ABSTRACT
RATIONALE, AIMS AND OBJECTIVES: Medication-related safety incidents are a source of concern to patients, policy makers and clinicians. The role of education in improving safety-critical practices in health care is poorly appreciated. This pilot study aimed to initiate collective discussion among professional groups of clinical staff about a range of medicine-related patient safety issues which were identified from a local incident reporting system. In engaging staff to collectively reflect on reported medication incidents we attempted to uncover a deeper understanding of local contextual issues and potential educational needs. METHODS: A mixed method study was conducted involving categorical analysis of 1058 medication incident reports (Phase 1) and the use of three mixed focus groups of clinical staff (Phase 2) in three acute hospitals in one locality in NHS Scotland. RESULTS: Focus group transcript analysis produced four main themes (e.g. the medical role) and 12 related sub-themes (e.g. pharmacological education and skill mix for administration of medicines) concerning medication-related practices and possible educational interventions. CONCLUSIONS: While it is necessary to review reported incident data and disseminate the educational messages for the improvement of quality, this traditional risk management process is inadequate on its own. Reporting systems can be enhanced by collective examination of reported information about medicines by local clinical teams. We identified a strong message from the focus groups for learning about each other and from each other, and that the method piloted may be an important inter-professional mechanism for improvement.
Subject(s)
Documentation , Health Knowledge, Attitudes, Practice , Medication Errors/prevention & control , Pharmacy Service, Hospital/organization & administration , Prescription Drugs , Safety Management/organization & administration , Decision Making , Focus Groups , Humans , Medication Errors/classification , Patient Discharge , Patient Safety , Pilot Projects , Professional Role , Time FactorsABSTRACT
AOAC Official Method 942.05, Ash in Animal Feed, has been applied in feed laboratories since its publication in the Official Methods of Analysis in 1942. It is a routine test with renewed interest due to the incorporation of "ash values" into modern equations for the estimation of energy content of dairy feed, beef feed, and pet food. As with other empirical methods, results obtained are a function of the test conditions. For this method, the critical conditions are the ignition time, ignition temperature, and any other furnace or weighing conditions. Complete ignition can be observed by the absence of black color (due to residual carbonaceous material) in the ash residue. To investigate performance of AOAC 942.05, 15 samples were chosen to be representative of a wide range of feed materials. These materials were tested at the conditions of AOAC 942.05 (ignition at 600 degrees C for 2 h) and similar or more rigorous conditions. The additional conditions investigated included: 600 degrees C for 4 h; 600 degrees C for 2 h, cool, and ignite 2 additional h; 600 degrees C for 2 h, cool, wet, dry, and ignite 2 additional h; 550 degrees C for 6 h; 550 degrees C for 3 h, cool, and ignite 3 additional h; and 550 degrees C for 3 h, cool, wet, dry, ignite 3 additional h. Results for all other conditions investigated were found to be significantly different from the current AOAC Method 942.05. All ignition conditions were significantly different from each other except two: 550 degrees C for 3 h, cool, ignite 3 additional h; and 550 degrees C for 3 h, cool, wet, dry, and ignite 3 additional h. Recommendations for modification to AOAC Official Method 942.05 are suggested based on statistical analysis of the data and a review of the literature.