Training pharmacists to deliver a complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis

Objective: To describe the training undertaken by pharmacists employed in a pharmacist-led information technology-based intervention study to reduce medication errors in primary care (PINCER Trial), evaluate pharmacists’ assessment of the training, and the time implications of undertaking the training. Methods: Six pharmacists received training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation forms were entered onto a Microsoft Excel spreadsheet, independently checked and the summary of results further verified. Frequencies were calculated for responses to the three-point Likert scale questions. Free-text comments from the evaluation forms and pharmacists’ diaries were analysed thematically. Key findings: All six pharmacists received 22 hours of training over five sessions. In four out of the five sessions, the pharmacists who completed an evaluation form (27 out of 30 were completed) stated they were satisfied or very satisfied with the various elements of the training package. Analysis of free-text comments and the pharmacists’ diaries showed that the principles of root cause analysis and educational outreach were viewed as useful tools to help pharmacists conduct pharmaceutical interventions in both the study and other pharmacy roles that they undertook. The opportunity to undertake role play was a valuable part of the training received. Conclusions: Findings presented in this paper suggest that providing the PINCER pharmacists with training in root cause analysis and educational outreach contributed to the successful delivery of PINCER interventions and could potentially be utilised by other pharmacists based in general practice to deliver pharmaceutical interventions to improve patient safety.

Root cause analysis applied to a finite element model's refinement of a negative stiffness structure

Negative Stiffness Structures are mechanical systems that require a decrease in the applied force to generate an increase in displacement. They are structures that possess special characteristics such as snap-through and bi-stability. All of these features make them particularly suitable for different applications, such as shock-absorption, vibration isolation and damping. From this point of view, they have risen awareness of their characteristics and, in order to match them to the application needed, a numerical simulation is of great interest. In this regard, this thesis is a continuation of previous studies in a circular negative stiffness structure and aims at refine the numerical model by presenting a new solution. To that end, an investigation procedure is needed. Amongst all of the methods available, root cause analysis was the chosen one to perform the investigation since it provides a clear view of the problem under analysis and a categorization of all the causes behind it. As a result of the cause-effect analysis, the main causes that have influence on the numerical results were obtained. Once all of the causes were listed, solutions to them were proposed and it led to a new numerical model. The numerical model proposed was of nonlinear type of analysis with hexagonal elements and a hyperelastic material model. The results were analyzed through force-displacement curves, allowing for the visualization of the structure’s energy recovery. When compared to the results obtained from the experimental part, it is evident that the trend is similar and the negative stiffness behaviour is present.

Can France really stop them? : A study grounded on the realist perspective about the French foreign policy towards Syria as the root cause of the Phenomenon of French Foreign Fighters

During the Syrian conflict the number of European Foreign Fighters has increased exponentially and has become an ever-growing concern for European policymakers. This phenomenon presents host of major security challenges for European policymakers and governments. Among European countries, France provides the highest number of citizens who have gone to Syria to fight against Assad´s regime. The French authorities have estimated that by mid-2014, over 700 French citizens have left France and travelled to Syria to fight. Historically France has had a relationship with Syria which started with its role as a border-drawing colonial power. Grounded in a framework of realism, that emphasizes nation-states as the primary actor within the international system, the analysis concentrates on the role of France´s foreign policy on the Syria as push factor for terrorism and radicalization. This paper attempts to determinate a specific correlation between the policy that France has been conducting towards Syria between 2000 and 2015, and the phenomenon of French Foreign Fighters. Findings suggest that France´s foreign policy towards Syria is the main root cause of the French Foreign Fighters phenomenon.

