O erro médico na imprensa portuguesa: quando os pacientes fazem parte da notícia

Esta investigação aborda a qualidade da produção noticiosa sobre o erro médico, como um fator essencial na construção do conhecimento público sobre o tema, com o objetivo de compreender que características definem tal produção e até que ponto poderão ser explicadas pela periodicidade e orientação editorial dos jornais; que conceito de erro médico é veiculado pela produção noticiosa sobre o tema; e quais são os protagonistas no discurso jornalístico sobre o erro médico. Foram analisadas as edições de três jornais portugueses, de 2008 a 2011, resultando num corpus de 266 (4,2%) artigos, que foram classificados de acordo com as seguintes variáveis: as fontes de informação citadas (o seu estatuto e especialidade, no caso dos médicos); os temas que são tratados; as características de enquadramento da informação publicada (tom, género jornalístico; e a presença e número de fontes de informação). Pela análise de conteúdo quantitativa, apurou-se que esse tema está em crescimento, essencialmente com notícias de tom negativo e fontes de informação habitualmente identificadas. Não há evidência para afirmar que a periodicidade e a orientação editorial expliquem as variações dessas características, a não ser relativamente ao número de fontes citadas. Vigoram as notícias centradas nos resultados dos erros (mortes ou lesões), provocados por "erros de omissão" e por "erros de comissão", envolvendo uma diversidade de protagonistas: são, tal como acontece na informação sobre saúde em geral, fontes oficiais e especializadas do campo da saúde. Destacam-se os médicos e os juristas e é dado relevo aos pacientes.

Metaphorisms in programming

This paper introduces the metaphorism pattern of relational specification and addresses how specification following this pattern can be refined into recursive programs. Metaphorisms express input-output relationships which preserve relevant information while at the same time some intended optimization takes place. Text processing, sorting, representation changers, etc., are examples of metaphorisms. The kind of metaphorism refinement proposed in this paper is a strategy known as change of virtual data structure. It gives sufficient conditions for such implementations to be calculated using relation algebra and illustrates the strategy with the derivation of quicksort as example.

Использование корреляционных матриц ошибок для оценки погрешностей в обратных задачах сейсмологии

სტატიაში განხილულია მიწისძვრების ჰიპოცენტრის კოორდინატების განსაზღვრის სიზუსტის შეფასება ცდომილებათა კორელაციური მატრიცის გამოყენებით. მიდგომა ითვალისწინებს წრფივ შემთხვევას, ამიტომ გაწრფივებას ვახდენთ ტეილორის ფორმულის გამოყენებით

Recovering the Elliott invariant from the Cuntz semigroup

Let A be a simple, separable C*-algebra of stable rank one. We prove that the Cuntz semigroup of C (T, A) is determined by its Murray-von Neumann semigroup of projections and a certain semigroup of lower semicontinuous functions (with values in the Cuntz semigroup of A). This result has two consequences. First, specializing to the case that A is simple, finite, separable and Z-stable, this yields a description of the Cuntz semigroup of C (T, A) in terms of the Elliott invariant of A. Second, suitably interpreted, it shows that the Elliott functor and the functor defined by the Cuntz semigroup of the tensor product with the algebra of continuous functions on the circle are naturally equivalent.

The generator problem for Z-stable C*-algebras

The generator problem was posed by Kadison in 1967, and it remains open until today. We provide a solution for the class of C*-algebras absorbing the Jiang-Su algebra Z tensorially. More precisely, we show that every unital, separable, Z-stable C*-algebra A is singly generated, which means that there exists an element x є A that is not contained in any proper sub-C*- algebra of A. To give applications of our result, we observe that Z can be embedded into the reduced group C*-algebra of a discrete group that contains a non-cyclic, free subgroup. It follows that certain tensor products with reduced group C*-algebras are singly generated. In particular, C*r (F ∞) ⨂ C*r (F ∞) is singly generated.

Framework para la capa de presentación de aplicaciones web

El framework dissenyat, denominat magis, ajuda als desenvolupadors organitzant la presentació de continguts, l'accés a les funcions i serveis de negoci, el flux de pàgines, el processament de formularis, el maneig d'errors i la gestió d'estat.

