UNDERSTANDING INTERRUPTIONS IN HEALTHCARE: DEVELOPING A MODEL

Developing a Model Interruption is a known human factor that contributes to errors and catastrophic events in healthcare as well as other high-risk industries. The landmark Institute of Medicine (IOM) report, To Err is Human, brought attention to the significance of preventable errors in medicine and suggested that interruptions could be a contributing factor. Previous studies of interruptions in healthcare did not offer a conceptual model by which to study interruptions. As a result of the serious consequences of interruptions investigated in other high-risk industries, there is a need to develop a model to describe, understand, explain, and predict interruptions and their consequences in healthcare. Therefore, the purpose of this study was to develop a model grounded in the literature and to use the model to describe and explain interruptions in healthcare. Specifically, this model would be used to describe and explain interruptions occurring in a Level One Trauma Center. A trauma center was chosen because this environment is characterized as intense, unpredictable, and interrupt-driven. The first step in developing the model began with a review of the literature which revealed that the concept interruption did not have a consistent definition in either the healthcare or non-healthcare literature. Walker and Avant’s method of concept analysis was used to clarify and define the concept. The analysis led to the identification of five defining attributes which include (1) a human experience, (2) an intrusion of a secondary, unplanned, and unexpected task, (3) discontinuity, (4) externally or internally initiated, and (5) situated within a context. However, before an interruption could commence, five conditions known as antecedents must occur. For an interruption to take place (1) an intent to interrupt is formed by the initiator, (2) a physical signal must pass a threshold test of detection by the recipient, (3) the sensory system of the recipient is stimulated to respond to the initiator, (4) an interruption task is presented to recipient, and (5) the interruption task is either accepted or rejected by v the recipient. An interruption was determined to be quantifiable by (1) the frequency of occurrence of an interruption, (2) the number of times the primary task has been suspended to perform an interrupting task, (3) the length of time the primary task has been suspended, and (4) the frequency of returning to the primary task or not returning to the primary task. As a result of the concept analysis, a definition of an interruption was derived from the literature. An interruption is defined as a break in the performance of a human activity initiated internal or external to the recipient and occurring within the context of a setting or location. This break results in the suspension of the initial task by initiating the performance of an unplanned task with the assumption that the initial task will be resumed. The definition is inclusive of all the defining attributes of an interruption. This is a standard definition that can be used by the healthcare industry. From the definition, a visual model of an interruption was developed. The model was used to describe and explain the interruptions recorded for an instrumental case study of physicians and registered nurses (RNs) working in a Level One Trauma Center. Five physicians were observed for a total of 29 hours, 31 minutes. Eight registered nurses were observed for a total of 40 hours 9 minutes. Observations were made on either the 0700–1500 or the 1500-2300 shift using the shadowing technique. Observations were recorded in the field note format. The field notes were analyzed by a hybrid method of categorizing activities and interruptions. The method was developed by using both a deductive a priori classification framework and by the inductive process utilizing line-byline coding and constant comparison as stated in Grounded Theory. The following categories were identified as relative to this study: Intended Recipient - the person to be interrupted Unintended Recipient - not the intended recipient of an interruption; i.e., receiving a phone call that was incorrectly dialed Indirect Recipient – the incidental recipient of an interruption; i.e., talking with another, thereby suspending the original activity Recipient Blocked – the intended recipient does not accept the interruption Recipient Delayed – the intended recipient postpones an interruption Self-interruption – a person, independent of another person, suspends one activity to perform another; i.e., while walking, stops abruptly and talks to another person Distraction – briefly disengaging from a task Organizational Design – the physical layout of the workspace that causes a disruption in workflow Artifacts Not Available – supplies and equipment that are not available in the workspace causing a disruption in workflow Initiator – a person who initiates an interruption Interruption by Organizational Design and Artifacts Not Available were identified as two new categories of interruption. These categories had not previously been cited in the literature. Analysis of the observations indicated that physicians were found to perform slightly fewer activities per hour when compared to RNs. This variance may be attributed to differing roles and responsibilities. Physicians were found to have more activities interrupted when compared to RNs. However, RNs experienced more interruptions per hour. Other people were determined to be the most commonly used medium through which to deliver an interruption. Additional mediums used to deliver an interruption vii included the telephone, pager, and one’s self. Both physicians and RNs were observed to resume an original interrupted activity more often than not. In most interruptions, both physicians and RNs performed only one or two interrupting activities before returning to the original interrupted activity. In conclusion the model was found to explain all interruptions observed during the study. However, the model will require an even more comprehensive study in order to establish its predictive value.

