Author supplied: A manufacturing process can be described by a sequence or combination of production steps. Based on this approach a manufacturing system has been developed that is capable to produce several different products in parallel. A batch size of one unit is possible and the production is pull-driven. The manufacturing system is based on agent technology and a special so-called product agent collects information about the assembly process. This agent will be connected to the actual product and can guide the disassembly process at the end of the products life. The agent will show the inverse steps to be taken to take a product apart. This approach can be used in the agent based manufacturing process described in this paper but the concept can also be used for other manufacturing systems. The paper discusses the possibilities as well as the restrictions of the method proposed here.
Background: Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically. Objectives: To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods: A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results: We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation's protocol. Conclusions: Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
Wetenschap en Techniek (W&T) worden met vaart de basisschool ingeduwd.Het werd tijd, gezien de enorme voorsprong van andere landen op dit gebied, en de rijke leeromgeving die W&T bieden. Maar wil je met zo’n vakgebied belangstelling voor bèta en techniek kweken, of veel meer? En hoe geef je vorm aan het onderzoekend leren dat gepropageerd wordt? Hoe krijg je kinderen van manipuleren van objecten in een onderzoekje, naar manipuleren van ideeen en begrippen? En hun leerkrachten tot het effectief begeleiden daarvan? Deze Openbare Les geeft een rondleiding door de keuken van de W&Tpracticumdidactiek en onderzoekend leren. De tekst in dit boekje is uitgebreider en vollediger dan de Openbare Les zelf. Enkele onderdelen komen in de lezing zelfs niet aan de orde.
