Segurança do doente em cuidados de saúde primários : aplicação do Diagrama de Ishikawa à análise de incidentes

RESUMO - A segurança do doente constitui um dos grandes desafios dos cuidados de saúde do séc. XXI e é um componente essencial da qualidade em saúde. Os Cuidados de Saúde Primários representam o primeiro nível de contacto dos indivíduos, da família e da comunidade com o sistema de saúde. O objectivo deste trabalho foi aplicar o Diagrama de Ishikawa no estudo dos incidentes ocorridos numa unidade de Cuidados de Saúde Primários – Unidade de Saúde Familiar Marginal. A análise das causas dos incidentes relatados (n=379) mostrou que os factores associados à „tarefa‟ foram os mais frequentes (n=196) e os factores associados ao doente foram os menos frequentes (n=22). A análise de correlações mostrou uma associação positiva entre os factores da tarefa e os factores da equipa e entre os factores da tarefa e os factores da comunicação (p<0.05). Esta análise mostrou ainda, uma associação negativa entre os factores das condições de trabalho e os factores da organização (p<0.05). As medidas de discriminação aplicadas aos resultados da análise de correlação múltipla, mostraram que os factores da comunicação, os factores individuais, as condições de trabalho e o contexto institucional foram as principais associações encontradas. A análise qualitativa de oito incidentes, permitiu reflectir sobre medidas de melhoria. Este estudo aponta para a utilidade da aplicação do Diagrama de Ishikawa no apuramento das causas sistémicas mais prováveis de um incidente, e na identificação de necessidades de atuação na gestão de risco dentro das organizações. Será, no entanto, necessário testar este instrumento em outras unidades de cuidados de Saúde Primários.

A comparative review of risk based portfolio allocations: An empirical study throughout rising yields

Since the financial crisis, risk based portfolio allocations have gained a great deal in popularity. This increase in popularity is primarily due to the fact that they make no assumptions as to the expected return of the assets in the portfolio. These portfolios implicitly put risk management at the heart of asset allocation and thus their recent appeal. This paper will serve as a comparison of four well-known risk based portfolio allocation methods; minimum variance, maximum diversification, inverse volatility and equally weighted risk contribution. Empirical backtests will be performed throughout rising interest rate periods from 1953 to 2015. Additionally, I will compare these portfolios to more simple allocation methods, such as equally weighted and a 60/40 asset-allocation mix. This paper will help to answer the question if these portfolios can survive in a rising interest rate environment.

Avaliação do risco de LMEMSLT : aplicação dos métodos RULA e SI / Florentino , António de Sousa Uva

RESUMO - A frequente insuficiência de informação e até, eventualmente, a presença de elementos cientificamente pouco robustos (ou mesmo hipotéticos) no procedimento de obtenção dos resultados finais (scores) com os diversos métodos de avaliação do risco, julga-se determinar a obtenção de distintos resultados no mesmo posto de trabalho e que interessam analisar. O presente estudo foi efectuado numa empresa da indústria automóvel e pretendeu contribuir para a efectividade do processo de avaliação do risco destas lesões em meio industrial. Utilizaram-se como ponto de partida as classificações de risco em postos de trabalho onde a aplicação do método OCRA — base do projecto de norma Europeu prEN 1005-5 para a estimativa do risco de LMEMSLT (Lesões Musculoesqueléticas do Membro Superior Ligadas ao Trabalho) — identificou níveis de risco moderados e/ou elevados (score OCRA ≥ 16,5). Assim nos postos de trabalho (n = 71) registou-se em vídeo a actividade de trabalho. Analisaram-se os principais factores de risco (postura, força, repetitividade e exposição a vibrações) com uma amostragem de segundo em segundo e aplicaram-se dois métodos: 1) RULA (McAtamney; Corlett, 1993); 2) SI (Moore; Garg, 1995). Dos resultados globais da aplicação dos métodos identificam- se discrepâncias evidentes: o método SI classificou 41 postos de risco elevado e o método RULA classificou apenas 26 postos de risco. Destaque para as divergências entre os postos classificados de risco elevado como, por exemplo: de entre os 41 postos com scores de risco da aplicação do método SI apenas se encontram 12 postos classificados de risco pelo método RULA. Os resultados permitem evidenciar validades preditivas diversas para os factores de risco analisados: 1) situações de aplicação de força (SI = 0,80; RULA = 0,66); 2) presença de posturas extremas (SI = 0,68; RULA = 0,48); 3) repetitividade (SI = 0,35; RULA = 0,43). Conclui-se pela divergência de resultados dos métodos SI e RULA aplicados nos mesmos postos de trabalho que tal situação alerta para a pertinência da utilização de um filtro que permita a identificação dos factores de risco presentes em cada posto de trabalho e que, por consequência, oriente a selecção do método mais indicado ou ainda, em oposição, do método contra-indicado. Este trabalho, como um contributo para uma efectiva identificação e avaliação do risco de LMEMSLT, conduz, no limite, à necessidade de elaboração de uma «grelha» das «grelhas» e de informação mais precisa sobre os métodos e sua aplicação, permitindo, desse modo, uma mais efectiva gestão do risco destas lesões.

