Significant Medication Errors Research Articles

Assessment of Adverse Childhood Experiences, Adverse Professional Experiences, Depression, and Burnout in USPhysicians.

To assess associations of adverse childhood experiences (ACEs) and adverse occupational experiences (AOEs) with depression and burnout in US physicians. We performed a secondary analysis of data from a representative sample survey of US physicians conducted between November 20, 2020, and March 23, 2021, and from a probability-based sample of other US workers. The ACEs, AOEs, burnout, and depression were assessed using previously published measures. Analyses included data from 1125 of the 3671 physicians (30.6%) who received a mailed survey and 6235 of 90,000 physicians (6.9%) who received an electronic survey. The proportion of physicians age 29-65 who had lived with a family member with substance misuse during childhood (673 of 5039[13.4%]) was marginally lower (P <.001) than that of workers in other professions (448 of 2505 [17.9%]). The proportion of physicians age 29-65 who experienced childhood emotional abuse (823 of 5038 [16.3%]) was similar to that of workers in other professions (406 of 2508 [16.2%]). The average physician depression T-score was 49.60 (raw score ± SD, 6.48±3.15), similar to the normed US average. The AOEs were associated with mild to severe depression, including making a recent significant medical error (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.02, P<.001), being named in a malpractice suit (OR, 1.30; 95% CI, 1.07 to 1.59, P=.008), and experiencing one or more coronavirus disease 2019-related AOEs (OR, 1.76; 95% CI, 1.56 to 1.99, P<.001). Having one or more ACEs was associated with mild to severe depression (OR, 1.58; 95% CI, 1.38 to 1.79, P<.001). The ACEs, coronavirus disease 2019-related AOEs, and medical errors were also associated with burnout. Assessing ACEs and AOEs and implementing selective primary prevention interventions may improve population health efforts to mitigate depression and burnout in physicians.

Appraising the Role of Pharmacists in Medication Reconciliation at Hospital Discharge: A Field-Based Study

Objective: To measure the effect of the pharmacist-led medication reconciliation service before hospital discharge on preventing potential medication errors. Methods: This behavioral interventional study took place in a public teaching hospital in Iraq between December 2022 and January 2023. It included inpatients who were taking four or more medications upon discharge from the internal medicine ward and the cardiac care unit. The researcher provided the patients with a medication reconciliation form and reconciliation form (including medication regimen and pharmacist instructions) before discharging them home. Any discrepancies between the patients’ understanding and the actual medication recommendations prescribed by the physician were identified and solved. Results: Fifty inpatients received a pharmacist-led medication reconciliation review before hospital discharge. Out of 50 patients, 44% had a clear understanding of their medications before the intervention. In contrast, 56% of the patients had at least one potential medication error before the reconciliation, which was addressed by the pharmacist's intervention. Approximately two-thirds (89.4%) of the potential medication errors were clinically significant, and 5.3% of these errors were serious. The most frequent potential error that prevented this was duplication (31.5%) (the patient was about to duplicate the same medication from different manufacturers or different medications from the same pharmacological class). Conclusion: Lack of medication reconciliation can cause significant medication errors, which might be serious and cause harm to patients. This study has the potential to shape policies and practices that prioritize medication safety and optimize patient outcomes during transitions of care.

Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants.

Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. Randomized controlled trial. Ambulatory patients initiating a DOAC or resuming one after a complication. Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. Coupons and assistance to increase the affordability of DOACs. Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. NCT04068727.

Impact of Pomegranate Juice on the Pharmacokinetics of CYP3A4- and CYP2C9-Mediated Drugs Metabolism: A Preclinical and Clinical Review.

