Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting

OBJECTIVE: Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. DESIGN: /st>Qualitative research design using documentary analysis and semi-structured interviews. SETTING: /st>Two large teaching hospitals in London; one providing acute and the other mental healthcare. PARTICIPANTS: /st>Sixty-two healthcare practitioners with experience of reporting and analysing incidents. RESULTS: /st>Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals. CONCLUSION: /st>Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.

Episodes in the Malaysian auditing sage

Purpose – The purpose of this paper is to examine the various episodes in the Malaysian auditing saga, covering the period of the first 40 years post-independence in 1957 to just before the onset of the Asian Financial Crisis in 1997. Design/methodology/approach – Based on documentary analysis, the paper offers a historical account of the development of the auditing profession with reference to the dynamic changes in its political and socio-economic environment. Findings – The paper concludes that the function of auditing in Malaysian society responded to political-economic pressures over time viz. changing from maintaining the economic policy to serve Western investors to accommodating ethnic relations, and to strengthening the bond between local and global corporate elites and the political leaders. Originality/value – Since, little is known of the professionalisation process in Malaysia, our analysis of the structural conditions during the 40 years from the achievement of independence from the British in 1957 to just before the onset of the Asian Financial Crisis in 1997 and our assessment of their implications for auditing contributes to knowledge in this area

Kormányzati koordináció Magyarországon. Esettanulmány az egyablakos ügyfélszolgálati reformról (Governmental coordination in Hungary: Case study on the one-stopgovernment service reform)

A tanulmány a központi kormányzat koordinációs politikájának jellemző mintázatait vizsgálja. A vizsgálat fókuszában a magyar kormányzati szférában újonnan bevezetett koordinációs eszköz, a kormányablak, mint egyablakos ügyfélszolgálati modell tanulmányozása áll. A kutatás empirikus bázisát a kormányzati és közigazgatási kulcsszereplőkkel készített kvalitatív interjúkból és a dokumentumelemzésből származó adatok analitikus vizsgálata adja. A szerző a tanulmányban szemügyre veszi a kormányzati koordináció gyakorlatát Magyarországon, elemzi, hogy ez mennyire tér el más országokétól. ____ The paper examines, on the basis of qualitative interviews and documentary analysis, the emerging patterns of government policy coordination in Hungary. The focus of the paper is on a recent case of innovative policy coordination measure introduced by the Hungarian government: the newly established “Government Windows”, the one-stop-government initiative. The paper investigates such questions as what the main characteristics of the coordination traditions in Hungary are, what are the specific structural features of the newly established governmental coordination instruments, and how do they differ from of other countries’ similar experiences.

Programa Nacional de Incentivo à Leitura - PROLER: avaliação da implementação pelo Comitê Potiguar

The National Reading Incentive Program (PROLER) is a national initiative to promote and encourage reading throughout the country, linked to the National Library Foundation (FBN) of the Ministry of Culture (MinC). This research aims to assess the PROLER’s implementation process in the state of Rio Grande do Norte, from the actions of their local committee. The framework is based on contextualize the policies that seek to encourage the book and reading, as well as the processes of implementation and evaluation of public policies. The research is understood as a qualitative descriptive-exploratory study, comprising a single case study. Makes use of semi-structured interview as a tool for data collection, which was attended by 8 members of Potiguar Committee as respondents. The techniques of bibliographical and documentary analysis were used for the analysis and discussion of data obtained from surveys and documents on PROLER; as to the content of the interviews, the technique used was the analysis of conversations. As for the results, the existence of four barriers to program implementation in the state that are worth mentioning is observed: a) the political-administrative discontinuity; b) the limited resources and few partnerships; c) the management of school libraries and absence from the post of librarian in the state and; d) the absence of a process or assessment tool able to evaluate the results or the impacts of actions taken by the Potiguar Committee. It was noticed that these limiting four come PROLER making the implementation of the Rio Grande do Norte a process that, although complying with the national regulations of teacher training and follow school libraries and their needs, not flawed to develop assessments that can measure program impacts, making the feedback process of ineffective policy. Another observation of this study is seen in the fact that the Committee did not get enough to supply their shares resources, as well as not being able to articulate new partnerships, thus contributing negatively to the scope of the program form and, consequently, for the effectiveness of their actions. Has even mentioning the fact that the Committee do nothing regarding the mismanagement of the libraries that are in their care, ie, do not use the power of coercion as guaranteed by the National Policy on Reading and federal laws that treat the school library, and is therefore ineffective in relation to compliance with the program guidelines

