Patient Safety Law: From Silos to Systems

Patient safety has become a significant and pressing policy issue. Around the world, governments, the health care sector and the public are increasingly cognizant of the need to improve the safety of care delivered by their health systems. Pressure for change has been created by highly publicized incidents in a number of countries involving unsafe acts that were significant both in scale and consequence and a number of empirical studies that revealed the high rates of unsafe acts and their consequences. The costs of unsafe health care – both personal and fiscal – to individuals, their families and their communities and to the state are massive. In this research project we explored one particular avenue for change – that is, the use of legal instruments by governments to improve patient safety. We did this through a comparative review of the use of legal instruments or frameworks in other countries (specifically Australia, Denmark, New Zealand, the United Kingdom, and the United States) as well as two non-health care related sectors in Canada (transportation and occupational health and safety). We began this research by reviewing the legal instruments and undertaking extensive literature reviews. Further information was gathered through in-person interviews with policy-makers and academics in the countries studied, and from policy-makers and academics expert in the health, occupational health and safety, and transportation sectors in Canada. Once descriptions of the various countries and sectors were drafted, we held small-group meetings with local experts on particular aspects of patient safety. We then hosted a national consultation meeting. We subsequently drafted this final report and the appendices, which fully describe the results of the background research. Finally, we prepared a summary version of the report as well as posters and papers to be published and delivered at conferences and meetings with relevant groups.

Coping with information silos: An examination of the medication management process in residential aged care facilities (RACFs)

The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in silos can negatively impact the quality of medication management processes in RACF settings. The implementation of commercial software applications like electronic medication charts need to be appropriately integrated to satisfy the collaborative information requirements of the RACF medication process.

Silos Tipovoĭ proekt

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Mathematical modelling and numerical simulation of phosphine flow during grain fumigation in leaky cylindrical silos

The phosphine distribution in a cylindrical silo containing grain is predicted. A three-dimensional mathematical model, which accounts for multicomponent gas phase transport and the sorption of phosphine into the grain kernel is developed. In addition, a simple model is presented to describe the death of insects within the grain as a function of their exposure to phosphine gas. The proposed model is solved using the commercially available computational fluid dynamics (CFD) software, FLUENT, together with our own C code to customize the solver in order to incorporate the models for sorption and insect extinction. Two types of fumigation delivery are studied, namely, fan- forced from the base of the silo and tablet from the top of the silo. An analysis of the predicted phosphine distribution shows that during fan forced fumigation, the position of the leaky area is very important to the development of the gas flow field and the phosphine distribution in the silo. If the leak is in the lower section of the silo, insects that exist near the top of the silo may not be eradicated. However, the position of a leak does not affect phosphine distribution during tablet fumigation. For such fumigation in a typical silo configuration, phosphine concentrations remain low near the base of the silo. Furthermore, we find that half-life pressure test readings are not an indicator of phosphine distribution during tablet fumigation.

On the mass flow rate from silos with lateral exit holes

The mass flow rate, (m) over dot, associated with the lateral outflow of dry, cohesionless granular material through circular orifices of diameter D made in vertical walls of silos was measured experimentally in order to determine also the influence of the wall thickness of the silo, w. Geometrical arguments, based on the outflow happening, are given in order to have a general correlation for (m) over dot embracing both quantities, D and w. The angle of repose appears to be an important characterization factor in these kinds of flows.

Evaluación de dióxido de carbono (CO2) obtenido de diferentes fuentes naturales para el control de Sitophilus zeamais Motschulsky (Coleoptera: curculionidae) aplicado en silos metálicos

La preocupante situación por el uso excesivo de productos químicos en granos almacenados, ha llevado a la búsqueda de métodos efectivos no químicos para prevenir las pérdidas ocasionadas por los insectos. Entre estos métodos tenemos el uso de atmósferas modificadas (AM) el cual ha sido utilizado en otros países con buenos resultados. Este método consiste en la descomposición o fermentación de materiales vegetales como substrato para la generación de CO2 (dióxido de carbono) en un biogenerador, conectado a silos metálicos u otros depósitos de granos herméticos donde el gas es transferido pasivamente al depósito de granos. Nos propusimos identificar fuentes naturales para la producción de CO2 y determinar la eficacia del método de atmósferas controladas en el control del Sitophilus zeamais Motsch. Para el estudio se realizaron dos etapas: Identificación de fuentes naturales para la producción de CO2 a partir del proceso de fermentación, donde se probaron caiia de azúcar, banano y maíz, utilizando para cada material tratamientos con y sin levadura comercial en concentración de 0.5% y 0% respectivamente de la cantidad total del material a fermentar en el biodigestor. Se determinó el momento inicial, máximo y final de la producción de CO2 . El tipo de biogenerador utilizado para todos los ensayos consistió de un depósito plástico de 18 l. de capacidad, donde se colocaron los materiales a fermentar. Se utilizó un indicador de agua. La variable a medir fue la emisión de burbujas en un período de tres minutos a intervalos de dos horas. Se determinó el porcentaje de mortalidad del S. zeamaiz en silos metálicos de 4qq. con maíz utilizando la AM. El silo metálico fue llenado con maiz hasta las 5/6 partes de su capacidad total; las jaulas que se utiüzaron fueron recipientes plásticos de 1L de capacidad con maíz-grano y 100 gorgojos del maíz adultos en su interior, colocadas a tres diferentes profundidades dentro del silo metálico. El porcentaje de C02 contenido en el silo metálico se midió con el método bioquímico del Hidróxido de Sodio (NaOH). El índice de mortalidad se evaluó a los 6, 8 y 10 días. Los mejores resultados en producción de gas se obtuvieron con el banano, con un rendimiento promedio de 91.9 y 52.6 burbujas por tres minutos a intervalos de dos horas en un período de 40 horas. Con un porcentaje mayor al 25% de CO 2 en el interior del silo metálico (atmósfera interna) y más de 6 días de exposición se obtuvo la mortalidad del gorgojo del maíz superior al 95%; concluyendo que la mortalidad del gorgojo del maíz estará en dependencia del porcentaje de CO2 en el interior del silo metálico.

Review of models for predicting the discharge rates of bulk particulates from silos and bins

Various models for predicting discharge rates have been developed over the last four decades by many research workers (notably Beverloo [1], Johanson [2], Brown [3], Carleton [4], Crewdson [5], Nedderman [6], Gu [7].). In many cases these models offer comparable approaches to the prediction of discharge rates of bulk particulates from storage equipment when solely gravity is acting to initiate flow (since they invariably consider the use of mass-flow design equipment). The models that have been developed consider a wide range of bulk particulates (coarse, incompressible, fine, cohesive) and most contemporary works have incorporated validation against test programmes. Research currently underway at The Wolfson Centre for Bulk Solids Handling Technology, University of Greenwich, has considered the relative performance of these models with respect to a range of bulk properties and with particular focus upon the flexibility of the models to cater for different geometrical factors for vessels.