Systems mapping workshops and their role in understanding medication errors in healthcare

In this paper for Applied Ergonomics, one of the two leading journals for ergonomics/human factors, Buckle et al. discuss the role of mapping workshops in understanding medication errors in healthcare. They draw upon research that used mapping workshops as a method that systems designers, including human factors/ergonomics specialists, can use to help generate a knowledge base for better design requirements. Buckle et al. applied systems mapping workshops for the first time to the problem of medication errors in healthcare. The workshops were designed using experiential group work principles. They involved a range of stakeholders from within the health service as well as those who supply the health sector, including designers who may be able to enhance the safety of products and systems used in healthcare. The opportunity for using these methods to study patient safety issues arose as a result of a scoping study undertaken on behalf of the UK Department of Health and The Design Council. As the scope of patient safety issues within the healthcare system and the range of stakeholder groups is large (National Patient Safety Agency 2005), it was believed that mapping workshops might enhance system design in health. The results were rich from a design perspective, giving specific details of actual incidences, contexts and practices, with further depth of information emerging in the group working sessions. A wealth of detail on aspects of medication error, especially in the community, emerged from creative, primary, secondary and patient-support group sessions. As a process, similar stakeholder workshops could help designers understand better the complexity and range of factors to be taken into account. The methods are now being used in many areas of healthcare and social care design, for example by the Technology Strategy Board funded research into Telecare (see http://www.aktive.org.uk/)

Search for neutral heavy leptons produced in ZZ decays

Weak isosinglet Neutral Heavy Leptons (νm) have been searched for using data collected by the DELPHI detector corresponding to 3.3 × 106 hadronic Z0 decays at LEP1. Four separate searches have been performed, for short-lived νm production giving monojet or acollinear jet topologies, and for long-lived νm giving detectable secondary vertices or calorimeter clusters. No indication of the existence of these particles has been found, leading to an upper limit for the branching ratio BR(Z0 → νmν̄) of about 1.3 × 10-6 at 95% confidence level for νm masses between 3.5 and 50 GeV/c2. Outside this range the limit weakens rapidly with the νm mass. The results are also interpreted in terms of limits for the single production of excited neutrinos. © Springer-Verlag 1997