Produção do mestrado profissional em ensino de ciências naturais e matemática da UFRN (física e química/2005-2012): papel dos documentos oficiais e características dos produtos educacionais

The importance of the Professionals Master in the field of science education is revealed by the recognition that they provide, to practicing teachers, in particular, training spaces for reflection and application of knowledge. This work appears in the context of the project "Research and training in teaching science and mathematics: a cutout of academic production in the northeast and overview of formative action in basic education" on the Centre for Education program, which main objective was to conduct studies description, analysis and evaluation of the academic production of Postgraduate Programs in Science Teaching of UFRPE, UFRN and UEPB and investigate the contribution of continuing education in stricto sensu level, of graduated teachers to improve the quality of basic education . We sought to examine a cut of academic production PPGECNM / UFRN, taking as reference dissertations of Natural Sciences, finished between the years 2005 and 2012, which have developed and applied educational products for high school students. More specifically we sought to conduct a general characterization of the dissertations analyzed for basic descriptors, to understand if and how the official documents governing the Brazilian education, especially science education, subsidized development of dissertations and identify current trends for science teaching are addressed and which ones are used in preparing the product of dissertations. The survey was based on documentary analysis, a type of qualitative approach in which the documents are objects of study in themselves. The results revealed that most of the work was developed in public schools, on subjects of physics and chemistry. During analytical reading of the text of the dissertations was observed that, in its construction, most of them addressed somehow, official documents governing the Brazilian educational system, that the products are basically teaching units and teaching approaches that are more focused on Experimentation and History and Philosophy of Science

Avaliação de política pública: o ProInfo e sua gestão no município de Parnamirim (2009-2012)

The dissertation assesses aspects of the management of IT in Education Program (ProInfo), in the municipality of Parnamirim-RN. Checks as their management functions, with the following objectives: a) Examine whether the objectives of the activities related to teachers' program are being implemented according to the official documents, b) examine if there is a monitoring program activities as the activities of teachers c) Identify whether teachers develop activities and environments using the technological resources of the internet. The research brings a central issue: How ProInfo is subsidizing the activities of the teachers involved in the program to achieve their goals effectively? As a central hypothesis of this work, to be a general north to the research, we have: the ProInfo establishes a fragile and discontinuous link between the management of the activities of teachers and the goals that he sets. The hypothesis was validated by the analysis of data from field research, when we encounter a series of limiting aspects of program effectiveness at the municipal level. This research was undertaken with managers of state and municipal schools and teachers, using a sample of four schools Parnamirim-RN, in order to include some aspects of program management at the municipal level and effectiveness goals proposed, focusing on teachers who participated in the training. The methodological process consisted of literature review, interviews and documentary analysis carried to the organs responsible for ProInfo statewide (UNDIME/RN ) and municipal level, next to the Municipal Education Parnamirim-RN. Based on data collected from empirical field research, it was found that the ProInfo lacks periodic reviews by the governing bodies of the program, about the actions developed through appropriate instruments, which enable a more realistic view of the results of the program ex post (during or after deployment)

O atendimento às adolescentes autoras de atos infracionais no estado do Rio Grande do Norte