Scanned Ion Beam Therapy for Thoracic Tumors

Although frequently cured of Hodgkin lymphoma, adolescents and young adults can develop radiation induced second cancers. These patients could potentially benefit from scanned ion radiotherapy yet likely would require motion mitigation strategies. In theory, four-dimensional (4D) optimization of ion beam fields for individual motion states of respiration can enable superior sparing of healthy tissue near moving targets, compared to other motion mitigation strategies. Furthermore, carbon-ion therapy can sometimes provide greater relative biological effectiveness (RBE) for cell sterilization in a target but nearly equivalent RBE in tissue upstream of the target, compared to proton therapy. Thus, we expected that for some patients with Hodgkin lymphoma, carbon-ion therapy would reduce the predicted risk of second cancer incidence in the breast compared with proton therapy. The purpose of this work was to determine whether 4D-optimized carbon-ion therapy would significantly reduce the predicted risk of radiation induced second cancers in the breast for female Hodgkin lymphoma patients while preserving tumor control compared with proton therapy. To achieve our goals, we first investigated whether 4D-optimized carbon beam tracking could reduce dose to volumes outside a moving target compared with 3D-optimized carbon beam tracking while preserving target dose coverage. To understand the reliability of scanned carbon beam tracking, we studied the robustness of dose distributions in thoracic targets to uncertainties in patient motion. Finally, we investigated whether using carbon-ion therapy instead of proton therapy would significantly reduce the predicted risk of second cancer in the breast for a sample of Hodgkin lymphoma patients. We found that 4D-optimized ion beam tracking therapy can reduce the maximum dose to critical structures near a moving target by as much as 53%, compared to 3D-optimized ion beam tracking therapy. We validated these findings experimentally using a scanned carbon ion synchrotron and a motion phantom. We found scanned carbon beam tracking to be sensitive to a number of motion uncertainties, most notably phase delays in tracking, systematic spatial errors, and interfractional motion changes. Our findings indicate that a lower risk of second cancer in the breast might be expected for some Hodgkin lymphoma patients using carbon-ion therapy instead of proton therapy. For our reference scenario, we found the ratio of risk to be 0.77 ± 0.35 for radiogenic breast cancer after carbon-ion therapy versus proton therapy. Our findings were dependent on the RBE values for tumor induction and the radiosensitivity of breast tissue, as well as the physical dose distribution.

Swath sonar bathymetry during SONNE cruise SO196 with links to multibeam raw data files

Multibeam data were measured during R/V Sonne cruise SO-196 (2008-03-02 to 2008-03-27) along survey profiles, transits and during stationary work. Data were achieved at the Okiwana Trough, particularly in the area of Yonaguni Knoll and Hatoma Knoll. The multibeam sonar system Kongsberg EM120 was operated using 191 beams and up to 150 deg aperture angle. The refraction correction was achieved using CTD profiles measured during this cruise. The quality of data might be reduced during bad weather periods. The dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Borges y sus editores : Itinerarios de Fervor de Buenos Aires (1923-1977)

En el marco del campo de estudios sobre las relaciones entre editores y escritores (Undsel 2004), este trabajo propone el estudio de un caso singular: el de Fervor de Buenos Aires, el inaugural poemario de Jorge Luis Borges. Publicado por primera vez en 1923, fue reeditado de distintas formas y a través de diferentes editoriales. Cada una de estas distintas ediciones presenta un complejo sistema de correcciones y borramientos. En este artículo nos centraremos en el estudio del recorrido editorial del libro donde se materializa ese sistema de correcciones y borramientos

Hegemonía y contrahegemonía en la América Latina de hoy. Apuntes hacia una nueva época

El despliegue sobre el presente latinoamericano de la problemática gramsciana de la hegemonía, exige tanto una elucidación de yerros y simplificaciones en la utilización de la categoría original, como un repaso histórico de la evolución social y cultural del continente. La estructura de clase, los modos de la lucha social y política, la configuración organizacional y la subjetividad de los luchadores, se han modificado profundamente en estos años, enmarcadas por una ofensiva de alcance estratégico del gran capital. Las concepciones gramscianas pueden (deben) constituir un auxilio fundamental a la hora de volver a pensar en una perspectiva de transformación social radical, que eluda el doble riesgo de la adaptación al orden existente, en un extremo, y un «choque frontal¼ contra el mismo que cambie eficacia real por radicalismo programático. Se encontrarán allí herramientas para examinar críticamente el pasado y el presente del pensamiento y las prácticas contestatarias de nuestro continente; y proyectarlas en dirección a su perspectiva futura.

