[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

Toward a cognitive taxonomy of medical errors.

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Managing the risks of medical technology: Do hazard surveillance systems provide an early warning of medical device problems?

The Food and Drug Administration (FDA) is responsible for risk assessment and risk management in the post-market surveillance of the U.S. medical device industry. One of the FDA regulatory mechanisms, the Medical Device Reporting System (MDR) is an adverse event reporting system intended to provide the FDA with advance warning of device problems. It includes voluntary reporting for individuals, and mandatory reporting for device manufacturers. ^ In a study of alleged breast implant safety problems, this research examines the organizational processes by which the FDA gathers data on adverse events and uses adverse event reporting systems to assess and manage risk. The research reviews the literature on problem recognition, risk perception, and organizational learning to understand the influence highly publicized events may have on adverse event reporting. Understanding the influence of an environmental factor, such as publicity, on adverse event reporting can provide insight into the question of whether the FDA's adverse event reporting system operates as an early warning system for medical device problems. ^ The research focuses on two main questions. The first question addresses the relationship between publicity and the voluntary and mandatory reporting of adverse events. The second question examines whether government agencies make use of these adverse event reports. ^ Using quantitative and qualitative methods, a longitudinal study was conducted of the number and content of adverse event reports regarding breast implants filed with the FDA's medical device reporting system during 1985–1991. To assess variation in publicity over time, the print media were analyzed to identify articles related to breast implant failures. ^ The exploratory findings suggest that an increase in media activity is related to an increase in voluntary reporting, especially following periods of intense media coverage of the FDA. However, a similar relationship was not found between media activity and manufacturers' mandatory adverse event reporting. A review of government committee and agency reports on the FDA published during 1976–1996 produced little evidence to suggest that publicity or MDR information contributed to problem recognition, agenda setting, or the formulation of policy recommendations. ^ The research findings suggest that the reporting of breast implant problems to FDA may reflect the perceptions and concerns of the reporting groups, a barometer of the volume and content of media attention. ^

Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study.

BACKGROUND In an effort to reduce firearm mortality rates in the USA, US states have enacted a range of firearm laws to either strengthen or deregulate the existing main federal gun control law, the Brady Law. We set out to determine the independent association of different firearm laws with overall firearm mortality, homicide firearm mortality, and suicide firearm mortality across all US states. We also projected the potential reduction of firearm mortality if the three most strongly associated firearm laws were enacted at the federal level. METHODS We constructed a cross-sectional, state-level dataset from Nov 1, 2014, to May 15, 2015, using counts of firearm-related deaths in each US state for the years 2008-10 (stratified by intent [homicide and suicide]) from the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, data about 25 firearm state laws implemented in 2009, and state-specific characteristics such as firearm ownership for 2013, firearm export rates, and non-firearm homicide rates for 2009, and unemployment rates for 2010. Our primary outcome measure was overall firearm-related mortality per 100 000 people in the USA in 2010. We used Poisson regression with robust variances to derive incidence rate ratios (IRRs) and 95% CIs. FINDINGS 31 672 firearm-related deaths occurred in 2010 in the USA (10·1 per 100 000 people; mean state-specific count 631·5 [SD 629·1]). Of 25 firearm laws, nine were associated with reduced firearm mortality, nine were associated with increased firearm mortality, and seven had an inconclusive association. After adjustment for relevant covariates, the three state laws most strongly associated with reduced overall firearm mortality were universal background checks for firearm purchase (multivariable IRR 0·39 [95% CI 0·23-0·67]; p=0·001), ammunition background checks (0·18 [0·09-0·36]; p<0·0001), and identification requirement for firearms (0·16 [0·09-0·29]; p<0·0001). Projected federal-level implementation of universal background checks for firearm purchase could reduce national firearm mortality from 10·35 to 4·46 deaths per 100 000 people, background checks for ammunition purchase could reduce it to 1·99 per 100 000, and firearm identification to 1·81 per 100 000. INTERPRETATION Very few of the existing state-specific firearm laws are associated with reduced firearm mortality, and this evidence underscores the importance of focusing on relevant and effective firearms legislation. Implementation of universal background checks for the purchase of firearms or ammunition, and firearm identification nationally could substantially reduce firearm mortality in the USA. FUNDING None.

