Approaches to reducing the most important patient errors in primary health care : patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients' contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants' suggestions revealed the content of four inter-related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from 'individualised community care'. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health-care.

Measurement errors in body size of sea scallops (Placopecten magellanicus) and their effect on stock assessment models

Body-size measurement errors are usually ignored in stock assessments, but may be important when body-size data (e.g., from visual sur veys) are imprecise. We used experiments and models to quantify measurement errors and their effects on assessment models for sea scallops (Placopecten magellanicus). Errors in size data obscured modes from strong year classes and increased frequency and size of the largest and smallest sizes, potentially biasing growth, mortality, and biomass estimates. Modeling techniques for errors in age data proved useful for errors in size data. In terms of a goodness of model fit to the assessment data, it was more important to accommodate variance than bias. Models that accommodated size errors fitted size data substantially better. We recommend experimental quantification of errors along with a modeling approach that accommodates measurement errors because a direct algebraic approach was not robust and because error parameters were diff icult to estimate in our assessment model. The importance of measurement errors depends on many factors and should be evaluated on a case by case basis.

Model-based influences on humans' choices and striatal prediction errors.

The mesostriatal dopamine system is prominently implicated in model-free reinforcement learning, with fMRI BOLD signals in ventral striatum notably covarying with model-free prediction errors. However, latent learning and devaluation studies show that behavior also shows hallmarks of model-based planning, and the interaction between model-based and model-free values, prediction errors, and preferences is underexplored. We designed a multistep decision task in which model-based and model-free influences on human choice behavior could be distinguished. By showing that choices reflected both influences we could then test the purity of the ventral striatal BOLD signal as a model-free report. Contrary to expectations, the signal reflected both model-free and model-based predictions in proportions matching those that best explained choice behavior. These results challenge the notion of a separate model-free learner and suggest a more integrated computational architecture for high-level human decision-making.

C. G. Jung and literary theory: the challenge from fiction

C.G. Jung and Literary Theory remedies a significant omission in literary studies by doing for Jung and poststructuralist literary theories what has been done extensively for Freud, Lacan and post-Freudian psychoanalysis. This work represents a complete departure from traditional Jungian literary criticism. Instead, radically new Jungian literary theories are developed of deconstruction, feminist theory, gender and psyche, the body and sexuality, spirituality, postcolonialism, historicism and reader-response. As well as linking Jung to the work of Derrida, Kristeva and Irigaray, the book traces contentious occult, cultural and political narratives in Jung's career. It contains a chapter on Jung and fascism in a literary context. [From the Publisher]

Investigating the Interhemisphere 14C Offset in the 1st Millennium AD and Assessment of Laboratory Bias and Calibration Errors

Past measurements of the radiocarbon interhemispheric offset have been restricted to relatively young samples because of a lack of older dendrochronologically secure Southern Hemisphere tree-ring chronologies. The Southern Hemisphere calibration data set SHCal04 earlier than AD 950 utilizes a variable interhemispheric offset derived from measured 2nd millennium AD Southern Hemisphere/Northern Hemisphere sample pairs with the assumption of stable Holocene ocean/ atmosphere interactions. This study extends the range of measured interhemispheric offset values with 20 decadal New Zealand kauri and Irish oak sample pairs from 3 selected time intervals in the 1st millennium AD and is part of a larger program to obtain high-precision Southern Hemisphere 14C data continuously back to 200 BC. We found an average interhemispheric offset of 35 ± 6 yr, which although consistent with previously published 2nd millennium AD measurements, is lower than the offset of 55–58 yr utilized in SHCal04. We concur with McCormac et al. (2008) that the IntCal04 measurement for AD 775 may indeed be slightly too old but also suggest the McCormac results appear excessively young for the interval AD 755–785. In addition, we raise the issue of laboratory bias and calibration errors, and encourage all laboratories to check their consistency with appropriate calibration curves and invest more effort into improving the accuracy of those curves.

