Improving disclosure of medical errors: Including patients and family members in the disclosure process

Over the last decade, adverse events and medical errors have become a main focus of interest for the standards of quality and safety in the U.S. healthcare system (Weinstein & Henderson, 2009). Particularly when a medical error occurs, the disclosure of medical errors and its practices have become a focal point of the healthcare process. Patients and family members who have experienced a medical error might be able to provide knowledge and insight on how to improve the disclose process. However, patient and family member are not typically involved in the disclosure process, thus their experiences go unnoticed. ^ The purpose of this research was to explore how best to include patients and family members in the disclosure process regarding a medical error. The research consisted of 28 qualitative interviews from three stakeholder groups: Hospital Administrators, Clinical Service Providers, and Patients and Family Members. They were asked for their ideas and suggestions on how best to include patients and family members in the disclosure process. Framework Analysis was used to analyze this data and find prevalent themes based on the primary research question. A secondary aim was to index categories created based on the interviews that were collected. Data was used from the Texas Disclosure and Compensation Study with Dr. Eric Thomas as the Principal Investigator. Full acknowledgement of access to this data is given to Dr. Thomas. ^ The themes from the research revealed that each stakeholder group was interested and open to including patients and family members in the disclosure process and that the disclosure process should not be a "one-way" avenue. The themes gave many suggestions regarding how to best include patients and family members in the disclosure process of a medical error. Secondary aims revealed several ways to assess the ideas and suggestion given by the stakeholders. Overall, acceptability of getting the perspective of patients and family members was the most common theme. Comparison of each stakeholder group revealed that including patients and family members would be beneficial to improving hospital disclosure practices. ^ Conclusions included a list of recommendations and measureable appropriate strategies that could provide hospital with key stakeholders insights on how to improve their disclosure process. Sharing patients and family members experience with healthcare providers can encourage a shift in culture where patients are valued and active in participating in hospital practices. To my knowledge, this research is the very first of its kind and moves the disclosure process conversation forward in a patient-family member inclusion direction that will assist in improving disclosure practices. Future research should implement and evaluate the success of the various inclusion strategies.^

Harmonization of trade in services by APEC members

This study maps out the degree of services trade liberalization by the APEC members toward achieving a Free Trade Area of the Asia-Pacific (FTAAP) and makes some comparative analyses. The study finds that the commitment level differs greatly between sensitive and less sensitive sectors, and that the commitment level under the ASEAN Framework Agreement (AFAS) package 8 is the highest among the four FTAs studied. It also finds that there are cross-country and sector-wide similarities in the pattern of service sector commitment under and across each of the FTAs; this implies that the shared domestic sensitivities can be overcome by an APEC-wide economic cooperation scheme for enhancing competitiveness (through, e.g., the Trans-Pacific Strategic Economic Partnership Agreement or TPP).

Análisis de los modelos de comportamiento de vigas de hormigón armado reforzadas a cortante con polímeros armados con fibras (frp). Validación y calibración experimental

