On doing ‘risk work’ in the context of successful outcomes:exploring how medication safety is brought into action through health professionals’ everyday working practices

Interest in risk has grown exponentially in healthcare, resulting in a plethora of policies and guidelines to manage risk at all levels across the healthcare system. However, the impact of risk on the nature and experiences of healthcare work remains a relatively neglected area of research on risk in healthcare. Building on the concept of ‘risk work’, in this article we examine how medication safety is brought into action through health professionals’ everyday working practices at the point of medication administration. Drawing on two closely related data sets, both generated in a large paediatric hospital providing secondary and tertiary care in England, we argue that medication-related risks are constructed and negotiated through situated social interactions. Frontline practitioners actively reconcile the logics of risk work and good-quality bedside patient care enabling them to get risk work done to successfully meet the formally established standards of quality and safety performance. ‘Risk work’ has the potential to make visible and explicit a range of risk-related practices that may not be acknowledged as such if they do not align with the established meanings of risk and the normative frameworks built around them. A focus on ‘risk work’ can bring in a new lens to the study of risk in healthcare with the potential to generate learning from how risk work gets done in the context of routine clinical practice and successful outcomes, rather than incidents and failures, in healthcare service provision

A Heteroscedastic Uncertainty Model for Decoupling Sources of MRI Image Quality

Quality control (QC) of medical images is essential to ensure that downstream analyses such as segmentation can be performed successfully. Currently, QC is predominantly performed visually at significant time and operator cost. We aim to automate the process by formulating a probabilistic network that estimates uncertainty through a heteroscedastic noise model, hence providing a proxy measure of task-specific image quality that is learnt directly from the data. By augmenting the training data with different types of simulated k-space artefacts, we propose a novel cascading CNN architecture based on a student-teacher framework to decouple sources of uncertainty related to different k-space augmentations in an entirely self-supervised manner. This enables us to predict separate uncertainty quantities for the different types of data degradation. While the uncertainty measures reflect the presence and severity of image artefacts, the network also provides the segmentation predictions given the quality of the data. We show models trained with simulated artefacts provide informative measures of uncertainty on real-world images and we validate our uncertainty predictions on problematic images identified by human-raters

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background: Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research. Methods: We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically. Results: 79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact. Conclusions: Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation

Improving health, well-being and parenting skills in parents of children with medical complexity::a scoping review protocol

IntroductionLess than 1% of children have complex medical conditions but account for one-third of all child health spending. The impact of suboptimal management of this group of children can have a considerable effect on families as well as services. Some families appear to cope more easily than others do, but there are compelling reasons to suggest that effective interventions may improve family coping and ultimately outcomes. Hospitalisation of their child presents a unique set of pressures and challenges for parents, but also an opportunity to intervene. However, the evidence is not well described in relation to this group of families. The primary objective of this scoping review is to identify parent and family-based interventions available to improve parental health, well-being, functioning or skills in the context of a child’s medically complex hospital admission and hospital care.Methods and analysisNine bibliographic databases will be searched spanning medicine, nursing, psychology, education, social work and the grey literature using a combination of index terms and text words related to parents, childhood, chronic illness and interventions. Study eligibility will be assessed by two researchers against preset inclusion and exclusion criteria. Key information from each study will be extracted and charted including year of publication, condition, severity, geographical setting, key concepts and definitions, aims, study population and sample size, methodology/methods, interventions, outcomes and key findings. Directed qualitative content analysis will be used to make sense of narrative findings within the included studies. Results will be presented which summarise the scope of the literature and identify key findings, potential areas for evidence synthesis and research gaps.Ethics and disseminationEthical approval is not required. The results of this review will be disseminated through publication in a peer-reviewed journal and feedback to stakeholders during the development of a hospital-based intervention.</jats:sec

Prevalence and Predictors of Vitamin D Insufficiency in Children: A Great Britain Population Based Study

Objectives To evaluate the prevalence and predictors of vitamin D insufficiency (VDI) in children In Great Britain. Design A nationally representative cross-sectional study survey of children (1102) aged 4–18 years (999 white, 570 male) living in private households (January 1997–1998). Interventions provided information about dietary habits, physical activity, socio-demographics, and blood sample. Outcome measures were vitamin D insufficiency (<50 nmol/L). Results Vitamin D levels (mean = 62.1 nmol/L, 95%CI 60.4–63.7) were insufficient in 35%, and decreased with age in both sexes (p<0.001). Young People living between 53–59 degrees latitude had lower levels (compared with 50–53 degrees, p = 0.045). Dietary intake and gender had no effect on vitamin D status. A logistic regression model showed increased risk of VDI in the following: adolescents (14–18 years old), odds ratio (OR) = 3.6 (95%CI 1.8–7.2) compared with younger children (4–8 years); non white children (OR = 37 [95%CI 15–90]); blood levels taken December-May (OR = 6.5 [95%CI 4.3–10.1]); on income support (OR = 2.2 [95%CI 1.3–3.9]); not taking vitamin D supplementation (OR = 3.7 [95%CI 1.4–9.8]); being overweight (OR 1.6 [95%CI 1.0–2.5]); <1/2 hour outdoor exercise/day/week (OR = 1.5 [95%CI 1.0–2.3]); watched >2.5 hours of TV/day/week (OR = 1.6[95%CI 1.0–2.4]). Conclusion We confirm a previously under-recognised risk of VDI in adolescents. The marked higher risk for VDI in non-white children suggests they should be targeted in any preventative strategies. The association of higher risk of VDI among children who exercised less outdoors, watched more TV and were overweight highlights potentially modifiable risk factors. Clearer guidelines and an increased awareness especially in adolescents are needed, as there are no recommendations for vitamin D supplementation in older children

