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PubMed2001

Clinical governance: risks and quality control in radiotherapy.

The professions involved in radiotherapy constantly strive to improve quality and to minimize errors and their effects. We are aware of our shortcomings but sometimes are powerless to take corrective action. We have seen that clinical governance requires some change in the medical culture but much has yet to be achieved in the standardization of medical processes. We would gain by sharing experiences of system failures, whether that be by reporting near misses or by disseminating details of litigation cases. In a specialty that depends on human processes and interactions, it is no surprise to find a measurable incidence of human errors. Sometimes this is also related to technological or design deficiencies and we rely too much on human interventions to overcome these. We would like to take positive steps to improve quality, such as those inherent in the new ISO9000 standards, but we are hindered by a variety of constraints--manpower, old technology, pressure to achieve high patient throughput. We need to make decisions for the future development of radiotherapy in the UK. We could settle for a system that is characterized by high throughput and high risk. Hopefully, we will receive the necessary encouragement and resources to strive for high standards of treatment and low risk.

Clinical Competence↗

PubMed1998

Evaluation of single-injection method of inulin and creatinine as a renal function test in normal cats.

A single injection method for estimating glomerular filtration rate (GFR) by measuring plasma inulin and creatinine clearances was evaluated in 10 healthy cats. GFRs were estimated from the plasma clearance (PC) by dividing the injected dose of an indicator by the area under the plasma disappearance curve (AUC). AUC was determined by 2 common pharmacokinetic analyses, the two-compartment model and the trapezoidal rule. AUCs determined by these two methods were significantly correlated both in inulin (r = 0.993) and creatinine (r = 0.959). To minimize errors, GFR was estimated by PC only if AUC/10 was greater than the area under the curve from the final sampling time to infinitive (A2). GFRs determined by PC of inulin at final sampling time of 180 and 240 min were 3.61 +/- 0.64 and 3.63 +/- 0.67 ml/min/kg of body weight (mean +/- SD), respectively. These values corresponded to the reference range reported for normal cats. In contrast, when creatinine was used as a maker, A2 was always greater than AUC/10 at any final sampling time and GFRs estimated using these AUCs of creatinine were significantly greater than those of inulin, suggesting creatinine may not be suitable indicator for the single injection method.

Animals↗

PubMed2005

Urban outpatient views on quality and safety in primary care.

OBJECTIVE: The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to "tell their stories" via focus groups. DESIGN: Moderators used a standard question guide. Researchers read the transcripts independently and reached consensus on major themes. Two coders independently assigned transcript statement to themes. SETTING: Three focus groups were conducted in three cities, including 21 patients from three clinics. PATIENTS: Patients with previously scheduled appointments at participating clinics were invited to join the focus groups. MEASUREMENTS AND MAIN RESULTS: Agreement between the two coders was 77.5% (kappa value 0.66). All but 2% of 187 distinct comments could be grouped into four categories: (1) Systems Issues (44% of comments). Long waits for providers and lack of access were the most common frustrations. Understaffing, underfunding and lack of health insurance were perceived as contributing to poor quality of care; (2) Interpersonal Skills (37%). Physician listening skills were valued. Participants felt patient attitudes affected care. (3) Knowledge and Technical Skills (9%). (4) Errors (7%). Medication errors, errors of inattention and technical errors were discussed. CONCLUSIONS: Patients provide important insights into complex systems issues, which can guide planners in improving quality and reducing errors. According to focus group participants, healthcare could be improved and made safer by increasing timely access to patients' own physicians, decreasing the time patients spend in waiting rooms, and adding staff to double-check prescriptions.

Ambulatory Care↗

PubMedDate not supplied

Capillary blood glucose monitoring.

The complications associated with inaccurate capillary blood glucose monitoring and poor control of diabetes are well known. This article explores the research identifying potential causes of inaccurate testing, examines ways of minimizing error and investigates quality control issues.

Bias↗

PubMed2006

Developing guidelines for syringe driver management.