Public-domain software for root image analysis

In the search for high efficiency in root studies, computational systems have been developed to analyze digital images. ImageJ and Safira are public-domain systems that may be used for image analysis of washed roots. However, differences in root properties measured using ImageJ and Safira are supposed. This study compared values of root length and surface area obtained with public-domain systems with values obtained by a reference method. Root samples were collected in a banana plantation in an area of a shallower Typic Carbonatic Haplic Cambisol (CXk), and an area of a deeper Typic Haplic Ta Eutrophic Cambisol (CXve), at six depths in five replications. Root images were digitized and the systems ImageJ and Safira used to determine root length and surface area. The line-intersect method modified by Tennant was used as reference; values of root length and surface area measured with the different systems were analyzed by Pearson's correlation coefficient and compared by the confidence interval and t-test. Both systems ImageJ and Safira had positive correlation coefficients with the reference method for root length and surface area data in CXk and CXve. The correlation coefficient ranged from 0.54 to 0.80, with lowest value observed for ImageJ in the measurement of surface area of roots sampled in CXve. The IC (95 %) revealed that root length measurements with Safira did not differ from that with the reference method in CXk (-77.3 to 244.0 mm). Regarding surface area measurements, Safira did not differ from the reference method for samples collected in CXk (-530.6 to 565.8 mm²) as well as in CXve (-4231 to 612.1 mm²). However, measurements with ImageJ were different from those obtained by the reference method, underestimating length and surface area in samples collected in CXk and CXve. Both ImageJ and Safira allow an identification of increases or decreases in root length and surface area. However, Safira results for root length and surface area are closer to the results obtained with the reference method.

Accident cause analysis. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Uncovering the root cause of ethnic difference in ability testing:differential test functioning, test familiarity and trait optimism as explanations of ethnic group differences

The present research represents a coherent approach to understanding the root causes of ethnic group differences in ability test performance. Two studies were conducted, each of which was designed to address a key knowledge gap in the ethnic bias literature. In Study 1, both the LR Method of Differential Item Functioning (DIF) detection and Mixture Latent Variable Modelling were used to investigate the degree to which Differential Test Functioning (DTF) could explain ethnic group test performance differences in a large, previously unpublished dataset. Though mean test score differences were observed between a number of ethnic groups, neither technique was able to identify ethnic DTF. This calls into question the practical application of DTF to understanding these group differences. Study 2 investigated whether a number of non-cognitive factors might explain ethnic group test performance differences on a variety of ability tests. Two factors – test familiarity and trait optimism – were able to explain a large proportion of ethnic group test score differences. Furthermore, test familiarity was found to mediate the relationship between socio-economic factors – particularly participant educational level and familial social status – and test performance, suggesting that test familiarity develops over time through the mechanism of exposure to ability testing in other contexts. These findings represent a substantial contribution to the field’s understanding of two key issues surrounding ethnic test performance differences. The author calls for a new line of research into these performance facilitating and debilitating factors, before recommendations are offered for practitioners to ensure fairer deployment of ability testing in high-stakes selection processes.

Application of multivariate statistical process control to fuel cell manufacturing

Univariate statistical control charts, such as the Shewhart chart, do not satisfy the requirements for process monitoring on a high volume automated fuel cell manufacturing line. This is because of the number of variables that require monitoring. The risk of elevated false alarms, due to the nature of the process being high volume, can present problems if univariate methods are used. Multivariate statistical methods are discussed as an alternative for process monitoring and control. The research presented is conducted on a manufacturing line which evaluates the performance of a fuel cell. It has three stages of production assembly that contribute to the final end product performance. The product performance is assessed by power and energy measurements, taken at various time points throughout the discharge testing of the fuel cell. The literature review performed on these multivariate techniques are evaluated using individual and batch observations. Modern techniques using multivariate control charts on Hotellings T2 are compared to other multivariate methods, such as Principal Components Analysis (PCA). The latter, PCA, was identified as the most suitable method. Control charts such as, scores, T2 and DModX charts, are constructed from the PCA model. Diagnostic procedures, using Contribution plots, for out of control points that are detected using these control charts, are also discussed. These plots enable the investigator to perform root cause analysis. Multivariate batch techniques are compared to individual observations typically seen on continuous processes. Recommendations, for the introduction of multivariate techniques that would be appropriate for most high volume processes, are also covered.

Improving patient safety: how and why incidences occur in nursing care

The present investigation was a cross-sectional, quantitative research study analyzing incidents associated with nursing care using a root-cause methodological analysis. The study was conducted in a public hospital intensive care unit (ICU) in Santiago de Chile and investigated 18 incidents related to nursing care that occurred from January to March of 2012. The sample was composed of six cases involving medications and the self-removal of therapeutic devices. The contributing factors were related to the tasks and technology, the professional work team, the patients, and the environment. The analysis confirmed that the cases presented with similar contributing factors, thereby indicating that the vulnerable aspects of the system are primarily responsible for the incidence occurrence. We conclude that root-cause analysis facilitates the identification of these vulnerable points. Proactive management in system-error prevention is made possible by recommendations.

