Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe Study

Aim: To determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. Methods: 1) Systematic reviews; 2) Retrospective review of unique medication items prescribed over a 12 month period to a 2% sample of patients from 15 general practices in England; 3) Interviews with 34 prescribers regarding 70 potential errors; 15 root cause analyses, and six focus groups involving 46 primary health care team members Results: The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for one in eight patients, involving around one in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with one in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology. Conclusion: Prescribing errors in general practices are common, although severe errors are unusual. Many factors increase the risk of error. Strategies for reducing the prevalence of error should focus on GP training, continuing professional development for GPs, clinical governance, effective use of clinical computer systems, and improving safety systems within general practices and at the interface with secondary care.

High-strength, healable, supramolecular polymer nanocomposites

A supramolecular polymer blend, formed via π-π interactions between a π-electron rich pyrenyl endcapped oligomer and a chain-folding oligomer containing pairs of π-electron poor naphthalene-diimide (NDI) units, has been reinforced with cellulose nanocrystals (CNCs) to afford a healable nanocomposite material. Nanocomposites with varying weight percentage of CNCs (from 1.25 to 20.0 wt.%) within the healable supramolecular polymeric matrix have been prepared via solvent casting followed by compression molding, and their mechanical properties and healing behavior have been evaluated. It is found that homogeneously dispersed films can be formed with CNCs at less than 10 wt.%. Above 10 wt.% CNC heterogeneous nanocomposites were obtained. All the nanocomposites formed could be re-healed upon exposure to elevated temperatures although, for the homogeneous films, it was found that the healing rate was reduced with increasing CNC content. The best combination of healing efficiency and mechanical properties was obtained with the 7.5 wt.% CNC nanocomposite which exhibited a tensile modulus enhanced by as much as a factor of 20 over the matrix material alone and could be fully re-healed at 85 °C within 30 minutes. Thus it is demonstrated that supramolecular nanocomposites can afford greatly enhanced mechanical properties relative to the unreinforced polymer, while still allowing efficient thermal healing.

Insect infection model for campylobacter jejuni reveals that O-methyl phosphoramidate has insecticidal activity

Galleria mellonella (wax moth) larvae have elsewhere been shown to be susceptible to pathogens such as Francisella tularensis, Burkholderia mallei, and Pseudomonas aeruginosa. We report that the larvae are rapidly killed by Campylobacter jejuni at 37 degrees C. Three strains of C. jejuni tested, 11168H (human diarrheal isolate), G1 (human Guillain-Barre syndrome isolate), and 81-176 (human diarrheal isolate), were equally effective at killing G. mellonella larvae. A panel of defined mutants of C. jejuni 11168H, in known or putative virulence genes, showed different degrees of attenuation in G. mellonella larvae. A mutant lacking the O-methyl phosphoramidate (MeOPN) capsule side group was attenuated, clearly demonstrating that MeOPN has a role in virulence. This new model of C. jejuni infection should facilitate the identification of novel virulence genes.

Nitrogen flows from European watersheds to coastal marine waters

Nitrogen flows from European watersheds to coastal marine waters Executive summary Nature of the problem • Most regional watersheds in Europe constitute managed human territories importing large amounts of new reactive nitrogen. • As a consequence, groundwater, surface freshwater and coastal seawater are undergoing severe nitrogen contamination and/or eutrophication problems. Approaches • A comprehensive evaluation of net anthropogenic inputs of reactive nitrogen (NANI) through atmospheric deposition, crop N fixation,fertiliser use and import of food and feed has been carried out for all European watersheds. A database on N, P and Si fluxes delivered at the basin outlets has been assembled. • A number of modelling approaches based on either statistical regression analysis or mechanistic description of the processes involved in nitrogen transfer and transformations have been developed for relating N inputs to watersheds to outputs into coastal marine ecosystems. Key findings/state of knowledge • Throughout Europe, NANI represents 3700 kgN/km2/yr (range, 0–8400 depending on the watershed), i.e. five times the background rate of natural N2 fixation. • A mean of approximately 78% of NANI does not reach the basin outlet, but instead is stored (in soils, sediments or ground water) or eliminated to the atmosphere as reactive N forms or as N2. • N delivery to the European marine coastal zone totals 810 kgN/km2/yr (range, 200–4000 depending on the watershed), about four times the natural background. In areas of limited availability of silica, these inputs cause harmful algal blooms. Major uncertainties/challenges • The exact dimension of anthropogenic N inputs to watersheds is still imperfectly known and requires pursuing monitoring programmes and data integration at the international level. • The exact nature of ‘retention’ processes, which potentially represent a major management lever for reducing N contamination of water resources, is still poorly understood. • Coastal marine eutrophication depends to a large degree on local morphological and hydrographic conditions as well as on estuarine processes, which are also imperfectly known. Recommendations • Better control and management of the nitrogen cascade at the watershed scale is required to reduce N contamination of ground- and surface water, as well as coastal eutrophication. • In spite of the potential of these management measures, there is no choice at the European scale but to reduce the primary inputs of reactive nitrogen to watersheds, through changes in agriculture, human diet and other N flows related to human activity.