The aim of this project was to develop clinical practice guidelines for the use and administration of pharmacological agents for symptom control via syringe drivers within Australia. By developing evidence-based clinical practice guidelines for the use of this common device, this project aimed to improve patient outcomes, reduce practice variation, minimize errors and encourage more efficient use of resources. A literature review identified current literature regarding syringe driver management and an expert panel was assembled to assist in the development of the guidelines. The development of these practice guidelines provides an example of how palliative care practitioners can use a framework of contemporary evidence to enhance clinical practice.

Clinical Nursing Research↗

PubMed2006

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Current regulations require that departments of pathology have a structured and active program of quality assurance (QA) and quality improvement (QI), with the goals of enhancing patient safety, minimizing error, ensuring timely delivery of reports, and monitoring physician competence. Types of potential error may evolve over time, and, as regulations become progressively more stringent, QA and QI programs need to be updated constantly. The Association of Directors of Anatomic and Surgical Pathology herein provides guidelines for QA and QI in surgical and autopsy pathology.

Autopsy↗

PubMed2004

Unintentional intravenous infusion of Golytely in a 4-year-old girl.

OBJECTIVE: To report an accidental intravenous infusion of Golytely (polyethylene glycol and electrolyte solution; PEG-ELS) in a pediatric patient that did not result in systemic toxicity. CASE SUMMARY: A 4-year-old Hispanic girl presented to the emergency department after ingestion of approximately 24 tablets of 6-mercaptopurine (6-MP) 2 hours earlier. She vomited twice after receiving syrup of ipecac at home. Upon arrival, her vital signs were temperature 36.2 degrees C, heart rate 102 beats/min, respiratory rate 42 breaths/min, and blood pressure 115/67 mm Hg. Her physical examination was normal. The patient received activated charcoal 1 g/kg. Golytely administered through a nasogastric tube was ordered. Upon reevaluation, it was noted that the patient had received 391 mL of Golytely intravenously. The infusion was immediately stopped. There was no evidence of acidosis, renal failure, or ethylene glycol toxicity. She was admitted for observation and was discharged 36 hours later. DISCUSSION: As of April 29, 2004, accidental intravenous infusion of PEG-ELS has not been previously reported. Potential toxicity from Golytely is mainly related to the molecular weight of PEG in the formulation. PEG can theoretically be degraded to ethylene glycol. It is thus important to monitor acid-base status, renal function, and pulmonary function in these patients. CONCLUSIONS: When administered correctly, an infusion of PEG-ELS by nasogastric tube is a safe gastrointestinal decontamination technique used in toxicology; PEG-ELS is not indicated for intravenous administration. Protocols need to be implemented in the workplace to minimize errors in the delivery of treatment to patients. Fortunately, this patient did not have any toxicity from the intravenous infusion of Golytely.

Child, Preschool↗

PubMed2005

Tropospheric CO observed with the NAST-I retrieval methodology, analyses, and first results.

High-resolution infrared spectra from aircraft and space-based observations contain information about tropospheric carbon monoxide (CO) as well as other trace species. A methodology for retrieving tropospheric CO from such remotely sensed spectral data has been developed for the National Polar-Orbiting Operational Environmental Satellite System's Airborne Sounder Testbed-Interferometer (NAST-I). CO profiles of the troposphere, together with its thermodynamic properties, are determined by use of a three-stage retrieval approach that combines the algorithms of physically based statistical eigenvector regression, simultaneous and iterative matrix inversion, and single-variable error-minimization CO profile matrix inverse retrieval. The NAST-I is collecting data while it is aboard high-altitude aircraft throughout many field campaigns. Detailed retrieval analyses based on the NAST-I instrument system along with retrieval results from several recent field campaigns are presented to demonstrate NAST-I CO retrieval capability.

Journal Article↗

PubMed2006

Recognition and classification of three-dimensional phase objects by digital Fresnel holography.