The Punica granatum L. (pomegranate) fruit juice contains large amounts of polyphenols, mainly tannins such as ellagitannin, punicalagin, and punicalin, and flavonoids such as anthocyanins, flavan-3-ols, and flavonols. These constituents have high antioxidant, anti-inflammatory, anti-diabetic, anti-obesity, and anticancer activities. Because of these activities, many patients may consume pomegranate juice (PJ) with or without their doctor's knowledge. This may raise any significant medication errors or benefits because of food-drug interactions that modulate the drug's pharmacokinetics or pharmacodynamics. It has been shown that some drugs exhibited no interaction with pomegranate, such as theophylline. On the other hand, observational studies reported that PJ prolonged the pharmacodynamics of warfarin and sildenafil. Furthermore, since it has been shown that pomegranate constituents inhibit cytochrome P450 (CYP450) activities such as CYP3A4 and CYP2C9, PJ may affect intestinal and liver metabolism of CYP3A4 and CYP2C9-mediated drugs. This review summarizes the preclinical and clinical studies that investigated the impact of oral PJ administration on the pharmacokinetics of drugs that are metabolized by CYP3A4 and CYP2C9. Thus, it will serve as a future road map for researchers and policymakers in the fields of drug-herb, drug-food and drug-beverage interactions. Preclinical studies revealed that prolonged administration of PJ increased the absorption, and therefore the bioavailability, of buspirone, nitrendipine, metronidazole, saquinavir, and sildenafil via reducing the intestinal CYP3A4 and CYP2C9. On the other hand, clinical studies are limited to a single dose of PJ administration that needs to be protocoled with prolonged administration to observe a significant interaction.

A Cell-Phone Medication Error eHealth App for Managing Safety in Chronically Ill Young Patients at Home: A Prospective Study.

Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.

National improvements in resident physician-reported patient safety after limiting first-year resident physicians’ extended duration work shifts: a pooled analysis of prospective cohort studies

BackgroundThe Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This...

Clinically significant medication errors in surgical units detected by clinical pharmacist: A real-life study.

Clinically significant medication errors in surgical units detected by clinical pharmacist: A real-life study.

Theory-Based Failure Modes and Effect Analysis for Medication Errors.

Medication Errors (MEs) are still significant challenges, especially in nonautomated health systems. Qualitative studies are mostly used to identify the parameters involved in MEs. Failing to provide accurate information in expert-based decisions can provoke unrealistic results and inappropriate corrective actions eventually. However, mostly, some levels of uncertainty accompany the decisions in real practice. This study tries to present a hybrid decision-making approach to assigning different weights to risk factors and considering the uncertainty in the ranking process in the Failure Modes and Effect Analysis (FMEA) technique. Initially, significant MEs are identified by three groups of qualified experts (doctors, nurses, and pharmacists). Afterward, for assigning weights to the risk factors, Z-number couples with the Stepwise Weight Assessment Ratio Analysis (SWARA) method, named Z-SWARA, to add reliability concept in the decision-making process. Finally, the identified MEs are ranked through the developed Weighted Aggregated Sum Product Assessment (WASPAS) method, namely, Z-WASPAS. To demonstrate the applicability of the proposed approach, the ranking results compare with typical methods, such as fuzzy-WASPAS and FMEA. The findings of the present study highlight improper medication administration as the main failure mode, which can result in a fatality or patient injury. Moreover, the utilization of multiple-criteria decision-making methods in combination with Z-number can be a useful tool in the healthcare management field since it can address the problems by considering reliability and uncertainty simultaneously.

Poster Presentation

Poster Presentation

Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors

Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error. To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout. This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study. Sleep-related impairment. Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection. Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively. In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review.

Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients. A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology." Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis. Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Aviation-Modeled Investigation of Significant Obstetric Events.

In this research, the authors attempted to ascertain whether or not the Root Cause Analysis Event Support and Engagement Team (RESET) investigates the use of U.S. Army aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Root cause analysis (RCA), originating in the manufacturing and engineering sectors, attempts to elucidate an underlying cause of a problem. Most recently, this process has been applied to the investigation of medical error. RESET was established in order to perform centralized investigation of significant medical error within U.S. Army medical and dental treatment facilities based on request from a hospital commander or general officer. Significant obstetric events are high profile, discussed in multiple safety forums, and an area of close RESET focus. Yet it is unclear if RESET investigates the use of aviation-based techniques by staff and/or organizations involved in serious obstetrical events. Therefore the present survey study was conducted. A structured, anonymous, voluntary survey was fielded to RESET staff in order to assess whether or not the RESET investigates the use of aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Five of six members of this small team completed the survey. Prebriefs, debriefs, and checklist use were consistently investigated. The employment of a sterile cockpit, first-name introductions, annual check ride, and emergency procedure rehearsal were infrequently investigated. Obstetric RESET investigations inconsistently ascertain whether or not some of the aviation-based techniques are utilized by staff members or organizations in which serious obstetrical events have occurred. Standardization of investigative procedures and education directed at under-investigated practices may optimize medical investigation using proven tenets of an aviation-based approach.