Borges y sus editores : Itinerarios de Fervor de Buenos Aires (1923-1977)

En el marco del campo de estudios sobre las relaciones entre editores y escritores (Undsel 2004), este trabajo propone el estudio de un caso singular: el de Fervor de Buenos Aires, el inaugural poemario de Jorge Luis Borges. Publicado por primera vez en 1923, fue reeditado de distintas formas y a través de diferentes editoriales. Cada una de estas distintas ediciones presenta un complejo sistema de correcciones y borramientos. En este artículo nos centraremos en el estudio del recorrido editorial del libro donde se materializa ese sistema de correcciones y borramientos

Hegemonía y contrahegemonía en la América Latina de hoy. Apuntes hacia una nueva época

El despliegue sobre el presente latinoamericano de la problemática gramsciana de la hegemonía, exige tanto una elucidación de yerros y simplificaciones en la utilización de la categoría original, como un repaso histórico de la evolución social y cultural del continente. La estructura de clase, los modos de la lucha social y política, la configuración organizacional y la subjetividad de los luchadores, se han modificado profundamente en estos años, enmarcadas por una ofensiva de alcance estratégico del gran capital. Las concepciones gramscianas pueden (deben) constituir un auxilio fundamental a la hora de volver a pensar en una perspectiva de transformación social radical, que eluda el doble riesgo de la adaptación al orden existente, en un extremo, y un «choque frontal¼ contra el mismo que cambie eficacia real por radicalismo programático. Se encontrarán allí herramientas para examinar críticamente el pasado y el presente del pensamiento y las prácticas contestatarias de nuestro continente; y proyectarlas en dirección a su perspectiva futura.

Hegemonía y contrahegemonía en la América Latina de hoy. Apuntes hacia una nueva época

El despliegue sobre el presente latinoamericano de la problemática gramsciana de la hegemonía, exige tanto una elucidación de yerros y simplificaciones en la utilización de la categoría original, como un repaso histórico de la evolución social y cultural del continente. La estructura de clase, los modos de la lucha social y política, la configuración organizacional y la subjetividad de los luchadores, se han modificado profundamente en estos años, enmarcadas por una ofensiva de alcance estratégico del gran capital. Las concepciones gramscianas pueden (deben) constituir un auxilio fundamental a la hora de volver a pensar en una perspectiva de transformación social radical, que eluda el doble riesgo de la adaptación al orden existente, en un extremo, y un «choque frontal¼ contra el mismo que cambie eficacia real por radicalismo programático. Se encontrarán allí herramientas para examinar críticamente el pasado y el presente del pensamiento y las prácticas contestatarias de nuestro continente; y proyectarlas en dirección a su perspectiva futura.

Borges y sus editores : Itinerarios de Fervor de Buenos Aires (1923-1977)

En el marco del campo de estudios sobre las relaciones entre editores y escritores (Undsel 2004), este trabajo propone el estudio de un caso singular: el de Fervor de Buenos Aires, el inaugural poemario de Jorge Luis Borges. Publicado por primera vez en 1923, fue reeditado de distintas formas y a través de diferentes editoriales. Cada una de estas distintas ediciones presenta un complejo sistema de correcciones y borramientos. En este artículo nos centraremos en el estudio del recorrido editorial del libro donde se materializa ese sistema de correcciones y borramientos

Swath sonar bathymetry during SONNE cruise SO202 (INOPEX) with links to multibeam raw data files

Multibeam data were measured during R/V SONNE cruise SO202 (INOPEX) along track lines of 6938 NM total length in the North Pacific and Bering Sea during transits and stationary work. Starting from Hokkaido (Japan) data were achieved east of the Kuril-Kamchatka Trench and south of the Aleutian Trench. The track crosses the Bowers Ridge, the continental margin of Alaska and the Umnak Plateau in the Bering Sea. Further data were gained in the North Pacific in the area of the Patton Seamounts, Gibson Seamount, Hess Rise and Shatsky Rise. The multibeam sonar system Simrad EM 120 from Kongsberg was operated using 191 beams and an aperture angle of 90° to 140° due to particular conditions. The refraction correction was achieved utilizing 6 CTD profiles measured during the cruise and one from cruise SO201. The quality of data might be reduced during bad weather periods. The dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Swath sonar bathymetry during POLARSTERN cruise ARK-XXII/1c (PS70) with links to multibeam raw data files