Aspergilli and Penicillia related to the surface of ripening italian grana type cheese and its ripening environment

Information available on the mycoflora associated to ripening Italian “grana type” cheese is very poor. Recently, ochratoxin A (OTA) was detected in samples of packed grated cheese [1]; therefore, the need of information to perform a risk management was highlighted. Moreover, sterigmatocystin (STC) has been reported in cheese and it is considered an emerging problem. Despite the fact that both of them are mycotoxins included in group 2B by IARC [2,3], no European regulation exists. So, the main goal of this work is to give for the first time a general overview about Penicillia and Aspergilli growing on the surface of ripening “grana type” cheese, with particular attention on mycotoxigenic species. To perform this, in 2013 and 2014 crust samples were scratched from ripening grana cheese wheels and also Potato Dextrose Agar plates were exposed to monitor ripening house air. Then, 140 fungal isolates were randomly chosen, purified and monosporic colonies were obtained for their identification at specie level. A polyphasic approach is followed, based on morphological characterisation, toxic extrolites profiling and gene sequencing. The identification is still in progress, but the first results based on the morphological approach showed the presence of mycotoxigenic Aspergilli (Aspergillus flavus and A. versicolor) and various Penicillium species; among them Penicillium chrysogenum, P. implicatum and P. solitum were identified. Only P. chrysogenum was reported to produce the mycotoxins cyclopiazonic acid (CPA) and roquefortine-C (ROQ-C) [4]. These results will be presented and discussed. [1] A. Biancardi, R. Piro, G. Galaverna, C. Dall’Asta, "A simple and reliable liquid chromatography–tandem mass spectrometry method for determination of ochratoxin A in hard cheese" International Journal of Food Sciences and Nutrition 64 (5), 2013, 632 – 640. [2] International Agency for Research on Cancer (IARC) “IARC Monographs on the Evaluation of Carcinogenic Risks to Humans” 31, 1983, 191 – 199. [3] International Agency for Research on Cancer (IARC) “IARC Monographs on the Evaluation of carcinogenic Risks to Humans”, suppl. 7, 1987, 72. [4] J. I. Pitt, D. A. Hocking, “Fungi and Food Spoilage” 1997, 291.

“Safety and health” as a criterion in the choice of tunneling method

Risk management is of paramount importance in the success of tunnelling works and is linked to the tunnelling method and to the constraints of the works. Sequencial Excavation Method (SEM) and Tun-nel Boring Machine (TBM) method have been competing for years. This article, part of a wider study on the influence of the â Safety and Healthâ criterion in the choice of method, reviews the existing literature about the criteria usually employed to choose the tunnelling method and on the criterion â Safety and Healthâ . This crite-rion is particularly important, due to the financial impacts of work accidents and occupational diseases. This article is especially useful to the scientific and technical community, since it synthesizes the relevance of each one of the choice criteria used and it shows why â Safety and Healthâ must be a criterion in the decision mak-ing process to choose the tunnelling method.

Avaliação de projetos de eficiência energética na iluminação pública

Dissertação de mestrado em Engenharia Industrial

Compendium of projects in the European nanosafety cluster

This is the third edition of the compendium. It documents the status of important projects on nanomaterial toxicity and exposure monitoring, integrated risk management, research infrstructure and coordination and support activities. The compendium is not intended to be a guidance document for human health and environmental safety management of nanotechnologies, as such guidance documents already exist and are widely available. Neither is the compendium intended to be a medium for the publication of scientific papers and research results, as this task is covered by scientific conferences and the reviewed press. The compendium aims to bring researchers closer together and show them the potential for synergy in their work. It is a means to establish links and communication between them during the actual research phase and well before the publication of their results. It thus focuses on the communication of projects' strategic aims, extensively covers specific work objectives and the methods used in research, and documents human capacities and available laboratory infrastructure. As such, the compendium supports collaboration on common goals and the joint elaboration of future plans, whilst compromising neither the potential for scientific publication, nor intellectual property rights. [Auteurs]

