A qualitative exploration of the underlying causes of preventable drug-related morbidity in primary care, resulting in hospitalisation

This study has explored the underlying causes of preventable drug-related admissions to hospital, from primary care through semi-structured interviews and review of patients’ medical records. Analysis of the data has revealed that communication failures between different groups of healthcare professionals and between healthcare professionals and patients contribute to preventable drug-related admissions, as do knowledge gaps about medication in both healthcare professionals and patients. In addition, working conditions for community pharmacists severely limit their ability to effectively act as a safety barrier to patients receiving inappropriate medication. Limitations include heavy workloads, lack of access to patients’ clinical information, poor relationships with general practitioners and time restrictions. The results of this study represent an important addition to our understanding of the contribution of human error as an underlying cause of preventable drug-related morbidity, and the factors which contribute to errors occurring in the primary healthcare setting.

Proposing a way forward: a review of standardisation in the use of age categories and ageing techniques in osteological analysis (2004 to 2009)

This study assesses the current state of adult skeletal age-at-death estimation in biological anthropology through analysis of data published in recent research articles from three major anthropological and archaeological journals (2004–2009). The most commonly used adult ageing methods, age of ‘adulthood’, age ranges and the maximum age reported for ‘mature’ adults were compared. The results showed a wide range of variability in the age at which individuals were determined to be adult (from 14 to 25 years), uneven age ranges, a lack of standardisation in the use of descriptive age categories and the inappropriate application of some ageing methods for the sample being examined. Such discrepancies make comparisons between skeletal samples difficult, while the inappropriate use of some techniques make the resultant age estimations unreliable. At a time when national and even global comparisons of past health are becoming prominent, standardisation in the terminology and age categories used to define adults within each sample is fundamental. It is hoped that this research will prompt discussions in the osteological community (both nationally and internationally) about what defines an ‘adult’, how to standardise the age ranges that we use and how individuals should be assigned to each age category. Skeletal markers have been proposed to help physically identify ‘adult’ individuals.

Early identification of stimulant treatment responders, partial responders and non-responders using objective measures in children and adolescents with hyperkinetic disorder

Background: The aim of this study was to evaluate stimulant medication response following a single dose of methylphenidate (MPH) in children and young people with hyperkinetic disorder using infrared motion analysis combined with a continuous performance task (QbTest system) as objective measures. The hypothesis was put forward that a moderate testdose of stimulant medication could determine a robust treatment response, partial response and non-response in relation to activity, attention and impulse control measures. Methods: The study included 44 children and young people between the ages of 7-18 years with a diagnosis of hyperkinetic disorder (F90 & F90.1). A single dose-protocol incorporated the time course effects of both immediate release MPH and extended release MPH (Concerta XL, Equasym XL) to determine comparable peak efficacy periods post intake. Results: A robust treatment response with objective measures reverting to the population mean was found in 37 participants (84%). Three participants (7%) demonstrated a partial response to MPH and four participants (9%) were determined as non-responders due to deteriorating activity measures together with no improvements in attention and impulse control measures. Conclusion: Objective measures provide early into prescribing the opportunity to measure treatment response and monitor adverse reactions to stimulant medication. Most treatment responders demonstrated an effective response to MPH on a moderate testdose facilitating a swift and more optimal titration process.

Judging size, distance and depth with an active telepresence system

A visual telepresence system has been developed at the University of Reading which utilizes eye tracing to adjust the horizontal orientation of the cameras and display system according to the convergence state of the operator's eyes. Slaving the cameras to the operator's direction of gaze enables the object of interest to be centered on the displays. The advantage of this is that the camera field of view may be decreased to maximize the achievable depth resolution. An active camera system requires an active display system if appropriate binocular cues are to be preserved. For some applications, which critically depend upon the veridical perception of the object's location and dimensions, it is imperative that the contribution of binocular cues to these judgements be ascertained because they are directly influenced by camera and display geometry. Using the active telepresence system, we investigated the contribution of ocular convergence information to judgements of size, distance and shape. Participants performed an open- loop reach and grasp of the virtual object under reduced cue conditions where the orientation of the cameras and the displays were either matched or unmatched. Inappropriate convergence information produced weak perceptual distortions and caused problems in fusing the images.