Los polímeros armados con fibras (FRP) se utilizan en refuerzos de estructuras de hormigón debido sobre todo a sus excelentes propiedades mecánicas, su resistencia a la corrosión y a su ligereza que se traduce en facilidad y ahorro en el transporte, puesta en obra y aplicación, la cual se realiza de forma muy rápida, con pocos operarios y utilizando medios auxiliares ligeros, minimizándose las interrupciones del uso de la estructura y las molestias a los usuarios. Las razones presentadas anteriormente, han despertado un gran inter´es por parte de diferentes grupos de investigación a nivel mundial y que actualmente se encuentran desarrollando nuevas técnicas de aplicación y métodos de cálculo. Sin embargo, las investigaciones realizadas hasta la fecha, muestran un procedimiento bien definido y aceptado en lo referente al cálculo a flexión, lo cual no ocurre con el refuerzo a cortante y aunque se ha demostrado que el refuerzo con FRP es un sistema eficaz para incrementar la capacidad ´ultima frente a esfuerzos cortantes, también se pone de manifiesto la necesidad de más estudios experimentales y teóricos para avanzar en el entendimiento de los mecanismos involucrados para este tipo de refuerzo y establecer un procedimiento de diseño apropiado que maximice las excelentes propiedades de este material. Los modelos que explican el comportamiento del refuerzo a cortante de elementos de hormigón armado son complejos y sin transposición directa a fórmulas ingenieriles. Las normas actualmente en vigor, generalmente, establecen empíricamente la capacidad cortante como la suma de las capacidades del hormigón y el refuerzo transversal de acero. Cuando un elemento es reforzado externamente con FRP, los modelos son evidentemente aun más complejos. Las guías y recomendaciones existentes proponen calcular la capacidad del elemento añadiendo la resistencia aportada por el refuerzo externo de FRP a la ya dada por el hormigón y acero transversal. Sin embargo, la idoneidad de este acercamiento es cuestionable puesto que no tiene en cuenta una posible interacción entre refuerzos. Con base en lo anterior se da origen al tema objeto de este trabajo, el cual está orientado al estudio a cortante de elementos de hormigón armado (HA), reforzados externamente con material compuesto de tejido unidireccional de fibra de carbono y resina epoxi. Inicialmente se hace una completa revisión del estado actual del conocimiento de la resistencia a cortante en elementos de hormigón armado con y sin refuerzo externo de FRP, prestando especial atención en los mecanismos actuantes estudiados hasta la fecha. La bibliografía consultada ha sido exhaustiva y actualizada lo que ha permitido el estudio de los modelos propuestos más importantes, tanto para la descripción del fenómeno de adherencia entre hormigón-FRP como de la valoración del aporte al cortante total hecho por el FRP, a través de sendas bases de datos de ensayos de pull-out y de vigas de hormigón armado ensayadas a cortante. Con base en todo lo anterior, se expusieron los mecanismos actuantes en el aporte a cortante hecho por el FRP en elementos de hormigón armado y la forma como las principales guías de cálculo existentes hasta la fecha los abordan. De igual forma se define un modelo de resistencia de esfuerzos para el FRP y se proponen dos modelos para el cálculo de las tensiones o deformaciones efectivas, de los cuales uno esta basado en el modelo de adherencia propuesto por Oller (2005) y el otro en una regresión multivariante para los mecanismos expuestos. Como complemento del estudio de los trabajos encontrados en la literatura, se lleva acabo un programa experimental que, además de aportar más registros a la exigua base de datos existentes, aporte mayor luz a los puntos que se consideran están deficientemente resueltos. Dentro de este programa se realizaron 32 ensayos sobre 16 vigas de 4.5 m de longitud (dos ensayos por viga), reforzadas a cortante con tejido unidireccional de CFRP. Finalmente, estos estudios han permitido proponer modificaciones a las formulaciones existentes en los códigos y guías en vigor. Abstract Its excellent mechanical properties, as well as its corrosion resistance and light weight, which make it easy to apply and inexpensive to ship to the worksite, are the basis of the extended use of fiber reinforced polymer (FRP) as external strengthening for structures. FRP strengthening is a rapid operation calling for only limited labor and lightweight ancillary equipment, all of which minimizes both the interruption of facility usage and user inconvenience. These advantages have aroused considerable interest in civil engineering science and technology and have led to countless applications the world over. Research studies on the shear strength of FRP-strengthened members have been much fewer in number and more controversial than the research on flexural strengthening, for which a more or less standardized and generally accepted procedure has been established. The research conducted and a host of applications around the world have shown that FRP strengthening is an effective technique for raising ultimate shear strength, but it has also revealed a need for further experimental and theoretical research to advance in the understanding of the mechanisms involved and establish suitable design procedures that optimize the excellent properties of this material The models that explain reinforced concrete (RC) shear strength behavior are complex and cannot be directly transposed to engineering formulas. The standards presently in place generally establish shear capacity empirically as the sum of the capacities of the concrete and the passive reinforcement. When members are externally strengthened with FRP, the models are obviously even more complex. The existing guides and recommendations propose calculating capacity by adding the external strength provided by the FRP to the contributions of the concrete and passive reinforcement. The suitability of this approach is questionable, however, because it fails to consider the interaction between passive reinforcement and external strengthening. The subject of this work is based in above, which is focused on externally shear strengthening for reinforced concrete members with unidirectional carbon fiber sheets bonded with epoxy resin. v Initially a thorough literature review on shear of reinforced concrete beams with and without external FRP strengthening was performed, paying special attention to the acting mechanisms studied to date, which allowed the study of the most important models both to describe the bond phenomenon as well as calculating the FRP shear contribution, through separate databases of pull-out tests and shear tests on reinforced concrete beams externally strengthened with FRP. Based on above, they were exposed the acting mechanisms in a FRP shear strengthening on reinforced concrete beams and how guidelines deal the topic. The same way, it is defined a FRP stress strength model and two more models are proposed for calculating the effective stress, one of these is based on the Oller (2005) bond model and another one is the data best fit, taking into account most of the acting mechanisms. To complement the theoretical part we develop an experimental program that, in addition to providing more records to the meager existing database provide greater understanding to the points considered poorly resolved. The test program included 32 tests of 16 beams (2 per beam) of 4.5 m long, shear strengthened with FRP, externally. Finally, modifications to the existing codes and guidelines are proposed.

