CWNA-108 approach - Certified Wireless Network Administrator Updated: 2023

Medication Administration Considerations With EN

If the medications are needed and alternative routes of drug delivery are not options, then the medications may be given through enteral feeding tubes. Several factors should be considered before administering medications concomitantly with EN. As discussed previously, feeding tube size and placement site should be considered. Gastric access is generally preferred over jejunal administration because gastric tubes are larger and less prone to clogging and because the stomach may be more tolerant of hypertonic medications.^[6,10] Gastric feedings may be administered by bolus or intermittent methods; EN and medications may thus be given at separate times.

Liquid Preparations

Selecting the most appropriate dosage form is also something to consider. Liquid preparations are the preferred formulations when possible because they are readily absorbed and are less likely to cause tube occlusions. Elixirs or suspensions are generally favored over syrups since syrups are more likely to cause clumping when exposed to EN.^[10,13,16] An important safety measure to take when administering liquid medications through enteral feeding tubes is to make sure that the drugs are drawn up and dispensed only in oral syringes (not syringes intended to give parenteral injections) in order to avoid the accidental parenteral administration of an oral formulation.^[10,13]

Adjustments in the medication dosage or frequency may be necessary when changing formulations. This is particularly important when switching from an extended-release product to a liquid preparation, which is usually immediate release and requires more frequent dosing. Another concern when administering liquid preparations to adults is that many are designed for use in children; therefore, large volumes of the drug must be given in order to achieve an adult dosage, and this could cause intolerability.^[5,10,16]

Although oral liquid medications are preferred for enteral administration, they may potentially cause adverse effects. Many liquid preparations are extremely hyperosmolar or contain large amounts of sorbitol, increasing the risk of GI intolerance. This is particularly troublesome when a large volume of drug is dispensed per dose.^[14,16] Hypertonic medications may not be well tolerated when delivered into the small intestine. The stomach, though, is able to dilute hyperosmolar substances with gastric juices before transferring the contents into the duodenum. However, if the hypertonic medications are administered too rapidly into the stomach, they may be "dumped" into the small bowel, resulting in osmotic diarrhea.^[17,18] If possible, hypertonic medications, especially when undiluted, should not be administered directly into the small intestine, such as with a jejunostomy tube. This may cause bloating, nausea, cramping, and diarrhea.^[18,19] Diluting the hyperosmolar liquid medication with 10–30 mL of sterile water before delivery through the feeding tube may help prevent these intestinal intolerances from occurring. More water may be needed when diluting medications that are either extremely hypertonic or being delivered directly into the small intestine.^[5,19] Unfortunately, osmolality data for some medications are not usually readily available, and the manufacturer or package insert must be consulted.^[19] Some liquid medications with a high osmolality are listed in Appendix A. The average osmolality values of other liquid preparations have been published elsewhere.^[17]

The sorbitol component of the medication itself can also cause GI distress with liquid preparations. Sorbitol is an inactive ingredient used as a sweetening agent to Excellerate medication taste as well as stability, but large amounts (i.e., ≥ 20 g per day) may cause an osmotic laxative effect, resulting in cramping and diarrhea. Even doses as low as 10 g per day may lead to bloating and flatulence.^[19,20] Although most liquid medications only contain a small amount of sorbitol, patients may be taking multiple products that contain this ingredient, thus increasing the cumulative effects.^[5] Unfortunately, since sorbitol is considered an inert substance, manufacturers may not always list it on the product label. Even when inactive ingredients are included on the label or in the package insert, the exact amount of sorbitol in the liquid preparation is generally not listed. Sorbitol content may also differ among manufacturers of a particular product. The best way to determine the sorbitol content of a liquid medication is to contact the drug manufacturer.^[19,20,21] Appendix B lists some medications that contain sorbitol, although the amount may vary by manufacturer. The sorbitol content of various oral liquids has been published elsewhere.^[20,21]