Influences on secured lending property valuations in the UK

A significant part of bank lending in the UK is secured on commercial property and valuations play an important part in this process. They are an integral part of risk management within the banking sector. It is therefore important that valuations are independent and objective and are used properly to ensure that secured lending is soundly based from the perspective of both lender and borrower. The purpose of this research is to examine objectivity and transparency in the valuation process for bank lending and to identify any influences which may undermine the process. A detailed analysis of 31 valuation negligence cases has been followed by two focus groups of lenders and valuers and also questionnaire surveys of commercial lenders and valuers. Many stakeholders exist, for example lenders, borrowers and brokers, who are able to influence the process in various ways. The strongest evidence of overt influence in the process comes from the method of valuer selection with borrowers and brokers seen to be heavily involved. There is some also some evidence of influence during the draft valuation process. A significant minority of valuers feel that inappropriate pressure is applied by borrowers and brokers yet there is no apparent part of the process that leads to this. The panel system employed by lenders is found to be a significant part of the system and merits further examination. The pressure felt by valuers needs more investigation along with the question of if and how the process could dispel such feelings. This is seen as particularly important in the context of bank regulation.

Forecasting the future: an overview of the strategic planning of the Bournemouth and Poole conurbation

An important part of strategic planning’s purpose should be to attempt to forecast the future, not simply to belatedly respond to events, or accept the future as inevitable. This paper puts forward a conceptual approach for seeking to achieve these aims and uses the Bournemouth and Poole area in Dorset as a vehicle for applying the basic methodology. The area has been chosen because of the significant issues that it currently faces in planning terms; and its future development possibilities. In order that alternative future choices for the area – different ‘developmental trajectories’ – can be evaluated, they must be carefully and logically constructed. Four Futures for Bournemouth/Poole have been put forward; they are titled and colour-coded: Future One is Maximising Growth – Golden Prospect which seeks to achieve the highest level of economic prosperity of the area; Future Two is Incremental Growth – Solid Silver which attempts to facilitate a steady, continuing, controlled pattern of the development for the area; Future Three is Steady State – Cobalt Blue which suggests that people in the area could be more concerned with preserving their quality of life in terms of their leisure and recreation rather than increasing wealth; Future Four is Environment First – Jade Green which makes the area’s environmental protection its top priority even at the possible expense of economic prosperity. The scenarios proposed here are not sacrosanct. Nor are they simply confined to the Bournemouth and Poole area. In theory, suitably modified, they could use in a variety of different contexts. Consideration of the scenarios – wherever located - might then generate other, additional scenarios. These are called hybrids, alloys and amalgams. Likewise it might identify some of them as inappropriate or impossible. Most likely, careful consideration of the scenarios will suggest hybrid scenarios, in which features from different scenarios are combined to produce alternative or additional futures for consideration. The real issue then becomes how best to fashion such a future for the particular area under consideration

PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

The relationship between land–ccean surface temperature contrast and radiative forcing