We demonstrate the validity of wavelet-based processing for recognition and classification of three-dimensional phase objects. One Fresnel digital hologram of each of the three-dimensional (3-D) phase objects to be classified is recorded. The electronic holograms are processed digitally to permit 3-D object information to be retrieved as two-dimensional digital complex images. We use a Mexican-hat wavelet- matched filter (WMF) to enhance the correlation peak and discriminate between the objects. The WMF performs a wavelet transform (WT) to enhance the significant features of the images and the correlation of the WT coefficients thus obtained. We compare the feasibility of a WMF-based object classifier with the matched-filter-based classifier to classify our four 3-D phase objects in a 3-D scene into true or false classes with minimal error.

Algorithms↗

PubMed2000

Interferometric data analysis based on Markov nonlinear filtering methodology.

For data processing in conventional phase shifting interferometry, Fourier transform, and least-squares-fitting techniques, a whole interferometric data series is required. We propose a new interferometric data processing methodology based on a recurrent nonlinear procedure. The signal value is predicted from the previous step to the next step, and the prediction error is used for nonlinear correction of an a priori estimate of the parameters phase, visibility, or frequency of interference fringes. Such a recurrent procedure is correct on the condition that the noise component be a Markov stochastic process realization. The accuracy and stability of the recurrent Markov nonlinear filtering algorithm were verified by computer simulations. It was discovered that the main advantages of the proposed methodology are dynamic data processing, phase error minimization, and high noise immunity against the influence of non-Gaussian noise correlated with the signal and the automatic solution of the phase unwrapping problem.

Algorithms↗

PubMed2006

Fast in vivo microextraction: a new tool for clinical analysis.

BACKGROUND: We sought to develop a technique with the potential to partly replace current methods of analysis based on blood draws. To achieve this goal, we developed an in vivo microextraction technique that is faster than conventional methods, interferes minimally with the investigated system, minimizes errors associated with sample preparation, and limits exposure to hazardous biological samples. METHODS: Solid-phase microextraction devices based on hydrophilic polypyrrole and polyethylene glycol coatings were used for direct extraction of drugs from the flowing blood of beagle dogs, over a period of 8 h. The drugs extracted on the probes were subsequently quantified by liquid chromatography coupled to tandem mass spectrometry. Two calibration strategies--external and standard on the fiber--were used to correlate the amount extracted with the in vivo concentration. RESULTS: Diazepam and its metabolites were successfully monitored over the course of a pharmacokinetic study, repeated 3 times on 3 beagles. The fast microextraction technique was validated by comparison with conventional plasma analysis, and a correlation factor of 0.99 was obtained. In addition to total concentrations, the method was useful for determining free drug concentrations. CONCLUSIONS: The proposed technique has several advantages and is suitable for fast clinical analyses. This approach could be used not only for drugs, but for any other endogenous or exogenous compounds.

Animals↗

PubMed2006

Comparability of indices for insulin resistance and insulin secretion determined during oral glucose tolerance tests.

BACKGROUND: Impaired insulin secretion (IS) and insulin resistance (IR) play an essential role in the pathogenesis of type 2 diabetes mellitus. Several simplifying indices were developed that calculate IS and/or IR from venous insulin and glucose concentrations. The aim of the present study was to compare these indices with each other and with regard to their efficiency to differentiate between non-diseased and diabetic glucose tolerance states. METHODS: Oral glucose tolerance tests were performed in 301 subjects. The study group was divided into five groups according to WHO/American Diabetes Association (ADA) cut-off values: apparently normotolerant, diabetic, isolated 2-h post-challenge hyperglycemic, isolated fasting hyperglycemic and intermediate groups. The minimal error rate (diagnostic non-efficiency) indicating a misclassification of a diabetic tolerance state was determined for 12 indices. RESULTS: The error rate was lower than 15% for the index of Cederholm and Wibell and for the indices of Stumvoll et al. The misclassification rates for the other indices (index of Matsuda and de Fronzo, index of Myllynen et al., HOMA IR, HOMA beta-cell, FIRI, QUICKI, index of McAuley and insulinogenic index) were 20-27%; however, the diagnostic sensitivity was close to a 1:1 chance of a correct decision. The hypothesis that isolated post-prandial hyperglycemia (IPH) and isolated fasting hyperglycemia (IFH) differ in their insulin sensitivity and insulin response could not be supported by the present results. CONCLUSIONS: The indices of Cederholm and Wibell and of Stumvoll et al. were found to be appropriate as diagnostic indicators of the pathogenesis of diabetic glucose tolerance and were more closely related to the glucose tolerance state than the other indices.

