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As the White House pushes for a proposal to renew a ban on military-style assault weapons, sales of such weapons and ammunition have surged.
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- Courier
- Interactive Tele-Journalism
- Local Report 2012
- Mobile Processing Libraries
- MoMA Android App
- NYU/ITP Course Syllabi
- ObscuraCam
- Participatory Media Research Projects at ITP
- Pro Android Media Book
- servi.js
- Video and Image Moblogging with a (video enabled) Camera Phone
- Whitman Local Report
- Whitman Local Report 2012
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delicious bookmarks
Category Archives: video blogging
Major League Baseball and the Live Web
Some time ago, I cut the cord.. disconnected from cable. Some time after that, I got rid of the antenna as well. I still watch television content, just not over the air or via cable; rather with a Mac Mini … Continue reading
Podcast Aggregation..
I was just looking through the feeds that I subscribe to in iTunes (audio and video podcasts) and noticed that every single one of them had a little exclamation point next to it indicating that it stopped updating as I … Continue reading
Posted in blogging, mobile, Streaming and Multi-Media, The Media, thoughts, Video, video blogging Tagged aggregation, audio, itunes, podcasting, podcasts, rocketboom, Video Leave a comment
Online Video Player Survey
For a project that I am working on, we are doing a quick survey to see what features and functionality people are interested in with regards to online video players. This doesn't pretend to be an exhaustive survey of the … Continue reading
Posted in ITP, Streaming and Multi-Media, Video, video blogging Leave a comment
ComVu – Mobile Broadcasting
Wow.. Steve Garfield just pointed me to: ComVu – Mobile Broadcasting . Live streaming from my mobile phone. This is something I have been looking for and/or contemplating developing for quite some time. What is especially nice is that they … Continue reading
Posted in Streaming and Multi-Media, telephony, Video, video blogging Leave a comment
more gumbo please at internet gumbo
"So, what is the roux of Internet video? What's going to make our soup into gumbo" more gumbo please at internet gumbo I for one am very much looking forward to the gumbo! Check it: vlogbot [ cardura 2mg pills … Continue reading
Posted in ITP, Streaming and Multi-Media, Video, video blogging Leave a comment

subset: commoncrawl


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the fluff off a bum
a fluffy bottom
laura simmons tarafından 4 Ekim 2003, Cumartesi
the fluff that gathers in your anus after a long day of sweating
dude you got bumfluff on your face
yar mudder tarafından 11 Haziran 2006, Pazar
In gaming terms, Bumfluff would be the term used for cheaters. People who are shite and need cheats so they can win.
2/7/03 16:27:36 (+Bumfluff) Vlad \o/
2/7/03 16:28:40 (@Vlad) fo you cheating cunt
2/7/03 16:28:40 (@Vlad) fo you cheating cunt
Cheese tarafından 2 Temmuz 2003, Çarşamba
Fluff from one's ass; usually blue.
"Dude, you got bumfluff on your face..."
-Mikey G- tarafından 12 Şubat 2003, Çarşamba


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The rise in cases of ADHD caught health officials off guard. But not parents, it comes up at children's schools, play grounds and whenever a group of moms and dads get together.
"It may just be a cause of today's technology with kids being in front of iPads and iPhones, tablets, whatever," says Kris Willing.
The CDC found 1 in 5 high school boys were diagnosed with attention deficit hyperactivity disorder. The number of overall cases is up 50% in the last decade.
"A lot of people think they can just spot a child and say 'oh that child is hyperactive.' That doesn't mean that child has a disorder," says Dr. Elena Reyes, clinical psychologist with Lee Memorial Health System.
Dr. Elena Reyes is director of behavioral medicine at the FSU family medicine residency program at Lee Memorial Health System. She believes there should be less focus on hyperactivity and more on attention deficit.
"The disorder is marked by the inattention. These children have a lot of difficulty with focusing their attention, they are very distractible, and they are very impulsive. So they get themselves in trouble a lot because they are sort of on the go without first stopping to filter," says Dr. Reyes.
A hallmark of ADHD is difficulty with executive functioning. Meaning a disabling lack of focus that gets in the way of performing everyday tasks.
"Just doing the basic things like, organize their breakfast, organize what you're going to wear to school today, what are the kinds of things you need in your back pack, what's your day going to look like," says Dr. Reyes.
A thorough evaluation should go into each diagnosis. It's not recommended before age seven.
"Then we are very cautious because we are trying to see what goes across different situations not just one situation," says Dr. Reyes.
Many experts and parents believe there could be a rush to judgment.
"Or people using it as a blanket diagnosis for something that may be another condition," says Willing.
But in real cases, ADHD is a real threat to a child's well being.
"The brain is an organ like the rest of the body and our neurotransmitters which allow for one brain cell to talk to the other, we know that there are some deficits there for children with attention deficit disorder," says Reyes.


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MEMPHIS - L.A. Armes, 79, died Thursday, April 1, 2004.
Services will be at 11 a.m. Saturday in Hughs Funeral Home Memorial Chapel with the Rev. Cliff Johnson officiating. Burial will be in Fairview Cemetery.
Mr. Armes was born April 10, 1924, in Wise County. He married Wilma Weyrick on Dec. 22, 1940, in Pettit.
Survivors include his wife; two daughters, Carolyn Morris of Memphis and Patricia Jolley of Phoenix; four grandchildren; and three great-grandchildren.
The family suggests memorials be to Fairview Cemetery Association, P.O. Box 265, Memphis, TX 79245.
Amarillo Globe-News, April 2, 2004
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With its refined silhouettes and thoughtfully designed curves, the Citterio 98 Flatware collection from Iittala is an excellent choice for everyday dining. Designed to comfortably hit in every hand, the Citterio utensils are considered contemporary classics. Crafted in matte-brushed stainless steel, each piece in the Citterio collection has a minimal, simple look that will complement casual breakfasts and formal dinners alike. Available in a five-piece place setting—dinner fork, knife, table spoon, dessert fork, and teaspoon—or a two-piece serving set, the Citterio 98 collection has a pleasant tactile experience that will be welcome at the dinner table.
Place Setting:
Dinner Fork: 7.75" L
Knife: 9" L
Table Spoon: 7.75" L
Dessert Fork: 7" L
Teaspoon: 6.5" L
Serving Set:
9.5" L x 1.75" W
Dishwasher Safe.
Antonio Citterio is a renowned contemporary designer. The Italian designer has created everything from modular sofas to bathroom fixtures to Vitra's industrial plant in Germany. Citterio also acts as a member of the Italian Design Council and works as a professor at the Università della Svizzera Italiana in Switzerland.
Founded in Iittala, Finland in 1881, Iittala first began as a glass factory. The company now celebrates generations of glassware objects including vases, dishes, and décor items, and maintains the tenet that objects should be distinctive, multifunctional, and enduring—both physically and aesthetically. Many renowned Scandinavian designers have designed for Iittala, including Kaj Franck, Alvar Aalto, and Oiva Toikka. Many of their most iconic designs including the Aalto Vase, Kartio glasses, and Kastehelmi dishware are still produced today.
Piano Flatware
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Consider a pendulum bob on a string attached to the ceiling. THe length of the pendulum is 1.00m. The bob is pulled off to the left, to a small angle with the vertical, and let go. The string is cut instantly by a razor blade at opposite end of the swing. The floor is 0.750m below the bob when the string is cut.
a) What is the bob's velocity when the string is cut. Explain.
b) determine the total amount of time from when the bob is first released, to when the bob hits the floor. (think of it in two parts: Before it is cut, it is simple pendulum. After it is cut, the bob is in freefall)
Thanks for your help, it is greatly appreciated!


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Nothing against green beer and bagels, well actually yes, everything against them -- they are disgusting. What exactly is wrong with various shades of pale yellow to deep brown for beer? And if a bagel is green, it usually means it's way past being edible.
These, however, are hardly tips of the hat – spare us the plastic green derbies, please – to Irish culture. With such a rich culture, what better way to honor it than reading some of its many magnificent writers?
Of course there is James Joyce and starting with "Dubliners" is a good way in. The stories are short and bring you right into Dublin of a century ago. There's Yates and Oscar Wilde, and if you have not delighted in their work, it is time.
A few years ago, I went on a kick reading modern Irish women writers. I stumbled upon an anthology and wound up reading all I could find by Marian Keyes and the late great Maeve Binchy.
Both women tap into the same characters in different novels, and we really get to know them. With Keyes it's the five Walsh sisters, all distinct, all familiar.
With Binchy it's been a series of characters over a lifetime. Binchy died in July, but had finished one last book, "A Week in Winter." It's set in an old stone house on the cliffs on the west coast of Ireland.
I'm yet to read her final novel, but thinking that reading Binchy, a shot of Tullamore Dew and with Black 47 in the background will make for a fine St. Patrick's Day and no green beer or moldy looking bagel will be involved.