Suspensions, which are often used for antibiotics, may be a more desirable type of liquid formulation. They generally contain less sorbitol than other liquid products, and most reconstituted antibiotic preparations have no sorbitol. Although suspensions may have a high osmolality, diluting with water will help decrease the tonicity.^[19,20,21]

When patients experience adverse GI effects, oftentimes the enteral tube feeding is blamed, but the hyperosmolality and sorbitol content of the liquid medication may be the causes. Several commonly used medications, such as acetaminophen liquid, have a high osmolality and contain sorbitol. Pharmacists can play a key role in identifying the potential medication culprits and evaluating the osmotic load and sorbitol amount. It may be necessary to change the medication to a therapeutically equivalent agent that does not contain sorbitol or an agent that has a lower osmolality. Switching the administrative route may also be helpful. Changing the medication formulation (e.g., from a liquid to a crushed tablet or opened capsule) may be another option.^[18,19] Generally, injectable formulations are not administered into the GI tract because these dosage forms are not apt to survive in gastric acidity, which can result in reduced drug absorption.^[14] The osmolality of parenteral drugs may be higher, potentially causing osmotic diarrhea, and the cost may be much greater.^[9] Although liquid medications are more convenient to administer via a feeding tube, it may not be the best option if GI distress occurs.

Some liquid formulations are not appropriate for administration via the enteral tube. These include lansoprazole oral suspension granules and mineral oil, which are too viscous and may occlude the tube. Sucralfate suspension is also not suitable because it may cause an insoluble mass or bezoar formation.^{[10,13,16,22]}

Syrups should also be avoided, particularly when mixed with enteral formulas. Syrups with an acidic pH (≤4) are the most problematic because of their physical incompatibility with EN formulations, which can result in clumping or thickening and may cause the feeding tube to become clogged. Similar problems with tube occlusions may occur with ferrous sulfate elixir, which is not a syrup but is also very acidic. Some liquid preparations that are not compatible with enteral tube feedings and cause clumping or precipitation are listed in Appendix C. Further diluting the syrup with water cannot prevent the physical incompatibilities between EN and syrups. An alternative liquid preparation is preferable. If this is not possible, the enteral feeding should be interrupted and the tube flushed with at least 30 mL of water before and after administering the incompatible syrup in order to separate the medication from the EN; the tube feeding may then resume.^[19,23] Not all syrups are considered physically incompatible with enteral products. Syrups are generally less preferable to other liquid formulations because many syrups have pH values of <4 and cause compatibility problems.^[23]

Solid Dosage Forms

When a liquid preparation is inappropriate or unavailable, certain solid dosage forms may be used for administration into feeding tubes. Most simple, compressed tablets, including those that are sugar- or film-coated, are immediate-release products and may be crushed. Crushing the tablet results in minimal pharmacokinetic changes to the drug and is similar to swallowing it whole. Crushing some preparations could cause a bitter taste if taken orally, but this is not an issue for administration via a feeding tube. Tablets should be crushed to a fine powder using a mortar and pestle and then mixed with 15–30 mL of water before delivery through the tube. Similarly, hard gelatin capsules that contain a powdered drug may be opened and the contents diluted in 10–15 mL of water to form a slurry before administration.^{[12,13,19,24]}

Administration of liquid-filled soft gelatin capsules is more challenging. One end of the capsule may be pierced with a needle, and its liquid contents can be squeezed out and mixed with water. A concern with this method is that all of the contents may not be removed from the capsule, which can result in underdosing. Alternatively, the entire soft gelatin capsule may be dissolved in a container of warm water and all of the contents given. Care should be taken not to administer the undissolved gelatin portion into the tube because this may cause occlusion.^[9,12,19]

Special care should be taken with some extended-release capsules that contain beads or pellets and certain capsules filled with enteric-coated granules. These capsules may be opened and emptied into the feeding tube, but their contents should not be crushed. Examples of medications that may be administered this way include diltiazem (Tiazac, Biovail Pharmaceuticals, Morrisville, NC) and verapamil (Verelan, UCB Pharma, Smyrna, GA).^[5,12,25] Ferrone et al.^[26] described how delayed-release pancreatic enzyme capsules that contain enteric-coated microspheres (Pancrecarb MS-4, Digestive Care, Inc., Bethlehem, PA) may be opened and the contents mixed with applesauce or apple juice before administration through the feeding tube. A potential complication with pouring capsule contents through any enteral access device is that tube occlusions may occur, so large-bore feeding tubes (≥14 French) are preferred.