Administration, Oral↗

PubMed1981

Task difficulty and aberrant behavior in severely handicapped students.

The influence of task difficulty on aberrant behavior was investigated with three severely handicapped students. Noticeably higher rates of problem behavior occurred in demand compared to no-demand conditions. In addition, there were higher rates of problem behaviors on difficult versus easy tasks. Both these findings were validated with visual discrimination and perceptual motor tasks. An errorless learning procedure effectively minimized errors and aberrant behavior in visual discrimination tasks but not in perceptual motor tasks. It was conceptualized that aberrant behavior was maintained by negative reinforcement contingencies. Difficult tasks were aversive to the children, who emitted aberrant responses to escape or avoid such tasks. By contrast, conditions in which no demands were made, easy tasks, and, in visual discrimination learning, errorless tasks, were less aversive and resulted in little or no problem behavior. Implications for reducing maladaptive behaviors through curricular modifications are discussed and contrasted to more traditional consequence manipulation approaches.

Achievement↗

PubMedDate not supplied

Design and performance of a dynaniic gas flux chamber.

Chambers are commonly used to measure the emission of many trace gases and chemicals from soil. An aerodynamic (flow through) chamber was designed and fabricated to accurately measure the surface flux of trace gases. Flow through the chamber was controlled with a small vacuum at the outlet. Due to the design using fans, a partition plate, and aerodynamic ends, air is forced to sweep parallel and uniform over the entire soil surface. A fraction of the air flowing inside the chamber is sampled in the outlet. The air velocity inside the chamber is controlled by fan speed and outlet suction flow rate. The chamber design resulted in a uniform distribution of air velocity at the soil surface. Steady state flux was attained within 5 min when the outlet air suction rate was 20 L/min or higher. For expected flux rates, the presence of the chamber did not affect the measured fluxes at outlet suction rates of around 20 L/min, except that the chamber caused some cooling of the surface in field experiments. Sensitive measurements of the pressure deficit across the soil layer in conjunction with measured fluxes in the source box and chamber outlet show that the outflow rate must be controlled carefully to minimize errors in the flux measurements. Both over- and underestimation of the fluxes are possible if the outlet flow rate is not controlled carefully. For this design, the chamber accurately measured steady flux at outlet air suction rates of approximately 20 L/min when the pressure deficit within the chamber with respect to the ambient atmosphere ranged between 0.46 and 0.79 Pa.

Air Movements↗

PubMed1999

Absolute quantitation of specific mRNAs in cell and tissue samples by comparative PCR.

A comparative PCR assay, for the absolute quantitation of specific mRNAs in cell and tissue samples, has been designed to overcome problems with previous techniques. cDNAs made from the RNAs are co-amplified with "competitor" plasmid templates under conditions in which reagents are not limiting at the equivalence point, thereby preventing competition between target and competitor templates and distinguishing the assay from competitive PCR assays. The cDNAs are serially diluted, and competitor templates concentrations are kept constant, rather than vice versa, as occurs in competitive PCR assays. Products from target and competitor templates are resolved by electrophoresis and measured by phosphorescent or fluorescent imagery. Both products are measured to minimize errors in the competitor:target ratio. A synthetic external standard RNA is included in the tissue lysis solution and co-purified with endogenous mRNAs, thereby being subjected to identical losses of yield during subsequent procedures. The determination of the number of copies of external standard cDNA allows inefficiencies of RNA extraction and cDNA synthesis to be taken into account. Standard concentrations of plasmids containing the endogenous target sequences are also measured, so that corrections can be made for discrepancies due to unequal amplification of target and competitor sequences. These corrections, together with the use of an external standard and the PCR conditions chosen, allow for the accurate, specific and sensitive determination of the absolute number of mRNA copies in a sample.