Online Thévenin Equivalent Determination Considering System Side Changes and Measurement Errors

This paper presents a new method for online determination of the Thèvenin equivalent parameters of a power system at a given node using the local PMU measurements at that node. The method takes into account the measurement errors and the changes in the system side. An analysis of the effects of changes in system side is carried out on a simple two-bus system to gain an insight of the effect of system side changes on the estimated Thévenin equivalent parameters. The proposed method uses voltage and current magnitudes as well as active and reactive powers; thus avoiding the effect of phase angle drift of the PMU and the need to synchronize measurements at different instances to the same reference. Applying the method to the IEEE 30-bus test system has shown its ability to correctly determine the Thévenin equivalent even in the presence of measurement errors and/or system side changes.

Characterization of human and instrument related measurement errors

Measurement is the act or the result of a quantitative comparison between a given quantity and a quantity of the same kind chosen as a unit. It is generally agreed that all measurements contain errors. In a measuring system where both a measuring instrument and a human being taking the measurement using a preset process, the measurement error could be due to the instrument, the process or the human being involved. The first part of the study is devoted to understanding the human errors in measurement. For that, selected person related and selected work related factors that could affect measurement errors have been identified. Though these are well known, the exact extent of the error and the extent of effect of different factors on human errors in measurement are less reported. Characterization of human errors in measurement is done by conducting an experimental study using different subjects, where the factors were changed one at a time and the measurements made by them recorded. From the pre‐experiment survey research studies, it is observed that the respondents could not give the correct answers to questions related to the correct values [extent] of human related measurement errors. This confirmed the fears expressed regarding lack of knowledge about the extent of human related measurement errors among professionals associated with quality. But in postexperiment phase of survey study, it is observed that the answers regarding the extent of human related measurement errors has improved significantly since the answer choices were provided based on the experimental study. It is hoped that this work will help users of measurement in practice to better understand and manage the phenomena of human related errors in measurement.

Errors associated with preparation of adult and paediatric parenteral nutrition in UK hospital pharmacies

Rationale: In UK hospitals, the preparation of all total parenteral nutrition (TPN) products must be made in the pharmacy as TPNs are categorised as high-risk injectables (NPSA/2007/20). The National Aseptic Error Reporting Scheme has been collecting data on pharmacy compounding errors in the UK since August 2003. This study reports on types of error associated with the preparation of TPNs, including the stage at which these were identified and potential and actual patient outcomes. Methods: Reports of compounding errors for the period 1/2004 - 3/2007 were analysed on an Excel spreadsheet. Results: Of a total of 3691 compounding error reports, 674 (18%) related to TPN products; 548 adult vs. 126 paediatric. A significantly higher proportion of adult TPNs (28% vs. 13% paediatric) were associated with labelling errors and a significantly higher proportion of paediatric TPNs (25% vs. 15% adult) were associated with incorrect transcriptions (Chi-Square Test; p<0.005). Labelling errors were identified equally by pharmacists (42%) and technicians (48%) with technicians detecting mainly at first check and pharmacists at final check. Transcription errors were identified mainly by technicians (65% vs. 27% pharmacist) at first check. Incorrect drug selection (13%) and calculation errors (9%) were associated with adult and paediatric TPN preparations in the same ratio. One paediatric TPN error detected at first check was considered potentially catastrophic; 31 (5%) errors were considered of major and 38 (6%) of moderate potential consequence. Five errors (2 moderate, 1 minor) were identified during or after administration. Conclusions: While recent UK patient safety initiatives are aimed at improving the safety of injectable medicines in clinical areas, the current study highlights safety problems that exist within pharmacy production units. This could be used in the creation of an error management tool for TPN compounding processes within hospital pharmacies.