HIV incidence estimates and HIV/AIDS concurrent diagnosis in Houston/Harris County

The purpose of this dissertation was to estimate HIV incidence among the individuals who had HIV tests performed at the Houston Department of Health and Human Services (HDHHS) public health laboratory, and to examine the prevalence of HIV and AIDS concurrent diagnoses among HIV cases reported between 2000 and 2007 in Houston/Harris County. ^ The first study in this dissertation estimated the cumulative HIV incidence among the individuals testing at Houston public health laboratory using Serologic Testing Algorithms for Recent HIV Seroconversion (STARHS) during the two year study period (June 1, 2005 to May 31, 2007). The HIV incidence was estimated using two independently developed statistical imputation methods, one developed by the Centers for Disease Control and Prevention (CDC), and the other developed by HDHHS. Among the 54,394 persons who tested for HIV during the study period, 942 tested HIV positive (positivity rate=1.7%). Of these HIV positives, 448 (48%) were newly reported to the Houston HIV/AIDS Reporting System (HARS) and 417 of these 448 blood specimens (93%) were available for STARHS testing. The STARHS results showed 139 (33%) out of the 417 specimens were newly infected with HIV. Using both the CDC and HDHHS methods, the estimated cumulative HIV incidences over the two-year study period were similar: 862 per 100,000 persons (95% CI: 655-1,070) by CDC method, and 925 per 100,000 persons (95% CI: 908-943) by HDHHS method. Consistent with the national finding, this study found African Americans, and men who have sex with men (MSM) accounted for most of the new HIV infections among the individuals testing at Houston public health laboratory. Using CDC statistical method, this study also found the highest cumulative HIV incidence (2,176 per 100,000 persons [95%CI: 1,536-2,798]) was among those who tested in the HIV counseling and testing sites, compared to the sexually transmitted disease clinics (1,242 per 100,000 persons [95%CI: 871-1,608]) and city health clinics (215 per 100,000 persons [95%CI: 80-353]. This finding suggested the HIV counseling and testing sites in Houston were successful in reaching high risk populations and testing them early for HIV. In addition, older age groups had higher cumulative HIV incidence, but accounted for smaller proportions of new HIV infections. The incidence in the 30-39 age group (994 per 100,000 persons [95%CI: 625-1,363]) was 1.5 times the incidence in 13-29 age group (645 per 100,000 persons [95%CI: 447-840]); the incidences in 40-49 age group (1,371 per 100,000 persons [95%CI: 765-1,977]) and 50 or above age groups (1,369 per 100,000 persons [95%CI: 318-2,415]) were 2.1 times compared to the youngest 13-29 age group. The increased HIV incidence in older age groups suggested that persons 40 or above were still at risk to contract HIV infections. HIV prevention programs should encourage more people who are age 40 and above to test for HIV. ^ The second study investigated concurrent diagnoses of HIV and AIDS in Houston. Concurrent HIV/AIDS diagnosis is defined as AIDS diagnosis within three months of HIV diagnosis. This study found about one-third of the HIV cases were diagnosed with HIV and AIDS concurrently (within three months) in Houston/Harris County. Using multivariable logistic regression analysis, this study found being male, Hispanic, older, and diagnosed in the private sector of care were positively associated with concurrent HIV and AIDS diagnoses. By contrast, men who had sex with men and also used injection drugs (MSM/IDU) were 0.64 times (95% CI: 0.44-0.93) less likely to have concurrent HIV and AIDS diagnoses. A sensitivity analysis comparing difference durations of elapsed time for concurrent HIV and AIDS diagnosis definitions (1-month, 3-month, and 12-month cut-offs) affected the effect size of the odds ratios, but not the direction. ^ The results of these two studies, one describing characteristics of the individuals who were newly infected with HIV, and the other study describing persons who were diagnosed with HIV and AIDS concurrently, can be used as a reference for HIV prevention program planning in Houston/Harris County. ^