The objective of this study was to investigate the assistance for the female adolescents perpetrators of offences in the state of Rio Grande do Norte. Through the Thematic Oral History and Documentary Analysis methods, we sought to uncover historical aspects of the work provided in women’s units of the Fundação dos Direitos das Crianças e Adolescentes (FUNDAC) [Foundation for the Rights of Children and Adolescents], from the experiences of professionals who have worked in these units since the beginning of their activities. For this, we made visits to FUNDAC and the Centro Educacional Padre João Maria (CEDUC) [Educational Center Father João Maria], to identify professionals who could participate in the study, as well as institutional documents on routine of treatment. Eight professionals were found from three identified units: Granja Santana, Instituto Padre João Maria and CEDUC, who were interviewed according to a semi-structured script. The analysis of the collected material is supported in Marxian theory and feminist perspective on the sexual division of labor. The results are organized into five areas of analysis: (1) the creation of the service units; (2) the deviant “behavior”: reasons for institutionalization of female adolescents; (3) educational proposal: a female version; service strategies and; the rules and punishment: the domesticated teenage girl. The study indicates that the commission of the offense by the female adolescents in state of Rio Grande do Norte (RN) has been associated with the conduct of their families, particularly their mothers. Moreover, in general, service strategies, educational proposals, disciplinary measures were and have been developed based on the naturalization of what is female. Therefore, the assistance to adolescent girls in RN, those thirty-five years, left intact the existing hierarchy in social relations between the sexes, it reproduced the subordination of female adolescents in the juvenile justice system.

Proposta de modelo de gestão de riscos para uma IFES visando a realização de auditoria baseada em riscos

Organizations are susceptible to the occurrence of many events that may affect the achievement of their objectives. As a result, Brazilian Public Administration supervisory bodies have required institutions to adopt risk management policies. Given the large number of recommendations issued by Federal Audit Court (TCU) to various Federal Institutions of Higher Education (IFES) in this area, it is proposed a risk management model for Universidade Federal do Rio Grande do Norte (UFRN). This is an applied, exploratory and qualitative study. Regarding to technical procedures, it is characterized as documentary analysis, bibliographical research, case study and action research. The bibliographical research was used to support the elaboration of the Risk Management Guide for Federal Institutions of Higher Education (GERIFES). The documentary analysis, in turn, was used with the aim of knowing the organizational structure and the university´s macroprocesses. The author works in the university internal auditing department and shares the same problem. This characterizes the work as an action research. The case study supported both the elaboration of the guide and the simulation of the specific functionality for the university information system, demonstrated through the User Manual Module "Risk Management" proposed for the Integrated System of Property, Administration and Contracts (SIPAC). This manual has been prepared in order to facilitate the use of this tool if it will be incorporated into the university information system. As research results, a risk management model for UFRN was elaborated and a simulation of an informational tool, which is able to manage risks related to events that may affect the achievement of institutional objectives, was provided to the university administration.

Crianças e investigação: aspectos teórico-metodológicos e cuidados éticos nas produções dos grupos de pesquisa da UFRN

The concepts of childhood are part of a cultural construction and vary throughout history politically, economically and socially. Nouns such as "childhood" and "child" did not exist as sense of unity in periods prior to modernity, reinforcing their historical character as concepts that have been socially constructed as profess the Historical Social Psychology, theoretical perspective which will support this research. The sociology of childhood distinguishes the terms and changes the approach toward the adult researcher approach with respect to children, aiming to give voice to the child. When it comes to defining the role of children in research, the researcher must take into consideration several relevant criteria such as age, gender, time, listening to the adults close to the children, the level of language and education and which children that will be heard in a group. It is from this discussion, considering the importance of children's participation in the research that are established the purpose of this work, namely, to analyze the theoretical and methodological aspects and ethical guidelines considered in the research process with children, by researchers at the UFRN, presenting as specific objectives: analyze and discuss, from research reports, the adopted ethical procedures and methods used in research with children. Set the goal, it was made a search of the UFRN Research Groups in SIGAA in order to select those which investigate children for participating in our survey. Among the centers of UFRN, we selected the Health Sciences Centre - CCSA, the Humanities Center, Letters and Arts - CCHLA, the Biosciences Center - CB and the Health Sciences Center - CCS, a total of 64 finalized reports to be analyzed. And here it is the observation that the foolish reports were not analyzed for ethical reasons as the guiding of this dissertation is the coordinator of the research group mentioned. In this study, we chose the documentary analysis of the finalized reports from UFRN research projects teachers / researchers as procedure to set up the corpus of the research. Data analysis was performed from the qualitative analysis in the following categories were established: the concept of childhood, concept of child, age of the subjects, the research context, theoretical and methodological care adopted and ethical care. It is hoped that this study will contribute with reflections on the ethical and theoretical and methodological care on research with children. The research showed how some of the results: significant number of reports excluded by repetition, most reports did not bring any closing remarks, no different procedures for children, with rare exceptions, the ethical issue was not mentioned in 50% of reports.

