A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals

Patient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including ‘never events’, ‘serious incidents’, ‘patient safety events’ and coroners’ Prevention of Future Deaths reports (PFDs) to monitor healthcare quality and safety. We conducted a systematic narrative review of PubMed and medRxiv on 19 February 2023 to explore the strengths and limitations of coroners’ PFDs and whether they could be a safety tool to help meet the WHO's Global Patient Safety Action Plan. We identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the COVID-19 pandemic. We found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing and monitoring PFDs limited their use and adoption as a patient safety tool for hospitals. To fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses and embeds technology to encourage the prevention of future deaths

Sustainability of the Catalytic Activity of a Silica-Titania Composite (STC) for Long-Term Indoor Air Quality Control

TiO2-assisted photocatalytic oxidation (PCO) is an emerging technology for indoor air quality control and is also being evaluated as an alternative trace contaminant control technology for crew habitats in space exploration. Though there exists a vast range of literature on the development of photocatalysts and associated reactor systems, including catalyst performance and performance-influencing factors, the critical question of whether photocatalysts can sustain their initial catalytic activity over an extended period of operation has not been adequately addressed. For a catalyst to effectively serve as an air quality control product, it must be rugged enough to withstand exposure to a multitude of low concentration volatile organic compounds (VOCs) over long periods of time with minimal loss of activity. The objective of this study was to determine the functional lifetime of a promising photocatalyst - the silica-titania composite (STC) from Sol Gel Solutions, LLC in a real-world scenario. A bench-scale STC-packed annular reactor under continuous irradiation by a UV-A fluorescent black-light blue lamp ((lambda)max = 365 nm) was exposed to laboratory air continuously at an apparent contact time of 0.27 sand challenged with a known concentration of ethanol periodically to assess any changes in catalytic activity. Laboratory air was also episodically spiked with halocarbons (e.g., octafluoropropane), organosulfur compounds (e.g., sulfur hexafluoride), and organosilicons (e.g., siloxanes) to simulate accidental releases or leaks of such VOCs. Total organic carbon (TOC) loading and contaminant profiles of the laboratory air were also monitored. Changes in STC photocatalytic performance were evaluated using the ethanol mineralization rate, mineralization efficiency, and oxidation intermediate (acetaldehyde) formation. Results provide insights to any potential catalyst poisoning by trace halocarbons and organosulfur compounds

Modeling Geometric Arrangements of TiO2-Based Catalyst Substrates and Isotropic Light Sources to Enhance the Efficiency of a Photocatalystic Oxidation (PCO) Reactor

The closed confined environments of the ISS, as well as in future spacecraft for exploration beyond LEO, provide many challenges to crew health. One such challenge is the availability of a robust, energy efficient, and re-generable air revitalization system that controls trace volatile organic contaminants (VOCs) to levels below a specified spacecraft maximum allowable concentration (SMAC). Photocatalytic oxidation (PCO), which is capable of mineralizing VOCs at room temperature and of accommodating a high volumetric flow, is being evaluated as an alternative trace contaminant control technology. In an architecture of a combined air and water management system, placing a PCO unit before a condensing heat exchanger for humidity control will greatly reduce the organic load into the humidity condensate loop ofthe water processing assembly (WPA) thereby enhancing the life cycle economics ofthe WPA. This targeted application dictates a single pass efficiency of greater than 90% for polar VOCs. ~ Although this target was met in laboratory bench-scaled reactors, no commercial or SBIR-developed prototype PCO units examined to date have achieved this goal. Furthermore, the formation of partial oxidation products (e.g., acetaldehyde) was not eliminated. It is known that single pass efficiency and partial oxidation are strongly dependent upon the contact time and catalyst illumination, hence the requirement for an efficient reactor design. The objective of this study is to maximize the apparent contact time and illuminated catalyst surface area at a given reactor volume and volumetric flow. In this study, a Ti02-based photocatalyst is assumed to be immobilized on porous substrate panels and illumination derived from linear isotropic light sources. Mathematical modeling using computational fluid dynamics (CFD) analyses were performed to investigate the effect of: 1) the geometry and configuration of catalyst-coated substrate panels, 2) porosity of the supporting substrate, and 3) varying the light source and spacing on contact time and illuminated catalyst area

The Effect of Photon Source on Heterogeneous Photocatalytic Oxidation of Ethanol by a Silica-Titania Composite

The objective of this study was to distinguish the effect of photon flux (i.e., photons per unit time reaching a surface) from that of photon energy (i.e., wavelength) of a photon source on the silica-titania composite (STC)-catalyzed degradation of ethanol in the gas phase. Experiments were conducted in a bench-scale annular reactor packed with STC pellets and irradiated with either a UV-A fluorescent black light blue lamp ((gamma)max=365 nm) at its maximum light intensity or a UV-C germicidal lamp ((gamma)max=254 nm) at three levels of light intensity. The STC-catalyzed oxidation of ethanol was found to follow zero-order kinetics with respect to CO2 production, regardless of the photon source. Increased photon flux led to increased EtOH removal, mineralization, and oxidation rate accompanied by lower intermediate concentration in the effluent. The oxidation rate was higher in the reactor irradiated by UV-C than by UV-A (38.4 vs. 31.9 nM/s) at the same photon flux, with similar trends for mineralization (53.9 vs. 43.4%) and reaction quantum efficiency (i.e., photonic efficiency, 63.3 vs. 50.1 nmol CO2 (mu)mol/photons). UV-C irradiation also led to decreased intermediate concentration in the effluent . compared to UV-A irradiation. These results demonstrated that STC-catalyzed oxidation is enhanced by both increased photon flux and photon energy

Characterization of Volume F Trash from Four Recent STS Missions: Microbial Occurrence, Numbers, and Identifications