Previous work has demonstrated that observed and modeled climates show a near-time-invariant ratio of mean land to mean ocean surface temperature change under transient and equilibrium global warming. This study confirms this in a range of atmospheric models coupled to perturbed sea surface temperatures (SSTs), slab (thermodynamics only) oceans, and a fully coupled ocean. Away from equilibrium, it is found that the atmospheric processes that maintain the ratio cause a land-to-ocean heat transport anomaly that can be approximated using a two-box energy balance model. When climate is forced by increasing atmospheric CO2 concentration, the heat transport anomaly moves heat from land to ocean, constraining the land to warm in step with the ocean surface, despite the small heat capacity of the land. The heat transport anomaly is strongly related to the top-of-atmosphere radiative flux imbalance, and hence it tends to a small value as equilibrium is approached. In contrast, when climate is forced by prescribing changes in SSTs, the heat transport anomaly replaces ‘‘missing’’ radiative forcing over land by moving heat from ocean to land, warming the land surface. The heat transport anomaly remains substantial in steady state. These results are consistent with earlier studies that found that both land and ocean surface temperature changes may be approximated as local responses to global mean radiative forcing. The modeled heat transport anomaly has large impacts on surface heat fluxes but small impacts on precipitation, circulation, and cloud radiative forcing compared with the impacts of surface temperature change. No substantial nonlinearities are found in these atmospheric variables when the effects of forcing and surface temperature change are added.

Exploring social barriers to adaptation: insights from Western Nepal

As the challenges and opportunities posed by climate change become increasingly apparent, the need for facilitating successful adaptation and enhancing adaptive capacity within the context of sustainable development is clear. With adaptation high on the agenda, the notion of limits and barriers to adaptation has recently received much attention within both academic and policymaking spheres. While emerging literature has been quick to depict limits and barriers in terms of natural, financial, or technologic processes, there is a clear shortfall in acknowledging social barriers to adaptation. It is against such a backdrop that this paper sets out to expose and explore some of the underlying features of social barriers to adaptation, drawing on insights from two case studies in the Western Nepal. This paper exposes the significant role of cognitive, normative and institutional factors in both influencing and prescribing adaptation. It explores how restrictive social environments can limit adaptation actions and influence adaptive capacity at the local level, particularly for the marginalised and socially excluded. The findings suggest a need for greater recognition of the diversity and complexity of social barriers, strategic planning and incorporation at national and local levels, as well as an emphasis on tackling the underlying drivers of vulnerability and social exclusion.

Inertia in Japanese organizations: knowledge management routines and failure to innovate

This paper argues that features of Japanese organizations, previously held to be the foundations of innovation, change and flexibility, can equally be significant barriers to change, innovation and adaptation in turbulent economic environments. This paper draws on two in-depth case studies of Japanese organizations. It shows how, in both cases, these firms displayed specific weaknesses in the ways in which they integrate and bundle knowledge, in particular around their research and development (R&D) functions. Despite the adoption of strategies of technological innovation and internationalization, the data suggest that the pursuit of both strategies is beset by barriers of inertia. Embedded internal network connections and knowledge-sharing routines between central R&D and other divisions are inappropriate for the revised strategy. Existing external connections, with preferred suppliers and customers within keiretsu structures, and close relationships with existing R&D partners retard these firms' strategic flexibility. With a limited variety of latent routines, knowledge, capabilities and agency to draw on when needed, these firms have limited organizational responsiveness and high levels of path-dependency.

Hospital catering systems and their impact on the sensorial profile of foods provided to older patients in the UK

Impaired sensorial perception is very common in older people and low sensorial quality of foods is associated with decreased appetite and dietary intake. Hospital undernutrition in older patients could be linked to sensorial quality of hospital food if the quality were low or inappropriate for older people. The aim of this study was to examine changes in the sensorial quality of different foods that occur as a result of the food journey (i.e. freezing, regeneration, etc.) in the most common hospital catering systems in the UK. A trained sensory panel assessed sensorial descriptors of certain foods with and without the hospital food journey as it occurs in the in-house and cook/freeze systems. The results showed effects of the food journey on a small number of sensorial descriptors related to flavour, appearance and mouthfeel. The majority of these effects were due to temperature changes, which caused accumulation of condensation. A daily variation in sensorial descriptors was also detected and in some cases it was greater than the effect of the food journey. This study has shown that changes occur in the sensory quality of meals due to hospital food journeys, however these changes were small and are not expected to substantially contribute to acceptability or have a major role in hospital malnutrition.