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Northwest NEWS
pril 22, 2002
Stallion Hill Center celebrates grand opening
Staff photo
Stallion Hill Center celebrated its grand opening March 14 . Italianissimo catered the event and music was provided by F Street Project. Among those celebrating the opening were Marney Ayers, Woodinville Chamber; Martha Dankers, owner; Gaylen Sauve, Woodinville Chamber; Scott Hageman, Woodinville mayor; Larry and Pamela Stewart, Synergy Construction, Hans Dankers, owner.


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Remember Soweto
For many years, on June 16/Soweto Day, protesters confronted the apartheid South African government at embassies and consulates around the world.
Huge protests in Peru against profiteering
Social upheaval in Peru culminated July 13 with President Alan Garcia calling upon the armed forces to join 15,000 national police in attempting to quell nationwide protests organized by the General Confederation of Peruvian Workers.
Texans grapple with pollution, chemical hazards
TEXAS CITY, Texas — Members from at least 10 unions convened at United Steelworkers Local 13-1 here July 10 to discuss how air pollutants affect health and safety. They met with Dr. Jonathan B. Ward Jr., a national authority on environmental toxicology at the University of Texas.
Baseball honors the Say-Hey Kid
Hall of Famer and baseball legend Willie "the Say-Hey Kid" Mays was honored at the 2007 Major League Baseball All Star game on July 10, at the San Francisco Giants' waterfront ballpark.
Grab a book and read: PWW summer reading picks
PWW readers and correspondents sent in their favorite summer reading suggestions to share with you. Enjoy!
Why they migrate
It appears that none of the Republican presidential candidates have respect for the words on the Statue of Liberty, as all would take harsh measures against immigrants. It also seems that they are willing to ignore the damaging effects of the North American Free Trade Agreement, despite the defeat of nearly every Republican candidate in races last fall in which free trade and fair trade were issues.
JULY 21: Ask the Communists
After 1929, in the midst of the Great Depression, America still retained a capitalist system. Although certain socialist-type policies such as welfare were implemented, no sweeping changes were made in an economic system that could have easily been seen at the time as a total failure. Why do you think radical changes advocated by socialists and communists failed to come about during this period?
One citys action points to 2008
On July 24, the city of New Haven, Conn., will become the first in the country to issue a municipal identification card that can be used by anyone who lives in the city regardless of immigration status. The Elm City Residence Card can be used at city libraries and parks and for other city services, parking meters and banking.
LETTERS: July 21, 2007
Solidarity in India Arkansas priorities: public health or arrests? Skeptic's questions Who is to blame? HP rocks


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Several states are considering the legalization of physician-assisted suicide.
End-of-life advocacy groups, like Compassion and Choice, have been working to push the cause, especially as a large number of baby boomers are beginning to face end-of-life issues.
Legislation legalizing assisted suicide are being considered in Connecticut, Vermont, New Jersey, Kansas, Hawaii, and Massachusetts.
Bills related to the issue are being considered in New Hampshire, New York, Arizona, and Montana.
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Are you seeking answers in life? Are you hurting? Are you facing a difficult situation?
Find peace with God, discover more about God or send us your prayer request.
Call The 700 Club Prayer Center at 1 (800) 823-6053, 24 hours a day.
A caring friend will be there to pray with you in your time of need.
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Created in this Craftsy class
Piece, Patch, Quilt: Basic Quiltmaking Skills taught by Gail Kessler
Learn quiltmaking basics in this free class, presented by Olfa. From tools and fabric to quilting and binding, find out how to create four easy quilts!
Other projects made as part of this class:
QuiltingEmmalynn quilt
QuiltingIH Quilt For Farmer George
QuiltingJosie quilt
Offer some kudos...
Join the conversation...
Ask a question...
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Although my 'cutting' needs to improve. After making a few of these, this one so far made me very happy. Practice makes perfect?
02/04/2014 Flag
It is very smart of you to practice by making pot holders. Good job!
02/09/2014 Flag
Yahoo! Love this. You've even got a loop. Something I have yet to figure out.... :D
04/01/2014 Flag


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Cool Entertainment Center
2011 Ford F-150 XL
Crutchfield Customer Review (What's this?)
"Coolness Factor"
Build Quality
Ease of Use
Sound Quality
Great Entertainment Center. It has a radio with great sound, a CD player, DVD player and a backup camera view screen all in one. It also includes a remote control. All for this price. Ford wants $300+ for just a radio with a CD player. I have had it for a month and it works great. The only problem with it is that the touchscreen can be a bit touchy.
Pros: Radio works great, has great sound and receives lots of stations. Works well with backup camera. Plays DVD's well.
Cons: Touch screen can be a bit touchy to use; real buttons would be better, but I can't complain for the price!


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ADF 11 Course 12-16 January in The Netherlands
By Steven Davelaar on Dec 23, 2008
Oracle University just released the ADF 11 course, covering many new ADF 11 features.
I will be teaching this course from 12 to 16 january 2009 in De Meern, the Netherlands.
There are still seats available. For a list of course topics and registration, use this link.


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Governor fills out cabinet
Roscoe 'Ross' Taylor appointed secretary
January 9, 2013
Gov. Earl Ray Tomblin last week appointed Roscoe "Ross" Taylor as cabinet secretary of the West Virginia Department of Administration. Taylor has served as acting secretary since February 201....
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Driver charged
A man faces several theft-related charges for assisting in a burglary that occurred at the Turkey Hill convenience store, 276 Route 87, Fairfield Township, on July 2.
James G. Williams, 45, of 643 Elmira St., allegedly served as a getaway driver after an accomplice smashed through the glass door of the Turkey Hill and stole 30 cartons of cigarettes, state police said.
According to court papers, Williams was identified via surveillance footage and photos posted of him on a social networking website. He also was identified by the accomplice.
Following his recent arraigned before District Judge Gary W. Whiteman on charges of burglary, shoplifting and criminal mischief, Williams was committed to Lycoming County Prison in lieu of $50,000 bail.
Assault alleged
A Montgomery man faces charges for allegedly assaulting his wife and attempting to hit her with a car while intoxicated at Broad Street and Fairfield Drive in Fairfield Township, on Dec. 29, state police said.
Ronald Lee Boore Jr., 49, of 37 Brook St., Montgomery, recently was arraigned before District Judge Jerry C. Lepley on charges of simple assault, recklessly endangering another person, harassment, careless driving, driving without a license and driving under the influence of intoxicants. He was committed to Lycoming County Prison in lieu of $7,500 bail.
Boore allegedly punched his wife in the face several times after she had picked him up in her vehicle. When the two exited the vehicle, Boore allegedly "kicked her to the ground and pulled her back up by her hair," an affidavit said. Boore allegedly then took possession of the car and made his wife "feel as if he was attempting to strike her with the vehicle," police said.
Caregiver charged
A caregiver to a man with cerebral palsy is accused of stealing more than $1,300 from his client via three unauthorized ATM withdrawals from Jan. 1 to Feb. 6, state police said in an affidavit.
Christopher M. Camacho, 31, of 1321 Walnut St., Jersey Shore, allegedly used his wheelchair-bound client's charge card without the client's permission. Camacho had been a caregiver to the victim for over three years prior to the alleged offenses, police said.
He has been sent a summons to appear before District Judge Gary W. Whiteman for a preliminary hearing to face charges related to theft and access device fraud.
Shoplifting alleged
Carl A. Seitzer, 34, of 1421 McKee Road, Cogan Station, faces shoplifting charges for merchandise he allegedly stole from Weis Markets, 1916 Lycoming Creek Road, on Dec. 1 and 2, Old Lycoming Township Police said.
Video surveillance shows Seitzer using a self-checkout lane on the above dates, allegedly pretending to scan several items valued at $37 before walking out of the store without paying for them, police said.
He has been sent a summons to appear before District Judge James H. Sortman for a preliminary hearing to face charges related to shoplifting and receiving stolen property.
Man accused of theft
Dale E. Reeder Jr., 41, of 3735 Lycoming Creek Road, faces charges for allegedly stealing over $2,850 worth of property from Powerplant Technologies, 3010 Lycoming Creek Road, between Dec. 28 and Dec. 29, court papers said.
Reeder allegedly sold the steel products and parts for a power generator to Staiman's Recycling Corp., 201 Hepburn St., police said.
Following his recent arraignment before District Judge Jon E. Kemp on charges of theft and receiving stolen property, Reeder was committed to Lycoming County Prison in lieu of $75,000 bail.
Bad checks alleged
PENNSDALE - Thomas P. Potoski, 44, of 43 Fairway Drive, Exeter, is accused of submitting a bad check to Lezzer Lumber, 194 Chad Road, Muncy Township, on July 7, according to Muncy Township Police.
The check was written out for $6,095, police said.
Potoski has been sent a summons to appear before District Judge Jon E. Kemp on Jan. 10 for a preliminary hearing.
DUI charged
PICTURE ROCKS - Joshua Seth-Michael Yerger, 31, of 206 Laurel Run Road, is accused of driving to his residence while under the influence of alcohol and harassing his mother, state police said.
State police were dispatched to Yerger's home following a report from his mother that her son had driven home drunk causing an argument to ensue between the two during which Yerger allegedly broke his mother's reading glasses and cellphone as well as scratched her arm, police said in an affidavit.
Yerger was sent a summons to appear before District Judge Jon E. Kemp for a preliminary hearing to faces charges of DUI, harassment and criminal mischief.
Thefts alleged
MUNCY - A woman and her boyfriend are accused of stealing $1,110 worth of property from a residence in the borough on Nov. 5, police said.
Casey M. Stidfole, 22, of 10 Blue Jay Drive, Watsontown, and Holly L. Craig, 19, of 180 Heatherbrook Estates, Muncy, allegedly stole a flat screen TV, an Xbox 360 video game system, four Xbox games, two Xbox controllers and $60 from a home at 13 S. Main St., court papers said.
Stidfole and Craig were sent a summons to appear before District Judge Jon E. Kemp for a preliminary hearing on Jan. 10. They will face charges related to theft and conspiracy.