The fate of space-generated solid wastes, including trash, for future missions is under consideration by NASA. Several potential treatment options are under active technology development. Potential fates for space-generated solid wastes: Storage without treatment; storage after treatment(s) including volume reduction, water recovery, sterilization, and recovery plus recycling of waste materials. For this study, a microbial characterization was made on trash returned from four recent STS missions. The material analyzed were 'Volume F' trash and other bags of accompanying trash. This is the second of two submitted papers on these wastes. This first one covered trash content, weight and water content. Upon receipt, usually within 2 days of landing, trash contents were catalogued and placed into categories: drink containers, food waste, personal hygiene items, and packaging materials, i.e., plastic film and duct tape. Microbial counts were obtained with cultivatable counts on agar media and direct counts using Acridine Orange fluorescent stain (AODC). Trash bag surfaces, 25 square cm , were also sampled. Direct counts were approximately 1 x 10(exp 6) microbes/square cm and cultivatable counts ranged from 1 x 10 to 1 X 10(exp 4) microbes/ square cm-2. Aerobic microbes, aerobic sporeformers, and yeasts plus molds were common for all four missions. Waste items from each category were placed into sterile ziplock bags and 1.5 L sterile DI water added. These were then dispersed by hand shaking for 2 min. prior to inoculation of count media or determining AODC. In general, cultivatable microbes were found in drinks, food wastes, and personal hygiene items. Direct counts were usually higher than cultivatable counts. Some pathogens were found: Staphylococcus auerus, Escherichia coli (fecal wastes). Count ranges: drink pouches - AODC 2 x 10(exp 6) to 1 X 10(exp 8) g(sub fw) (exp -1); cultivatable counts variable between missions; food wastes: Direct counts were close to aerobic plate counts. Counts ranged from 10(exp 6) to 10(exp 9) per g(sub fw). Identities of isolates from cultivation media were obtained using a Biolog Microbial ID System or microSEQ molecular ID methodology using an ABI3130 gene analyzer

Feasibility of Ultraviolet Light Emitting Diodes as an Alternative Light Source for Photocatalysis

The objective of this study was to determine whether ultraviolet light emitting diodes (UV-LEDs) could serve as an alternative photon source efficiently for heterogeneous photocatalytic oxidation (PCO). An LED module consisting of 12 high-power UV-A LEDs was designed to be interchangeable with a UV-A fluorescent black light blue (BLB) lamp in a Silica-Titania Composite (STC) packed bed annular reactor. Lighting and thermal properties were characterized to assess the uniformity and total irradiant output. A forward current of (I(sub F)) 100 mA delivered an average irradiance of 4.0 m W cm(exp -2), which is equivalent to the maximum output of the BLB, but the irradiance of the LED module was less uniform than that of the BLB. The LED- and BLB-reactors were tested for the oxidization of 50 ppmv ethanol in a continuous flow-through mode with 0.94 sec space time. At the same irradiance, the UV-A LED reactor resulted in a lower PCO rate constant than the UV-A BLB reactor (19.8 vs. 28.6 nM CO2 sec-I), and consequently lower ethanol removal (80% vs. 91%) and mineralization efficiency (28% vs. 44%). Ethanol mineralization increased in direct proportion to the irradiance at the catalyst surface. This result suggests that reduced ethanol mineralization in the LED- reactor could be traced to uneven irradiance over the photocatalyst, leaving a portion of the catalyst was under-irradiated. The potential of UV-A LEDs may be fully realized by optimizing the light distribution over the catalyst and utilizing their instantaneous "on" and "off' feature for periodic irradiation. Nevertheless, the current UV-A LED module had the same wall plug efficiency (WPE) of 13% as that of the UV-A BLB. These results demonstrated that UV-A LEDs are a viable photon source both in terms of WPE and PCO efficiency

Characterization of Volume F Trash from Four Recent STS Missions: Weights, Categorization, Water Content

The fate of space-generated solid wastes, including trash, for future missions is under consideration by NASA. Several potential treatment options are under consideration and active technology development. Potential fates for space-generated solid wastes are: Storage without treatment; storage after treatment(s) including volume reduction, water recovery, sterilization, and recovery plus recycling of waste materials. Recycling might be important for partial or full closure scenarios because of the prohibitive costs associated with resupply of consumable materials. For this study, we determined the composition of trash returned from four recent STS missions. The trash material was 'Volume F' trash and other trash, in large zip-lock bags, that accompanied the Volume F trash. This is the first of two submitted papers on these wastes. This one will cover trash content, weight and water content. The other will report on the microbial Characterization of this trash. STS trash was usually made available within 2 days of landing at KSC. The Volume F bag was weighed, opened and the contents were catalogued and placed into one of the following categories: food waste (and containers), drink containers, personal hygiene items - including EVA maximum absorbent garments (MAGs)and Elbow packs (daily toilet wipes, etc), paper, and packaging materials - plastic firm and duct tape. Trash generation rates for the four STS missions: Total wet trash was 0.602 plus or minus 0.089 kg(sub wet) crew(sup -1) d(sup -1) containing about 25% water at 0.154 plus or minus 0.030 kg(sub water) crew(sup -1) d(sup -1) (avg plus or minus stdev). Cataloguing by category: personal hygiene wastes accounted for 50% of the total trash and 69% of the total water for the four missions; drink items were 16% of total weight and 16% water; food wastes were 22% of total weight and 15% of the water; office waste and plastic film were 2% and 11% of the total waste and did not contain any water. The results can be used by NASA to determine requirements and criteria for Waste Management Systems on future missions

The Scuppernong River Project, Volume 1: Explorations of Tyrrell County Maritime History

PAST Foundation, UNC Coastal Studies Institute, East Carolina Universit