Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

Use of nutritional complete supplements in older adults with dementia: systematic review and meta-analysis of clinical outcomes

Background & Aims: Malnutrition is prevalent in people diagnosed with dementia however ensuring adequate oral intake within this group is often problematic. It is important to determine whether providing nutritionally complete oral nutritional supplements (ONS) drinks is an effective way of improving clinical outcomes for older people with dementia. This paper systematically reviewed clinical, wellbeing and nutritional outcomes in people with long-term cognitive impairment. Methods: The CINAHL, Medline and EMBASE databases were searched from their inception until January 2012. Reference lists of the included papers, foreign language papers and review articles obtained were manually searched. Results: Twelve articles were included in the review containing 1076 people in the supplement groups (intervention) and 748 people in the control groups. Meta-analysis shows there was a significant improvement in weight (p=<0.0001), Body Mass Index (BMI) (p=<0.0001) and cognition at 6.5+/-3.9 month follow up (p=0.002) when supplements were given compared to the control group. Conclusions: Providing ONS drinks has a positive effect on weight gain and cognition at follow up in older people with dementia. Additional research is required in both comparing nutritional supplements to vitamin/mineral tablets and high protein/calorie shots and clinical outcomes relevant to hospitalised people with dementia.

Migration, immobility and displacement outcomes following extreme events

There is growing international concern at the rise in the severity of impact and frequency of extreme environmental events, potentially as a manifestation of global environmental change. There is a widely held belief that this trend could be linked with a future rise in the migration or displacement of human populations. However, recent approaches to migration influenced by environmental change call into question the notion that migration can be ascribed in a singular way to particular environmental causes or events. This paper undertakes a systematic review of evidence on population movements associated with weather-related extreme events. The paper demonstrates that in the face of extreme environmental events, it is important to distinguish between three outcomes – migration, displacement, and immobility – each of which interact and respond to multiple drivers. It also proposes a further insight: that both those who move, and those who do not move, may find themselves trapped and vulnerable in the face of such extreme events. A review of evidence suggests that short-term displacement that goes hand-in-hand with loss of life, destruction of property and economic disruption poses significant risks not because it is ‘environmental migration’, but because it represents a failure of adaptation to environmental change.

Predicting outcomes following cognitive behavior therapy in child anxiety disorders: the influence of genetic, demographic and clinical information

Background. Within a therapeutic gene by environment (GxE) framework, we recently demonstrated that variation in the Serotonin Transporter Promoter Polymorphism; 5HTTLPR and marker rs6330 in Nerve Growth Factor gene; NGF is associated with poorer outcomes following cognitive behaviour therapy (CBT) for child anxiety disorders. The aim of this study was to explore one potential means of extending the translational reach of G×E data in a way that may be clinically informative. We describe a ‘risk-index’ approach combining genetic, demographic and clinical data and test its ability to predict diagnostic outcome following CBT in anxious children. Method. DNA and clinical data were collected from 384 children with a primary anxiety disorder undergoing CBT. We tested our risk model in five cross-validation training sets. Results. In predicting treatment outcome, six variables had a minimum mean beta value of 0.5: 5HTTLPR, NGF rs6330, gender, primary anxiety severity, comorbid mood disorder and comorbid externalising disorder. A risk index (range 0-8) constructed from these variables had moderate predictive ability (AUC = .62-.69) in this study. Children scoring high on this index (5-8) were approximately three times as likely to retain their primary anxiety disorder at follow-up as compared to those children scoring 2 or less. Conclusion. Significant genetic, demographic and clinical predictors of outcome following CBT for anxiety-disordered children were identified. Combining these predictors within a risk-index could be used to identify which children are less likely to be diagnosis free following CBT alone or thus require longer or enhanced treatment. The ‘risk-index’ approach represents one means of harnessing the translational potential of G×E data.

Introduction: some notes on the generative study of L3 acquisition.

This article serves as a state-of the-science review of the blossoming field of generative third language (L3) acquisition as well as an introduction to this special issue on the same topic. We present and argue for the relevance of adult L3/Ln acquisition for many perennial questions that have sat at the core of linguistic approaches to adult language acquisition since the Principles and Parameters framework was first adopted into second language acquisition (SLA; e.g. Flynn, 1985, 1987; Liceras, 1985; White, 1985a, 1985b; Schwartz, 1986). Furthermore, we highlight the unique, specific questions that have emerged from studying L3/Ln from a generative perspective thus far while suggesting refinements to these questions and additional ones that should emerge in future inquiry.

Understanding the nature and outcomes of early bilingualism: Romance languages as heritage languages

In this introduction to the special issue on Romance languages as heritage languages, I aim to contextualize the scope of this issue and the contribution it makes to the emerging field of linguistic studies to heritage language bilingualism. Key issues pertaining to the empirical study and epistemology of heritage language bilingualism are presented as well as a critical introduction to the individual articles that comprise this issue.