Seasonality of respiratory syncytial virus infection in Texas

Respiratory syncytial virus (RSV) is a common cause of respiratory infection in infants and children that can result in bronchiolitis or pneumonia. Each year in the United States, it causes up to 400 deaths and 125,000 hospitalizations among children less than one year of age. RSV is transmitted by direct or close contact with contaminated secretions, which may involve droplets and fomites. Monthly administration of a monoclonal RSV antibody, palivizumab (Synagis™, MedImmune, Gaithersburg, MD), in premature infants, infants with chronic lung disease, or congenital heart disease has been shown to significantly reduce the risk of severe RSV infection. The Centers for Disease Control and Prevention's (CDC) National Respiratory and Enteric Virus Surveillance System (NREVSS) is a laboratory based passive reporting system that collects state, regional, and national RSV data. The CDC defines the RSV season onset as “the first of 2 consecutive weeks during which the mean percentage of specimens testing positive for RSV antigen is 10%.” RSV season offset is defined as the last of 2 consecutive weeks during which the percentage of positive specimens is less than or equal to 10%. Annual RSV epidemics generally occur during the winter and early spring months, but the RSV season is known to vary by national regions. Precise delineation of the RSV epidemiology by region could maximize protection from RSV and minimize the cost of RSV immune prophylaxis. ^ The purpose of this thesis is to define the RSV season in Texas over time; compare the RSV season of the state of Texas and its regions with the national norms; and to compare RSV seasonality between the various regions in Texas. ^ This study was a retrospective analysis of data reported to NREVSS to evaluate potential disparities in the onset weeks, offset weeks, and duration of the annual RSV season in Texas. Data were collected from 70 reporting sites, and includes information from the 2004–2005 to 2009–2010 RSV seasons. ^ The observed median onset (week 44) and offset week (week 8) for the Texas were consistent with national estimates for the South. Regional estimates and statistical analysis suggested that the RSV season in Texas would be better represented by regions. Regional seasonal comparisons revealed considerable variation in season offset and duration between many of the geographic regions within Texas. This trend should be studied further.^

Is Group Lending A Good Enforcement Scheme for Achieving High Repayment Rates?: Evidence from Field Experiments in Vietnam

Microfinance institutions employ various kinds of incentive schemes but estimating the effect of each scheme is not easy due to endogeneity bias. We conducted field experiments in Vietnam to capture the role of joint liability, monitoring, cross-reporting, social sanctions, communication and group formation in borrowers’ repayment behavior. We find that joint liability contracts cause serious free-riding problems, inducing strategic default and lowering repayment rates. When group members observe each others’ investment returns, participants are more likely to choose strategic default. Even after introducing a cross-reporting system and/or penalties among borrowers, the default rates and the ratios of participants who chose strategic default under joint liability are still higher than those under individual lending. We also find that joint liability lending often failed to induce mutual insurance among borrowers. Those who had been helped or who had repaid a little in the previous round were more likely to default strategically and repay a little again in the current round and those who paid large amounts were always the same individuals.

Real-time determination of airspace wind speed field based on FDR = Determinación en tiempo real del campo de velocidad del viento basado en registradores de datos de vuelo

