Do not disturb! The impact of wearing red aprons on medication administration in PICU

Introduction and Aims: Medication errors cause significant morbidity and mortality to patients. The reported financial cost to the NHS annually is £1 billion, but could be up to £2.5 billion. Medication errors are one of the most frequently reported incidents on paediatric intensive care (PIC). Evidence of effective interventions that prevent medication errors is currently limited. However, implementing red apron use for medication administration aims to permit uninterrupted, dedicated time for nurses whilst preparing medications. The effectiveness that this intervention has on minimising medication administration errors in PIC is unknown. This project aimed to evaluate PIC medication administration errors after implementation of safe medication policy that included wearing red aprons. Methods: A retrospective review of PIC medication administration incidents reported during a six-month period before (November 2015-April 2016) and after (November 2016-April 2017) the introduction of the red apron intervention and the promotion of safe medication management. Type and frequency of incidents occurring pre and post intervention were compared. Results: Fifteen medication errors were reported before the intervention. This increased to 20 following. Interestingly, three types of errors that were reported before the intervention did not occur after, but five new error types were only reported after the intervention (figure 1). Four error types were reported at similar frequencies before and after the intervention. Discussion and conclusion: This study has provided valuable insight into medication administration error reporting. It appears that this intervention may not reduce errors in the short term, but may have an effect on culture and behaviour of medication error reporting. This includes raising awareness of medication errors amongst staff, and highlighting the importance of and support for safe administration of medications and reporting of errors. Further research will examine benefits of and barriers to implementing interventions aimed at improving medication safety for children in PIC

Coupling marine ecosystem state with environmental management and conservation: A risk-based approach

\ua9 2024 The Author(s)The sustainability of marine ecosystems demands a focus on ecological improvement, necessitating managers and conservationists to consider a range of actions from those that limit stressors to those that actively restore. Deciding the most appropriate action should be informed by environmental context, which includes assessing information on both degradation and recovery potential. Here, we provide an analysis of how the degree of ecological degradation coupled with the stressor regime can inform environmental management and conservation actions (e.g., stressor reductions, adaptive management, assisted recovery/restoration). With this analysis we design a risk framework combining principles that define ecosystem resilience and recovery times with those that characterize stressor regimes (i.e., the number, type, and impact). The combination of these principles defines where an ecosystem is placed along sliding scales of degradation and recovery and likely response to protective and restorative interventions. It is designed to facilitate place-based conversations regarding the risks of different management actions informed by the temporal dynamics of ecosystem degradation and recovery

Barriers to coastal planning and policy use of environmental research in Aotearoa-New Zealand

Identifying barriers to the effective use of science in coastal management of Aotearoa-New Zealand is easy, due to the present lack of complicated governance and management structures, coupled with an emphasis on funding science that includes pathways to implementation. This opinion piece discusses four areas that still hinder effective use of science, all of which are likely to be problematic for other countries. We initially focus on why the science may not be used related to: misunderstandings (linguistic and conceptual differences including indigenous world views); timing of information delivery; uncertainty surrounding the information (knowledge limitations and funding); and top-down constraints (legal systems, politics and institutional objectives). We use Aotearoa-New Zealand examples to demonstrate the barriers operating within each area and discuss three potential solutions. Importantly our analysis indicates that researchers alone cannot transcend these barriers; rather, we need to work as part of an ecosystem, requiring commitment from all society, extending beyond the usual suspects (management agencies). We believe that ecological and systems education from junior school levels through to universities have an important role to play in setting the context to overcome current barriers

A multicenter assessment of single-cell models aligned to standard measures of cell health for prediction of acute hepatotoxicity.

Assessing the potential of a new drug to cause drug-induced liver injury (DILI) is a challenge for the pharmaceutical industry. We therefore determined whether cell models currently used in safety assessment (HepG2, HepaRG, Upcyte and primary human hepatocytes in conjunction with basic but commonly used endpoints) are actually able to distinguish between novel chemical entities (NCEs) with respect to their potential to cause DILI. A panel of thirteen compounds (nine DILI implicated and four non-DILI implicated in man) were selected for our study, which was conducted, for the first time, across multiple laboratories. None of the cell models could distinguish faithfully between DILI and non-DILI compounds. Only when nominal in vitro concentrations were adjusted for in vivo exposure levels were primary human hepatocytes (PHH) found to be the most accurate cell model, closely followed by HepG2. From a practical perspective, this study revealed significant inter-laboratory variation in the response of PHH, HepG2 and Upcyte cells, but not HepaRG cells. This variation was also observed to be compound dependent. Interestingly, differences between donors (hepatocytes), clones (HepG2) and the effect of cryopreservation (HepaRG and hepatocytes) were less important than differences between the cell models per se. In summary, these results demonstrate that basic cell health endpoints will not predict hepatotoxic risk in simple hepatic cells in the absence of pharmacokinetic data and that a multicenter assessment of more sophisticated signals of molecular initiating events is required to determine whether these cells can be incorporated in early safety assessment

Solving Nonlinear Parabolic Equations by a Strongly Implicit Finite-Difference Scheme