Animals↗

PubMed1995

Post-ischemia ERG recovery is influenced by temperature.

In experimental work on retinal ischemia and its medical management, we have been disturbed by the large variations in the electroetinogram (ERG) recovery of rabbit eyes subjected to similar degrees of ischemia. We investigated whether body temperature might be one of the critical factors. We studied pigmented Dutch rabbits that had been subjected to 60 min of ocular ischemia followed by 4 h of reperfusion at different body temperatures. Ischemia was produced by cannulating the anterior chamber and raising the intraocular pressure. Scotopic ERGs and rectal temperatures were recorded at regular intervals. Rabbits with a subnormal mean temperature of 35.5-37.7 degrees C throughout the experiment showed mean a- and b-wave recoveries of 131.52% and 107.68% of preischemic values after 4 h reperfusion. At temperatures between 37.8-38.9 degrees C, the a- and b-waves only recovered to 88.43% and 32.0% respectively. Even small degrees of cooling greatly enhanced post-ischemic ERG recovery. This may explain some of the variations in ERG recovery that have been reported in the literature. We suggest that body temperature should be tightly controlled between 37.8 and 38.9 degrees C during ischemia experiments to stabilize results and minimize errors in judging therapeutic effects. Retinal cooling may be a means to protect the retina against ischemic damage in clinical situations.

Animals↗

PubMed1982

Rehabilitation following brain damage: some neurophysiological mechanisms. A therapeutic approach based on theories of motor control.

Rehabilitation programmes concerned with functional recovery of patients with central nervous system (CNS) lesions may be in need of developing processes more consistent with prevailing concepts of motor control and of behavioural requirements by the CNS for motor learning. Both central and peripheral factors can play important roles in providing for finely orchestrated and relatively accurate learned motor performance. The relative influence of each of these factors on motor recovery is determined, in part, by the actions observed, i.e. control of body ("mid-line") and/or limb ("peripheral") position, by the interaction between two principal features of the control system, fixation (stability) and motion, by the inherent plasticity of structures, and by the ability of cerebral mechanisms to code, store and recall information with minimal error and time delay. A functional theory for governing spatial and temporal components of motor performance is presented; this is based upon three attributes: (a) attainment of control of fixation and motion of midline (eye-head-trunk) and peripheral structures in developmental order; (b) organization of serial fixation-motion steps in the guidance-manipulation functions of limbs, and (c) provision for coding spatial and temporal information related to both fixation and motion.

Central Nervous System Diseases↗

PubMed1982

Intracranial physiology and biomechanics. Clinical data on pressure-volume relationships and their interpretation.

The intracranial pressure-volume (PV) relationship was examined postoperatively after removal of brain tumors in two groups of patients (13 in all). Changes of ventricular fluid pressure were analyzed by a method involving fluid injection into the lateral ventricle. A technique has been developed which provides quantitative data on the PV relationship with minimal error. The results confirm the exponential nature of the PV relationships. Various parameters characterizing the intracranial volume compliance, the cerebrospinal fluid pressure, and their interrelationship were investigated. It was found that 1) intracranial PV dependence is accurately defined by three parameters; 2) in patients who are not critically ill delta P/ delta V at P = P mean does not vary statistically, and may be used as one of the important parameters to determine the regulation of the intracranial PV relationships. Examples are presented of the use of the data from the PV test for the control o the intracranial PV relationship. Examples are also given of the computation of volume redistribution in the cranium, both spontaneous and evoked by clinical tests. Analysis of the results allows the conclusion that the intracranial volume compliance concerned is an active compliance, which is controlled by the systems maintaining brain function.

Biomechanical Phenomena↗