The relationship between forensic science and judicial error: a study covering error sources, bias, and remedies

Summary : Forensic science - both as a source of and as a remedy for error potentially leading to judicial error - has been studied empirically in this research. A comprehensive literature review, experimental tests on the influence of observational biases in fingermark comparison, and semistructured interviews with heads of forensic science laboratories/units in Switzerland and abroad were the tools used. For the literature review, some of the areas studied are: the quality of forensic science work in general, the complex interaction between science and law, and specific propositions as to error sources not directly related to the interaction between law and science. A list of potential error sources all the way from the crime scene to the writing of the report has been established as well. For the empirical tests, the ACE-V (Analysis, Comparison, Evaluation, and Verification) process of fingermark comparison was selected as an area of special interest for the study of observational biases, due to its heavy reliance on visual observation and recent cases of misidentifications. Results of the tests performed with forensic science students tend to show that decision-making stages are the most vulnerable to stimuli inducing observational biases. For the semi-structured interviews, eleven senior forensic scientists answered questions on several subjects, for example on potential and existing error sources in their work, of the limitations of what can be done with forensic science, and of the possibilities and tools to minimise errors. Training and education to augment the quality of forensic science have been discussed together with possible solutions to minimise the risk of errors in forensic science. In addition, the time that samples of physical evidence are kept has been determined as well. Results tend to show considerable agreement on most subjects among the international participants. Their opinions on possible explanations for the occurrence of such problems and the relative weight of such errors in the three stages of crime scene, laboratory, and report writing, disagree, however, with opinions widely represented in existing literature. Through the present research it was therefore possible to obtain a better view of the interaction of forensic science and judicial error to propose practical recommendations to minimise their occurrence. Résumé : Les sciences forensiques - considérés aussi bien comme source de que comme remède à l'erreur judiciaire - ont été étudiées empiriquement dans cette recherche. Une revue complète de littérature, des tests expérimentaux sur l'influence du biais de l'observation dans l'individualisation de traces digitales et des entretiens semi-directifs avec des responsables de laboratoires et unités de sciences forensiques en Suisse et à l'étranger étaient les outils utilisés. Pour la revue de littérature, quelques éléments étudies comprennent: la qualité du travail en sciences forensiques en général, l'interaction complexe entre la science et le droit, et des propositions spécifiques quant aux sources d'erreur pas directement liées à l'interaction entre droit et science. Une liste des sources potentielles d'erreur tout le long du processus de la scène de crime à la rédaction du rapport a également été établie. Pour les tests empiriques, le processus d'ACE-V (analyse, comparaison, évaluation et vérification) de l'individualisation de traces digitales a été choisi comme un sujet d'intérêt spécial pour l'étude des effets d'observation, due à son fort recours à l'observation visuelle et dû à des cas récents d'identification erronée. Les résultats des tests avec des étudiants tendent à prouver que les étapes de prise de décision sont les plus vulnérables aux stimuli induisant des biais d'observation. Pour les entretiens semi-structurés, onze forensiciens ont répondu à des questions sur des sujets variés, par exemple sur des sources potentielles et existantes d'erreur dans leur travail, des limitations de ce qui peut être fait en sciences forensiques, et des possibilités et des outils pour réduire au minimum ses erreurs. La formation et l'éducation pour augmenter la qualité des sciences forensiques ont été discutées ainsi que les solutions possibles pour réduire au minimum le risque d'erreurs en sciences forensiques. Le temps que des échantillons sont gardés a été également déterminé. En général, les résultats tendent à montrer un grand accord sur la plupart des sujets abordés pour les divers participants internationaux. Leur avis sur des explications possibles pour l'occurrence de tels problèmes et sur le poids relatif de telles erreurs dans les trois étapes scène de crime;', laboratoire et rédaction de rapports est cependant en désaccord avec les avis largement représentés dans la littérature existante. Par cette recherche il était donc possible d'obtenir une meilleure vue de l'interaction des sciences forensiques et de l'erreur judiciaire afin de proposer des recommandations pratiques pour réduire au minimum leur occurrence. Zusammenfassung : Forensische Wissenschaften - als Ursache und als Hilfsmittel gegen Fehler, die möglicherweise zu Justizirrtümern führen könnten - sind hier empirisch erforscht worden. Die eingestzten Methoden waren eine Literaturübersicht, experimentelle Tests über den Einfluss von Beobachtungseffekten (observer bias) in der Individualisierung von Fingerabdrücken und halbstandardisierte Interviews mit Verantwortlichen von kriminalistischen Labors/Diensten in der Schweiz und im Ausland. Der Literaturüberblick umfasst unter anderem: die Qualität der kriminalistischen Arbeit im Allgemeinen, die komplizierte Interaktion zwischen Wissenschaft und Recht und spezifische Fehlerquellen, welche nicht direkt auf der Interaktion von Recht und Wissenschaft beruhen. Eine Liste möglicher Fehlerquellen vom Tatort zum Rapportschreiben ist zudem erstellt worden. Für die empirischen Tests wurde der ACE-V (Analyse, Vergleich, Auswertung und Überprüfung) Prozess in der Fingerabdruck-Individualisierung als speziell interessantes Fachgebiet für die Studie von Beobachtungseffekten gewählt. Gründe sind die Wichtigkeit von visuellen Beobachtungen und kürzliche Fälle von Fehlidentifizierungen. Resultate der Tests, die mit Studenten durchgeführt wurden, neigen dazu Entscheidungsphasen als die anfälligsten für Stimuli aufzuzeigen, die Beobachtungseffekte anregen könnten. Für die halbstandardisierten Interviews beantworteten elf Forensiker Fragen über Themen wie zum Beispiel mögliche und vorhandene Fehlerquellen in ihrer Arbeit, Grenzen der forensischen Wissenschaften und Möglichkeiten und Mittel um Fehler zu verringern. Wie Training und Ausbildung die Qualität der forensischen Wissenschaften verbessern können ist zusammen mit möglichen Lösungen zur Fehlervermeidung im selben Bereich diskutiert worden. Wie lange Beweismitten aufbewahrt werden wurde auch festgehalten. Resultate neigen dazu, für die meisten Themen eine grosse Übereinstimmung zwischen den verschiedenen internationalen Teilnehmern zu zeigen. Ihre Meinungen über mögliche Erklärungen für das Auftreten solcher Probleme und des relativen Gewichts solcher Fehler in den drei Phasen Tatort, Labor und Rapportschreiben gehen jedoch mit den Meinungen, welche in der Literatur vertreten werden auseinander. Durch diese Forschungsarbeit war es folglich möglich, ein besseres Verständnis der Interaktion von forensischen Wissenschaften und Justizirrtümer zu erhalten, um somit praktische Empfehlungen vorzuschlagen, welche diese verringern. Resumen : Esta investigación ha analizado de manera empírica el rol de las ciencias forenses como fuente y como remedio de potenciales errores judiciales. La metodología empleada consistió en una revisión integral de la literatura, en una serie de experimentos sobre la influencia de los sesgos de observación en la individualización de huellas dactilares y en una serie de entrevistas semiestructuradas con jefes de laboratorios o unidades de ciencias forenses en Suiza y en el extranjero. En la revisión de la literatura, algunas de las áreas estudiadas fueron: la calidad del trabajo en ciencias forenses en general, la interacción compleja entre la ciencia y el derecho, así como otras fuentes de error no relacionadas directamente con la interacción entre derecho y ciencia. También se ha establecido una lista exhaustiva de las fuentes potenciales de error desde la llegada a la escena del crimen a la redacción del informe. En el marco de los tests empíricos, al analizar los sesgos de observación dedicamos especial interés al proceso de ACE-V (análisis, comparación, evaluación y verificación) para la individualización de huellas dactilares puesto que este reposa sobre la observación visual y ha originado varios casos recientes de identificaciones erróneas. Los resultados de las experimentaciones realizadas con estudiantes sugieren que las etapas en las que deben tornarse decisiones son las más vulnerables a lös factores que pueden generar sesgos de observación. En el contexto de las entrevistas semi-estructuradas, once científicos forenses de diversos países contestaron preguntas sobre varios temas, incluyendo las fuentes potenciales y existehtes de error en su trabajo, las limitaciones propias a las ciencias forenses, las posibilidades de reducir al mínimo los errores y las herramientas que podrían ser utilizadas para ello. Se han sugerido diversas soluciones para alcanzar este objetivo, incluyendo el entrenamiento y la educación para aumentar la calidad de las ciencias forenses. Además, se ha establecido el periodo de conservación de las muestras judiciales. Los resultados apuntan a un elevado grado de consenso entre los entrevistados en la mayoría de los temas. Sin embargo, sus opiniones sobre las posibles causas de estos errores y su importancia relativa en las tres etapas de la investigación -la escena del crimen, el laboratorio y la redacción de informe- discrepan con las que predominan ampliamente en la literatura actual. De este modo, esta investigación nos ha permitido obtener una mejor imagen de la interacción entre ciencias forenses y errores judiciales, y comenzar a formular una serie de recomendaciones prácticas para reducirlos al minimo.