Multibeam data were measured as part of the project HERMES during R/V Polarstern cruise ARK-XXII/1 (2007-05-29 to 2007-07-25) along transits and survey profiles and partly during stationary work. Data were achieved mainly in the coastal areas of northern Norway, at the Hakon Mosby Mud Volcano at the continental margin approx. 200 nm off the norwegian coast and the AWI-Hausgarten area approx. 150 nm west of Svalbard. A number of surveys were carried out in the coastal areas of northern Norway (Sula Reef, Roest Reef, Traena area, Floholmen area, Sotbakken area) and around the area of the Hakon Mosby Mud Volcano. The multibeam sonar system Atlas Hydrosweep DS-2 (Atlas Hydrographic, http://www.atlashydro.com) was operated using 59 beams and 90° aperture angle. The refraction correction was achieved using CTD profiles measured during this cruise or, during transits, utilizing the system's own cross fan calibration. The quality of data might be reduced during bad weather periods or adverse sea ice conditions (only in the AWI-Hausgarten area). This dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Swath sonar bathymetry during POLARSTERN cruise ANT-XXVI/3 (PS75) with links to multibeam raw data files

Multibeam data were collected during R/V Polarstern cruise ANT-XXVI/3 along track lines of about 10,400 NM total length along transits, survey profiles and during stationary work. Departing in New Zealand the ship passed Pacific Antarctic Ridge heading to Ross Sea. Main working area was the Amundsen Sea and Bellingshausen Sea. Recorded bathymetry is supplementing existing tracks e.g. of R.V. James Clark Ross and R.V. Nathaniel B. Palmer. The refraction correction was achieved utilizing CTD profiles or by the system's own cross fan calibration. The quality of data might be reduced during bad weather periods or adverse sea ice conditions. The dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Swath sonar bathymetry during POLARSTERN cruise ANT-XVI/4 (PS53) with links to multibeam raw data files

Multibeam data were collected without operator supervision on R/V Polarstern cruise ANT-XVI/4 along track lines of 6385 NM total length. Data were achieved during transits and stationary work on the route from Cape Town to Bremerhaven via the Cape Verde Islands and the Canary Islands. The multibeam sonar system Hydrosweep DS-2 was operated using 59 beams and 90° aperture angle. The quality of data might be reduced during bad weather periods or adverse sea ice conditions. The dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Swath sonar bathymetry during POLARSTERN cruise ANT-XV/4 (PS49) with links to multibeam raw data files

Multibeam data were collected without operator supervision on R/V Polarstern cruise ANT-XV/4 along track lines of about 7000 NM total length. Data were achieved during transits and stationary work in the western Weddell Sea, at the Weddell-Scotia Confluence, and on a transect along the Prime Meridian of about 1300 NM length, between 69°S and 47°S. The multibeam sonar system Hydrosweep DS-2 was operated using 59 beams and 90° aperture angle. The quality of data might be reduced during bad weather periods or adverse sea ice conditions. The dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.

Swath sonar bathymetry during POLARSTERN cruise ARK-XXII/1b (PS70) with links to multibeam raw data files

Multibeam data were measured as part of the project HERMES during R/V Polarstern cruise ARK-XXII/1 (2007-05-29 to 2007-07-25) along transits and survey profiles and partly during stationary work. Data were achieved mainly in the coastal areas of northern Norway, at the Hakon Mosby Mud Volcano at the continental margin approx. 200 nm off the norwegian coast and the AWI-Hausgarten area approx. 150 nm west of Svalbard. A number of surveys were carried out in the coastal areas of northern Norway (Sula Reef, Roest Reef, Traena area, Floholmen area, Sotbakken area) and around the area of the Hakon Mosby Mud Volcano. The multibeam sonar system Atlas Hydrosweep DS-2 (Atlas Hydrographic, http://www.atlashydro.com) was operated using 59 beams and 90° aperture angle. The refraction correction was achieved using CTD profiles measured during this cruise or, during transits, utilizing the system's own cross fan calibration. The quality of data might be reduced during bad weather periods or adverse sea ice conditions (only in the AWI-Hausgarten area). This dataset contains raw data that are not processed and thus may contain errors and blunders in depth and position.