Medication administration errors for older people in long-term residential care

Background Older people in long-term residential care are at increased risk of medication errors. The purpose of this study was to evaluate a computerised barcode medication management system designed to improve drug administrations in residential and nursing homes, including comparison of error rates and staff awareness in both settings. Methods All medication administrations were recorded prospectively for 345 older residents in thirteen care homes during a 3-month period using the computerised system. Staff were surveyed to identify their awareness of administration errors prior to system introduction. Overall, 188,249 attempts to administer medication were analysed to determine the prevalence of potential medication administration errors (MAEs). Error classifications included attempts to administer medication at the wrong time, to the wrong person or discontinued medication. Analysis compared data at residential and nursing home level and care and nursing staff groups. Results Typically each resident was exposed to 206 medication administration episodes every month and received nine different drugs. Administration episodes were more numerous (p < 0.01) in nursing homes (226.7 per resident) than in residential homes (198.7). Prior to technology introduction, only 12% of staff administering drugs reported they were aware of administration errors being averted in their care home. Following technology introduction, 2,289 potential MAEs were recorded over three months. The most common MAE was attempting to give medication at the wrong time. On average each resident was exposed to 6.6 potential errors. In total, 90% of residents were exposed to at least one MAE with over half (52%) exposed to serious errors such as attempts to give medication to the wrong resident. MAEs rates were significantly lower (p < 0.01) in residential homes than nursing homes. The level of non-compliance with system alerts was low in both settings (0.075% of administrations) demonstrating virtually complete error avoidance. Conclusion Potentially inappropriate administration of medication is a serious problem in long-term residential care. A computerised barcode system can accurately and automatically detect inappropriate attempts to administer drugs to residents. This tool can reliably be used by care staff as well as nurses to improve quality of care and patient safety

Sandbox university: Estimating influence of institutional action

The approach presented in this article represents a generalizable and adaptable methodology for identifying complex interactions in educational systems and for investigating how manipulation of these systems may affect educational outcomes of interest. Multilayer Minimum Spanning Tree and Monte-Carlo methods are used. A virtual Sandbox University is created in order to facilitate effective identification of successful and stable initiatives within higher education, which can affect students' credits and student retention - something that has been lacking up until now. The results highlight the importance of teacher feedback and teacher-student rapport, which is congruent with current educational findings, illustrating the methodology's potential to provide a new basis for further empirical studies of issues in higher education from a complex systems perspective

A systems approach to policy evaluation

There is growing interest in evaluating policy implementation in ways that grapple with the complexity of the process. This article offers an example of using systems methodology to explore how the child protection policy in child contact centres has functioned in practice. Rather than just asking the traditional evaluation question “is it working?” this study sought to understand how the policy was working and how it was interpreted as it interacted with other systems, producing conflicts, local variation and emergent effects. It illustrates how the systems concepts of ‘emergence’, ‘local rationality’, ‘socio-technical systems’ and ‘feedback for learning’ can contribute new knowledge and understanding to a complex policy evaluation problem

Enhancing innovation between scientific and indigenous knowledge: pioneer NGOs in India

Abstract Background Until recently, little attention has been paid to local innovation capacity as well as management practices and institutions developed by communities and other local actors based on their traditional knowledge. This paper doesn't focus on the results of scientific research into innovation systems, but rather on how local communities, in a network of supportive partnerships, draw knowledge for others, combine it with their own knowledge and then innovate in their local practices. Innovation, as discussed in this article, is the capacity of local stakeholders to play an active role in innovative knowledge creation in order to enhance local health practices and further environmental conservation. In this article, the innovative processes through which this capacity is created and reinforced will be defined as a process of "ethnomedicine capacity". Methods The field study undertaken by the first author took place in India, in the State of Tamil Nadu, over a period of four months in 2007. The data was collected through individual interviews and focus groups and was complemented by participant observations. Results The research highlights the innovation capacity related to ethnomedical knowledge. As seen, the integration of local and scientific knowledge is crucial to ensure the practices anchor themselves in daily practices. The networks created are clearly instrumental to enhancing the innovation capacity that allows the creation, dissemination and utilization of 'traditional' knowledge. However, these networks have evolved in very different forms and have become entities that can fit into global networks. The ways in which the social capital is enhanced at the village and network levels are thus important to understand how traditional knowledge can be used as an instrument for development and innovation. Conclusion The case study analyzed highlights examples of innovation systems in a developmental context. They demonstrate that networks comprised of several actors from different levels can synergistically forge linkages between local knowledge and formal sciences and generate positive and negative impacts. The positive impact is the revitalization of perceived traditions while the negative impacts pertain to the transformation of these traditions into health commodities controlled by new elites, due to unequal power relations

The visual side of safety

In this chapter, I address what I believe to be a complementary discussion for this book on the relationship between safety, models and culture. One interesting angle of analysis is indeed to focus on drawings, graphics or visualisations that have supported powerful heuristics designed to channel ways of thinking the complex topic of safety, analytically and communicatively. In order to build the argument about the importance of how drawings, pictures or visualisation structure the understanding of safety individuals and become a support for action, some illustrations are offered, covering different categories of actors populating high risks systems, from process operators to engineers and managers. From there, a discussion of more research oriented drawings is developed, based on two illustrations: the Heinrich-Bird pyramid and the Swiss Cheese Model. They are considered from several analytical categories including their generic, normative, metaphoric aspects along with their status as inscriptions, boundary and performative objects

Human error in information security: exploring the role of interruptions and multitasking in action slips

Breaches of cyber-security often arise unintentionally from the human user such as when switching between subtasks or external interruptions, disrupting the flow of work and leading to action slips in the execution of a task procedure [1, 2]. There has been little research into the perceived effects of task interruption and switching on computer-based tasks when such action slips can potentially compromise information security. Semi-structured interviews were conducted on nine university employees who regularly handle sensitive information, designed to identify which features of information-sensitive computer-based tasks are the most susceptible to disruption. Potential sources of human error in were identified with task interruption judged to be more likely than multitasking as a source of error. The interview findings will serve as the basis of experimental investigations into how disruptions in the flow of a task procedure can cause action slips that may compromise the handling of sensitive data. Well-informed empirical work in the area of Cyberpsychology is critical to understanding the processes involved, and to guiding potential solutions rooted in human-machine interface design and human computer interaction