The joint influence of personal achievement goals and classroom goal structures on achievement-relevant outcomes

The authors provide an analytic framework for studying the joint influence of personal achievement goals and classroom goal structures on achievement-relevant outcomes. This framework encompasses 3 models (the direct effect model, indirect effect model, and interaction effect model), each of which addresses a different aspect of the joint influence of the 2 goal levels. These 3 models were examined together with a sample of 1,578 Japanese junior high and high school students from 47 classrooms. Results provided support for each of the 3 models: Classroom goal structures were not only direct, but also indirect predictors of intrinsic motivation and academic self-concept, and some cross-level interactions between personal achievement goals and classroom goal structures were observed (indicating both goal match and goal mismatch effects). A call is made for more research that takes into consideration achievement goals at both personal and structural levels of representation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)

Interaction between vitamin D receptor gene polymorphisms and 25-hydroxyvitamin D concentrations on metabolic and cardiovascular disease outcomes

AIM: 25-hydroxyvitamin D (25OHD) concentrations have been shown to be associated with major clinical outcomes, with a suggestion that individual risk may vary according to common genetic differences in the vitamin D receptor (VDR) gene. Hence, we tested for the interactions between two previously studied VDR polymorphisms and 25OHD on metabolic and cardiovascular disease-related outcomes in a large population-based study. METHODS: Interactions between two previously studied VDR polymorphisms (rs7968585 and rs2239179) and 25OHD concentrations on metabolic and cardiovascular disease-related outcomes such as obesity- (body mass index, waist circumference, waist-hip ratio (WHR)), cardiovascular- (systolic and diastolic blood pressure), lipid- (high- and low-density lipoprotein, triglycerides, total cholesterol), inflammatory- (C-reactive protein, fibrinogen, insulin growth factor-1, tissue plasminogen activator) and diabetes- (glycated haemoglobin) related markers were examined in the 1958 British Birth cohort (n up to 5160). Interactions between each SNP and 25OHD concentrations were assessed using linear regression and the likelihood ratio test. RESULTS: After Bonferroni correction, none of the interactions reached statistical significance except for the interaction between the VDR SNP rs2239179 and 25OHD concentrations on waist-hip ratio (WHR) (P=0.03). For every 1nmol/L higher 25OHD concentrations, the association with WHR was stronger among those with two major alleles (-4.0%, P=6.26e-24) compared to those with either one or no major alleles (-2.3%, P≤8.201e-07, for both) of the VDR SNP rs2239179. CONCLUSION: We found no evidence for VDR polymorphisms acting as major modifiers of the association between 25OHD concentrations and cardio-metabolic risk. Interaction between VDR SNP rs2239179 and 25OHD on WHR warrants further confirmation.

Exploring expatriate outcomes

This editorial article introduces this special issue of the International Journal of Human Resource Management devoted to the outcomes of expatriate assignments. We set the topic in context. We start by summarizing the traditional view on expatriate outcomes. We then argue that recent developments in the field suggest the need to build a more sophisticated and complex analysis on the topic that incorporates different perspectives (e.g. the organization, the expatriate, their co-workers and their families) and additional types of international experiences and organizations. We then present some difficulties in developing such an analysis. Specifically, using a new typology of complementary relationships among outcomes (i.e. temporal, among-group and among-outcome consistencies), we point out some complications to achieve those relationships. We conclude by introducing the papers in the special edition that all in some way aim to contribute to our understanding of expatriate outcomes.

What next for children's services? Can policy at a local or national level have any significant impact on the outcomes for children and their families?

In England at both strategic and operational levels, policy-makers in the public sector have undertaken considerable work on implementing the findings of the Every Child Matters report and subsequently through the Children's Act 2004. Legislation has resulted in many local authorities seeking to implement more holistic approaches to the delivery of children's services. At a strategic level this is demonstrated by the creation of integrated directorate structures providing for a range of services, from education to children's social care. Such services were generally under the management of the Director of Children's Services, holding statutory responsibilities for the delivery of services formally divided into the three sectors of education, health and social services. At a national level, more fundamental policy developments have sought to establish a framework through which policy-makers can address the underlying causes of deprivation, vulnerability and inequality. The Child Poverty Act, 2010, which gained Royal Assent in 2010, provides for a clear intention to reduce the number of children in poverty, acknowledging that ‘the best way to eradicate child poverty is to address the causes of poverty, rather than only treat the symptoms’. However, whilst the policy objectives of both pieces of legislation hold positive aspirations for children and young people, a change of policy direction through a change of government in May 2010 seems to be in direct contrast to the intended focus of these aims. This paper explores the impact of new government policy on the future direction of children's services both at the national and local levels. At the national level, we question the ability of the government to deliver the aspirations of the Child Poverty Act, 2010, given the broad range of influences and factors that can determine the circumstances in which a child may experience poverty. We argue that poverty is not simply an issue of the pressure of financial deprivation, but that economic recession and cuts in government spending will further increase the number of children living in poverty.

Eastern partnership migrants in Germany: outcomes, potentials and challenges

Despite the ongoing dialogue on facilitating mobility between the European Union and the Eastern Partnership (EaP) countries, very little is known about the magnitude and characteristics of migration from these countries. We find that EaP migrants experience worse labor market outcomes than other migrant groups, but current and potential migrants hold qualifications in those areas were skill shortages are expected. Therefore, the monitoring and supervision of EaP integration will be consequential in order to understand how much of the current brain waste is driven by poor assessment of foreign qualifications, and to unleash the potential of migration for the German economy.