CONTEXTUALIZAÇÃO E AS PERSPECTIVAS DA EDUCAÇÃO SALESIANA A PARTIR DO DOCUMENTO DAS LINHAS ORIENTADORAS DA MISSÃO EDUCATIVA DO INSTITUTO DAS FILHAS DE MARIA AUXILIADORA

A presente dissertação teve como objetivos contextualizar e analisar as perspectivas da educação salesiana a partir do documento das Linhas Orientadoras da Missão Educativa do Instituto das Filhas de Maria Auxiliadora, tendo em vista aprofundar o contexto histórico e sociocultural da fundação do Instituto das Filhas de Maria Auxiliadora e do desenvolvimento da missão educativa salesiana, com a finalidade de atuar no campo da educação, indicar os fundamentos interdisciplinares que compreendem os fundamentos teóricos para a prática educativa em relação aos aspectos sociológicos, antropológicos, teológicos e pedagógicos, além de algumas experiências práticas da educação salesiana. A pesquisa considera a contextualização da sua prática educativa a partir de diversas contribuições teóricas realizadas em torno da história do Instituto e dos conhecimentos interdisciplinares que integram seus propósitos e seus projetos educativos. Com a perspectiva de analisar as orientações e conteúdos do documento é utilizada a técnica da análise documental que permite interpretar o seu significado, analisar e indicar algumas perspectivas de educação salesiana presentes no documento e que envolvem os seus princípios, propósitos e as suas ações em relação à educação. Por meio da observação participante alguns aspectos práticos das perspectivas da educação salesiana foram demonstrados. Portanto, a investigação permite o mapeamento das perspectivas fundamentais da educação salesiana a partir das Linhas Orientadoras e a possibilidade de aprofundar a significatividade das perspectivas de referência para a prática educativa conforme são indicadas no documento: as dimensões cultural, evangelizadora, social e comunicativa da educação, que são os elementos e princípios fundamentais do Sistema Educativo Salesiano. A concepção de educação salesiana que se constrói a partir de uma visão interdisciplinar, complexa e dimensional, com uma perspectiva de uma estratégia projetual. Os seus princípios integram alguns valores que são considerados como fundamentais para a realização de uma educação integral: a comunidade educativa, o trabalho educativo realizado em equipe, a espiritualidade juvenil, a preventividade e a pedagogia do ambiente. Sobretudo, os núcleos centrais indicados pelo documento orientam as comunidades para a realização de um pensamento projetual, considerando as diversas dimensões da educação, com uma especial abertura para uma contínua projeção das suas intenções e da sua prática educativa. Enfim, encontramos algumas contribuições para a educação a partir do pensamento pedagógico e prático da educação salesiana, especialmente em relação à proposta de pensar a educação de forma complexa e multidimensional.

