referenced private communications. Minor corrections, additions and changes merely advance the issue number after the decimal point. The reader is invited to report any errors and omissions that have escaped the proof-reading, to answer the unresolved questions noted and to suggest additional material associated with this subject.

Primality-testing Mersenne Numbers (II)

Reports the factor-filtering and primality-testing of Mersenne Numbers Mp for p < 100000, the latter using the ICL 'DAP' Distributed Array Processor.

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.

Adjoint goal-based error norms for adaptive mesh ocean modelling

Flow in the world's oceans occurs at a wide range of spatial scales, from a fraction of a metre up to many thousands of kilometers. In particular, regions of intense flow are often highly localised, for example, western boundary currents, equatorial jets, overflows and convective plumes. Conventional numerical ocean models generally use static meshes. The use of dynamically-adaptive meshes has many potential advantages but needs to be guided by an error measure reflecting the underlying physics. A method of defining an error measure to guide an adaptive meshing algorithm for unstructured tetrahedral finite elements, utilizing an adjoint or goal-based method, is described here. This method is based upon a functional, encompassing important features of the flow structure. The sensitivity of this functional, with respect to the solution variables, is used as the basis from which an error measure is derived. This error measure acts to predict those areas of the domain where resolution should be changed. A barotropic wind driven gyre problem is used to demonstrate the capabilities of the method. The overall objective of this work is to develop robust error measures for use in an oceanographic context which will ensure areas of fine mesh resolution are used only where and when they are required. (c) 2006 Elsevier Ltd. All rights reserved.

Mersenne Numbers: consolidated results

This document provides and comments on the results of the Lucas-Lehmer testing and/or partial factorisation of all Mersenne Numbers Mp = 2^p-1 where p is prime and less than 100,000. Previous computations have either been confirmed or corrected. The LLT computations on the ICL DAP is the first implementation of Fast-Fermat-Number-Transform multiplication in connection with Mersenne Number testing. This paper championed the disciplines of systematically testing the Mp, and of double-sourcing results which were not manifestly correct. Both disciplines were adopted by the later GIMPS initiative, the 'Great Internet Mersenne Prime Search, which was itself one of the first web-based distributed-community projects.

Overview: oxidant and particle photochemical processes above a south-east Asian tropical rain forest (the OP3 project); introduction, rationale, location, characteristics and tools

In April–July 2008, intensive measurements were made of atmospheric composition and chemistry in Sabah, Malaysia, as part of the "Oxidant and particle photochemical processes above a South-East Asian tropical rainforest" (OP3) project. Fluxes and concentrations of trace gases and particles were made from and above the rainforest canopy at the Bukit Atur Global Atmosphere Watch station and at the nearby Sabahmas oil palm plantation, using both ground-based and airborne measurements. Here, the measurement and modelling strategies used, the characteristics of the sites and an overview of data obtained are described. Composition measurements show that the rainforest site was not significantly impacted by anthropogenic pollution, and this is confirmed by satellite retrievals of NO2 and HCHO. The dominant modulators of atmospheric chemistry at the rainforest site were therefore emissions of BVOCs and soil emissions of reactive nitrogen oxides. At the observed BVOC:NOx volume mixing ratio (~100 pptv/pptv), current chemical models suggest that daytime maximum OH concentrations should be ca. 105 radicals cm−3, but observed OH concentrations were an order of magnitude greater than this. We confirm, therefore, previous measurements that suggest that an unexplained source of OH must exist above tropical rainforest and we continue to interrogate the data to find explanations for this.