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Mary Gregory is an executive coach at Mary Gregory, Leadership Coaching and Facilitation, and author of Ego: Get Over Yourself and Lead.

Leading change can often feel like riding a roller coaster. You must deal with not only the twists and turns of transformation but also people's fears and concerns. Change creates uncertainty, which triggers anxiety, causing people to challenge or resist your proposals. Ignoring people's concerns or trying to persuade them to agree without genuinely understanding them or their needs risks false buy-in and even sabotage.

Empathy is the core skill for genuinely understanding where people are coming from and dissolving resistance, making change management smoother. Read on to explore why empathy is an absolute must and for tips on cultivating this heart-centered skill as part of your leadership.

Understanding Resistance

Any change, whether we want it or not, is an emotional journey.

When a change is desired, we feel excitement and anticipation. On the other hand, when a change is imposed, we tend to feel fear. This is often linked to our human need to be included, have a say and contribute to our destiny. When any of these factors are missing, we will likely feel immense fear and defend ourselves by resisting. Understanding this very human process is the first step to being able to do something about it.

Another element of being human that is helpful to understand is that when it comes to emotional experiences, fear and excitement are more closely aligned than you might think. Consider that roller coaster ride. During the ups and downs, fast turns and loop-the-loops, both emotions are generally experienced, and they may even merge.

So if excitement and fear are so closely associated, what might people need to shift their feelings from fear toward excitement? What part of the journey might be creating anxiety? And how can this be addressed so that people start to feel more hopeful about the future and their part in it?

The Role Empathy Can Play

Empathy is the ability to really tune into the experiences of another, sitting side by side with shared understanding. It's not about feeling sorry for someone; it's about getting another person or group of people's experience. The role this plays when leading change is invaluable on many levels:

• Building Trust: Empathy supports trust building by demonstrating that you are in tune with your team and understand their feelings and concerns. Listening to people and understanding how they feel is the start of building bridges and finding ways to navigate significant changes together.

• Empowering Communication: Understanding your team's feelings, their perspective on the situation and how the change will impact them means you are in a much better position to explain the change to them in a way that resonates. It also means you can more easily identify what might be difficult for them and find ways to overcome these things.

• Increasing Motivation: Think about a time when you felt fully understood by somebody. Now think about how that impacted your mood and sense of well-being. When someone really gets us, the impact can be one of relief, inner calm, increased hope and greater connection with that person or situation. The "feel-good" factor that empathy provides results in people being more open to change and more willing to engage with new possibilities.

• Creative Problem-Solving: Empathy can help you tap into your team's creative potential. When they feel heard, they're more likely to develop innovative solutions.

• Conflict Resolution: Empathy suspends "right and wrong." The intention is to understand and appreciate different perspectives, seek common ground, resolve conflict and ensure a more harmonious change process.

Cultivating Empathy

Being fully present with someone, listening with an open heart, asking open-ended questions and validating another's feelings are the foundations of empathy. Practice these four skills regularly. And share your journey in developing empathy to encourage others.

In the end, leading change isn't just about corporate strategies. It's about connecting hearts and minds. Empathy isn't just a tool; it's the heart of leadership. By acknowledging the concerns that lead to resistance, practicing empathy and reaping its benefits, you're not only ensuring a smoother and happier change journey but also embarking on transforming your organization into a safe, supportive, innovative and joyful workplace.

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Preparation before your arrival

Prior to your arrival at LSE you will receive details about optional readings and online learning materials which are designed to help you to prepare for the programme.  