Sistema de comunicación para mensajería de ficheros (HL7)

El proyecto consiste en la creación de un sistema de mensajería que permita el envío y recepción de ficheros generados por el software de gestión sanitaria UNIT4 Ekon Salus. Las tareas a realizar son, por un lado, la portabilidad del sistema actual basado en Visual Basic a Java y, por el otro, la implementación de un sistema de control y notificación de errores, ya sean generados por el contenido de los ficheros o por la comunicación entre los programas de envío y recepción que constituyen el sistema de mensajería.

The hospital pharmacist: an important contributor to improved patient safety in the hospital.

Injectable drugs are high-risk products and their reconstitution in hospital wards is a potential source of errors. Thus, in order to secure the reconstitution process and thereby improve safety, the pharmacy department of Lausanne University Hospital is focusing on developing ready-to-use forms (CIVAS). These preparations are compounded in controlled clean rooms and are analyzed prior to release. In the intensive care unit, amiodarone 12.5 mg/mL in glucose 5% is one of the high-risk preparations, which has led the pharmacy to develop a ready-to-use solution. To this end, a one-year stability study was initiated, and the preliminary results (after six months) are illustrated here. A stability-indicating HPLC method was developed and validated for monitoring the concentration of amiodarone. Batches were stored at 5 °C and 30 °C, which were analyzed immediately after preparation, after one, two, four and six months of storage. The pH and osmolality values were monitored at the respective time intervals. It was observed that after six months, all the results were within specifications. However, the pH values started to decrease after two months when amiodarone was stored at 30 °C. After six months, a degradation peak appeared on the chromatogram of these solutions, which suggested that amiodarone is more stable at 5 °C. The preliminary results obtained in this study indicated that injectable amiodarone solutions are stable for six months under refrigerated storage conditions. The study is ongoing.

A two-stage approach for tonic identification in indian art music

In this paper we propose a new approach for tonic identification in Indian art music and present a proposal for acomplete iterative system for the same. Our method splits the task of tonic pitch identification into two stages. In the first stage, which is applicable to both vocal and instrumental music, we perform a multi-pitch analysis of the audio signal to identify the tonic pitch-class. Multi-pitch analysisallows us to take advantage of the drone sound, which constantlyreinforces the tonic. In the second stage we estimate the octave in which the tonic of the singer lies and is thusneeded only for the vocal performances. We analyse the predominant melody sung by the lead performer in order to establish the tonic octave. Both stages are individually evaluated on a sizable music collection and are shown toobtain a good accuracy. We also discuss the types of errors made by the method.Further, we present a proposal for a system that aims to incrementally utilize all the available data, both audio and metadata in order to identify the tonic pitch. It produces a tonic estimate and a confidence value, and is iterative in nature. At each iteration, more data is fed into the systemuntil the confidence value for the identified tonic is above a defined threshold. Rather than obtain high overall accuracy for our complete database, ultimately our goal is to develop a system which obtains very high accuracy on a subset of the database with maximum confidence.

Oral Correction in Foreign Language Classrooms

This paper analyses the correction of errors and mistakes made by students in the Foreign Language Teaching classroom. Its goal is to point out typical correction behaviors in Cape Verde in Language Teaching classrooms and raise teachers’ consciousness concerning better correction practice.