Saúde da população “trans”: uma revisão sistemática da produção teórica brasileira

This dissertation analyzed the existing work on travestility and transsexuality whose problematic research focused on issues related to health and / or health services. For this purpose, a Literature Review Systematized Descriptive in virtual databases was performed: Bank of Higher Education Personnel Improvement Coordination Thesis (CAPES), Brazilian Digital Library of Theses and Dissertations (BDTD), Scielo and PubMed, between the years 1997 and 2014 in Brazil. We used the search terms "transsexual," "transvestite" and "transgender", each associated with the search term "health", in Portuguese and English. Complementing this search, we used the Documentary Analysis methodology to assess pamphlets productions, institutional documents and non-governmental organizations (NGOs), which were incorporated into the discussion. 295 papers were identified, among theses, dissertations and scientific articles. Of these, 223 were excluded and 72 selected for analysis. Thus, it obtained five theses and dissertations 21 on the topic of travestility and 7 theses and dissertations 9 that deal with transsexuality. Among the selected papers, 16 deal with transsexuality and health, 5 address the issue of travestility and health and work, 9 refer to the term "transgender" and "health". Even though it is an emerging field of research, there is an apparent deviation of the speech, previously anchored in questions whose topics are related to confrontation, infection or illness by HIV / AIDS (level of specialized care) for discussions on the health care for transsexuals in the process (level of specialized care). Still, few papers have specific trans attention in primary care associated with a comprehensive health care, with the empowerment of individuals, respecting the power of life, which are configured as important issues for the Public Policy on Health today.

Organisational and systems factors impacting on patient safety in acute care organisations: lessons from four multi-site research studies

Background Patient safety is concerned with preventable harm in healthcare, a subject that became a focus for study in the UK in the late 1990s. How to improve patient safety, presented both a practical and a research challenge in the early 2000s, leading to the eleven publications presented in this thesis. Research question The overarching research question was: What are the key organisational and systems factors that impact on patient safety, and how can these best be researched? Methods Research was conducted in over 40 acute care organisations in the UK and Europe between 2006 and 2013. The approaches included surveys, interviews, documentary analysis and non-participant observation. Two studies were longitudinal. Results The findings reveal the nature and extent of poor systems reliability and its effect on patient safety; the factors underpinning cases of patient harm; the cultural issues impacting on safety and quality; and the importance of a common language for quality and safety across an organisation. Across the publications, nine key organisational and systems factors emerged as important for patient safety improvement. These include leadership stability; data infrastructure; measurement capability; standardisation of clinical systems; and creating an open and fair collective culture where poor safety is challenged. Conclusions and contribution to knowledge The research presented in the publications has provided a more complete understanding of the organisation and systems factors underpinning safer healthcare. Lessons are drawn to inform methods for future research, including: how to define success in patient safety improvement studies; how to take into account external influences during longitudinal studies; and how to confirm meaning in multi-language research. Finally, recommendations for future research include assessing the support required to maintain a patient safety focus during periods of major change or austerity; the skills needed by healthcare leaders; and the implications of poor data infrastructure.

Política de promoção da exportação : um olhar sobre a evolução da cultura de melão do Rio Grande do Norte

Some sectors in Brazil are earning notoriety in the international market, configuring itself in dynamic areas for the Country. The most typical case is the agribusiness. Rio Grande do Norte state has important role, because 90% of the output of the melon exported by Brazil is produced at Assu/Mossoró. The present work planned to verify the evolution of the culture of the melon produced at Assu/Mossoró area, from 1990 to 2003. Through descriptive research, utilizing the case study and documentary analysis of secondary data this work showed the evolution of the area reaped of melon in the pole Assu/Mossoró, the quantity produced of melon and of the value of the output of the melon between 1990 and 2003. The research verified that all of the factors studied show growth during the analyzed period, showing up the importance of the agribusiness for the region. However the analysis shows the vulnerability of the sector concerning external macroeconomics factors, such as the exchange rates. Showing the importance and/or dependence of the producers for public actions to development of the culture, that might be on areas like infrastructure, economics or taxes

Relações interorganizacionais e eficiência coletiva: um estudo de caso no arranjo produtivo local de confecções do Agreste de Pernambuco