Modeling Dependence Structure and Forecasting Portfolio Value-at-Risk with Dynamic Copulas

We study the asymmetric and dynamic dependence between financial assets and demonstrate, from the perspective of risk management, the economic significance of dynamic copula models. First, we construct stock and currency portfolios sorted on different characteristics (ex ante beta, coskewness, cokurtosis and order flows), and find substantial evidence of dynamic evolution between the high beta (respectively, coskewness, cokurtosis and order flow) portfolios and the low beta (coskewness, cokurtosis and order flow) portfolios. Second, using three different dependence measures, we show the presence of asymmetric dependence between these characteristic-sorted portfolios. Third, we use a dynamic copula framework based on Creal et al. (2013) and Patton (2012) to forecast the portfolio Value-at-Risk of long-short (high minus low) equity and FX portfolios. We use several widely used univariate and multivariate VaR models for the purpose of comparison. Backtesting our methodology, we find that the asymmetric dynamic copula models provide more accurate forecasts, in general, and, in particular, perform much better during the recent financial crises, indicating the economic significance of incorporating dynamic and asymmetric dependence in risk management.

Modeling Dependence Structure and Forecasting Market Risk with Dynamic Asymmetric Copula

We investigate the dynamic and asymmetric dependence structure between equity portfolios from the US and UK. We demonstrate the statistical significance of dynamic asymmetric copula models in modelling and forecasting market risk. First, we construct “high-minus-low" equity portfolios sorted on beta, coskewness, and cokurtosis. We find substantial evidence of dynamic and asymmetric dependence between characteristic-sorted portfolios. Second, we consider a dynamic asymmetric copula model by combining the generalized hyperbolic skewed t copula with the generalized autoregressive score (GAS) model to capture both the multivariate non-normality and the dynamic and asymmetric dependence between equity portfolios. We demonstrate its usefulness by evaluating the forecasting performance of Value-at-Risk and Expected Shortfall for the high-minus-low portfolios. From back-testing, e find consistent and robust evidence that our dynamic asymmetric copula model provides the most accurate forecasts, indicating the importance of incorporating the dynamic and asymmetric dependence structure in risk management.

Apport de la systématique dans l'amélioration de la compréhension des systèmes de prise en compte des risques en entreprise

La gestion des risques est souvent appréhendée par l'utilisation de méthodes linéaires mettant l'accent sur des raisonnements de positionnement et de type causal : à tel événement correspond tel risque et telle conséquence. Une prise en compte des interrelations entre risques est souvent occultée et les risques sont rarement analysés dans leurs dynamiques et composantes non linéaires. Ce travail présente ce que les méthodes systémiques et notamment l'étude des systèmes complexes sont susceptibles d'apporter en matière de compréhension, de management et d'anticipation et de gestion des risques d'entreprise, tant sur le plan conceptuel que de matière appliquée. En partant des définitions relatives aux notions de systèmes et de risques dans différents domaines, ainsi que des méthodes qui sont utilisées pour maîtriser les risques, ce travail confronte cet ensemble à ce qu'apportent les approches d'analyse systémique et de modélisation des systèmes complexes. En mettant en évidence les effets parfois réducteurs des méthodes de prise en compte des risques en entreprise ainsi que les limitations des univers de risques dues, notamment, à des définitions mal adaptées, ce travail propose également, pour la Direction d'entreprise, une palette des outils et approches différentes, qui tiennent mieux compte de la complexité, pour gérer les risques, pour aligner stratégie et management des risques, ainsi que des méthodes d'analyse du niveau de maturité de l'entreprise en matière de gestion des risques. - Risk management is often assessed through linear methods which stress positioning and causal logical frameworks: to such events correspond such consequences and such risks accordingly. Consideration of the interrelationships between risks is often overlooked and risks are rarely analyzed in their dynamic and nonlinear components. This work shows what systemic methods, including the study of complex systems, are likely to bring to knowledge, management, anticipation of business risks, both on the conceptual and the practical sides. Based on the definitions of systems and risks in various areas, as well as methods used to manage risk, this work confronts these concepts with approaches of complex systems analysis and modeling. This work highlights the reducing effects of some business risk analysis methods as well as limitations of risk universes caused in particular by unsuitable definitions. As a result this work also provides chief officers with a range of different tools and approaches which allows them a better understanding of complexity and as such a gain in efficiency in their risk management practices. It results in a better fit between strategy and risk management. Ultimately the firm gains in its maturity of risk management.

