Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals

Objective: To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. Materials and Methods: A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. Results: We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Discussion: Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. Conclusion: In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors

Impedance Analysis of an RMU for On-line PD Measurement

Abstract A new system to monitor partial discharges (PD) online in medium-voltage power cables is being developed. On-line measurement implies that the equipment can be applied when the cable is in operation, i.e. without disrupting service. A PD gives a high frequency pulse, propagating through the MV power cable. At the termination cable, the PD pulses partially reflect and partially propagate into the connected Ring Main Unit (RMU) due to the impedance transition. For correct interpretation of PD signals from the cable under test, it is essential to know the involved impedances up to several megahertz. An analysis of the impedances of the RMU elements is performed. A theoretical analysis based on lumped impedances is verified using various measurements. The measurements have been carried out on a test-grid consisting of two RMUs and several cables and show good agreement with predictions. This method of analysis will be used in the on-line PD monitoring system

Assessing the potential of phytolith analysis to investigate local environment and prehistoric plant resource use in temperate regions:A case study from Williamson’s Moss, Cumbria, Great Britain

Please note: this work is permanently embargoed in OpenBU. No public access is forecasted for this item. To request private access, please click on the locked Download file link and fill out the appropriate web form.First author draf

How combinations of control elements create tensions and how these can be managed:An embedded case study

This paper explores how combinations of management control (MC) elements can create tensions, and what supervisors can do to manage these tensions. We extend the literature on the interplay of MC elements by examining the underlying micro-processes that give rise to tensions between MC elements. Specifically, drawing on both the MC and the organization literature, we investigate how interactions between MC elements can simultaneously enhance and diminish control effectiveness, for which we coin the term tension complexity, and how these tensions can change over time, which we label tension dynamics. We empirically inform our study with an embedded case study in a public sector organization in the Netherlands. Using interviews, desk research, and observations, this study specifically investigates how an organization-level MC element (the value 'self-management') relates to departmental MC elements, creating tensions. The findings highlight that tensions, because of their dynamic and complex nature, require continuous attention from managers. Furthermore, the case findings demonstrate how department managers can influence the tensions by affecting the balance, balance tendency, and intensity of the MC elements within them. We conclude by providing suggestions for further research into the interactions of MC elements

Multi-messenger observations of a binary neutron star merger

On 2017 August 17 a binary neutron star coalescence candidate (later designated GW170817) with merger time 12:41:04 UTC was observed through gravitational waves by the Advanced LIGO and Advanced Virgo detectors. The Fermi Gamma-ray Burst Monitor independently detected a gamma-ray burst (GRB 170817A) with a time delay of ~1.7 s with respect to the merger time. From the gravitational-wave signal, the source was initially localized to a sky region of 31 deg2 at a luminosity distance of 40+8-8 Mpc and with component masses consistent with neutron stars. The component masses were later measured to be in the range 0.86 to 2.26 Mo. An extensive observing campaign was launched across the electromagnetic spectrum leading to the discovery of a bright optical transient (SSS17a, now with the IAU identification of AT 2017gfo) in NGC 4993 (at ~40 Mpc) less than 11 hours after the merger by the One- Meter, Two Hemisphere (1M2H) team using the 1 m Swope Telescope. The optical transient was independently detected by multiple teams within an hour. Subsequent observations targeted the object and its environment. Early ultraviolet observations revealed a blue transient that faded within 48 hours. Optical and infrared observations showed a redward evolution over ~10 days. Following early non-detections, X-ray and radio emission were discovered at the transient’s position ~9 and ~16 days, respectively, after the merger. Both the X-ray and radio emission likely arise from a physical process that is distinct from the one that generates the UV/optical/near-infrared emission. No ultra-high-energy gamma-rays and no neutrino candidates consistent with the source were found in follow-up searches. These observations support the hypothesis that GW170817 was produced by the merger of two neutron stars in NGC4993 followed by a short gamma-ray burst (GRB 170817A) and a kilonova/macronova powered by the radioactive decay of r-process nuclei synthesized in the ejecta