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Macbeth, a Carlsbad, CA-based footwear, apparel, and accessory
lifestyle brand, is proud to announce its third Studio Project
collaboration with Green Day bassist Mike Dirnt.
Dirnt has been rocking crowds around the world with his band, Green
Day, since 1987. With the release of the epic, award-winning album
"Dookie" in 1994, Green Day became one of the first punk rock bands to
capture the attention of the mainstream, and 2004's "American Idiot"
was an international sensation, selling over 15 million copies
worldwide, winning multiple Grammy Awards and spawning a Broadway
This third Studio Project from Dirnt will accompany Macbeth's Spring
2011 Collection, and like Dirnt's past collaborations, this one is also
fully vegan. Dirnt chose to outfit Macbeth's existing silhouette, The
Schubert, in a rugged military green upper, comprised of organic
cotton, PET (recycled plastic fibers) and a recycled polyester woven
material, while the black outsole consists of recycled rubber
components from tires. Additionally, the adhesive is a water-based,
synthetic, vegan glue.
Dirnt has chosen to donate his royalties from the collaboration to
The National Military Family Association's Operation Purple, a program
created to empower military children and their families to develop and
maintain healthy and connected relationships, in spite of the current
military environment. Created in 2004 to fill a need identified by
military parents to help them help their kids, Operation Purple
periodically sponsors camps that provide military kids with an
opportunity to have fun and make friends in an environment where they
are reminded that they are our nation's youngest heroes.
"I'm really excited to be teaming up with Macbeth for another Studio
Project," explains Dirnt. "Macbeth is a great company, producing
quality product in a conscious way, and I'm always happy to find a way
to lend a hand to great programs like Operation Purple."
More at Macbeth: HERE.


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|SMV, Crossing the Jordan strike deal for marketplace
Crossing the Jordan earlier this month finalized an agreement with the owners of the Sonoma Mountain Village to open the Sonoma Mountain Marketplace, a large collective of local merchants and vendors selling antiques, vendors selling new and used items, artisan hand-made products and much more.
In addition, there will an indoor and outdoor Certified Farmers Market.
The first phase of the project calls for more than 150 vendors inside of the bottom floor of the 200,000 sq. ft. main building at Sonoma Mountain Village with plans to move upstairs as the Marketplace grows. This offers an opportunity for local merchants to open "mini" businesses inside the street fair.
Crossing the Jordan expects to have the Marketplace up and running Aug. 9.
The Sonoma Mountain Marketplace will be open every single weekend, Saturday and Sunday from 10 a.m.-6 p.m., year round.
The 1900's Main Street theme will include live performances right in the middle of the market, creating a theme park-like experience. Sonoma Mountain Eats will offer healthy food choices while other food carts will include other sweet favorites such as kettle corn and cotton candy.
The Sonoma Mountain Village has over 3,300 parking spots and the design of the building along with the large courtyards and outdoor patio seating will allow for a dining and family entertaining experience.
Crossing the Jordan is a local non-profit in Sonoma County that houses and brings hope to women and children in the community seeking to transform their lives.
Crossing the Jordan serves women that were homeless, battered, struggling with addiction or human trafficked. Its 12-month Life Transformation Program is funded primarily through industries. The non-profit currently has more than 60 beds in the three facilities, three thrift stores and a textile recycling operation.
The Sonoma Mountain Marketplace hopes to create career opportunities for the graduates of its programs.
For more information, go to www.SonomaMountainMarketplace.com.


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The Kansas Health Foundation is an organization dedicated to improving the health of all Kansans. We do not receive taxpayer dollars or any kind of funding from the state or federal government. We do not solicit or accept donations. Our funding stems solely from an endowment created by the sale of Wesley Medical Center.
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UNFCCC Releases Workshop Report on Costs and Benefits of Adaptation Options
8 September 2010: The UNFCCC Secretariat has published the report (FCCC/SBSTA/2010/9) of the technical workshop on costs and benefits of adaptation options, organized under the Nairobi Work Programme (NWP) on impacts, vulnerability and adaptation to climate change.
The workshop was held in Madrid, Spain, from 22-24 June 2010. Discussions addressed methodologies for assessing costs and benefits of adaptation options and how these methodologies are applied in and across different sectors. Participants also considered the role of assessments in the overall adaptation planning and implementation cycle, in particular how assessments assist in identifying appropriate adaptation measures and practices and in avoiding maladaptation. The report includes a summary of recommendations and concludes with issues for follow-up and further consideration under the NWP. The report will be considered by the 33rd session of the Subsidiary Body for Scientific and Technological Advice (SBSTA). [The Workshop Report] [Climate Change Policy & Practice Story on the Workshop]