Solvency Capital estimation and Risk Measures

This paper examines why a financial entity’s solvency capital estimation might be underestimated if the total amount required is obtained directly from a risk measurement. Using Monte Carlo simulation we show that, in some instances, a common risk measure such as Value-at-Risk is not subadditive when certain dependence structures are considered. Higher risk evaluations are obtained for independence between random variables than those obtained in the case of comonotonicity. The paper stresses, therefore, the relationship between dependence structures and capital estimation.

How to use the standard model with own data?

In this work discuss the use of the standard model for the calculation of the solvency capital requirement (SCR) when the company aims to use the specific parameters of the model on the basis of the experience of its portfolio. In particular, this analysis focuses on the formula presented in the latest quantitative impact study (2010 CEIOPS) for non-life underwriting premium and reserve risk. One of the keys of the standard model for premium and reserves risk is the correlation matrix between lines of business. In this work we present how the correlation matrix between lines of business could be estimated from a quantitative perspective, as well as the possibility of using a credibility model for the estimation of the matrix of correlation between lines of business that merge qualitative and quantitative perspective.

Impact of an intervention to control risk associated with patient transfer.

QUESTION UNDER STUDY: Hospitals transferring patients retain responsibility until admission to the new health care facility. We define safe transfer conditions, based on appropriate risk assessment, and evaluate the impact of this strategy as implemented at our institution. METHODS: An algorithm defining transfer categories according to destination, equipment monitoring, and medication was developed and tested prospectively over 6 months. Conformity with algorithm criteria was assessed for every transfer and transfer category. After introduction of a transfer coordination centre with transfer nurses, the algorithm was implemented and the same survey was carried out over 1 year. RESULTS: Over the whole study period, the number of transfers increased by 40%, chiefly by ambulance from the emergency department to other hospitals and private clinics. Transfers to rehabilitation centres and nursing homes were reassigned to conventional vehicles. The percentage of patients requiring equipment during transfer, such as an intravenous line, decreased from 34% to 15%, while oxygen or i.v. drug requirement remained stable. The percentage of transfers considered below theoretical safety decreased from 6% to 4%, while 20% of transfers were considered safer than necessary. A substantial number of planned transfers could be "downgraded" by mutual agreement to a lower degree of supervision, and the system was stable on a short-term basis. CONCLUSION: A coordinated transfer system based on an algorithm determining transfer categories, developed on the basis of simple but valid medical and nursing criteria, reduced unnecessary ambulance transfers and treatment during transfer, and increased adequate supervision.

Maps as risk mitigation tools. Adaptation of the Swiss hazard assessment and mapping methodology to a Moroccan site: Beni Mellal

