Wrong drug administration errors amongst anaesthetists in a South African teaching hospital: research

A confidential, self-reporting survey was sent out to all 65 anaesthetists (25 specialists and 40 registrars) in the Department of Anaesthesia at the University of Cape Town with the aim of determining the incidence and possible causes of "wrong drug" administrations. The response rate was 95%. 93.5 % of respondents admitted to having administered the wrong drug at some stage of their anaesthetic career. 19/62 (30.6%) have injected the wrong drug or the correct drug into the wrong site on at least three occasions. 56.9 % of incidents involved muscle relaxants with suxamethonium chloride administered instead of fentanyl accounting for nearly a third of cases. 17.6 % of reported incidents were classified as being dangerous, with the potential to cause either severe haemodynamic instability and / or neurological damage or seizures. SAJAA Vol.10(2) 2004: 7-

The anaesthetist and the World Health Organization Surgical Safety Checklist

No Abstract

The amazing Minivent ventilator

In the mid-1960s Dr Anthony Cohen, an anaesthetist in private practice in Johannesburg, developed the Minivent respirator in response to the lack of ventilators that existed at that time in operating theatres in both private and state hospitals. The remarkable, rugged, miniature ventilator had only four components, could fit into an anaesthetist’s pocket and required no electrical power source. The pressure generated by the distension of a reservoir bag by the flow of anaesthetic gases to the patient triggered inspiration and the switch from inspiration to expiration was controlled by a pressure-sensitive magnetically operated bobbin. The device operated as a minute volume divider. Respiratory rate was obtained by counting the clicking noise from the bobbin and, provided there was no leak, tidal volume was easily calculated by dividing the gas flow by the respiratory rate. The device was widely used in numerous countries including South Africa, the United Kingdom, Australia and Canada.Keywords: anaesthesia, history of anaesthesia, medical equipment, ventilator

Drug administration errors by South African anaesthetists - a survey

Objectives. To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. Design. A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. Results. A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. Conclusions. Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a ‘syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents. South African Medical Journal Vol. 96(7) 2006: 630-63

Drug administration errors by South African anaesthetists – a survey

No Abstract. Southern African Journal of Anaesthesia and Analgesia Vol. 12(1) 2006: 4

Herschel/SPIRE observations of the dusty disk of NGC 4244

We present Herschel/SPIRE images at 250, 350, and 500 mu m of NGC 4244, a typical low-mass, disk-only and edge-on spiral galaxy. The dust disk is clumpy and shows signs of truncation at the break radius of the stellar disk. This disk coincides with the densest part of the Hi disk. We compare the spectral energy distribution (SED), including the new SPIRE fluxes, to 3D radiative transfer models; a smooth model disk and a clumpy model with embedded heating. Each model requires a very high value for the dust scale-length (h(d) = 2-5 h(*)), higher dust masses than previous models of NGC 4244 (M-d = 0.47-1.39 x 10(7) M-circle dot) and a face-on optical depth of tau(f.o.)(V) = 0.4-1.12, in agreement with previous disk opacity studies. The vertical scales of stars and dust are similar. The clumpy model much better mimics the general morphology in the sub-mm images and the general SED. The inferred gas-to-dust mass ratio is compatible with those of similar low-mass disks. The relatively large radial scale-length of the dust disk points to radial mixing of the dusty ISM within the stellar disk. The large vertical dust scale and the clumpy dust distribution of our SED model are both consistent with a scenario in which the vertical structure of the ISM is dictated by the balance of turbulence and self-gravity

The role of Comprehension in Requirements and Implications for Use Case Descriptions

Within requirements engineering it is generally accepted that in writing specifications (or indeed any requirements phase document), one attempts to produce an artefact which will be simple to comprehend for the user. That is, whether the document is intended for customers to validate requirements, or engineers to understand what the design must deliver, comprehension is an important goal for the author. Indeed, advice on producing ‘readable’ or ‘understandable’ documents is often included in courses on requirements engineering. However, few researchers, particularly within the software engineering domain, have attempted either to define or to understand the nature of comprehension and it’s implications for guidance on the production of quality requirements. Therefore, this paper examines thoroughly the nature of textual comprehension, drawing heavily from research in discourse process, and suggests some implications for requirements (and other) software documentation. In essence, we find that the guidance on writing requirements, often prevalent within software engineering, may be based upon assumptions which are an oversimplification of the nature of comprehension. Hence, the paper examines guidelines which have been proposed, in this case for use case descriptions, and the extent to which they agree with discourse process theory; before suggesting refinements to the guidelines which attempt to utilise lessons learned from our richer understanding of the underlying discourse process theory. For example, we suggest subtly different sets of writing guidelines for the different tasks of requirements, specification and design

NDE of Polymer Composites Using Magnetic Resonance Techniques

Polymer based materials have become increasingly important in structural applications primarily due to their high strength to weight ratio. As the use of polymer-based composites has increased, so has the need for reliable non-destructive evaluation techniques. In this paper, a new NDE method for these materials is proposed. The technique relies on the observation of an electron paramagnetic resonance (epr) absorption at the site of damage in a polymer. Using applied magnetic field gradients the physical location of damage can be discerned and an image of the damage site can be obtained. This should allow the detection of cracks and delaminations with high resolution, good sensitivity and good contrast

The Effective Fragment Molecular Orbital Method for Fragments Connected by Covalent Bonds

We extend the effective fragment molecular orbital method (EFMO) into treating fragments connected by covalent bonds. The accuracy of EFMO is compared to FMO and conventional ab initio electronic structure methods for polypeptides including proteins. Errors in energy for RHF and MP2 are within 2 kcal/mol for neutral polypeptides and 6 kcal/mol for charged polypeptides similar to FMO but obtained two to five times faster. For proteins, the errors are also within a few kcal/mol of the FMO results. We developed both the RHF and MP2 gradient for EFMO. Compared to ab initio, the EFMO optimized structures had an RMSD of 0.40 and 0.44 {\AA} for RHF and MP2, respectively.Comment: Revised manuscrip