Inhimillisten virheiden tarkastelu ydinvoimalaitosten käyttökokemusten hyödyntämisessä

Tässä työssä on kuvattu ydinvoimalaitosten käyttökokemusten tutkimusta keskittyen erityisesti inhimillisten toimintojen tarkasteluun. Työssä on kerrottu kansainvälisistä vaatimuksista ja järjestöistä sekä yleisesti käyttökokemusten tutkimuksessa käytössä olevista menetelmistä keskittyen perussyyanalyysimenetelmiin. Suomen osalta työssä on käsitelty lainsäädännön asettamia velvoitteita ja muita vaatimuksia, jotka ydinvoima-alalla koostuvat lähinnä Säteilyturvakeskuksen YVL-ohjeista. Viranomaisena toimivan Säteilyturvakeskuksen, alan tutkimusta suorittavan Valtion teknillisen tutkimuskeskuksen ja Teollisuuden Voima Oy:n käyttökokemusten tutkimiseen liittyvät organisaatiot ja menettelytavat on esitelty. Fortum Power and Heat Oy:n omistaman ja käyttämän Loviisan ydinvoimalaitoksen käyttökokemusten hyödyntäminen on käsitelty tarkemmin. Loviisan voimalaitoksen organisaatio ja käyttökokemusten sekä inhimillisten virheiden käsittelymenetelmiä on esitelty ja analysoitu. Työn alkuvaiheessa Loviisan voimalaitoksella inhimillisistä virheistä kerätystä tiedosta koottu tietokanta järjesteltiin kuntoon. Järjestelyn jälkeen tietoa analysoitiin ja analysoinnin tulokset on esitetty tässä työssä. Sekä järjestelyn että analysoinnin aikana havaitut kehityskohteet kirjattiin muistiin. Pienet toimenpiteet suoritettiin heti ja suuremmat kirjattiin tämän työn toimenpide-ehdotuksiin. Kehittämiskeinoja on ehdotettu virheiden luokittelumenetelmään ja käyttökokemusten käsittelymenetelmiin.

Perussyyanalyysien käyttö ydinvoimalaitosten tapahtumien tutkinnassa

Tämä diplomityö käsittelee perussyyanalyysien käyttöä Loviisan voimalaitoksella tapahtumien tutkinnassa. Diplomityössä käydään läpi erilaisia maailmalla käytössä olevia perussyyanalyysimenetelmiä. Nykyään Loviisan voimalaitoksella ei ole ohjeessa määritelty miten perussyyanalyysit tulee tehdä, joten diplomityön tulosten perusteella on tarkoitus valita Loviisan voimalaitokselle sopiva menetelmä. Diplomityössä tehdään eräs perussyyanalyysi kahdella eri menetelmällä, jotka tuntuivat sopivilta menetelmiltä Loviisan voimalaitoksille. Perussyyanalyysimenetelmät, joita käytetään, ovat Loviisassa käytetty sovellettu HPES-menetelmä ja yhdysvaltalaisten ydinvoimaviranomaisten kehittämä HPIP-menetelmä. Perussyyanalyysien valmistuttua ja tuloksia vertaillessa tultiin siihen lopputulokseen, ettei Loviisan voimalaitoksella ole tarvetta vaihtaa nykyisin käytössä olevaa mutta ohjeistamatonta menetelmää. Loviisan voimalaitokselle tehtävään uuteen perussyyanalyysiohjeeseen liitetään menetelmäkuvaus sovelletusta HPES-menetelmästä. Menetelmäkuvauksessa kuvataan miten HPES-menetelmää käytetään perussyyanalyysien tekoon Loviisan voimalaitoksella.