Dans le contexte climatique actuel, les régions méditerranéennes connaissent une intensification des phénomènes hydrométéorologiques extrêmes. Au Maroc, le risque lié aux inondations est devenu problématique, les communautés étant vulnérables aux événements extrêmes. En effet, le développement économique et urbain rapide et mal maîtrisé augmente l'exposition aux phénomènes extrêmes. La Direction du Développement et de la Coopération suisse (DDC) s'implique activement dans la réduction des risques naturels au Maroc. La cartographie des dangers et son intégration dans l'aménagement du territoire représentent une méthode efficace afin de réduire la vulnérabilité spatiale. Ainsi, la DDC a mandaté ce projet d'adaptation de la méthode suisse de cartographie des dangers à un cas d'étude marocain (la ville de Beni Mellal, région de Tadla-Azilal, Maroc). La méthode suisse a été adaptée aux contraintes spécifiques du terrain (environnement semi-aride, morphologie de piémont) et au contexte de transfert de connaissances (caractéristiques socio-économiques et pratiques). Une carte des phénomènes d'inondations a été produite. Elle contient les témoins morphologiques et les éléments anthropiques pertinents pour le développement et l'aggravation des inondations. La modélisation de la relation pluie-débit pour des événements de référence, et le routage des hydrogrammes de crue ainsi obtenus ont permis d'estimer quantitativement l'aléa inondation. Des données obtenues sur le terrain (estimations de débit, extension de crues connues) ont permis de vérifier les résultats des modèles. Des cartes d'intensité et de probabilité ont été obtenues. Enfin, une carte indicative du danger d'inondation a été produite sur la base de la matrice suisse du danger qui croise l'intensité et la probabilité d'occurrence d'un événement pour obtenir des degrés de danger assignables au territoire étudié. En vue de l'implémentation des cartes de danger dans les documents de l'aménagement du territoire, nous nous intéressons au fonctionnement actuel de la gestion institutionnelle du risque à Beni Mellal, en étudiant le degré d'intégration de la gestion et la manière dont les connaissances sur les risques influencent le processus de gestion. L'analyse montre que la gestion est marquée par une logique de gestion hiérarchique et la priorité des mesures de protection par rapport aux mesures passives d'aménagement du territoire. Les connaissances sur le risque restent sectorielles, souvent déconnectées. L'innovation dans le domaine de la gestion du risque résulte de collaborations horizontales entre les acteurs ou avec des sources de connaissances externes (par exemple les universités). Des recommandations méthodologiques et institutionnelles issues de cette étude ont été adressées aux gestionnaires en vue de l'implémentation des cartes de danger. Plus que des outils de réduction du risque, les cartes de danger aident à transmettre des connaissances vers le public et contribuent ainsi à établir une culture du risque. - Severe rainfall events are thought to be occurring more frequently in semi-arid areas. In Morocco, flood hazard has become an important topic, notably as rapid economic development and high urbanization rates have increased the exposure of people and assets in hazard-prone areas. The Swiss Agency for Development and Cooperation (SADC) is active in natural hazard mitigation in Morocco. As hazard mapping for urban planning is thought to be a sound tool for vulnerability reduction, the SADC has financed a project aimed at adapting the Swiss approach for hazard assessment and mapping to the case of Morocco. In a knowledge transfer context, the Swiss method was adapted to the semi-arid environment, the specific piedmont morphology and to socio-economic constraints particular to the study site. Following the Swiss guidelines, a hydro-geomorphological map was established, containing all geomorphic elements related to known past floods. Next, rainfall / runoff modeling for reference events and hydraulic routing of the obtained hydrographs were carried out in order to assess hazard quantitatively. Field-collected discharge estimations and flood extent for known floods were used to verify the model results. Flood hazard intensity and probability maps were obtained. Finally, an indicative danger map as defined within the Swiss hazard assessment terminology was calculated using the Swiss hazard matrix that convolves flood intensity with its recurrence probability in order to assign flood danger degrees to the concerned territory. Danger maps become effective, as risk mitigation tools, when implemented in urban planning. We focus on how local authorities are involved in the risk management process and how knowledge about risk impacts the management. An institutional vulnerability "map" was established based on individual interviews held with the main institutional actors in flood management. Results show that flood hazard management is defined by uneven actions and relationships, it is based on top-down decision-making patterns, and focus is maintained on active mitigation measures. The institutional actors embody sectorial, often disconnected risk knowledge pools, whose relationships are dictated by the institutional hierarchy. Results show that innovation in the risk management process emerges when actors collaborate despite the established hierarchy or when they open to outer knowledge pools (e.g. the academia). Several methodological and institutional recommendations were addressed to risk management stakeholders in view of potential map implementation to planning. Hazard assessment and mapping is essential to an integrated risk management approach: more than a mitigation tool, danger maps represent tools that allow communicating on hazards and establishing a risk culture.

Del artículo de revisión a la recomendación profesional: La uniformación y material de protección individual para los equipos del ámbito prehospitalario de urgencias y emergencias

The Spanish Society of Nursing Emergency (SEEUE) has several lines documentaries that can be consulted on its web page and that have been spread through various publications: Statutes, scientific recommendations, professional recommendations, statements and allegations, grounds for nursing emergency, guarantees and rules, documents of interest and legislation. Set this that composed the regulatory environment, legal and recommendations which society poses to the collective nurse from the area of the emergency, as well as the rest of actors associated with urgent assistance (institutional and administratively) and through what has been the work of conceptualization and definition in our area the past few years. Part of this documentation offer possibilities for scientific endorsement and professional and invites to continue building knowledge and evidence. It is in this sense in which this work can and should be defined from a literature review approach and under the scheme of "review article". The working Group in Primary Care (PC) of the SEEUE, decided to build a Professional Recommendation (PR) in one of the areas of "uncertainty/variability" in the employment context and historical demand of nurses and other emergency care team on security issues: "The uniform and personal protective equipment for professional teams on prehospital emergency areas”.