MPA Welcome & Introductory Teaching 

From mid-September (exact date TBC) you will need to attend MPA Welcome events and introductory teaching sessions. These will take place prior to the start of the LSE Autumn Term dates. The welcome sessions include campus enrolment, a programme introduction, compulsory introductory teaching in mathematics, statistics, academic writing and presentation skills plus sessions to introduce opportunities and resources available to you during your studies.

If you have not studied mathematics and statistics for some time, the MPA introductory teaching provides a challenging but accessible introduction to some of the key skills and techniques required for the degree. For other students, it serves as a refresher course.

First year

In the first year, you will take three compulsory courses, in micro- and macro-economics, political science and quantitative methods of analysis. These provide a rigorous foundation to support you in your second year.

You will also select optional courses (electives) to the value of one unit from a range of options.

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Micro and Macro Economics for Public Policy 

You will learn macro- and micro- economic concepts, models and methods suitable for appraising policy, applicable in a wide variety of contexts. This includes the study of demand and supply, the labour market, public goods, market failure, inflation and monetary policy, fiscal policy and debt, and exchange rates. 

Political Science for Public Policy
You will learn concepts and models for understanding the behaviour of political actors and why they lead to particular outcomes. This includes the study of voting, political parties, interest groups, legislative politics, corruption, democratisation and ethnic conflict. These tools are essential for designing policy interventions to achieve desired future outcomes. 

Quantitative Approaches and Policy Analysis 
You will learn skills for the quantitative evaluation of public policies, such as causal relationships; randomised control trials; difference-in-difference estimation; instrumental variables; regression discontinuity designs and cost-benefit analysis. 

Option courses (electives) - Year one

In addition to your required core courses, you will take full unit or half-unit option courses (electives). The SPP offers a wide range of courses as options.

You can review the 2023/24 option list here.

Second Year

The key features of the second year are the MPA Capstone and the option to choose a specialisation to be a part of your degree title.

You will also choose a range of option courses (electives) from the School of Public Policy (or elsewhere in LSE, subject to permission and availability).

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The MPA Capstone 

The MPA Capstone is a compulsory one unit course. You will carry out analysis and research, as part of a team, in order to address a practical policy issue relevant to a real-life client organisation. It allows you to extend your capabilities by applying what you have learned in the MPA core courses in a professional context. 

Option courses (electives)

Your remaining second year course units will be made up of option courses (electives) from a wide range available in the School of Public Policy or (with permission and subject to availability) from elsewhere in LSE.

You may choose to write a Policy Paper (6,000 words) or a Dissertation (10,000 words) as one of your option courses. You will choose your own subject if you decide to write a Policy Paper or Dissertation, which you will develop in consultation with your allocated supervisor.  

Specialisms

You can either choose to pursue a general MPA or you can request that one of the following specialisms is added to your degree title.

The current specialisms are:

• Economic Policy
• International Development
• Inequality and Poverty
• Social Impact
• International Political Economy

Each specialism has one or more courses attached to it (please refer to the programme regulations and click on 'MPA course list' for details). To be eligible for a specialism to be added to your degree title, you must meet the requirements to be eligible for the overall degree and pass the courses attached to your chosen specialism. You can only choose one specialism but you can take courses from other specialisms as option courses (electives).

For the most up-to-date list of optional courses please visit the relevant School Calendar page.  

Rob De La Espriella is the CEO of BlueDragon IPS and a leading expert in solving complex problems in modern operating environments.

Traditional Approaches To Solving Workplace Problems Are Not Working

The harsh reality is that most tools and techniques used today to investigate organizational and programmatic failures, human performance deficiencies, equipment failures and accidents/incidents originated in the 20th century. For example, the “5 Whys” root cause analysis technique was developed in the 1930s for the automobile manufacturing industry. The Fishbone diagram came about in the 1940s. While these tools provided value in the past, they were designed for less complex times.