Toimitusvarmuuden parantaminen yrityksen sisäistä toimintaa tehostamalla

Time’s meaning as a competitive factor has been growing significantly from 1970’s to 2000. Product life cycles have got significantly shorter, customers are not ready to keep their own inventories and fast changing markets are making it dangerous to count on forecasts. All these factors are forcing companies to shorten their lead times and answer to customer hopes on faster basis. Good delivery reliability is increasing its importance in making difference between competitors.In this thesis we get deep into KWH Pipe Ltd. Finland’s, and especially Vaasa factory’s, delivery reliability problems. Target is to find causes, which are causing problems in delivery reliability. In year 2007 has delivery reliability been 87 %, as management has set target in 95 %. Delivery reliability has been quite the same for few years now, and at the same time storage values have been growing up. The causes of poor delivery reliability were searched by analyzing company’s order-delivery-process using among other things root cause analysis. Furthermore the meters, which are used in company at the moment, are analyzed and some new meters are suggested to take in use. As outcome of process analysis is a list of confirmed problems in order of priority and by using this list it is possible to decide of actions, which are taken in future to bring delivery reliability to better level.

Tapahtumien tutkinnan systematisointi Loviisan voimalaitoksella

Tämä diplomityö käsittelee tapahtumien tutkinnan systematisointia Loviisan voimalaitoksella. Nykyisin Loviisan voimalaitoksella tutkitaan tapahtumia usealla tavalla eikä raporttien tuloksia pystytä täysin hyödyntämään. Diplomityössä käydään läpi erilaisia tapahtumien tutkintamenetelmiä sekä tutustutaan perussyyanalyysimenetelmiin. Matalan tason tapahtumien tutkintaan kehitettiin kysymyslista, jolla saadaan helposti selville tapahtumien ongelma-alueet. Kysymyslista mahdollisti myös tapahtumien laaja-alaisen luokittelun, jonka avulla tunnistetaan eri tapahtumien kautta ilmenneitä yhteisiä ongelma-alueita. Tapahtumien tutkintaan liittyy myös riskien arviointi. Tässä diplomityössä kehitettiin riskimatriisi tapahtuman vakavuuden ja jatkoselvitystarpeen arvioinnin avuksi. Perussyyanalyysimenetelmistä AcciMap-menetelmä osoittautui käyttökelpoiseksi ja sitä suositellaan kokeiltavaksi seuraavan inhimilliseen toimintaan liittyvän perussyyanalyysin yhteydessä.

Real-time context-aware network security policy enforcement system (RC-NSPES)

The major technical objectives of the RC-NSPES are to provide a framework for the concurrent operation of reactive and pro-active security functions to deliver efficient and optimised intrusion detection schemes as well as enhanced and highly correlated rule sets for more effective alerts management and root-cause analysis. The design and implementation of the RC-NSPES solution includes a number of innovative features in terms of real-time programmable embedded hardware (FPGA) deployment as well as in the integrated management station. These have been devised so as to deliver enhanced detection of attacks and contextualised alerts against threats that can arise from both the network layer and the application layer protocols. The resulting architecture represents an efficient and effective framework for the future deployment of network security systems.

Desperdício de dieta enteral em UTI: análise de modo de falhas e efeitos de danos ao paciente grave

Pós-graduação em Enfermagem (mestrado profissional) - FMB

Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?

PURPOSE OF REVIEW: Critical incident reporting alone does not necessarily improve patient safety or even patient outcomes. Substantial improvement has been made by focusing on the further two steps of critical incident monitoring, that is, the analysis of critical incidents and implementation of system changes. The system approach to patient safety had an impact on the view about the patient's role in safety. This review aims to analyse recent advances in the technique of reporting, the analysis of reported incidents, and the implementation of actual system improvements. It also explores how families should be approached about safety issues. RECENT FINDINGS: It is essential to make as many critical incidents as possible known to the intensive care team. Several factors have been shown to increase the reporting rate: anonymity, regular feedback about the errors reported, and the existence of a safety climate. Risk scoring of critical incident reports and root cause analysis may help in the analysis of incidents. Research suggests that patients can be successfully involved in safety. SUMMARY: A persisting high number of reported incidents is anticipated and regarded as continuing good safety culture. However, only the implementation of system changes, based on incident reports, and also involving the expertise of patients and their families, has the potential to improve patient outcome. Hard outcome criteria, such as standardized mortality ratio, have not yet been shown to improve as a result of critical incident monitoring.