Search results

The purpose of this paper is to evaluate the common themes leading or contributing to clinical incidents in a UK teaching hospital.

A root‐cause analysis was conducted on patient safety incidents. Commonly occurring root causes and contributing factors were collected and correlated with incident timing and severity.

In total, 65 root‐cause analyses were reviewed, highlighting 202 factors implicated in the clinical incidents and 69 categories were identified. The 14 most commonly occurring causes (encountered in four incidents or more) were examined as a key‐root or contributory cause. Incident timing was also analysed; common factors were encountered more frequently during out‐hours – occurring as contributory rather than a key‐root cause.

In total, 14 commonly occurring factors were identified to direct interventions that could prevent many clinical incidents. From these, an “Organisational Safety Checklist” was developed to involve departmental level clinicians to monitor practice.

This study demonstrates that comprehensively investigating incidents highlights common factors that can be addressed at a local level. Resilience against clinical incidents is low during out‐of‐hours periods, where factors such as lower staffing levels and poor service provision allows problems to escalate and become clinical incidents, which adds to the literature regarding out‐of‐hours care provision and should prove useful to those organising hospital services at departmental and management levels.

The aim of this paper is to generate a debate regarding the value of incident reporting in the UK.

This paper critiques the dominant approach to patients in the UK.

It is suggested that the reliability of health care processes would need to substantially improve before an incident reporting system can have a meaningful impact on patient safety.

Greater benefits in patient safety will be accrued by focusing resources on designing reliable processes rather than the extension of incident reporting.

This paper offers a local perspective on a potentially flawed national strategy.

The remarkable achievements being promoted through inclusive education practices make the deficiencies associated with educational exclusion all the more noticeable. Despite many schools adopting the philosophy of inclusion, avoidable educational exclusion of students with special needs still persists in educational systems worldwide. This is because the preparation of competent teachers to respond to variations in student populations in schools is very difficult to achieve. A major reason for this difficulty is that most student education programs fail to nurture collaborative instructional practice culture in student teachers, which can enable them to work well with others to teach all students. Utilizing the status, certainty, autonomy, relatedness, and fairness (SCARF) model developed by David Rock, this chapter contributes to existing knowledge on student teacher development by theorizing and offering practical ways to enact collaborative instructional practices in inclusive education. The chapter addresses this issue by reporting student teachers' experiences in a course unit on inclusive education in one Australian university that adopted a collaborative instructional practice, deepening their understanding and practice of inclusion.

This paper aims to examine the attitudes and experiences of information professionals with descriptive standards and collection management systems (CMSs) used for managing documentary heritage collections held by cultural heritage institutions in New Zealand (NZ). The aim is that such insights will inform decision-making around promoting documentary heritage collections discoverability and accessibility, in terms of advocating for appropriate system requirements when procuring or updating CMSs, and application of descriptive standards.

A qualitative design was applied to investigate the attitudes and experiences of information professionals working in libraries, archives and records management institutions, museums and public galleries. Data was collected through semi-structured interviews with thirteen participants who worked across ten different cultural heritage institutions.

The findings reveal that variances among metadata in libraries, museums, public galleries, archives and records management institutions continue to lead to challenges around discovery and access of documentary heritage. If opportunities for connecting documentary heritage collections in the age of linked data are to be realized, the sector needs to work collectively to address these variances along with consideration of the CMSs used. The study findings highlight issues currently affecting the NZ cultural heritage sector goal to make collections discoverable and more widely accessible.

The findings highlight a need for deeper research into CMSs used by the cultural heritage sector as these systems have an impact on metadata management including constraining the application of appropriate descriptive standards for documentary heritage collections.

This paper presents the outcomes of a study of the choice of location for distribution centres in logistics operations. A conceptual frame work of location selection for distribution centre is worked out through three main stages. At the first stage, a general geographical area for distribution centre is identified based on the Centre of Gravity principle, taking into consideration socio‐economic factors. The second stage of the selection process involves the identification of alternative locations for the distribution centre and the airports and seaports to be used for in bound and out bound cargo flows within the defined general geographical area. The third stage focuses on specific site selection among the identified alternative locations for the distribution centre based on the quantitative approach. This involves a mathematical model which aims to optimise either the total distribution cost or the integration of total distance transport with given relevant volumes of cargo. In order to illustrate the conceptual frame work, a case study of a logistics service provider will be provided. Data from the case study proved that the conceptual framework for selection is valid and can be of value to logistics companies in their operations and management.

Neuroscientific technologies have begun to change the ways in which we understand, respond to, and treat drug addiction. According to addiction researchers, neuroscience marks a new era because of its potential to locate the causes of addiction within the brain and to treat addiction through altering neurochemistry. However, little is known about how addiction neuroscience and new neurochemical treatments shape individuals' experience of addiction and constitute new arrangements of knowledge and power that shape subjectivity and governance. This chapter addresses these domains by drawing on an analysis of scientific literature about addiction neuroscience and qualitative interviews with people being treated for addiction with buprenorphine, a pharmaceutical treatment for opioid dependence. The chapter charts four major themes in the addiction neuroscience literature (pleasure and the limbic system, rationality and the role of the prefrontal cortex, theories of plasticity, and the role of volition) and explores how each of these is incorporated, adapted, or rejected by individuals being treated for addiction with a pharmaceutical. This analysis demonstrates how neuroscientific ideas are mediated by the lived experiences of those being treated under a neuroscientific model. It also suggests that while neuroscientific interventions, like pharmaceuticals, shape the experience of those being treated for addiction, so too do many other forces, including social circumstances, moral frameworks, the drive for autonomy, and the quest to be “normal.”

In considering the lager beer industry of Denmark it may not seem out of place to recall the main facts regarding the researches of E. C. Hansen. It is due to Hansen, a Dane, that the brewing industry throughout the world was placed on a scientific basis so far as the employment of pure yeast cultures is concerned. The brewing of lager beer had been for long successfully practised in certain European countries, notably in Germany. In a word what may be termed the mechanical technik was well understood, but a knowledge of the underlying biological principles so far as they related to the nature and action of the yeast employed had not advanced so far. The study of micro‐organisms in general had but just commenced. Their very existence in many cases was not even suspected. The employment of yeast in brewing practice was largely of the “hit and miss” kind, and continued to be so until fifty years ago. It is true, of course, that excellent beer was being made in this country and on the continent, both top and bottom fermentation kinds, as it had been for centuries past, but the power to control the nature of the beer by using a pure culture of a selected variety of yeast was not possible until Hansen had made his investigations and published the results in 1883.

HARDLY had the dispute at BL ended and the men had gone back to work amidst universal rejoicing (apart from the more militant of the shop stewards) than several hundred of them had to be sent back home, rightly on full pay, because of a plague of fleas that had invaded the factory. Talk about scratching for a living…!

In a recent issue of the Municipal Journal there appeared a short but apparently inspired article on the subject of London Government, in which is foreshadowed another drastic and apparently imminent alteration of the system of local administration at present in operation in the Metropolis.

Japanese organizations have been forced to re-evaluate their management systems in light of recent economic and competitive pressures. Much can be learned about the adjustments of the Japanese management mindset, and a more competitive Japan may emerge as a result of successful adaptation. This study makes a longitudinal examination of the dynamic nature of management practices and thinking in the Japanese banking industry. Pressures on key industries in Japan during this time, e.g. the financial sector, provide insight into how adaptable Japanese institutions might be. The study finds important areas of meaningful change, supporting a crossvergence approach.