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.

An event-based approach to validating solar wind speed predictions: high-speed enhancements in the Wang-Sheeley-Arge model

One of the primary goals of the Center for Integrated Space Weather Modeling (CISM) effort is to assess and improve prediction of the solar wind conditions in near‐Earth space, arising from both quasi‐steady and transient structures. We compare 8 years of L1 in situ observations to predictions of the solar wind speed made by the Wang‐Sheeley‐Arge (WSA) empirical model. The mean‐square error (MSE) between the observed and model predictions is used to reach a number of useful conclusions: there is no systematic lag in the WSA predictions, the MSE is found to be highest at solar minimum and lowest during the rise to solar maximum, and the optimal lead time for 1 AU solar wind speed predictions is found to be 3 days. However, MSE is shown to frequently be an inadequate “figure of merit” for assessing solar wind speed predictions. A complementary, event‐based analysis technique is developed in which high‐speed enhancements (HSEs) are systematically selected and associated from observed and model time series. WSA model is validated using comparisons of the number of hit, missed, and false HSEs, along with the timing and speed magnitude errors between the forecasted and observed events. Morphological differences between the different HSE populations are investigated to aid interpretation of the results and improvements to the model. Finally, by defining discrete events in the time series, model predictions from above and below the ecliptic plane can be used to estimate an uncertainty in the predicted HSE arrival times.

Predictions of the arrival time of coronal mass ejections at 1AU: an analysis of the causes of errors

Three existing models of Interplanetary Coronal Mass Ejection (ICME) transit between the Sun and the Earth are compared to coronagraph and in situ observations: all three models are found to perform with a similar level of accuracy (i.e. an average error between observed and predicted 1AU transit times of approximately 11 h). To improve long-term space weather prediction, factors influencing CME transit are investigated. Both the removal of the plane of sky projection (as suffered by coronagraph derived speeds of Earth directed CMEs) and the use of observed values of solar wind speed, fail to significantly improve transit time prediction. However, a correlation is found to exist between the late/early arrival of an ICME and the width of the preceding sheath region, suggesting that the error is a geometrical effect that can only be removed by a more accurate determination of a CME trajectory and expansion. The correlation between magnetic field intensity and speed of ejecta at 1AU is also investigated. It is found to be weak in the body of the ICME, but strong in the sheath, if the upstream solar wind conditions are taken into account.

Representing El Niño in coupled ocean–atmosphere GCMs: the dominant role of the atmospheric component

A systematic modular approach to investigate the respective roles of the ocean and atmosphere in setting El Niño characteristics in coupled general circulation models is presented. Several state-of-the-art coupled models sharing either the same atmosphere or the same ocean are compared. Major results include 1) the dominant role of the atmosphere model in setting El Niño characteristics (periodicity and base amplitude) and errors (regularity) and 2) the considerable improvement of simulated El Niño power spectra—toward lower frequency—when the atmosphere resolution is significantly increased. Likely reasons for such behavior are briefly discussed. It is argued that this new modular strategy represents a generic approach to identifying the source of both coupled mechanisms and model error and will provide a methodology for guiding model improvement.