scholarly journals Changes in error rates in the Australian key incident monitoring and management system program

2020 ◽  
Vol 30 (2) ◽  
pp. 257-264
Author(s):  
Stephanie Gay ◽  
Tony Badrick
Keyword(s):  
Management System ◽  
Best Practice ◽  
Error Rates ◽  
Medical Laboratories ◽  
Root Cause ◽  
Best Practice Guidelines ◽  
Risk Cost ◽  
The Cost ◽  
Incident Monitoring ◽  
System Program

Introduction: The Key incident monitoring and management system program (KIMMS) program collects data for 19 quality indicators (QIs) from Australian medical laboratories. This paper aims to review the data submitted to see whether the number of errors with a higher risk priority number (RPN) have been reduced in preference to those with a lower RPN, and to calculate the cost of these errors. Materials and methods: Data for QIs from 60 laboratories collected through the KIMMS program from 2015 until 2018 were retrospectively reviewed. The results for each QI were averaged for the four-year average and coefficient of variation. To review the changes in QI frequency, the yearly averages for 2015 and 2018 were compared. By dividing the total RPN by 4 and multiplying that number by the cost of recollection of 30 AUD, it was possible to assign the risk cost of these errors. Results: The analysis showed a drop in the overall frequency of incidents (6.5%), but a larger drop in risk (9.4%) over the period investigated. Recollections per year in Australia cost the healthcare industry 27 million AUD. If the RPN data is used, this cost increases to 66 million AUD per year. Conclusions: Errors with a higher RPN have fallen more than those with lower RPN. The data shows that the errors associated with phlebotomy are the ones that have most improved. Further improvements require a better understanding of the root cause of the errors and to achieve this, work is required in the collection of the data to establish best-practice guidelines.

Northern yellow-cheeked crested gibbons (Nomascus annamensis) travel and scan more at the cost of rest when in the presence of tourists

2020 ◽  
Vol 70 (4) ◽  
pp. 427-443
Author(s):  
Jessica L. Williams ◽  
Alison M. Behie
Keyword(s):  
Global Economy ◽  
National Park ◽  
Best Practice ◽  
Nature Reserve ◽  
Great Ape ◽  
Best Practice Guidelines ◽  
Tourism Sector ◽  
Crested Gibbons ◽  
The Cost ◽  
The Impact

Abstract The tourism sector is a fast-growing contributor to the global economy, and nature-based tourism (NBT), particularly in Asia and Africa, is booming. Through the creation of jobs and revenue NBT has the potential to combat deforestation in regions that are economically poor, but of high biodiversity value. Inspired by the success of gorilla tourism in Uganda and Rwanda, several gibbon tourism projects have been initiated in Southeast Asia and China. Despite the existence of these programmes, no research has been done to investigate the impact of tourism on the behaviour of gibbons. To address this, we collected observational data on a group of northern yellow-cheeked crested gibbons (Nomascus annamensis) at Veun Sai-Siem Pang National Park (VSSPNP), Cambodia, in the presence and absence of tourists. We found there was a significant increase in the amount of time individuals spent scanning their environment and travelling at the cost of rest when in the presence of tourists. We also found that individuals were significantly more likely to self-groom in the presence of tourists. These results highlight the importance of scientific research in implementing successful, low-impact NBT programmes that consider animal behavioural changes. We are continuing to collect data on gibbons at VSSPNP and at Mt. Gaoligong National Nature Reserve, China with the aim of extending the IUCN’s best-practice guidelines for great-ape tourism to include the small apes.

Case Study—Failure Analysis of a Multiplexer

2016 ◽  
Author(s):  
Michael Woo ◽  
Marcos Campos ◽  
Luigi Aranda
Keyword(s):  
Failure Analysis ◽  
High Reliability ◽  
Component Failure ◽  
Root Cause ◽  
Knowing That ◽  
Cause Of Failure ◽  
The Cost

Abstract A component failure has the potential to significantly impact the cost, manufacturing schedule, and/or the perceived reliability of a system, especially if the root cause of the failure is not known. A failure analysis is often key to mitigating the effects of a componentlevel failure to a customer or a system; minimizing schedule slips, minimizing related accrued costs to the customer, and allowing for the completion of the system with confidence that the reliability of the product had not been compromised. This case study will show how a detailed and systemic failure analysis was able to determine the exact cause of failure of a multiplexer in a high-reliability system, which allowed the manufacturer to confidently proceed with production knowing that the failure was not a systemic issue, but rather that it was a random “one time” event.

Opioid crisis in primary care? An audit of high-dose opioid prescribing at Bangholm GP Practice

2020 ◽  
Vol 70 (suppl 1) ◽  
pp. bjgp20X711581
Author(s):  
Charlotte Greene ◽  
Alice Pearson
Keyword(s):  
Chronic Pain ◽  
Back Pain ◽  
Practice Guidelines ◽  
Best Practice ◽  
Evidence Base ◽  
High Dose ◽  
Opioid Prescription ◽  
Opioid Prescribing ◽  
Best Practice Guidelines