El estudio del comportamiento de la atmósfera ha resultado de especial importancia tanto en el programa SESAR como en NextGen, en los que la gestión actual del tránsito aéreo (ATM) está experimentando una profunda transformación hacia nuevos paradigmas tanto en Europa como en los EE.UU., respectivamente, para el guiado y seguimiento de las aeronaves en la realización de rutas más eficientes y con mayor precisión. La incertidumbre es una característica fundamental de los fenómenos meteorológicos que se transfiere a la separación de las aeronaves, las trayectorias de vuelo libres de conflictos y a la planificación de vuelos. En este sentido, el viento es un factor clave en cuanto a la predicción de la futura posición de la aeronave, por lo que tener un conocimiento más profundo y preciso de campo de viento reducirá las incertidumbres del ATC. El objetivo de esta tesis es el desarrollo de una nueva técnica operativa y útil destinada a proporcionar de forma adecuada y directa el campo de viento atmosférico en tiempo real, basada en datos de a bordo de la aeronave, con el fin de mejorar la predicción de las trayectorias de las aeronaves. Para lograr este objetivo se ha realizado el siguiente trabajo. Se han descrito y analizado los diferentes sistemas de la aeronave que proporcionan las variables necesarias para obtener la velocidad del viento, así como de las capacidades que permiten la presentación de esta información para sus aplicaciones en la gestión del tráfico aéreo. Se ha explorado el uso de aeronaves como los sensores de viento en un área terminal para la estimación del viento en tiempo real con el fin de mejorar la predicción de las trayectorias de aeronaves. Se han desarrollado métodos computacionalmente eficientes para estimar las componentes horizontales de la velocidad del viento a partir de las velocidades de las aeronaves (VGS, VCAS/VTAS), la presión y datos de temperatura. Estos datos de viento se han utilizado para estimar el campo de viento en tiempo real utilizando un sistema de procesamiento de datos a través de un método de mínima varianza. Por último, se ha evaluado la exactitud de este procedimiento para que esta información sea útil para el control del tráfico aéreo. La información inicial proviene de una muestra de datos de Registradores de Datos de Vuelo (FDR) de aviones que aterrizaron en el aeropuerto Madrid-Barajas. Se dispuso de datos de ciertas aeronaves durante un periodo de más de tres meses que se emplearon para calcular el vector viento en cada punto del espacio aéreo. Se utilizó un modelo matemático basado en diferentes métodos de interpolación para obtener los vectores de viento en áreas sin datos disponibles. Se han utilizado tres escenarios concretos para validar dos métodos de interpolación: uno de dos dimensiones que trabaja con ambas componentes horizontales de forma independiente, y otro basado en el uso de una variable compleja que relaciona ambas componentes. Esos métodos se han probado en diferentes escenarios con resultados dispares. Esta metodología se ha aplicado en un prototipo de herramienta en MATLAB © para analizar automáticamente los datos de FDR y determinar el campo vectorial del viento que encuentra la aeronave al volar en el espacio aéreo en estudio. Finalmente se han obtenido las condiciones requeridas y la precisión de los resultados para este modelo. El método desarrollado podría utilizar los datos de los aviones comerciales como inputs utilizando los datos actualmente disponibles y la capacidad computacional, para proporcionárselos a los sistemas ATM donde se podría ejecutar el método propuesto. Estas velocidades del viento calculadas, o bien la velocidad respecto al suelo y la velocidad verdadera, se podrían difundir, por ejemplo, a través del sistema de direccionamiento e informe para comunicaciones de aeronaves (ACARS), mensajes de ADS-B o Modo S. Esta nueva fuente ayudaría a actualizar la información del viento suministrada en los productos aeronáuticos meteorológicos (PAM), informes meteorológicos de aeródromos (AIRMET), e información meteorológica significativa (SIGMET). ABSTRACT The study of the atmosphere behaviour is been of particular importance both in SESAR and NextGen programs, where the current air traffic management (ATM) system is undergoing a profound transformation to the new paradigms both in Europe and the USA, respectively, to guide and track aircraft more precisely on more efficient routes. Uncertainty is a fundamental characteristic of weather phenomena which is transferred to separation assurance, flight path de-confliction and flight planning applications. In this respect, the wind is a key factor regarding the prediction of the future position of the aircraft, so that having a deeper and accurate knowledge of wind field will reduce ATC uncertainties. The purpose of this thesis is to develop a new and operationally useful technique intended to provide adequate and direct real-time atmospheric winds fields based on on-board aircraft data, in order to improve aircraft trajectory prediction. In order to achieve this objective the following work has been accomplished. The different sources in the aircraft systems that provide the variables needed to derivate the wind velocity have been described and analysed, as well as the capabilities which allow presenting this information for air traffic management applications. The use of aircraft as wind sensors in a terminal area for real-time wind estimation in order to improve aircraft trajectory prediction has been explored. Computationally efficient methods have been developed to estimate horizontal wind components from aircraft velocities (VGS, VCAS/VTAS), pressure, and temperature data. These wind data were utilized to estimate a real-time wind field using a data processing approach through a minimum variance method. Finally, the accuracy of this procedure has been evaluated for this information to be useful to air traffic control. The initial information comes from a Flight Data Recorder (FDR) sample of aircraft landing in Madrid-Barajas Airport. Data available for more than three months were exploited in order to derive the wind vector field in each point of the airspace. Mathematical model based on different interpolation methods were used in order to obtain wind vectors in void areas. Three particular scenarios were employed to test two interpolation methods: a two-dimensional one that works with both horizontal components in an independent way, and also a complex variable formulation that links both components. Those methods were tested using various scenarios with dissimilar results. This methodology has been implemented in a prototype tool in MATLAB © in order to automatically analyse FDR and determine the wind vector field that aircraft encounter when flying in the studied airspace. Required conditions and accuracy of the results were derived for this model. The method developed could be fed by commercial aircraft utilizing their currently available data sources and computational capabilities, and providing them to ATM system where the proposed method could be run. Computed wind velocities, or ground and true airspeeds, would then be broadcasted, for example, via the Aircraft Communication Addressing and Reporting System (ACARS), ADS-B out messages, or Mode S. This new source would help updating the wind information furnished in meteorological aeronautical products (PAM), meteorological aerodrome reports (AIRMET), and significant meteorological information (SIGMET).

Behavior-Based Safety: Developing a Regional Guidance

A behavior-based safety program improves overall safety culture and safety performance of an organization. A solid behavior-based safety program is achieved by successfully implementing key components. Key components include management commitment to the process, an effective training program, a cohesive observation process and a successful data collecting and reporting system. This Applied Capstone project defines a regional approach for each of the key components of a behavior-based safety program. Recommendations resulting from the project provide the company studied guidance on developing a consistent behavior-based safety program.