A repairability index for reinforced concrete members based on fracture mechanics

This paper proposes a repairability index for damage assessment in reinforced concrete structural members. The procedure discussed in this paper differs from the standard methods in two aspects: the structural and damage analyses are coupled and it is based on the concepts of fracture and continuum damage mechanics. The relationship between the repairability index and the well-known Park and Ang index is shown in some particular cases.

On the flexural vibration of cylinders under axial loads:Numerical and experimental study

The flexural vibration of a homogeneous isotropic linearly elastic cylinder of any aspect ratio is analysed in this paper. Natural frequencies of a cylinder under uniformly distributed axial loads acting on its bases are calculated numerically by the Ritz method with terms of power series in the coordinate directions as approximating functions. The effect of axial loads on the flexural vibration cannot be described by applying infinitesimal strain theory, therefore, geometrically nonlinear strain–displacement relations with second-order terms are considered here. The natural frequencies of free–free, clamped–clamped, and sliding–sliding cylinders subjected to axial loads are calculated using the proposed three-dimensional Ritz approach and are compared with those obtained with the finite element method and the Bernoulli–Euler theory. Different experiments with cylinders axially compressed by a hydraulic press are carried out and the experimental results for the lowest flexural frequency are compared with the numerical results. An approach based on the Ritz formulation is proposed for the flexural vibration of a cylinder between the platens of the press with constraints varying with the intensity of the compression. The results show that for low compressions the cylinder behaves similarly to a sliding–sliding cylinder, whereas for high compressions the cylinder vibrates as a clamped–clamped one.

Influence of the Second Flexural Mode on the Response of High-Speed Bridges

This paper deals with the assessment of the contribution of the second flexural mode to the dynamic behaviour of simply supported railway bridges. Alluding to the works of other authors, it is suggested in some references that the dynamic behaviour of simply supported bridges could be adequately represented taking into account only the contribution of the fundamental flexural mode. On the other hand, the European Rail Research Institute (ERRI) proposes that the second mode should also be included whenever the associated natural frequency is lower than 30 Hz]. This investigation endeavours to clarify the question as much as possible by establishing whether the maximum response of the bridge, in terms of displacements, accelerations and bending moments, can be computed accurately not taking account of the contribution of the second mode. To this end, a dimensionless formulation of the equations of motion of a simply supported beam traversed by a series of equally spaced moving loads is presented. This formulation brings to light the fundamental parameters governing the behaviour of the beam: damping ratio, dimensionless speed $ \alpha$=VT/L, and L/d ratio (L stands for the span of the beam, V for the speed of the train, T represents the fundamental period of the bridge and d symbolises the distance between consecutive loads). Assuming a damping ratio equal to 1%, which is a usual value for prestressed high-speed bridges, a parametric analysis is conducted over realistic ranges of values of $ \alpha$ and L/d. The results can be extended to any simply supported bridge subjected to a train of equally spaced loads in virtue of the so-called Similarity Formulae. The validity of these formulae can be derived from the dimensionless formulation mentioned above. In the parametric analysis the maximum response of the bridge is obtained for one thousand values of speed that cover the range from the fourth resonance of the first mode to the first resonance of the second mode. The response at twenty-one different locations along the span of the beam is compared in order to decide if the maximum can be accurately computed with the sole contribution of the fundamental mode.