THE SURVEY OF SAFETY CULTURE IN RSUP Dr.KARIADI SEMARANG

Patient safety in hospitals is a crucial issue as significant medication errors occur in some countries. Patient safety incidence is inevitably related to safety culture implemented in hospitals. This survey aims to investigate the dimension of patient safety serving as a strong area and dimension for potential improvement. This study used a cross-sectional approach involving 361 subjects in all units in RSUP Dr. Kariadi. Findings are presented in graphs and frequency tables. This study found three dimensions of strength area involving management support regarding patient safety (92.93%), organizational learning-continuous improvement (91.73%), and unit cooperation (86.1%). Meanwhile, the area for potential improvement involving employment (45.43%), incidence report frequency (58.07%), and open communication (60.67%). Dimensions serving as strength areas need to be maintained while dimension for potential improvement need for support to cultivate patient safety culture in RSUP Dr. Kariadi.

Perceptions of a night float system for intern doctors in an internal medicine program: an Asian perspective.

Long duty hours have been associated with significant medical errors, adverse events, and physician “burn-out”. An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors’ perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p<0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p<0.001) and reduce physician “burn-out” (95% vs. 5%, p<0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician “burn-out”.

Pharmacist Outpatient Prescription Review in the Emergency Department: A Pediatric Tertiary Hospital Experience.

This study aimed to assess the frequency, type, and potential severity of errors intercepted by pharmacists on review of discharge prescriptions in a pediatric emergency department (ED). This was a retrospective, observational study conducted in the ED of a pediatric teaching hospital. A daily report of prescriptions from the previous day was reviewed by a pharmacist for safety and efficacy. If an intervention was deemed necessary, the prescriber was contacted for clarification. In situations where patient harm could occur, the physician performing follow-ups was contacted by phone. The interventions were categorized based on type and potential severity. Physician response rates and intervention acceptance rates were assessed. Approximately 23,600 prescriptions were reviewed during a 1-year period with 60 interventions (0.25% intervention rate). Of the 60 interventions, 3% were estimated to have no severity, 80% were estimated to have minor, 12% moderate, and 5% major potential severity. The most common types of interventions were optimization of therapy, drug overdose, or dose omission at 33%, 32%, and 14%, respectively. Eighty-five percent of physicians responded; 73% accepted the intervention whereas 27% provided a rationale for their decision. More importantly, valuable information was gained, allowing for implementation of system fixes to prevent future errors. On an average, pharmacists spent 45 minutes reviewing and clarifying prescriptions each day. Pharmacists in the ED can provide a valuable service by reviewing discharge prescriptions. A small amount of time dedicated to this service can lead to detection of clinically significant preventable medication errors and optimization of prescription therapy.

Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009.

Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

Significant Medical Errors Experienced by 21% of Americans

Significant Medical Errors Experienced by 21% of Americans

Poor Employment Conditions Adversely Affect Mental Health Outcomes Among Surgical Trainees

Poor mental health in junior clinicians is prevalent and may lead to poor productivity and significant medical errors. We aimed to provide contemporary data on the mental health of surgical trainees and identify risk factors relating to poorer mental health outcomes. A detailed questionnaire was developed comprising questions based on the 36-item short-form health survey (SF-36) and Physical Activity Questionnaire. Each of the questionnaires has proven validity and reliability in the clinical context. Ethics approval was obtained from the Royal Australasian College of Surgeons. The questionnaire was aimed at surgical registrars. We used Physical Activity Questionnaire, SF-36 scores and linear regression to evaluate the effect of putative predictors on mental health. A total of 83 responses were collected during the study period, of which 49 (59%) were from men and 34 (41%) were from women. The mean Mental Component Summary (MCS) score for both sexes was significantly lower than the population mean at ages 25-34 (p < 0.001). Poor satisfaction with one's work culture and a feeling of a lack of support at work were extremely strong predictors of a lower MCS score (p < 0.001). Hours of overtime worked, particularly unpaid overtime, were also strong predictors of a poorer score. Australian surgical trainees reported lower MCS scores from the SF-36 questionnaire compared to the general population. Increasing working hours, unpaid overtime, poor job security, and job satisfaction were associated with poorer scores among trainees. Interventions providing improved working conditions need to be considered by professional training bodies and employers.