Controlo interno na prevenção de erros e fraudes

Atualmente, as situações de erros e fraudes, têm ocorrido com muita frequência a nível mundial. Por exemplo em Cabo Verde estas têm vindo a ganhar espaço nos mídias, onde a todo momento aparece casos de erros e fraudes, como por exemplo, os casos da Sociedade Cabo-verdiana de Tabacos, Banco Comercial do Atlântico, Caixa Económica, Câmara Municipal da Ribeira Brava, Associação Sport Club Moreirense, Sociedade de Segurança Industrial, Marítima e Comercial, Ministério das Finanças entre outros. Essas situações desfavoráveis para qualquer empresa, são derivadas de uma gestão menos cuidada dos recursos, e dos valores e princípios éticos cultivados pelas pessoas. O triângulo de fraude criada por Donald Cressey demonstra os motivos que leva um individuo a cometer atos fraudulentos, como sendo a motivação, a pressão e a oportunidade. Neste sentido, o controlo interno surge como uma ferramenta muito importante e fundamental para mitigar os riscos advenientes da ocorrência de erros e fraudes, suscetíveis de acontecer nas empresas. O controlo interno traduz num conjunto de medidas que protegem o património da empresa e garantem o cumprimento dos seus objetivos entretanto, como qualquer outra ferramenta de gestão está possui determinadas limitações que podem ser ultrapassadas com a utilização de alguns procedimentos básicos e, ou alternativos de controlo interno. É imprescindível que um sistema de controlo interno, para além de implementado, adequado e em funcionamento, seja mantido e acompanhado. O estudo dos casos da SILMAC, SA e da SCT, SA, mostram a importância que o controlo interno tem na prevenção e deteção de erros e fraudes, pois denota-se que as fraudes cometidas aconteceram na sequência de fraquezas de controlo interno e no excesso de confiança depositada nos colaboradores. Currently, the situations of errors and fraud have occurred very often in the world. Cape Verde in these situations have gained ground in the media, where every moment appears to errors and fraud cases, such as cases of “Sociedade cabo-verdiana de tabacos, Banco Comercial do Atlântico, Caixa Económica, Câmara Municipal da Ribeira Brava, Associação Sport Club Moreirense, Sociedade de segurança industrial, marítima e comercial, Ministério de finanças” amongst others. These situations which unfavorable for any company, are derived from a less carefully management of resources and ethical principles and values cultivated by people. The fraud triangle created by Donald Cressey, demonstrates reasons that lead an individual to commit fraudulent acts, such as motivation, opportunity and pressure. In this sense, internal control emerges as a very important tool to mitigate the risks arising from situations of errors and fraud, which are likely to happen in companies. The internal control translates into a set of measures that protect the assets of the business and ensure the fulfillment of its objectives however, like any other management tool is has limitations, however these can be overcome with the use of basic procedures, or alternative internal control. It is essential that an internal control system, in addition to implemented, adequate and functioning is maintained and monitored. The case studies of SILMAC and SCT, show the importance of internal control is the prevention and detection of errors and fraud. For note that the fraud occurred following oversights in its internal control and confidence in their employees.

Intrahippocampal cholinergic grafts in aged rats compensate impairments in a radial maze and in a place learning task

Age-related cognitive impairments were studied in rats kept in semi-enriched conditions during their whole life, and tested during ontogeny and adult life in various classical spatial tasks. In addition, the effect of intrahippocampal grafts of fetal septal-diagonal band tissue, rich in cholinergic neurons, was studied in some of these subjects. The rats received bilateral cell suspensions when aged 23-24 months. Starting 4 weeks after grafting, they were trained during 5 weeks in an 8-arm maze made of connected plexiglass tunnels. No age-related impairment was detected during the first eight trials, when the maze shape was that of a classical radial maze in which the rats had already been trained when young. The older rats were impaired when the task was made more difficult by rendering two arms parallel to each other. They developed an important neglect of one of the parallel tunnels resulting in a high amount of errors before completion of the task. In addition, the old rats developed a systematic response pattern of visits to adjacent arms in a sequence, which was not observed in the younger subjects. None of these behaviours were observed in the old rats with a septal transplant. Sixteen weeks after grafting, another experiment was conducted in a homing hole board task. Rats were allowed to escape from a large circular arena through one hole out of many, and to reach home via a flexible tube under the table. The escape hole was at a fixed position according to distant room cues, and olfactory cues were made irrelevant by rotating the table between the trials. An additional cue was placed on the escape position. No age-related difference in escape was observed during training. During a probe trial with no hole connected and no proximal cue present, the old untreated rats were less clearly focussed on the training sector than were either the younger or the grafted old subjects. Taken together, these experiments indicate that enriched housing conditions and spatial training during adult life do not protect against all age-related deterioration in spatial ability. However, it might be that the considerable improvement observed in the grafted subjects results from an interaction between the graft treatment and the housing conditions.