We discuss the numerical solution of nonlinear parabolic partial differential equations, exhibiting finite speed of propagation, via a strongly implicit finite-difference scheme with formal truncation error $\mathcal{O}\left[(\Delta x)^2 + (\Delta t)^2 \right]$. Our application of interest is the spreading of viscous gravity currents in the study of which these type of differential equations arise. Viscous gravity currents are low Reynolds number (viscous forces dominate inertial forces) flow phenomena in which a dense, viscous fluid displaces a lighter (usually immiscible) fluid. The fluids may be confined by the sidewalls of a channel or propagate in an unconfined two-dimensional (or axisymmetric three-dimensional) geometry. Under the lubrication approximation, the mathematical description of the spreading of these fluids reduces to solving the so-called thin-film equation for the current's shape $h(x,t)$. To solve such nonlinear parabolic equations we propose a finite-difference scheme based on the Crank--Nicolson idea. We implement the scheme for problems involving a single spatial coordinate (i.e., two-dimensional, axisymmetric or spherically-symmetric three-dimensional currents) on an equispaced but staggered grid. We benchmark the scheme against analytical solutions and highlight its strong numerical stability by specifically considering the spreading of non-Newtonian power-law fluids in a variable-width confined channel-like geometry (a "Hele-Shaw cell") subject to a given mass conservation/balance constraint. We show that this constraint can be implemented by re-expressing it as nonlinear flux boundary conditions on the domain's endpoints. Then, we show numerically that the scheme achieves its full second-order accuracy in space and time. We also highlight through numerical simulations how the proposed scheme accurately respects the mass conservation/balance constraint.Comment: 36 pages, 9 figures, Springer book class; v2 includes improvements and corrections; to appear as a contribution in "Applied Wave Mathematics II

Vaginal preparation with chlorhexidine at cesarean section to reduce endometritis and prevent sepsis: A randomized pilot trial (PREPS)

INTRODUCTION: Cesarean sections are the most common major operation worldwide. One in 10 women develops a surgical-site infection after cesarean section. The PREPS pilot trial was developed to assess the feasibility of a randomized controlled trial of vaginal cleansing with chlorhexidine before cesarean section, to reduce infectious morbidity. MATERIAL AND METHODS: A multi-center, open-label, parallel-group pilot randomized controlled trial across 4 UK maternity units. Women aged ≥16 years, undergoing elective or emergency cesarean section, ≥34 weeks of gestation, and able to give informed consent were eligible. Women were randomized 1:1 to chlorhexidine 0.05% or no cleansing and were followed up until 6 weeks after cesarean section. The feasibility of a larger randomized controlled trial was assessed by the pilot trial's recruitment, ability to use verbal consent in an emergency, adherence, follow-up and withdrawal rates. The main clinical outcome collected was Center for Disease Control and Prevention (CDC) classification of endometritis at 30 days. Trial registration number is ISRCTN33435996. RESULTS: A total of 320 women (128% of target) were randomized. Of these, 93% (95% CI 89%-95%) received their allocated intervention. Of the 88 women who had an emergency cesarean section, verbal consent was initially given by 32 (36%) women, with the remainder having sufficient time to give written consent. Endometritis (CDC definition) was collected from medical notes of 96% of women, 68% (95% CI 63%-73%) were followed up at both 14 and 30 days by telephone, and we were able to collect patient-reported outcomes. In the vaginal cleansing arm 2/152 (1.3%) women had endometritis compared with 1/155 (0.7%) in the no cleansing arm (RR 2.08, 95% CI 0.19-22.31). CONCLUSIONS: It is possible to perform a randomized controlled trial in women undergoing an elective or emergency cesarean section, using a verbal-followed-by-written consent process, while maintaining high adherence and retaining women in the trial

Patient-centred measurement in ophthalmology – a paradigm shift

Ophthalmologists and researchers in ophthalmology understand what a rapidly evolving field ophthalmology is, and that to conduct good research it is essential to use the latest and best methods. In outcomes research, one modern initiative has been to conduct holistic measurement of outcomes inclusive of the patient's point of view; patient-centred outcome. This, of course, means including a questionnaire. However, the irony of trying to improve outcomes research by being inclusive of many measures is that the researcher may not be expert in all measures used. Certainly, few people conducting outcomes research in ophthalmology would claim to be questionnaire experts. Most tend to be experts in their ophthalmic subspecialty and probably simply choose a popular questionnaire that appears to fit their needs and think little more about it. Perhaps, unlike our own field, we assume that the field of questionnaire research is relatively stable. This is far from the case. The measurement of patient-centred outcomes with questionnaires is a rapidly evolving field. Indeed, over the last few years a paradigm shift has occurred in patient-centred measurement

Tissue-engineered tracheal replacement in a child: a 4-year follow-up study

In 2010, a tissue-engineered trachea was transplanted into a 10-year-old child using a decellularized deceased donor trachea repopulated with the recipient's respiratory epithelium and mesenchymal stromal cells. We report the child's clinical progress, tracheal epithelialization and costs over the 4 years. A chronology of events was derived from clinical notes and costs determined using reference costs per procedure. Serial tracheoscopy images, lung function tests and anti-HLA blood samples were compared. Epithelial morphology and T cell, Ki67 and cleaved caspase 3 activity were examined. Computational fluid dynamic simulations determined flow, velocity and airway pressure drops. After the first year following transplantation, the number of interventions fell and the child is currently clinically well and continues in education. Endoscopy demonstrated a complete mucosal lining at 15 months, despite retention of a stent. Histocytology indicates a differentiated respiratory layer and no abnormal immune activity. Computational fluid dynamic analysis demonstrated increased velocity and pressure drops around a distal tracheal narrowing. Cross-sectional area analysis showed restriction of growth within an area of in-stent stenosis. This report demonstrates the long-term viability of a decellularized tissue-engineered trachea within a child. Further research is needed to develop bioengineered pediatric tracheal replacements with lower morbidity, better biomechanics and lower costs