Design equations for reinforced concrete members strengthened in shear with external FRP reinforcement formulated in an evolutionary multi-objective framework

Methods for predicting the shear capacity of FRP shear strengthened RC beams assume the traditional approach of superimposing the contribution of the FRP reinforcing to the contributions from the reinforcing steel and the concrete. These methods become the basis for most guides for the design of externally bonded FRP systems for strengthening concrete structures. The variations among them come from the way they account for the effect of basic shear design parameters on shear capacity. This paper presents a simple method for defining improved equations to calculate the shear capacity of reinforced concrete beams externally shear strengthened with FRP. For the first time, the equations are obtained in a multiobjective optimization framework solved by using genetic algorithms, resulting from considering simultaneously the experimental results of beams with and without FRP external reinforcement. The performance of the new proposed equations is compared to the predictions with some of the current shear design guidelines for strengthening concrete structures using FRPs. The proposed procedure is also reformulated as a constrained optimization problem to provide more conservative shear predictions.

Fracture of concrete structural members subjected to blast

If reinforced concrete structures are to be safe under extreme impulsive loadings such as explosions, a broad understanding of the fracture mechanics of concrete under such events is needed. Most buildings and infrastructures which are likely to be subjected to terrorist attacks are borne by a reinforced concrete (RC) structure. Up to some years ago, the traditional method used to study the ability of RC structures to withstand explosions consisted on a choice between handmade calculations, affordable but inaccurate and unreliable, and full scale experimental tests involving explosions, expensive and not available for many civil institutions. In this context, during the last years numerical simulations have arisen as the most effective method to analyze structures under such events. However, for accurate numerical simulations, reliable constitutive models are needed. Assuming that failure of concrete elements subjected to blast is primarily governed by the tensile behavior, a constitutive model has been built that accounts only for failure under tension while it behaves as elastic without failure under compression. Failure under tension is based on the Cohesive Crack Model. Moreover, the constitutive model has been used to simulate the experimental structural response of reinforced concrete slabs subjected to blast. The results of the numerical simulations with the aforementioned constitutive model show its ability of representing accurately the structural response of the RC elements under study. The simplicity of the model, which does not account for failure under compression, as already mentioned, confirms that the ability of reinforced concrete structures to withstand blast loads is primarily governed by tensile strength.

Behaviour of Concrete Structural Members Subjected to Air Blast Loading

Numerical analysis is a suitable tool in the design of complex reinforced concrete structures under extreme impulsive loadings such as impacts or explosions at close range. Such events may be the result of terrorist attacks. Reinforced concrete is commonly used for buildings and infrastructures. For this reason, the ability to accurately run numerical simulations of concrete elements subjected to blast loading is needed. In this context, reliable constitutive models for concrete are of capital importance. In this research numerical simulations using two different constitutive models for concrete (Continuous Surface Cap Model and Brittle Damage Model) have been carried out using LS-DYNA. Two experimental benchmark tests have been taken as reference. The results of the numerical simulations with the aforementioned constitutive models show different abilities to accurately represent the structural response of the reinforced concrete elements studied.

Comportamiento a fatiga por cortante de elementos lineales de hormigón armado sin cercos