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 prevalence and nature of prescribing and monitoring errors in English general practice – a retrospective case note review

Objective To determine the prevalence and nature of prescribing and monitoring errors in general practices in England. Design Retrospective case note review of unique medication items prescribed over a 12 month period to a 2% random sample of patients. Mixed effects logistic regression was used to analyse the data. Setting Fifteen general practices across three primary care trusts in England. Data sources Examination of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients. Main outcome measures Prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions. Results Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval 4.4 - 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age less than 15 (Odds Ratio (OR) 1.87, 1.19 to 2.94, p=0.006) or greater than 64 years (OR 1.68, 1.04 to 2.73, p=0.035), and higher numbers of unique medication items prescribed (OR 1.16, 1.12 to 1.19, p<0.001). Conclusion Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed based on the study findings.

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Literary Love Making in Nicholas Sparks Novels: Finding the Balance Between the Writer's Life and Writer's Work in Bestselling Romantic Love

For almost a decade now Nicholas Sparks has been writing love stories. Not only has he been publishing his stories, but they have received high acclaim in each of their installments. Several of his novels have been made into major motion pictures and increased his popularity quite significantly. His status as a successful romantic fiction writer is undeniable, but the question is, why? What is it about Nicholas Sparks that makes his novels so engaging, and personally, what do I need to do as an aspiring novelist to try and acquire the same literary status? Sparks’s novels reach readers at a number of different levels, thus giving them appeal no matter the intellectual intent of the reader. Theoretically, Sparks engages reader response techniques as well as formalist processes such as “habitualization” and “defamiliarization,” while also developing engaging plot lines that represent many of the experiences from his own life. His writing is not only academically redeemable, but it is also creatively stimulating; between the two, Sparks represents the thunder and lightning combination all writers strive for while trying to achieve literary success. This project also offers a creative element in which I attempt to exemplify many of the traits discussed in the analytical sections of this document, by recreating them in a creative, fictitious fashion. Themes such as: motion versus stasis, life versus death, and the ordinary versus the extraordinary all exist within the narrative structure of my short story “Trip to Fall.” Besides these thematic elements, the creative section strives to represent the balance Sparks achieves between the experiences of his own life and the fictitious world he creates. Overall, this project delves into the life of Nicholas Sparks to better understand the inspiration for his writing at the level of form as well as content, while also paying tribute to Sparks’s style through a representation of his work in my own words.

The ethics and practical importance of defining, distinguishing and disclosing nursing errors : a discussion paper

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of ‘nursing error’, the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of ‘nursing error’ fits with the new ‘system approach’ to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is ‘right’ for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

Career in writing : Judah Waten and the cultural politics of a literary career

This thesis examines the literary career of Judah Waten (1911-1985) in order to focus on a series of issues in Australian cultural history and theory. The concept of the career is theorised as a means of bringing together the textual and institutional dimensions of writing and being a writer in a specific cultural economy. The guiding question of the argument which re-emerges in different ways in each chapter is: in what ways was it possible to write and to be a writer in a given time and place? Waten's career as a Russian-born, Jewish, Australian nationalist, communist and realist writer across the middle years of this century is, for the purposes of the argument, at once usefully exemplary and usefully marginal in relation to the literary establishment. His texts provide the central focus for individual chapters; at the same time each chapter considers a specific historical moment and a specific set of issues for Australian cultural history, and is to this extent self-contained. Recent work in narrative theory, literary sociology and Australian literary and cultural studies is brought together to revise accepted readings of Waten's texts and career, and to address significant absences or problems in Australian cultural history. The sequence of issues shaping Waten's career in writing is argued in terms of the following conjunctions of theoretical and historical categories: proletarianism, modernity and theories of the avant-garde; the "e;migrant"e; writer and minority literatures; realism, political purpose and narrative self-situation; communism, nationalism and literary practice in the cold war; utopianism and the "e;literary witness"e; narrative of the Soviet Union; assimilationism, multicultural theory and the "e;non-Anglo-Celtic"e; writer; theories of autobiographical writing, and autobiography in Waten's career. The purpose of the thesis is not to discover a single key to Waten's writing across the oeuvre but rather to plot the specific occasions of this writing in the context of the structure of a career and the cultural institutions within which it was formed.