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|Home | About | Journals | Submit | Contact Us | Français
Objective. In addition to providing new capabilities, the introduction of technology in complex, sociotechnical systems, such as health care and aviation, can have unanticipated side effects on technical, social, and organizational dimensions. To identify potential accidents in the making, the authors looked for side effects from a natural experiment, the implementation of bar code medication administration (BCMA), a technology designed to reduce adverse drug events (ADEs).
Design. Cross-sectional observational study of medication passes before (21 hours of observation of 7 nurses at 1 hospital) and after (60 hours of observation of 26 nurses at 3 hospitals) BCMA implementation.
Measurements. Detailed, handwritten field notes of targeted ethnographic observations of in situ nurse–BCMA interactions were iteratively analyzed using process tracing and five conceptual frameworks.
Results. Ethnographic observations distilled into 67 nurse–BCMA interactions were classified into 12 categories. We identified five negative side effects after BCMA implementation: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences.
Conclusion. These side effects might create new paths to ADEs. We recommend design revisions, modification of organizational policies, and "best practices" training that could potentially minimize or eliminate these side effects before they contribute to adverse outcomes.
Reducing the risk of adverse drug events (ADEs) is a national priority.1 Adverse events related to medication errors are common, costly, and often preventable. The Harvard Medical Practice study found that 19% of adverse events were related to medications,2 a finding confirmed by the Colorado/Utah study of adverse events during hospitalization.3 Medication administration in the acute care inpatient setting is a complex system requiring coordination among physicians who order the medications, pharmacists who verify and dispense the medications, and nursing personnel who administer medications to the patients. In an analysis of 334 medication errors from 11 acute care wards, 39% of the problems were judged to occur during physician ordering, 12% during transcription and verification, 11% during pharmacy dispensing, and 38% during nursing administration.4
Computerized support systems are advocated to reduce the risk of ADEs at each of these stages in medication administration.5 These systems, including computerized physician order entry, automated dispensing systems, and bar code reconciliation, are believed to reduce reliance on memory, increase access to information, and increase compliance with "best practice" procedures.6 For example, Bates7 found an 86% decrease in intercepted serious medication errors associated with the introduction of a computerized order entry system in three medical units at a large urban hospital. Similarly, medication alerts,8 a bedside computerized prescribing critiquing system,9 a decision support system for antibiotic prescribing,10 and automated dispensing units integrated with information about a patient's medication profile11 were associated with improved prescribing outcomes or reduced medication errors.
The Veterans Health Administration (VA), one of the largest health care systems in the United States with 163 medical centers nationwide, is a leader in the use of medical informatics systems. Since 1996, the VA has used an integrated electronic database for patient clinical information, the Veterans Health Information Systems and Technology Architecture (VistA), which enables staff to access administration and demographic data in addition to radiology, laboratory, and pathology information from any computer on the network. In 1997, the VA implemented computerized order entry (CPRS),12 which is integrated with the VistA database. A Graphical User Interface (GUI) for CPRS was subsequently developed and implemented to replace the original command line interface.
Recently, the VA internally developed bar code medication administration (BCMA) software, based heavily on prototype software deployed at the Topeka VA medical center in 1995. With BCMA, patients wear bar-coded wristbands, and unit dose medications are bar-coded in the pharmacy before delivery to a patient's medication drawer. Nurses scan the patient's wristband to access up-to-date medication order data in BCMA, which was input into CPRS by physicians and verified in VistA by pharmacists. When the nurse scans a medication, it is automatically documented as administered at that time if the bar code number matches the number for a medication displayed on the primary BCMA screen. If there is a mismatch, whether it is a different medication, dose, form, or time, an immediate warning pops up as an alert box. Implementation of BCMA and associated hardware was mandated to be completed throughout the VA by 2000. The BCMA software is continuously revised by a national development team, including a second release planned for May of 2002 that is intended to better meet the needs of the Intensive Care Unit (ICU) setting, with expanding IV medication functionality and supporting documentation of STAT verbal orders prior to pharmacy verification.
Even with the most effective systems, the introduction of a new technology into a complex setting is never a panacea.13 In addition to providing new capabilities, new technologies have unanticipated side effects on technical, social, organizational, economic, cultural, and political dimensions of work.14 Kaplan15 and the Institute of Medicine report16 recommend a proactive approach to patient safety, including the injunction to "examine new technologies . . . for threats to safety and redesign them before accidents occur." Even as barcode-enabled point of care medication administration systems reduce the frequency of some failure modes,17–19 the transformation of the medication administration process creates new, potentially predictable paths to adverse drug events. We asked the question: What negative, unintended side effects, if any, resulted from the introduction of BCMA that might create new paths to ADEs? This paper describes negative, unanticipated side effects that were identified by targeted ethnographic observation prior to and following system implementation and have implications for system redesign that can be incorporated prior to the occurrence of adverse events.
Nurses access BCMA software using a laptop permanently fixed to a wheeled medication cart and linked by a wireless network to the VA's electronic databases. Data entered into BCMA via a bar code scanner are used to verify that the correct patient gets the ordered medications in the correct dose and route at the correct time. To identify the patient, the nurse logs into the BCMA software and scans a bar code representing the patient's identification number (ID) on his wristband. The computer then displays the medications that are "DUE," based on the time the wristband is scanned and information in the patient's active electronic record (Figure 1). As the bar code of each medication is scanned, if the information about the drug formulation matches the displayed information, the system automatically records the medication as administered by the nurse at the time of scanning. If the scanned information on the medication does not match, the nurse is alerted to the discrepancy by a pop-up dialog box. The nurse cannot override this alert but has the option of typing in a bar code number for either a patient's wristband or a medication in place of scanning. The scanning of bar coded wristbands is intended to reduce the risk of patients receiving medications intended for another. Scanning each medication barcode is intended to verify that the medication, dose, route, and administration time match what was ordered.
We observed medication administration on acute care and nursing home wards of three VA hospitals selected on the basis of BCMA implementation schedules and willingness to participate (Table 1). The hospitals varied in size from small (3000 acute care admission per year) to moderate (9000 admissions per year); hospitals 1 and 2 were university affiliated. In all hospitals at the time of observation, the same computerized physician order entry system (CPRS) had been used for at least 1 year before introduction of BCMA, and the mandated BCMA system had been in operational use on all three shifts for at least 1 month. During the observations in hospital 2, full documentation on the paper MAR was maintained in parallel with BCMA for the purpose of providing a backup system, whereas in the other two hospitals documentation was maintained solely in the BCMA software at the time of observation.
Sites selected hardware (scanners, ethernets, batteries, and computer terminals) from among nationally recommended options. Staff personnel were trained through national "train the trainer" workshops, manuals to direct local training, and conference calls with local experts describing the changes associated with software updates. All nurses received four hours of hands-on training as well as hardware and software maintenance support from Information Resource Management (IRM). This study did not examine training, on-site support, or hardware or physical ergonomic issues associated with local decisions.
Ethnographic observations before and after the natural experiment of introducing a new technology, BCMA, into a complex, sociotechnical setting were used to identify new paths to failure in the complex process of medication administration in the acute care inpatient setting. These observations were targeted in that data collection and analysis were guided by five conceptual frameworks from the human factors literature base20:
RPD is a model of expert decision making under uncertainty, in dynamic settings, and with high consequences for erroneous action.21 In contrast to the optimal decision making model, in which careful review of all relevant factors in series results in the selection of the "optimal" choice, the RPD model emphasizes that expert nurses make decisions about which medication to administer to which patient based on past experience by selecting an early workable option that trades off conflicting goals and uncertainties. Thus, for nurses administering medications, we were primed to observe (1) cues to assess the patient state and the identity of the patient and medications, (2) resolution of competing goals, and (3) strategies to reduce uncertainty.
Second, in human–computer interaction22 terms, medication administration is a task that requires the nurse to interact with a computerized system with automated features. Research on automation in aviation cockpits has revealed predictable failures, referred to as "automation surprises,"23 that occur when the automation initiates actions that are surprising to the human partner. The potential for automation surprises is increased when three factors converge:
During the observations, if a nurse was surprised by actions initiated by the BCMA software, we collected data about the action taken by the software, the displayed information, the nurse's interpretation of the automated action, the vulnerabilities to failure created by the inability to anticipate that action, and the outcome.
Third, workload is the perception of task demands by a human agent. It depends on performance criteria, task structure, task duration, and the complexity and variability of task demands, among other factors.24 In both aviation and anesthesiology, research finds predictable adaptations to reduce workload.25 From this research base, we anticipated strategies to reduce workload during peak times, including trading accuracy for speed, reducing performance criteria, shedding tasks, deferring tasks, and recruiting resources from other personnel, and noted when these strategies increased the vulnerability to ADEs.