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings: protocol for a systematic review of qualitative studies

ABSTRACTIntroduction: There is increasing evidence that electronic prescribing (ePrescribing) or Computerized Provider/Physician Order Entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitativeapproaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support (CDS).Methods and analysis: Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest, and SCOPUS. In addition, other sources will besearched for ongoing studies (ClinicalTrials.gov) and grey literature: HMIC, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by two reviewers. Qualitative studies, either standalone or in the context of mixed methods designs, reporting the perspectives of any actors involved in the implementation,management and use of ePrescribing/CPOE systems in hospital-based care settings will be included.Data extraction will be conducted by two reviewers using a piloted form. Quality appraisal will be based on criteria from the CASP and SRQR checklists. Studies will not be excluded based on quality assessment. A post-synthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.Ethics and dissemination: The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.Systematic review registration: PROSPERO CRD42016035552.STRENGTHS AND LIMITATIONS OF THIS STUDY• Although a number of systematic reviews have been conducted to date on ePrescribing or CPOE systems, only a few have focused on hospital settings.• According to the scoping searches conducted by the authors, only two existing reviews included qualitative studies, of which, only one focused on providers’ perceptions in a hospital setting.• To the best of the knowledge of the authors, this is the first systematic review of qualitative evidence relating to the management and use/optimisation of ePrescribing systems in hospital settings, not limited to the implementation process, and including any reported perspectives (i.e. not only health professionals, but also managers, commissioners, patients and relatives/carers).• The review will not address perceptions and experiences related to non-hospital based settings

The role of paediatric nurses in medication safety prior to the implementation of electronic prescribing:a qualitative case study

Objectives: To explore paediatric nurses’ experiences and perspectives of their role in the medication process and how this role is enacted in everyday practice. Methods: A qualitative case study on a general surgical ward of a paediatric hospital in England, one year prior to the planned implementation of ePrescribing. Three focus groups and six individual semi-structured interviews were conducted, involving 24 nurses. Focus groups and interviews were audio-recorded, transcribed, anonymized and subjected to thematic analysis. Results: Two overarching analytical themes were identified: the centrality of risk management in nurses’ role in the medication process and the distributed nature of nurses’ medication risk management practices. Nurses’ contribution to medication safety was seen as an intrinsic feature of a role that extended beyond just preparing and administering medications as prescribed and placed nurses at the heart of a dynamic set of interactions, practices and situations through which medication risks were managed. These findings also illustrate the collective nature of patient safety. Conclusions: Both the recognized and the unrecognized contributions of nurses to the management of medications needs to be considered in the design and implementation of ePrescribing systems

Antibiotic mediated synthesis of gold nanoparticles with potent antimicrobial activity and their application in antimicrobial coatings

We report a one-pot synthesis of spherical gold nanoparticles (52-22 nm) and their capping with cefaclor, a second-generation antibiotic, without use of other chemicals. The differently sized gold nanoparticles were fabricated by controlling the rate of reduction of gold ions in aqueous solution by varying the reaction temperature (20-70 C). The primary amine group of cefaclor acted as both the reducing and capping agent for the synthesis of gold nanoparticles leaving the b-lactam ring of cefaclor available for activity against microbes. Antimicrobial testing showed that cefaclor reduced gold nanoparticles have potent antimicrobial activity against both Gram-positive (Staphylococcus aureus) and Gram-negative (Escherichia coli) bacteria as compared to cefaclor or gold nanoparticles alone. The minimum inhibition concentrations (MICs) of cefaclor reduced gold nanoparticles were 10m gmL1 and 100m gmL1 for S. aureus and E. coli respectively. The cefaclor reduced gold nanoparticles were further coated onto poly(ethyleneimine) (PEI) modified glass surfaces to obtain antimicrobial coatings suitable for biomedical applications and were tested against E. coli as an exemplar of activity. The antimicrobial coatings were very robust under adverse conditions (pH 3 and 10), inhibited the growth of E. coli on their surfaces, and could be used many times with retained activity. Results from a combined spectroscopic (FTIR) and microscopic study (AFM) suggest that the action of these novel particles is through the combined action of cefaclor inhibiting the synthesis of the peptidoglycan layer and gold nanoparticles generating "holes" in bacterial cell walls thereby increasing the permeability of the cell wall, resulting in the leakage of cell contents and eventually cell death

Astrocyte pathology and the absence of non-cell autonomy in an induced pluripotent stem cell model of TDP-43 proteinopathy

Glial proliferation and activation are associated with disease progression in amyotrophic lateral sclerosis (ALS) and frontotemporal lobar dementia. In this study, we describe a unique platform to address the question of cell autonomy in transactive response DNA-binding protein (TDP-43) proteinopathies. We generated functional astroglia from human induced pluripotent stem cells carrying an ALS-causing TDP-43 mutation and show that mutant astrocytes exhibit increased levels of TDP-43, subcellular mislocalization of TDP-43, and decreased cell survival. We then performed coculture experiments to evaluate the effects of M337V astrocytes on the survival of wild-type and M337V TDP-43 motor neurons, showing that mutant TDP-43 astrocytes do not adversely affect survival of cocultured neurons. These observations reveal a significant and previously unrecognized glial cell-autonomous pathological phenotype associated with a pathogenic mutation in TDP-43 and show that TDP-43 proteinopathies do not display an astrocyte non-cell-autonomous component in cell culture, as previously described for SOD1 ALS. This study highlights the utility of induced pluripotent stem cell-based in vitro disease models to investigate mechanisms of disease in ALS and other TDP-43 proteinopathies