Integrating nitrogen fluxes at the European scale

Executive summary Nature of the problem • Environmental problems related to nitrogen concern all economic sectors and impact all media: atmosphere, pedosphere, hydrosphere and anthroposphere. • Therefore, the integration of fluxes allows an overall coverage of problems related to reactive nitrogen (Nr) in the environment, which is not accessible from sectoral approaches or by focusing on specific media. Approaches • This chapter presents a set of high resolution maps showing key elements of the N flux budget across Europe, including N2 and Nr fluxes. • Comparative nitrogen budgets are also presented for a range of European countries, highlighting the most efficient strategies for mitigating Nr problems at a national scale. A new European Nitrogen Budget (EU-27) is presented on the basis of state-of-the-art Europe-wide models and databases focusing on different segments of Europe’s society. Key findings • From c. 18 Tg Nr yr −1 input to agriculture in the EU-27, only about 7 Tg Nr yr− 1 find their way to the consumer or are further processed by industry. • Some 3.7 Tg Nr yr−1 is released by the burning of fossil fuels in the EU-27, whereby the contribution of the industry and energy sectors is equal to that of the transport sector. More than 8 Tg Nr yr−1 are disposed of to the hydrosphere, while the EU-27 is a net exporter of reactive nitrogen through atmospheric transport of c. 2.3 Tg Nr yr−1. • The largest single sink for Nr appears to be denitrifi cation to N2 in European coastal shelf regions (potentially as large as the input of mineral fertilizer, about 11 Tg N yr–1 for the EU-27); however, this sink is also the most uncertain, because of the uncertainty of Nr import from the open ocean. Major uncertainties • National nitrogen budgets are diffi cult to compile using a large range of data sources and are currently available only for a limited number of countries. • Modelling approaches have been used to fill in the data gaps in some of these budgets, but it became obvious during this study that further research is needed in order to collect necessary data and make national nitrogen budgets inter-comparable across Europe. • In some countries, due to inconsistent or contradictory information coming from different data sources, closure of the nitrogen budget was not possible. Recommendations • The large variety of problems associated with the excess of Nr in the European environment,including adverse impacts, requires an integrated nitrogen management approach that would allow for creation and closure of N budgets within European environments. • Development of nitrogen budgets nationwide, their assessment and management could become an effective tool to prioritize measures and prevent unwanted side effects.

What GPs need to know about palliative-care drugs: ketamine

This is the first in a short series of articles that focus on what GPs should consider when monitoring and prescribing specialist-initiated palliative-care drugs. This first article summarises the key issues for patients receiving ketamine.

A thermoresponsive supramolecular polymer network comprising pyrene-functionalized gold nano-particles and a chain-folding polydiimide.

A thermoresponsive, supramolecular nanocomposite has been prepared by the addition of pyrenyl functionalized gold nanoparticles (AuNPs) to a polydiimide that contains receptor residues designed to form defined complexes with pyrene. The novel pyrenyl-functionalized AuNPs (P-AuNPs) were characterized by transmission electron microscopy, with surface functionalization confirmed by infrared and UV–visible spectroscopic analyses. Mixing solutions of the P-AuNPs and a π-electron-deficient polydiimide resulted in the formation of electronically complementary, chain-folded and π–π-stacked complexes, so affording a new supramolecular nanocomposite network which precipitated from solution. The P-AuNPs bind to the polydiimide via π–π stacking interactions to create supramolecular cross-links. UV–visible spectroscopic analysis confirmed the thermally reversible nature of the complexation process, and transmission electron microscopy (TEM), infrared spectroscopy (IR), and differential scanning calorimetry (DSC) were used to characterize the supramolecular-nanocomposite material. The supramolecular polymer network is insoluble at room temperature, yet may be dissolved at temperatures above 60 °C. The thermal reversibility of this system is maintained over five heat/cool cycles without diminishment of the network characteristics. In contrast to the individual components, the nanocomposite formed self-supporting films, demonstrating the benefit of the supramolecular network in terms of mechanical properties. Control experiments probing the interactions between a model diimide compound that can also form a π-stacked complex with the π-electron rich pyrene units on P-AuNPs showed that, while complexation was readily apparent, precipitation did not occur because a supramolecular cross-linked network system could not be formed with this system.

Oligomeric pseudorotaxanes adopting infinite-chain lattice superstructures

Above a critical chain length, where oligomers contain five or more recognition units, apparently infinite donor–acceptor polypseudorotaxanes are formed in the solid state. X-ray crystallographic analyses of three different examples have shown that although the oligomeric chains are undoubtedly discrete and monodisperse, they nevertheless appear to be infinite in the crystal.

Carl von Clausewitz: On War

OUP Abridged edition, based on the Howard & Paret translation. Includes my Introduction.

Developing consensus on hospital prescribing indicators of potential harms amenable to decision support

Aim: To develop a list of prescribing indicators specific for the hospital setting that would facilitate the prospective collection of high severity and/or high frequency prescribing errors, which are also amenable to electronic clinical decision support (CDS). Method: A three-stage consensus technique (electronic Delphi) was carried out with 20 expert pharmacists and physicians across England. Participants were asked to score prescribing errors using a 5-point Likert scale for their likelihood of occurrence and the severity of the most likely outcome. These were combined to produce risk scores, from which median scores were calculated for each indicator across the participants in the study. The degree of consensus between the participants was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or more was achieved. Results: A total of 80 prescribing errors were identified by consensus as being high or extreme risk. The most common drug classes named within the indicators were antibiotics (n=13), antidepressants (n=8), nonsteroidal anti-inflammatory drugs (n=6), and opioid analgesics (n=6).The most frequent error type identified as high or extreme risk were those classified as clinical contraindications (n=29/80). Conclusion: 80 high risk prescribing errors in the hospital setting have been identified by an expert panel. These indicators can serve as the basis for a standardised, validated tool for the collection of data in both paperbased and electronic prescribing processes, as well as to assess the impact of electronic decision support implementation or development.

GP guide to drugs used in palliative care: psychostimulants

This is the third in a short series of articles that focus on what GPs should consider when monitoring and prescribing specialist‐initiated palliative‐care drugs. Here, the authors summarise the key issues around the shortterm use of psychostimulants in palliative care.