Consider that we are now in the 21st century. Why are many regulated industries, including aerospace, defense, energy, pharmaceuticals and healthcare, still relying on antiquated problem-solving methods? As a result, these industries experience incredibly high instances of recurring human errors, organizational and programmatic breakdowns, accidents and incidents, quality issues, as well as insurance claims, fraud, waste and abuse cases. Mostly because organizations fail to uncover and address their deepest underlying causes.

Let’s consider an example. Over a period of five years, a high-tech manufacturing company experienced 12 separate events involving electrical arc flash that resulted in severe injuries to technicians. The company used the “5 Whys” for incident investigations and kept identifying “inadequate PPE” and “lack of adherence to procedures” as root causes. However, had they looked deeper, they would have uncovered larger institutional problems related to production pressures, inadequate staffing and deficiencies in their safety culture. And they left open the possibility that a future event could cause a fatality.

This is just one example, but statistics tell the full story. There are not thousands of new root causes to explain this volume of issues. Problems recur because organizations fail to perform the type of deep-dive analyses required to identify the true underlying causes. Continued reliance on outdated methods perpetuates a vicious cycle of recurrence, describing the well-known definition of insanity.

A New Breed Of Problems In The Modern Workplace Is Driving The Need To Update Our Approach

Today’s modern socio-technical working environments put tremendous pressure on human performance and create a new breed of intricate, multifaceted problems. This includes the proliferation of high technology; matrixed organization charts where we serve multiple bosses with a plethora of collateral duties; a large volume of regulations, requirements, programs, processes and procedures; the advent of Big Data and data analytics; and certainly not least, the local, regional and national cultural pressures and political correctness in the modern workplace. Solving these modern, complex problems requires a modern approach.

Six Keys To Solving Complex Problems In The 21st Century

Forward-thinking problem solvers are adopting new approaches that incorporate contemporary concepts that allow a more holistic, human-centric approach, captured below in six keys to solving the complex problems of the 21st century.

1. Critical Thinking

The unbiased and intellectually disciplined process of gathering, organizing and analyzing data, evidence and information so we can draw insights and solve problems. Critical thinking is one of two anchors for complex problem-solving.

2. Systems Thinking

The second of two anchors for solving complex problems. Using systems thinking, we can conduct a systems inventory of affected programs, processes and procedures to establish a holistic approach that attacks problems from multiple perspectives.

3. Unbiased Questions

Generating unbiased, evidence-based questions that are anchored to specific standards for performance and insights from data analysis create more effective lines of inquiry.

4. Analysis Of Defenses

An assessment of the effectiveness of the line of defenses put in place to guard us from hazards and help us succeed in managing our complex operations to determine where they failed. This is essential to our holistic approach and must be conducted every time.

5. In-Depth Causal Analysis

Not the same as data analysis, this approach uncovers the small set of deep-seated causes that have far-ranging effects and will continue to generate events. As previously stated, there are not thousands of new root causes creating thousands of recurring problems each year.

6. Effective Corrective Actions

Incorporating modern concepts (such as the Hierarchy of Hazard Controls and Lean Mistake-Proofing) to produce actions more likely to prevent recurrence. Traditional corrective actions that include more procedure requirements and training have not done much to prevent recurrence.

The Benefits Of Modernizing Your Problem-Solving System

A modern approach to solving recurring problems allows organizations to finally move beyond mere event causes and address the deepest underlying sources of recurring issues. The payoff includes:

• Modernized Mission Assurance: A system that accounts for modern workplace dynamics.

• Enhanced Critical Thinking: A system that creates stronger problem-solvers and decision makers.

• Continuous Improvement Culture: A system that proactively assesses and improves our line of defense.

• Higher Reliability: A system that eliminates latent organizational and programmatic weaknesses, reducing problem recurrence and improving consistency of operations.

• Reduced Operating Costs: A system that keeps personnel working on mission-critical tasks and not on recurring problems.

• Stronger Public Trust: An advanced problem-solving system that builds public trust and confidence, leading to a competitive advantage and improved market share.

• Greater Regulatory Trust: A system that proactively self-identifies and addresses complex problems, demonstrates credibility and increases regulator trust and confidence.