BackgroundOpioids are effective analgesics for acute and palliative pain, but there is no evidence base for long-term pain relief. They also carry considerable risks such as overdose and dependence. Despite this, they are increasingly prescribed for chronic pain. In the UK, opioid prescribing more than doubled between 1998 and 2018.AimAn audit at Bangholm GP Practice to understand the scale of high-strength opioid prescribing. The aim of the audit was to find out if indications, length of prescription, discussion, and documentation at initial consultation and review process were consistent with best-practice guidelines.MethodA search on Scottish Therapeutics Utility for patients prescribed an average daily dose of opioid equivalent ≥50 mg morphine between 1 July 2019 and 1 October 2019, excluding methadone, cancer pain, or palliative prescriptions. The Faculty of Pain Medicine’s best-practice guidelines were used.ResultsDemographics: 60 patients (37 females), average age 62, 28% registered with repeat opioid prescription, 38% comorbid depression. Length of prescription: average 6 years, 57% >5 years, 22% >10 years. Opioid: 52% tramadol, 23% on two opioids. Indications: back pain (42%), osteoarthritis (12%), fibromyalgia (10%). Initial consultation: 7% agreed outcomes, 35% follow-up documented. Review: 56% 4-week, 70% past year.ConclusionOpioid prescribing guidelines are not followed. The significant issues are: long-term prescriptions for chronic pain, especially back pain; new patients registering with repeat prescriptions; and no outcomes of treatment agreed, a crucial message is the goal is pain management rather than relief. Changes have been introduced at the practice: a patient information sheet, compulsory 1-month review for new patients on opioids, and in-surgery pain referrals.

scholarly journals Introducing New Guidelines on Geoheritage Conservation in Protected and Conserved Areas

Geoheritage ◽  
2021 ◽  
Vol 13 (2) ◽  
Author(s):  
Roger Crofts ◽  
Dan Tormey ◽  
John E. Gordon
Keyword(s):  
Practice Guidelines ◽  
Best Practice ◽  
Communication To The Public ◽  
The Public ◽  
Best Practice Guidelines ◽  
The World ◽  
New Guidelines ◽  
The Many ◽  
Ethical Basis ◽  
Improve Practice

AbstractThis paper introduces newly published guidelines on geoheritage conservation in protected and conserved areas within the “IUCN WCPA Best Practice Guidelines” series. It explains the need for the guidelines and outlines the ethical basis of geoheritage values and geoconservation principles as the fundamental framework within which to advance geoheritage conservation. Best practice in establishing and managing protected and conserved areas for geoconservation is described with examples from around the world. Particular emphasis is given to the methodology and practice for dealing with the many threats to geoheritage, highlighting in particular how to improve practice for areas with caves and karst, glacial and periglacial, and volcanic features and processes, and for palaeontology and mineral sites. Guidance to improve education and communication to the public through modern and conventional means is also highlighted as a key stage in delivering effective geoconservation. A request is made to geoconservation experts to continue to share best practice examples of developing methodologies and best practice in management to guide non-experts in their work. Finally, a number of suggestions are made on how geoconservation can be further promoted.

scholarly journals Development of the “Hamburg Best Practice Guidelines for ICV−Enzyme Replacement therapy (ERT) in CLN2 Disease” Based on 6 Years Treatment Experience in 48 Patients

2021 ◽  
pp. 088307382198915
Author(s):  
Christoph Schwering ◽  
Gertrud Kammler ◽  
Eva Wibbeler ◽  
Martin Christner ◽  
Johannes K.-M. Knobloch ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Enzyme Replacement Therapy ◽  
Replacement Therapy ◽  
Practice Guidelines ◽  
Best Practice ◽  
Vision Loss ◽  
Neuronal Ceroid Lipofuscinosis ◽  
Enzyme Replacement ◽  
Best Practice Guidelines

Intracerebroventricular enzyme replacement therapy (ICV-ERT) for CLN2 disease represents the first approved treatment for neuronal ceroid lipofuscinosis (NCL) diseases. It is the first treatment where a recombinant lysosomal enzyme, cerliponase alfa, is administered into the lateral cerebral ventricles to reach the central nervous system, the organ affected in CLN2 disease. If untreated, CLN2 children show first symptoms such as epilepsy and language developmental delay at 2-4 years followed by rapid loss of motor and language function, vision loss, and early death. Treatment with cerliponase alfa has shown to slow the rapid neurologic decline. However, the mode of administration by 4 hour-long intracerebroventricular infusions every 14 days represents a potentially greater risk of infection compared to intravenous enzyme replacement therapies. The Hamburg NCL Specialty Clinic was the first site worldwide to perform intracerebroventricular enzyme replacement therapy in children with CLN2 disease. In order to ensure maximum patient safety, we analysed data from our center from more than 3000 intracerebroventricular enzyme replacement therapies in 48 patients over 6 years with regard to the occurrence of device-related adverse events and device infections. Since starting intracerebroventricular enzyme replacement therapy, we have also developed and continuously improved the “Hamburg Best Practice Guidelines for ICV–Enzyme Replacement Therapy (ERT) in CLN2 Disease.” Results from this study showed low rates for device-related adverse events and infections with 0.27% and 0.33%, respectively. Therefore, following our internal procedural guidelines has shown to improve standardization and patient safety of intracerebroventricular enzyme replacement therapy for CLN2 disease.

scholarly journals Global leadership in IPECP research; an intro to co-creation of best practice guidelines

2021 ◽  
pp. 100445
Author(s):  
Hossein Khalili ◽  
Anthony Breitbach ◽  
Gail Jensen ◽  
Sharla King ◽  
Barbara Maxwell ◽  
...  
Keyword(s):  
Practice Guidelines ◽  
Best Practice ◽  
Global Leadership ◽  
Best Practice Guidelines
Sign in / Sign up

Export Citation Format

Share Document