Fourth, the introduction of computerized support systems is often coupled with increased adherence to organizational policies and procedures, increasing opportunities for authority—responsibility doublebind situations, researched primarily in military settings.26 When procedures are not applicable, practitioners must either deviate from the procedures to meet their goals, potentially increasing individual vulnerability to punitive or legal action, or follow the procedures, potentially increasing the vulnerability to undesirable outcomes. When observed nurses encountered authority-responsibility doublebind situations, we took detailed notes about their strategies to resolve the situations, including tailoring procedures, rote rule-following, covert work practices, or activities to reduce the risks of punitive action that might have undesirable effects.
The last conceptual framing is that medication administration is a distributed and cooperative activity conducted in a social setting. Successful coordination across distributed agents depends on a high level of mutual awareness, sometimes referred to as common ground. Common ground is defined as items that are shared among human agents, including knowledge, goals, frames of reference, and beliefs about the current and future state of affairs.27 When electronic systems replace paper-based systems, a commonly observed side effect is the degradation of coordination as a result of privatizing information that was previously publicly accessible (e.g., electronic flight strips28). For example, coordination between controllers of the London underground is aided by lighted fixed line diagram displays that are viewable and easily referenced by physical gesturing. Replacing this display with individual workstation displays degraded coordination by reducing the ability to use the display as a shared frame of reference.29 When a nurse was observed to be surprised by actions of other personnel, we interviewed opportunistically to see if design choices that reduce support for mutual awareness contributed to coordination breakdowns.
One observer (EP), trained in ethnographic field observations in complex settings,30 conducted all observations before and after BCMA implementation (Table 2). Each observation session lasted from one to seven hours and included observations during all parts of day, evening, and night shifts. To minimize the effect of observations on behavior, we informed the observed nurses that no one, including their nurse managers, would be provided with information that could trigger a punitive response since observations were de-identified for person, place, and time, and we did not collect demographic or medication error data. Prior to BCMA implementation, seven nurses were observed for a total of 21 hours during 10 medication passes at one hospital. Following BCMA implementation, 26 nurses were observed for a total of 60 hours during 23 medication passes at the three hospitals. We targeted timing of the observations to include observations immediately after implementation, after initial problems were resolved, and after the system was fully adopted into the workflow (ranging from 1 week to 13 months).
In addition, the same observer also watched computerized order entry (2 physicians, 2 hours) and order verification by inpatient pharmacists (5 pharmacists, 2 pharmacy technicians, 10 hours) at hospital 1. Twenty complementary interviews were conducted with practitioners, computer support personnel, and nurse managers from the three hospitals. The focus of the interviews was to elicit perceived barriers to intended system use and reactions to possible redesign, organizational, and training interventions to reduce side effects. Finally, critical decision method interviews31 about a "near-miss, wrong-patient" case were conducted with nurses, a nurse manager, and a pharmacist to understand why the nurse using the BCMA software did not detect a patient mismatch.
During the observations, we recorded time-stamped, detailed, handwritten field notes of verbal and physical behavior, targeted at the identification of negative, unanticipated side effects, as well as information captured in the electronic patient record.
The data were iteratively analyzed using the conceptual theoretical frameworks from the human factors literature to recognize and abstract emerging patterns (Figure 2). Process tracing protocols32 for all of the observations were created that detailed the activities, grouped into several broad categories. Particularly interesting interaction sequences were represented and analyzed as mini-cases. The mini-cases were then grouped by emerging themes, and supplementary data from the detailed notes based on the themes were collated. Finally, the themes were matched to similar patterns documented in other complex, high-consequence, sociotechnical domains along with design, organizational, or training strategies to reduce the side effects, when available.
Analysis of the process tracing protocols identified 67 unique mini-cases, which were exclusively grouped into 12 categories based on a prominent theme (Table 3).
Figure 3 provides an overview of a mini-case that has poor usability33 as a prominent theme. In this case, workload on an acute care ward was unexpectedly high as a result of unanticipated absences of staff and patient factors (a coworker's emergency absence in the middle of a shift, attendance of another staff member at a meeting, discharge of a patient "against medical advice," a new patient admitted from the emergency department with continuing chest pain). Using the computerized order entry system, a physician ordered two medications to be given immediately to treat the new patient's chest pain (without otherwise informing the nurse of the order, which used to be accomplished by a red color code on the outside of a paper chart before the implementation of computerized order entry but is now communicated less frequently other than through the written order because new orders cannot be highlighted in CPRS or BCMA). The nurse, anticipating that these medications would be ordered, looked in BCMA but found no cardiac medications (note that pending and discontinued medications are not displayed). He then looked in the order entry system and found two "pending" medications. The nurse borrowed and administered one of the two medications (taken from another patient's medication drawer) and waited for a less critical medication to arrive from pharmacy. He could not document the medication administration in BCMA since the medication was not yet displayed (medications need to first be ordered by physicians and then verified by pharmacists prior to display), and only displayed medications could be documented as administered with the observed version of BCMA. The nurse then turned his attention to preparing another patient for discharge. When the nurse later documented the medication administration, the administration time was automatically documented as the time the medication was scanned, several hours after it was administered. This time was not changed to reflect the actual administration time, partly because changing medication administration times required a long, confusing sequence of activities in a separate, command line interface. Poor usability was a prominent theme in this mini-case. It was difficult for the nurse to accomplish his goals in this nonroutine situation because (1) pending and discontinued medication orders were not displayed, (2) medications that were not displayed could not be documented as administered, (3) it was not possible to see changes to medication orders without first opening a patient record, (4) it was difficult to "undo" actions, and (5) it was difficult to revise database information after it had been entered.
To illustrate the next step of the process-tracing analysis, several elements in this mini-case were re-represented in more abstract, less domain-specific terminology that points to concepts drawn from the human factors literature. First, nursing expertise was brought to bear in ways that resulted in deviations from a "procedural" model of medication administration: rotely and sequentially administering medications displayed on an interface to a series of patients during a "medication pass."34 For example, knowledge and assessment of the risk of ischemic complications were used to anticipate two pending medication orders and prioritize administering one medication over other tasks. Second, a goal conflict resulted in "violation" of a "best practice" procedure.35 In this case, the goal of following the "best practice" procedure of having a pharmacist verify a medication ordered by a physician prior to administration (to increase order accuracy and decrease the possibility of allergic reactions or interactions with other medications, among other reasons) conflicted with the goal of intervening as quickly as possible to reduce cardiac risk, including the potential for a code. Third, in choosing to meet performance (medical) goals, an authority-responsibility doublebind situation occurred, in which the nurse felt the responsibility to act without having the authority to document the action.36 As a result, the medication was documented at a different time from when it was administered, which could be viewed as a covert work practice. Fourth, the dynamics of the workload distribution encouraged task prioritization strategies of delaying documentation until after a high-tempo period.37 When there was difficulty in documenting information, either because the automatically generated data was incorrect or because medications were not displayed, the nurses moved on rather than take the time to ensure accurate documentation at that moment. Finally, system design choices created the potential for coordination breakdowns.38 The reliance of the physician on BCMA to communicate a new, high-priority order for imminent administration could be viewed as a poor strategy, even though there was no adverse outcome due to the nurse's anticipation of the order, because the software was not designed to actively highlight priority or new medication orders. In addition, the difficulty in correcting the difference between the actual and documented medication administration time could enable physicians, pharmacists, or other nurses to make incorrect inferences based on the data. For example, a nurse on the next shift could delay medication administration. Similarly, the inability to document administration of medications not displayed creates the potential for coordination breakdowns between multiple nurses (e.g., a covering RN could administer medications that have already been given) and physicians (e.g., a physician might unnecessarily increase the dose of a medication if he bases his inferences on an inaccurate administration time).
Following similar re-representations of each mini-case based on the conceptual frameworks and guided by insights from the interviews, the data were analyzed for recurring patterns across the cases. This iterative top-down and bottom-up data analysis revealed five negative, unanticipated side effects following the introduction of BCMA:
There were four cases in which nurses expressed surprise at automated actions initiated by the BCMA software, which is the stereotypic reaction to a classic breakdown in human–computer interaction, referred to as an "automation surprise."39 Two cases involved IV medications that were automatically dropped from the medication list a number of hours after the scheduled administration time. One was a chemotherapy medication whose administration was delayed due to lack of an IV site, and another was a patient who received Ativan late because he was off the ward for several hours. In another case, a nurse was surprised that an antibiotic was not available as a result of an automatic stop order. In all of these cases, the nurses detected that the automatically removed medications were intended to be given and eventually administered them, but their surprise indicated that their expectation that the medication would be displayed in BCMA was violated, and they reported that this design decision created a new potential path to missed medications.