Take Aways

In closing, we must acknowledge some cold, hard truths. Traditional problem-solving tools have proven less than effective for preventing recurring failures in today’s complex landscape, resulting in preventable accidents and fatalities, costing industries money each year. The modern sociotechnical workplace has bred a new class of complex and challenging problems that require innovative tactics with the latest advancements in holistic problem-solving.

Rather than chasing symptoms with outdated reductionist tools and techniques, organizations should update their performance improvement and corrective action programs with methodologies that are designed to solve problems in the 21st century. By addressing those systemic gaps, they can achieve the fundamental transformation needed to prevent recurring issues, avoid preventable tragedies and meet the challenges of the modern era.

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Today, the Biden Administration released its highly anticipated Executive Order on Safe, Secure and Trustworthy Artificial Intelligence, setting forth a broad vision of the Administration’s legal, regulatory, and policy approach to the development and implementation of Artificial Intelligence in the United States. Through the EO, the Administration seeks to assert American leadership in an area where there is concern that the federal government’s efforts are not keeping pace with the speed at which the technology is being adopted or regulated in other countries. The EO also makes clear that the Administration will require measures to ensure safe and responsible development and use of AI, but that it will take an overall cautious approach to regulation in this area in order to ensure continued innovation and not unnecessarily stifle the economic potential of the technology.

The EO provides a roadmap of some of the key issues that the Administration has been focused on as it seeks to develop guardrails for the technology. Specifically, the EO directs action around new standards for AI safety and security, measures to protect Americans’ privacy, consumer and workforce protections, promoting innovation and competition, advancing American leadership abroad, and ensuring responsible and effective government use of AI.

The EO should be of interest to clients across a wide variety of industries, with heightened immediate importance to government contractors and large technology companies that are developing advanced AI systems. The EO sets forth areas where the Administration is directing the development of appropriate standards going forward, including guidance for federal government agencies’ use of AI, for red-teaming models, and for detecting AI-generated content and authenticating official content. Meaningful resources will be dedicated across a broad range of government agencies to create and implement these standards as well as to develop other policies and reports required by the EO. Companies developing AI products or using AI in any way (or that are planning to do so in the future)—which is certain to be most companies—will need to be cognizant of these standards and recommendations as they are being developed. Our experience indicates that companies should not be waiting for these standards and recommendations to be rolled out, but should be carefully watching agency developments and anticipating future guidelines based on the areas of demonstrated interest from the Administration.

The EO also highlights key areas where the Administration (and others) have been raising concerns about potential risks of discrimination and other consumer protection concerns— including in education, health care, housing, and employment. At the same time, the Administration also is focusing on ways to promote innovation and competition. AI is a groundbreaking yet disruptive technology, with many areas of potential concern. However, it is also an area where there are meaningful opportunities both for companies and for consumers. The EO attempts to balance these considerations and ensure orderly technological development that provides benefits without raising substantial new or expanded risks.

The EO also focuses on critical concerns about privacy and cybersecurity. The EO endorses the need for bipartisan national privacy legislation to protect all Americans (with a focus on children). It further provides support for the development of “privacy enhancing technologies” as a means of realizing the benefits of AI without raising new privacy concerns. The EO also recognizes that there are meaningful cybersecurity concerns raised by AI technology, and establishes an advanced cybersecurity program to develop AI tools to find and fix vulnerabilities in critical software. 

Companies will want to review the EO to understand whether there are immediate obligations being imposed on them. For example, the EO—leveraging the authority of the Defense Production Act—will require companies developing any foundation model that poses a serious risk to national security, national economic security, or national public health and safety to share the results of red-teaming efforts with the federal government. However, it is important to recognize that most of the EO is focused on future efforts by the federal government that are intended to shape standards, norms, and legal requirements going forward. Despite the fact that these requirements do not impose immediate obligations on most companies, it is critical that companies understand the issues that the EO is concerned with and pay close attention to how federal agencies approach the requirements of the EO over the coming months as many of the requirements are intended to eventually flow down to the private sector.