LO51: Incidence of clinically relevant medication errors after implementation of an electronic medication reconciliation process

Introduction: Medication discrepancies are unintended differences between a patient’s outpatient and inpatient medication regimens, and occur in up to 60% of hospital admissions. Canadian emergency departments (EDs) have implemented medication reconciliation forms that are pre-populated with outpatient medication dispensing data in order to reduce medication discrepancies and resultant adverse drug events. However, these forms may introduce errors of commission by prompting prescribers to reorder discontinued or potentially harmful medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of pre-populated medication reconciliation forms. Methods: This chart review included admitted patients who were enrolled in a parent study in which a research pharmacist prospectively collected best-possible medication histories (BPMHs) in the ED using all available information sources. Following discharge, research assistants uninvolved with the parent study compared medication orders documented within 48 h of admission with the BPMH to identify medication discrepancies and errors of commission. Errors of commission were defined as inappropriate continuations of medications and reordering discontinued medications. An independent panel adjudicated the clinical significance of the errors. We used regression methods to identify factors associated with errors. The sample size was limited by enrolment into the parent study. Results: Of 151 patients, 71 (47%; 95%CI 39.2-54.9) were exposed to 112 medication errors. Of these errors, 75.9% (85/112; 95%CI 67.1-82.9) were discrepancies, of which 18.8% (16/85; 95%CI 12.0-28.4) were clinically significant. Errors of commission made up 24.1% (27/112; 95%CI 17.3-32.8) of all errors, of which 37.0% (10/27; 95%CI 18.8-55.2) were clinically significant. Taking 8 or more medications was associated with a 5-fold greater odds of experiencing a medication error after controlling for confounders (OR 5.00; 95%CI 2.45-10.17; p&amp;lt;0.001). Conclusion: Clinically significant medication discrepancies and errors of commission remain common despite the implementation of electronically pre-populated medication reconciliation forms. Prospective studies are needed to evaluate whether using pre-populated medication reconciliation forms increases the risk of introducing errors of commission.

Professionalism among Intern Doctors of Different Medical College Hospitals in Bangladesh

This descriptive cross-sectional study was conducted to explore the status of professionalism regarding knowledge, attitude and practice among intern doctors of different medical college Hospitals in Bangladesh. Study period was July 2015 June 2016.Sample size was 300 and convenient sampling technique was adopted. Study was carried out among all Bangladeshi intern doctors of 4 governments and 2 non-governments selected medical college Hospitals of Dhaka and outside Dhaka. Total 300 intern doctors responded to a self-administered questionnaire. Male female ratio was almost 1:1. Concept of professionalism and level of knowledge regarding its various aspects are not satisfactory in large extends. But attitude towards most of the major principles of professionalism are as much as positive like USA and UK physicians. However, regarding honesty with patients, one statement like physicians should disclose all significant medical errors to affected patients and/or guardians, only 36.9% agreed with this. Similarly, only 43% agreed the statement of re-certification examination to maintain professional competence. Regarding attitude and practice of major attributes &amp; responsibilities of professionalism there is no significant difference (p&gt;0.05) between male and female intern doctors working in different medical college hospitals; but regarding practice there is a significant difference (p&lt;0.05) among intern doctors working in government and non-government hospitals. This study recommended that institutional agreement should be on a definition, setting expectations &amp; curriculum framework regarding professionalism to increase scope of teaching &amp; learning in our undergraduate &amp; post-graduate students.Bangladesh Journal of Medical Education Vol.7(2) 2016: 17-22