Risk assessment for public health from human interaction with ornamental waters

Water is essential to life; nevertheless ingestion of contaminated water could result in death caused by waterborne diseases such as cholera. Pathogens present in the water can cause diseases, other than those resulting from water ingestion, being registered an increase in the number of case reports in recent years. It is not clear if this increase is due either to a better case reporting system or to an increase in microorganism’s virulence. The generalized use of antibiotics in agriculture and animal farming contributed to their dissemination in the environment which promotes microorganism selection and emergence of resistant strains. This phenomenon can be enhanced by the ability of microorganism to persist within complex communities known as biofilms. In the present work we aim to characterize the microbial population present in ornamental waters and perform a risk assessment for public health resulting from human interaction with it.

Trends in the prevalence of birth defects in Illinois and Chicago.

Description based on: 1989-1994.

Was an increase in cocaine use among injecting drug users in New South Wales, Australia, accompanied by an increase in violent crime?

Background: A sharp reduction in heroin supply in Australia in 2001 was followed by a large but transient increase in cocaine use among injecting drug users (IDU) in Sydney. This paper assesses whether the increase in cocaine use among IDU was accompanied by increased rates of violent crime as occurred in the United States in the 1980s. Specifically, the paper aims to examine the impact of increased cocaine use among Sydney IDU upon police incidents of robbery with a weapon, assault and homicide. Methods: Data on cocaine use among IDU was obtained from the Illicit Drug Reporting System (IDRS). Monthly NSW Police incident data on arrests for cocaine possession/ use, robbery offences, homicides, and assaults, were obtained from the Bureau of Crime Statistics and Research. Time series analysis was conducted on the police data series where possible. Semi-structured interviews were conducted with representatives from law enforcement and health agencies about the impacts of cocaine use on crime and policing. Results: There was a significant increase in cocaine use and cocaine possession offences in the months immediately following the reduction in heroin supply. There was also a significant increase in incidents of robbery where weapons were involved. There were no increases in offences involving firearms, homicides or reported assaults. Conclusion: The increased use of cocaine among injecting drug users following the heroin shortage led to increases in violent crime. Other States and territories that also experienced a heroin shortage but did not show any increases in cocaine use did not report any increase in violent crimes. The violent crimes committed did not involve guns, most likely because of its stringent gun laws, in contrast to the experience of American cities that have experienced high rates of cocaine use and violent crime.

Changes in the initiation of heroin use after a reduction in heroin supply

Increasing heroin use in Australia over the past 30 years has been associated with a decline in the age of initiation to heroin use. The 2001 Australian heroin shortage was used to assess the effects of a reduction in heroin supply on age of initiation into heroin injecting. Data collected from regular injecting drug users (IDU) over the period 1996-2004 as part of the Australian Illicit Drug Reporting System were examined for changes in self- reported age of first heroin use after the onset of the heroin shortage. Estimates were also made of the number of young people who may not have commenced injecting heroin during the heroin shortage. The proportion of IDU interviewed in the IDRS who were aged

Documenting the heroin shortage in New South Wales

Australian heroin markets have recently undergone dramatic change, sparking debate about the nature of such markets. This study aimed to determine the onset, peak and decline of the heroin shortage in New South Wales (NSW), using the most appropriate available methods to detect market level changes. The parameters of the heroin shortage were determined by reviewing: reports of heroin users about availability and price (derived from the existing literature and the Illicit Drug Reporting System); qualitative interviews with injecting drug users, and health and law enforcement professionals working in the illicit drug field; and examining data on heroin seizures over the past decade. There was a marked reduction in heroin supply in NSW in early 2001. An increase in the price of heroin occurred in 2001, whereas it had decreased steadily since 1996. A reduction in purity also occurred, as reported by drug users and heroin seizures. The peak period of the shortage appears to have been January to April 2001. The market appears to have stabilised since that time, although it has not returned to pre- 2001 levels: heroin prices have decreased in NSW for street grams, but not to former levels, and the price of `caps' (street deals) remain elevated. Heroin purity in NSW has remained low, with perhaps a 10% increase above the lowest recorded levels. These data support the notion that the heroin market in NSW underwent significant changes, which appear to have involved a lasting shift in the nature of the market.

Error recovery in a hospital pharmacy

A field study was performed in a hospital pharmacy aimed at identifying positive and negative influences on the process of detection of and further recovery from initial errors or other failures, thus avoiding negative consequences. Confidential reports and follow-up interviews provided data on 31 near-miss incidents involving such recovery processes. Analysis revealed that organizational culture with regard to following procedures needed reinforcement, that some procedures could be improved, that building in extra checks was worthwhile and that supporting unplanned recovery was essential for problems not covered by procedures. Guidance is given on how performance in recovery could be measured. A case is made for supporting recovery as an addition to prevention-based safety methods.