A side effect of replacing the paper medication administration record (MAR) with BCMA appears to be degraded coordination between nurses and physicians. During the observations, numerous coordination breakdowns occurred between nurses and physicians, some of which might not have occurred with the previous paper-based system. Prior to BCMA, physicians were observed to have quick access at the bedside to current medication administration information and nurses had immediate access to information about pending and discontinued orders on their paper MAR. Immediately after BCMA implementation, most physicians were not aware of how to access medication administration information, and the display was restricted to fixed 7-day window (Saturday to Sunday). Although the CPRS software was subsequently updated to provide physicians with increased access to BCMA data, in a focus group conducted October 26, 2001, seven of seven residents stated that they did not systematically look at a patient's medication orders in BCMA unless a question was asked because it is a time-intensive process. In comparison, they estimated that with a paper-based system at another hospital, they reviewed the medication orders for each patient an average of 3 times/week.
Degraded coordination between nurses and physicians can lead to predictable new paths to adverse events, including failing to detect erroneous medication orders, verifications, or administrations, failing to renew automatically discontinued medications, failing to prioritize a STAT medication order over other activities, or failing to explain why laboratory values are unusually high or low for an at-risk patient.
Nurses at all three hospitals consistently used strategies to increase efficiency that circumvented the intended use of BCMA (Table 4). For example, we observed that all nurses typed in at least one patient identification number rather than scanning the wristband barcode.
Before the introduction of BCMA, system developers predicted that an additional benefit of the system would be improved documentation efficiency through scanning barcodes rather than typing information.40 Nurses felt that there were efficiency benefits only when scanning was consistently reliable, when there were no deviations from routine actions such as refused medications, and when paper-based systems were not used for parallel documentation. In addition, barcodes are normally scanned during busy, high workload periods. This characteristic works against the commonly observed strategy in event-driven, high-consequence domains, such as take-offs in aviation, to free mental and physical resources during busy periods by shifting other tasks to less busy periods.41
Scanning wristbands to identify patients was dropped more frequently than scanning medication barcodes, a finding also reported in a study of a different barcode-enabled point of care system in a private institution.42 A variety of factors might explain this finding. Obvious factors include that wristband barcodes did not scan as reliably as medication barcodes43 and that wristbands could not be scanned in some cases (e.g., isolation patients, patients who removed wristbands because of swollen limbs or discomfort, particularly in long-term care).44 In addition, nurses uniformly believed that typing in a 7-digit number took less time than wheeling a large medication cart into a room and scanning a wristband. In addition to these factors, there were also more subtle barriers to scanning wristbands. Most nurses tried to avoid disturbing sleeping patients, particularly if they anticipated that a patient had no oral medications during the medication pass. They tried to minimize interrupting discussions between patients, family, and health care practitioners. In addition, several nurses explained that they employed strategies to reduce distractions during medication preparation in order to better detect inaccurate medication orders. When they scanned the patient wristband, patients often distracted the nurse by requesting an action or information.45 Finally, several nurses expressed concern that other nurses or physicians would log them out of BCMA if they left the computer console.
Shortly after BCMA implementation, many nurses stated that they felt timeliness of medication administration was greatly increased in priority. Similarly, nurses at every hospital were observed to be anxious when required to type an explanation for late medications, generally 30 minutes before and 60 minutes after the scheduled administration time. In addition, several nurses stated that they were concerned that analyses of timeliness of medication administration by individual nurses would be much easier to do with the electronic data than with handwritten data. Further research is needed to understand how an increase in emphasis on timely medication administration affects decision tradeoffs during goal conflicts. One nurse stated that she believed that nurses would be more likely to delay other activities during the medication pass that should not be delayed in order to ensure timely medication administration. Figure 4 depicts interruptions that were acted on during medication administration on a chemotherapy ward before BCMA implementation, including fixing restraints on a patient at risk of falling.
Computerized systems, such as BCMA, are often effective at streamlining routine operations, making the system both more efficient and easier to anticipate others' actions and detect erroneous actions. A frequent tradeoff from streamlining routine operations is that non-routine sequences of activity become more difficult to perform. For example, prior to BCMA, although there was no "taper dose" feature in the computerized order entry system, a physician could enter a description in a text box at the bottom of a single order (e.g., prednisone taper: start at 60 mg decrease 10 milligrams every other day until at 10 mg, then decrease to 5 mg for 2 days). Prior to BCMA, one pharmacist estimated that he would verify a taper dose order in less than 1 minute and pass the free text note on to nursing personnel. After the introduction of BCMA, a pharmacist, in order to create the order in a scannable format, was observed to take 17 minutes to break a taper dose order into daily orders at the exact dose, a total of 14 new orders, and discontinue the original order. In addition, the pharmacist expressed the hope that the physician would not rewrite the order in the original format, as the observed pharmacist explained had occurred in the past when a physician did not understand why the order had been changed. Although a taper order is a specific example of an issue that can be resolved through software enhancements, it illustrates the observed pattern of decreased flexibility when machine algorithms critique human actions, because the "vocabulary" used in communicating with a machine is restricted. When the format is not well known or cumbersome to the practitioner, decreased flexibility might lead to new vulnerabilities and the reduced ability to detect erroneous actions.
One of the greatest challenges with BCMA is how to support flexibility in the event that the system goes down, either for scheduled maintenance or because of an unexpected loss of power. There appears to be great variability in how institutions have adapted BCMA to enable flexibility given the potentially high consequences of being unprepared for the infrequent but predictable eventuality of loss of power. For example, these adaptations have followed the introduction of BCMA in several hospitals in order to provide a backup system:
Bar coding is advocated as a technology to reduce errors in several health care settings.46 To improve proactively the effectiveness of the BCMA system in the Veteran's Health Administration, we identified five negative, unintended side effects with the potential to create predictable new paths to ADEs: (1) nurses confused by automated removal of medications by BCMA, (2) degraded coordination between nurses and physicians, (3) nurses dropping activities to reduce workload during busy periods, (4) increased prioritization of monitored activities during goal conflicts, and (5) decreased ability to deviate from routine sequences.
None of these side effects is inherent in barcode-enabled point of care technology. It is likely that design revisions, modification of organizational policies, and "best practices" training can proactively reduce each of these side effects before accidents occur. "Automation surprises," for example, are known to result from automated actions that are "strong" in that they occur without immediately preceding direction from a user combined with weak feedback about past and future automation activities. The automation can be made less "strong," such as by eliminating automated removal of medications without prior approval from the human partner or by providing the capability for users to restore automatically dropped medications. Alternatively, increasing the feedback about automated actions, such as by displaying a "grayed out" medication to indicate that it was removed from the display, would make it easier for users to be aware of the change. Cooperative solutions, such as using pharmacy personnel to remind physicians when orders have been automatically discontinued, could also be explored.
A primary contributor to the degraded coordination between the nurses and physicians appears to be the loss of quick, coded communication via artifacts that can be viewed "at a glance." This functionality could be designed into BCMA or other software. Specifically, "longshot visualizations"47 could be designed that would allow both nurses and physicians to see at a glance when medication orders have changed for multiple patients on a ward, similar to the functionality provided by circular color codes on patient paper charts representing STAT, discontinued, new order, and no change. In addition, the medication administration history window could be redesigned to allow physicians to quickly scan, search, and review medication orders for multiple patients. Similarly, nurses could be provided quicker access to pending and discontinued medication information to make it easier to anticipate orders and detect erroneous actions. Finally, strategies adapted to the paper MAR that had side benefits for coordination, such as "flagging" pages to remember to do an action (that could then be seen by others who looked at the paper MAR), could be supported in BCMA. Design changes to improve coordination can generally be characterized as increasing the "openness" of the workspace, meaning to increase the ability for health care practitioners to be aware of activities being conducted by others. "Open workspaces" have been shown to improve anticipation, synchronization of activities, detection of erroneous actions, and other forms of coordination.48
System redesign and best practices can also reduce workload burdens to make it less likely that nurses circumvent the system during busy periods as an adaptation to increase efficiency. Circumventing the system will predictably lead to increased vulnerabilities to mis-identification of patients and medications as well as inaccurate administration data. Obvious strategies to reduce workload, such as decreasing staff/patient ratios, might not always be possible, given the national nursing shortage and increased acuity of hospitalized patients. Alternatively, eliminating unnecessary steps or shifting data entry to lower intensity times could reduce the workload burden. For example, rather than typing the same reason for every late medication for a patient off the ward, data entry might be batched or a default entry provided. In addition, improving the interface usability would decrease workload, such as by making it possible to document refused medications without exiting the system.49 Finally, the system could be designed to better fit the natural workflow of providing patient care. For example, wristbands for patients could be scanned after medications have been prepared to minimize interaction between the nurse and patient during medication preparation, particularly when patients are sleeping or prone to interrupt the nurses.