Sistemes logístics de codificació i identificació, i perspectives de futur

Comptar amb sistemes sofisticats de gestió o programes ERP (Enterprise Resource Planning) no és suficient per a les organitzacions. Per a què aquests recursos donin resultats adequats i actualitzats, la informació d’entrada ha de llegir-se de forma automàtica, per aconseguir estalviar en recursos, eliminació d’errors i assegurar el compliment de la qualitat. Per aquest motiu és important comptar amb eines i serveis d’identificació automàtica i col•lecció de dades. Els principals objectius a assolir (a partir de la introducció al lector de la importància dels sistemes logístics d’identificació en un entorn global d’alta competitivitat), són conèixer i comprendre el funcionament de les tres principals tecnologies existents al mercat (codis de barres lineals, codis de barres bidimensionals i sistemes RFID), veure en quin estat d’implantació es troba cadascuna i les seves principals aplicacions. Un cop realitzat aquest primer estudi es pretén comparar les tres tecnologies per o poder obtenir perspectives de futur en l’àmbit de l’autoidentificació. A partir de la situació actual i de les necessitats de les empreses, juntament amb el meravellós món que sembla obrir la tecnologia RFID (Radio Frequency Identification), la principal conclusió a la que s’arribarà és que malgrat les limitacions tècniques dels codis de barres lineals, aquests es troben completament integrats a tota la cadena logística gràcies a l’estandarització i la utilització d’un llenguatge comú, sota el nom de simbologies GTIN (Global Trade Item Number), durant tota la cadena de subministres que garanteixen total traçabilitat dels productes gràcies en part a la gestió de les bases de dades i del flux d’informació. La tecnologia RFUD amb l’EPC (Electronic Product Code) supera aquestes limitacions, convertint-se en el màxim candidat per a substituir els limitats codis de barres. Tot i això, RFID, amb l’EPC, no serà un adequat identificador logístic fins que es superin importants barreres, com són la falta d’estandarització i l’elevat cost d’implantació.

Spatio-temporal Brain Dynamics Mediating Post-error Behavioral Adjustments.

Optimal behavior relies on flexible adaptation to environmental requirements, notably based on the detection of errors. The impact of error detection on subsequent behavior typically manifests as a slowing down of RTs following errors. Precisely how errors impact the processing of subsequent stimuli and in turn shape behavior remains unresolved. To address these questions, we used an auditory spatial go/no-go task where continual feedback informed participants of whether they were too slow. We contrasted auditory-evoked potentials to left-lateralized go and right no-go stimuli as a function of performance on the preceding go stimuli, generating a 2 × 2 design with "preceding performance" (fast hit [FH], slow hit [SH]) and stimulus type (go, no-go) as within-subject factors. SH trials yielded SH trials on the following trials more often than did FHs, supporting our assumption that SHs engaged effects similar to errors. Electrophysiologically, auditory-evoked potentials modulated topographically as a function of preceding performance 80-110 msec poststimulus onset and then as a function of stimulus type at 110-140 msec, indicative of changes in the underlying brain networks. Source estimations revealed a stronger activity of prefrontal regions to stimuli after successful than error trials, followed by a stronger response of parietal areas to the no-go than go stimuli. We interpret these results in terms of a shift from a fast automatic to a slow controlled form of inhibitory control induced by the detection of errors, manifesting during low-level integration of task-relevant features of subsequent stimuli, which in turn influences response speed.