This work is a study in the Local Productive Arrangement of confections from Agreste of Pernambuco, as a relevant sector in economic and social aspect. This research has as central aim to understand how the inter-organizational relations influence the collective efficiency of arrangement. The theoretical framework employed highlights the approaches that deal with the benefits of business agglomeration for the develop­ment of firms and regions. It has discussed the approach of small and medium enter­ prises and industrial districts (SCHMITZ, 1997), which introduce the concept of col­ lective efficiency, explaining that only those externalities explained by Marshall (1996) are not sufficient to explain the competitive advantage of enterprises, expand­ing the idea that organizations achieve competitive advantage not acting alone. To examine the influences of relations in the collective efficiency, it has been taken as analytical perspective theory of social networks (GRANOVETTER, 1973, 1985; BURT, 1992; UZZI, 1997) because it has believe that this approach provides subsi­ dies for a structural analysis of social relationships in face the behavior of human ac­tion. By examining the organizations in a social network, you should understand the reason of this establishment of the relationship, their benefits, and as the information flow takes place and density of links between the actors (Powell; SMITH-DOERR, 1994). As for the methods, this study is characterized as a case study, in according to the purposed objectives, in addition to qualitative method. Also, due to recovering of the historical milestones of the arrangement, it is used a sectional approach with longitudinal perspective (VIEIRA, 2004). The primary and secondary data were used in order to understand the evolutionary process of the sector and their inter-actors re­ lationships in the arrangement for the promotion of development, for both, was used the contend and documentary analysis technique, respectively (DELLAGNELO ; SIL­VA, 2005). The approach of social networks has permitted understand that social re­lationships may extend the collective efficiency of the arrangement, and therefore need to develop policies that encourage the legalization of informal companies in ar­rangement, by showing up themselves representative. Thus, the relations estab­ lished in LPA of confections from Agreste of Pernambuco need for more effective mechanisms to broaden the collective efficiency. Therefore, this way as take place has directly benefited only a group of companies that are linked in some way the sup­portive institutions. So we can conclude that the inter-actor relations have limited the collective efficiency of LPA, being stimulated by the institutions in support only to groups of entrepreneurs, even those that produce external relations for all clustered companies

Relações interorganizacionais e confiança no setor da carcinicultura: um estudo de caso na camanor produtos marinhos

This study investigated how the types of confidence based on competence and good will act in the formation and maintenance of cooperation relationships between the Camanor and its partners (Aquatec, Purina, Caçuá, Uvifrios and Malta / Cleyton). It used organizational approaches on networks based primarily on studies of Powell (1987, 1990), Das and Teng (2000, 2001), Child (2001) and Contractor and Lorange (2004) which have described the advantages that cooperative relationships can provide, as well as their limits as alternative governance structures. Confidence has been considered an important factor affecting the actions and development of organizations involved in networks or in strategic alliances (ZAHEER; HARRIS, 2006) and is the most appropriate control mechanism in these situations (SYDOW, 1998). Confidence is seen from two different approaches: the economic and the sociological (ZAHEER; HARRIS, 2006). To facilitate the understanding of confidence some typologies have been created, as proposed by Barney and Hansen (1994), Lane (1998), Das and Teng (2000), Child (2001) and Wever, Martens and Vandenbempt (2005). This study made use of the case study as proposition of Yin (2005). Semi-structured interviews were held with pre-determined routes, in a single stage performed in early 2008. The research subjects were owners and / or responsible for Camanor and its business partners (Aquatec, Purina, Caçuá, Uvifrios and Malta / Cleyton). Also secondary data were collected in several sites related to the industry and enterprises studied, in addition to data collected by previous studies conducted by CARCINEREDES (2006). The primary data were analyzed using the analysing technique of the content proposed by Bardin (1994). Regarding the secondary data, they were qualitatively analyzed according to documentary analysis technique (BARDIN, 1994). Thus, through the data collected, could be concluded that although there is confidence based on good faith in relationships(UZZI, 1998; OF; TENG, 2001), their presence does not determine the formation and / or maintenance of a partnership, serves only in order to facilitate the relationship, making them more flexible. The confidence based on competence (DAS; TENG, 2001) influenced the formation and maintenance of relations studied. Because whether or not to form a relationship with another organization it is used the perception of the partner acts, namely the reputation (image) as decision basis. And it is through the verification of the performance of the partner activities that will determine the continuation of the partnership