The perception of increased emphasis on timely medication administration will likely drift over time based on how organizations respond to medication administration data. If an organization builds incentive rewards based on medication administration timeliness or punishes individual nurses for taking more time than others, the perception will be reinforced. If an organization clearly communicates that timeliness is a lower priority than other goals, such as reducing patient falls, and restricts access to the time data, the perception will be reduced. Although the organizational context is likely to be the most important contributor to perception of timeliness as a priority, redesign of BCMA might reduce this side effect. Medications that are particularly important to administer at the intended time could be distinguished from others on the display. Dialog boxes that require documentation of why a medication is late could be eliminated. Parameters defining "on-time" medication administration could be enlarged.
Finally, the system could be redesigned to allow an increased ability to deviate from a idealized workflow. As specific deviations are identified, features can be designed to support them, such as by creating a "taper dose" order feature in the computerized order entry system. In addition, flexibility can be increased through generic features such as free text fields, "undo," "drag and drop," "select," "copy and paste," and "batch." Flexibility can also be increased by allowing tailoring of options available in dialog boxes, making it easier to revise administration time data and document changes in status from "given" to "refused" or "held." Finally, features could be added to support the ability to write "free text" information-only notes to document administration of medication orders not viewed on the screen.
It is not surprising that negative side effects were identified after the implementation of BCMA. It is axiomatic that technology change has far-reaching impacts on the way in which work is conducted in a field of practice, even with the most successful technologies.50 In opposition to the view that a change in medium (e.g., computerized order entry instead of handwritten prescriptions) can be introduced without greatly altering complex systems embedded in social settings, we believe that little of the former roles, strategies, and paths to failure are preserved across the technology change boundary.51
This study illustrates how targeted observational studies before and after naturally occurring points of change can be used to better understand processes of transformation and adaptation.52 The points of change form natural experiments where a change, the new technology, disturbs a system. Observers calibrated to patterns in human-machine performance watch how the system re-settles into a new equilibrium state. The point-of-change provides opportunities to learn how the system actually functions and sometimes malfunctions by observing how practitioners accommodate and adapt to the technology change. The system is examined to see how the technology transforms roles, judgments, and coordination, as well as how people adapt to the mix of new capabilities and new complexities. This information provides insight for organizational, design, and training post-conditions to make the system more useful and reduce unintended, negative side effects from the change.
In addition, observing at points of change can add to the knowledge base of how changes impact cognition and collaboration in a way that uniquely reveals the complex, inner workings of human-human interactions with a "black box" of technology. This knowledge enables better advance predictions of the effects of a change, especially side effects such as new complexities and vulnerabilities. It also serves as a stimulus to envision alternative design concepts. Armed with this knowledge, we can find higher leverage points for change and develop new concepts for support. If we can better anticipate the reverberations of new technology prior to the process of change, new directions can be pursued when intervention is less difficult and costly.
This study has several limitations. Our objective was to identify proactively negative side effects prior to the occurrence of adverse events. The study was not designed to evaluate the effectiveness of BCMA in reducing the frequency of predefined failure modes at the three participating hospitals or to identify beneficial side effects, such as more efficient and accurate requests for missing medications from pharmacy. Because our findings, as in any analysis of complex, interacting, multifaceted field data, depend on our conceptual frameworks, we likely did not find all side effects. For example, the introduction of BCMA might have impacted institutional views of accountability for adverse drug events. In addition, we observed primarily on acute care wards and nursing homes at three institutions, and it is unclear how these findings would generalize to other settings, such as intensive care units (ICUs) or institutions without 24-hour access to pharmacy. In addition, the ability to generalize these findings to other bar coding applications, such as software designed for the clinical laboratory or blood banking, remains a question to be addressed by future research.
Side effects following the introduction of BCMA were observed that might create new paths to ADEs. These side effects have implications for system redesign, modification of organizational policies, and "best practices" training that might be implemented before the occurrence of adverse events. Investigation of the natural experiment of implementation of new technology can forestall potential accidents in the making by identifying new sources of hazard and developing system redesign, organizational or training initiatives to protect against them.
We thank the BCMA development team, led by Mr. Richard Singer, for their hard work and willingness to collaborate to improve the software design, James Bagian, MD, for sharing his knowledge of vulnerabilities with the use of BCMA; David Woods, Ph.D., for sharing findings on research on side effects of technology change; Steve Sawyer, PhD, for reviewing the paper; and Denis Coelho, Ph.D., for conducting pilot research.
This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (Project no. SAF 20-049). The views expressed in this article are those of the authors and do not necessarily represent the view of the Department of Veterans Affairs.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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What would happen to your bird if something happened to you? Do you ever plan to retire? Will you and your pet birds have sufficient resources for the future? We already consider our birds members of the family, so we should also factor them into our financial plans to secure their future without us.
Patricia Drago, a nationally certified retirement specialist based on Long Island, New York, suggested planning from the perspective of a parent rather than an owner. "Pets are like perpetual children. They're never going to grow up and move away. You plan for retirement for yourself, but when you have pets, you have to be sure that you have enough of a nest egg to support their everyday needs, such as food, toys, housing and other incidentals. Veterinary care is expensive. With birds, especially the long-lived species, it's a long-term commitment."
Find someone willing to take your pets if you die or be the guardian if you become incapacitated. Discuss it with the people involved first, then set aside some money to defray the costs they'll incur.
Drago suggested going with an Individual Retirement Account (IRA) for a conservative savings plan. "The beneficiary can be a trust you've set up to take care of your bird," said Drago. "You can fund the IRA for as little as $25 a month. This is a great way to go, especially if you're young because the IRA will presumably have a long time to grow."An IRA offers benefits specially set aside for your bird and its future caretaker. "You want to be specific about this money you put aside for the bird's care," said Drago. "Create a separate fund for the bird in the eventuality that you predecease your parrot, apart from anything you've set up for family members. You may not be able to contribute as much as you'd like to your bird's fund, but whatever it is will help defray eventual costs."
"High- and mid-level investors may wish to consider funding the trust with an annuity," Drago added. "Put the annuity within the trust, and designate it for the care of your bird. You can often fund an annuity or a financial contract with specifically set payments as you go. Again, consult your attorney for specific advice."
Why Plan Ahead?The law considers pets personal property. Ownership of the pet will pass to the heir by probate or intestacy, but the heir might not be the person the owner would have chosen to care for a beloved pet. According to New York attorney Halan Freilicher, if something happens to the owner and he or she has not specifically provided for the pet in a will or trust, the law will not distinguish between the pet and the owner's alarm clock.
A parrot might be traumatized by the sudden loss of an owner, and if the court doesn't settle the ownership issue for months, the parrot may be forced to deal with another separation shock just as things were settling down.
Now that you've decided which investment plan is best for you and your bird, how much money will your bird require? BIRD TALK magazine reader Terri Pakula of New York established the amount she put in trust for her birds by first estimating how much she spends on each bird per year. She then multiplied the amount by each bird's life expectancy and factored in veterinary and new cage expenses.
You know your finances best. Start tracking your monthly bird spending now, so you can calculate an annual figure. Be honest about your expenditures. Now's not the time to pretend you didn't buy five toys this month!
Will Vs. TrustThe difference between a will and a trust is that a will is basically a set of instructions, which is implemented by a death, Freilicher explained. A trust is a legal entity that holds, maintains and disposes of property over time. A trust can be implemented any time, even while the person is still alive. A will provides for the one-time distribution of a person's property. A trust is an ongoing enterprise. Some states, such Alaska, Florida and New York, allow setting up trusts for the care of pets.
"With a will, you can leave your pet to a chosen person after you die, and leave that same person money which you ask him or her to use to take care of your pet," said New York attorney Halan Freilicher. "With a trust, you can choose a person to take care of your pet any time you become incapacitated, and then set aside money that can only be used for the benefit of that pet. You can even specify the brands of pet food that may be bought with funds from the trust."
The simplest way is to have an attorney set it up. Find an attorney whose practice includes estate planning to set up a trust for your pet. Before you set the initial appointment, ask specifically whether the attorney is familiar with setting up trusts for the benefit of an animal."
In the event that you suddenly become incapable of taking care of your bird, your trust will go into effect. Make sure someone you trust has the key to your home and knows how to take care of your pet. Keep that person's contact information in your wallet. Give the person's contact information to whomever the authorities are most likely to call if anything happens to you, and consider posting the person's contact information on your refrigerator as a part of your list of emergency phone numbers. Check with your local fire department and see if they have a pet registry.
Trust Advantages
*Content generated by our loyal visitors, which includes comments and club postings, is free of constraints from our editors' red pens, and therefore not governed by I-5 Publishing, LLC's Gold Standard Quality Content, but instead allowed to follow the free form expression necessary for quick, inspired and spontaneous communication.
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John Busby is author of 'The Busby Report - A National Plan For Survival in the 21st Century' - a starting point for many in the UK who come across Peak Oil. The report considers the measures to be taken to ensure the survival of the United Kingdom in a new century during which the worlds oil will run out. It is available at www.after-oil.co.uk
In the following report, John Busby looks at why nuclear power, cited by many as an important mitigation tool for global warming and peak oil, just is not the answer.
Why nuclear power is not the answer to global warming
1. Introduction
Although not every scientist agrees, emissions of carbon dioxide from the combustion of fossil fuels, mostly petroleum, natural gas and coal are considered to be a major factor in causing the onset of global warming. Unacceptable rises in temperature are leading to rising sea levels from the melting of polar ice and corresponding climate changes may effect plant and animal life in otherwise temperate zones.
Technological advances reduce the growth in energy demand to around 1% below the rate of economic growth, but the worlds demand for energy is expected to continue to rise exponentially, particularly in respect to emerging economies such as China and India. What is desired is a number of renewable sources of energy, not limited by resource depletion (as is the case with fossil fuels) that are "clean" in that they emit little or no so-called "greenhouse gases". Renewable sources include wind and sea current power, but nuclear power, which is purported to meet both criteria, must be excluded, as it does not fulfil either.
2. Could all our energy be supplied by nuclear power?
Before considering alternative sources, it is necessary to understand the size of the problem by examining current global energy consumption. Energy units exhibit little uniformity, but the joule can be used as a universally acceptable basis for analysis. Big numbers have to be employed to express global energy parameters, i.e., the exajoule (joule x 1018) and the petajoule (joule x 1015), abbreviated as EJ and PJ respectively. The worlds energy consumption in 2003 was 409 EJ, of which fossil fuels provided 90% as primary energy. Of this 60 EJ was in the form of electrical energy, with only 10 EJ of it provided by nuclear generation.
If not restrained by uranium supply problems, nuclear power could in theory substitute for gas and coal for all the worlds electricity generation, but electricity is not readily adaptable for mobile transport.
Transport constrained to fixed guide systems, such as rail and tramways can use electrical energy directly from current collectors, but mobile transport able to move on roads or rough terrain uses mostly liquid fuels derived from oil. As oil reserves deplete, liquid fuels will be synthesised increasingly from natural gas and then coal, until all fossil fuels able to be economically extracted are exhausted.
To use electrical energy as an alternative to conventional liquid fuels for mobile transport requires the production of hydrogen from electrolysis and its subsequent cryogenic liquefaction for on-vehicle storage. This has an inherent energy penalty over the derivatives of primary fuels and of course, unless the electricity used to produce the hydrogen fuel is from a renewable and "clean" source, offers no panacea to global warming. Assuming mobile transport requires 40% of global energy and taking into account the energy loss in conversion, the requirement for global electrical generation rises from 409 EJ to 700 EJ. The problem is that electrical energy of whatever means of generation is a poor substitute for the adaptable primary energy obtained from fossil fuels.
Assuming world economic growth of 3%/annum, with growth in energy requirements 1% less, extrapolating from 2003 to 2020, increases the energy requirement to 980 EJ.
A typical 1200 MW nuclear power plant produces 32 PJ per annum, so to provide for 700 EJ around 22,000 nuclear power stations would have to be built. To provide for 980 EJ would require 30,000 stations, each requiring 200 tonnes/annum of uranium fuel. To fuel this number of stations, around 6,000,000 tonnes/annum of uranium production would be required.
Current world annual mine production totals only 36,000 tonnes/annum of which only Canada and Australia produce ore of a high grade at around 10,000 tonnes and 8,000 tonnes resp. The balance of 30,000 tonnes required to meet the 2003 nuclear generators demand for 66,000 tonnes/annum came from inventories, ex-weapons material, MOX and re-worked mine tailings. This secondary uranium supply is due to run out within a decade, so primary production would have to be increased 167-fold to match the anticipated global energy needs exclusively from nuclear power in 2020. *
From the above projections it is clear that nuclear power has no chance of matching the coming energy deficit by supplying the needs of an equivalent hydrogen economy to that currently sustained by fossil fuels. Even if there was sufficient uranium to fuel it, the building of a parc of 30,000 nuclear power stations would be an impossible prospect. The processing and sequestering of the consequential enormous volume of radioactive waste would be also be an impossible task.
3. Can the worlds electrical energy be supplied by nuclear power?
An MIT team ** have produced a more modest plan for the building of 1500 power stations of 1 GWe generation capacity by 2050. They calculate that an anticipated global total electricity consumption of 39,000 GWh from now to then can be matched by such a programme. But they assume a total uranium consumption for their scenario of 17,000,000 tonnes. In 2050 mining production to match demand would be 340,000 tonnes/annum, which would require a 9-fold increase in current production rates.
Uranium reserves of ore of a sufficiently high grade (see below for a definition of this) are estimated at only 3,500,000 tonnes. So to get round this difficulty, MIT compute that the reserves can be expanded to suit the requirement by progressive increases in the uranium price. They consider that ore deposits of grades between 0.001% and 0.03% would hold 22,000,000 tonnes of uranium and would be viable at increased uranium prices without unacceptable consequent rises in the electricity price. However, with the processing of these low ore grades there is a yield loss and larger energy inputs, leading to a negative energy gain in the overall nuclear fuel cycle.
In 2050 when the 1500 reactors are in service, if the required 340,000 tonnes/annum of uranium were to be extracted from the best of the low grade ores, i.e., 0.03%, with an optimistic yield of 50%, the mining of 2.3 billion tonnes of rock, plus the removal of the over-burden would be needed every year. Assuming that by 2050 the best of the ores has been taken, to extract the same from the lowest remaining, i.e. 0.001%, the yield would be even lower at say 10% and the production of 340,000 tonnes of uranium would require the mining of 340 billion tonnes of ore, plus the overburden.
The scale of such inconceivable operations and the commensurate input energy provided largely by fossil fuels is totally non-viable. This impressive academic team has therefore misunderstood the mechanisms associated with mineral extraction and there is no chance that their parc of 1500 nuclear power plants can be fueled.
4. Is there enough uranium to supply the currently operating nuclear stations for their remaining years of operation?
There is a current world building programme of around 40 new stations, some existing stations are having their operational life extended and some are now being de-commissioned. The current uranium fuel consumption of 66,000 tonnes/annum supports the equivalent of around 290 stations of 1 GWe capacity, but with varying load factors and generating capacity around 400 stations are currently in operation.
As the secondary sources of uranium, which currently provide 45% of the fuel demand are expected to be exhausted by 2012, over half of the operating stations will close within a decade for lack of fuel. Uranium mining production having passed two recent production peaks in 1997 and 2001 is now in decline. The end of the competition from secondary sources might intensify mining activity and lead to a temporary resurgence in production, but to open new mines, always assuming that suitable opportunities emerge to locate them, will take more than the intervening 10 years.
A parc of around 450 nuclear power stations, maintained by the replacement of ageing reactors and the building of yet more, would require a supply of 90,000 tonnes/annum, so that mining production will have to increase 2½ times in the next 7 years an unlikely prospect.
A shortfall in supply seems inevitable and the generation from the new stations will stall.
5. Is nuclear power "clean"?
Then the claim for the carbon-free status of nuclear power proves to be false. Carbon dioxide is released in every component of the nuclear fuel cycle except the actual fission in the reactor. Fossil fuels are involved in the mining, milling, conversion and enrichment of the ore, in the handling of the mill tailings, in the fuel can preparation, in the construction of the station and in its de-commissioning and demolition, in the handling of the spent waste and its processing and in digging the hole in the rock for its deposition.
The lower the ore grade, the more energy is consumed in the fuel processing, so that the amount of the carbon dioxide released in the overall fuel cycle depends on the ore grade. Only Canada and Australia have ores of a sufficiently high grade to avoid excessive carbon releases and to provide an adequate energy gain. At ore grades below 0.01% for soft ores and 0.02% for hard ores more CO2 than an equivalent gas-fired station is released and more energy is absorbed in the cycle that is gained in it. Ores of a grade approaching the "crossover" point such as those in India of 0.03%, if used, risk going into negative energy gain if there are a few "hiccups" in the cycle. ***
The industry points to the presence of uranium in phosphates and seawater, but the concentrations are so low that the energy required to extract it would exceed many times the energy obtained from any nuclear power resulting and the resulting carbon emissions would be massive.
6. Global warming
Maybe the world does not need to stop all carbon dioxide emissions, but even a doubling of nuclear generation capacity were possible it would only provide 20 EJ, i.e., 5% of world energy consumption. There is no possibility of an extension of nuclear capacity solving to any significant degree the problem of global warming.
It is claimed that nuclear power meets the two characteristics of sustainability and zero or low carbon dioxide emissions and so might be able to substitute for fossil fuels once they are exhausted and in the meantime to avoid release of some greenhouse gases. The claims are baseless.
In conclusion, perhaps the scale of global warming has been overstated by omitting to take into account fossil fuel depletion. A guide to the maximum amount of carbon dioxide released from the combustion of fossil fuels can be calculated, given that they are limited. The graph **** accessible on the web shows that if economic growth continues as currently, the reserves of oil, gas and then most of the coal will have emptied by the end of the century. From a knowledge of the carbon content of the three fuels, it is then possible to work out the total amount of carbon dioxide likely to be released.
This comes out as 5 exagrams or 5,000 billion tonnes.
An earth scientist should be able to work out the temperature rise that the release of this limited amount, mostly over the next 50 years, is likely to produce. Before hampering the world with useless measures unable to reduce the eventual amount of the release of carbon dioxide, it would be more appropriate to estimate the ultimate consequences of todays immoderate exploitation and exhaustion of fossil fuels.
* WNA Symposium 2004, Dzhakishev,
** MIT "The Future of Nuclear Power", http://web.mit.edu/nuclearpower/
*** Storm van Leeuwen and Smith, http://www.oprit.rug.nl/deenen/
**** http://www.after-oil.co.uk/energy3.gif
For a full analysis of the consequences of fossil fuel depletion see The Busby Report on http://www.after-oil.co.uk
John Busby 22 May 2005
Melford Road
Bury St. Edmunds IP29 4PY
Phone: 01284 830138
Fax: 01284 830808
Website: http://www.after-oil.co.uk
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