Las estructuras de hormigón son susceptibles de sufrir los efectos asociados a las acciones de fatiga cuando estas se ven sometidas a un elevado número de cargas repetidas. Muchas de estas estructuras no requieren armadura transversal para cumplir los condicionantes de dimensionamiento estático como por ejemplo las losas superiores de tableros de puentes, los muros de contención, las losas de transición de puentes, las torres eólicas o las estructuras marítimas. La mayor parte de los códigos de diseño vigentes no incluyen una comprobación específica del nivel de seguridad a cortante de estas estructuras para acciones de fatiga, y aquellas que lo hacen prefieren utilizar expresiones de tipo empírico basadas en curvas S-N que relacionan el número de ciclos resistentes con el valor de la carga aplicada. A pesar de que el empleo de curvas S-N es de gran utilidad desde un punto de vista práctico, estas curvas no permiten comprender el proceso de rotura por cortante para cargas repetidas. El objetivo principal de esta Tesis es el de estudiar el comportamiento a cortante de elementos de hormigón armado sin cercos sometidos a fatiga. Además, el análisis es ampliado al estudio del comportamiento transversal de los voladizos de las losas superiores de tableros de puentes de hormigón que de forma habitual son diseñados sin armadura de cortante. De forma habitual estos elementos se diseñan atendiendo a criterios de dimensionamiento estáticos sin tener en cuenta la resistencia a cortante cuando se ven sometidos a cargas cíclicas. A pesar de que las cargas de fatiga son inferiores a aquellas que producen el fallo estático, es importante tener en cuenta el comportamiento de estos elementos ante cargas repetidas. Los trabajos experimentales existentes en vigas de hormigón armado sin cercos evidenciaron diferencias significativas entre los modos de fallo ante cargas estáticas y cíclicas. Estos trabajos llegaron a la conclusión de que estos elementos diseñados para tener un fallo dúctil por flexión pueden llegar a desarrollar un tipo de fallo frágil por cortante cuando se ven sometidos a cargas repetidas. El proceso de rotura por cortante en elementos de hormigón armado sin cercos sometidos a fatiga es un proceso complejo que debe ser estudiado en profundidad debido al carácter frágil de este tipo de fallo. Los trabajos experimentales permitieron comprobar que el origen de este fallo tiene lugar tras la formación de una fisura de cortante a partir de una fisura de flexión formada durante los primeros ciclos en el vano de cortante. Tras la formación de esta fisura, esta se va propagando hacia la cabeza de compresión hasta que finalmente se produce el fallo como consecuencia de la destrucción de la cabeza de compresión cuando la altura alcanzada por esta es insuficiente para resistir la fuerza de compresión aplicada en esta zona. Por otra parte, la propagación de esta fisura diagonal puede desarrollarse por completo en el instante en el que esta se forma derivando en un tipo de fallo por cortante más frágil que el anterior. El proceso de fatiga es estudiado en esta Tesis mediante un modelo mecánico. Por una parte, se propone un modelo predictivo para determinar el número de ciclos acumulados hasta que se forma la fisura diagonal en función del estado tensional que se tiene en la punta de una fisura crítica de flexión formada en los primeros ciclos. Por otra parte, la resistencia a fatiga tras la formación de la fisura diagonal se analiza teniendo en cuenta el daño por fatiga acumulado en la cabeza de compresión y las variables que afectan a la propagación de esta fisura de cortante. Para la evaluación de la resistencia a fatiga tras la formación de la fisura crítica de cortante en este tipo de elementos, se plantea un modelo teórico basado en conceptos de Mecánica de la Fractura adaptados al hormigón. Este modelo puede ser aplicado a vigas de hormigón armado sin cercos de canto constante o variable siguiendo diferentes procedimientos. Una campaña experimental ha sido llevada a cabo con el objetivo de estudiar el comportamiento a cortante de vigas de hormigón armado sin cercos de canto variable sometidas a cargas estáticas y de fatiga. Se han desarrollado un total de diez ensayos estáticos y de fatiga para diferentes niveles de carga y esbelteces de cortante, teniendo lugar diferentes modos de fallo. Estos elementos fueron diseñados para reproducir, a escala real y de forma simplificada, los voladizos laterales de las losas superiores de tableros de puentes de carretera de hormigón. Los resultados experimentales demostraron que el tipo de fallo desarrollado depende de varios parámetros como por ejemplo el nivel de carga máxima, el nivel de oscilación de tensiones en la armadura longitudinal, la esbeltez de cortante o la calidad del hormigón utilizado entre otros. Para valores similares de esbeltez de cortante, los ensayos de fatiga realizados permitieron comprobar que la rotura por cortante de estos elementos está asociada a niveles de carga máxima elevados, mientras que el fallo por fatiga de la armadura longitudinal tiene mayor probabilidad de ocurrir en elementos sometidos a elevados niveles de oscilación de tensiones en esta armadura. Además, estos ensayos han sido analizados a través del modelo propuesto para tratar de comprender el comportamiento resistente de estos elementos sometidos a cargas de fatiga. Concrete structures are able to suffer fatigue when they are subjected to high number of cyclic loads. Many of these need not shear reinforcement to satisfy static design requirements, such as bridge deck slabs, retaining walls, bridge approach slabs, wind towers or maritime structures among others. Many codes of practice do not include a verification of the shear fatigue safety. Moreover, those which include it still prefer empirical S-N-based approaches that provide the number of cycles as a function of applied forces. S-N models are practical but they do not provide information to understand the shear fatigue process. The main objective of this Thesis is to study shear behaviour of reinforced concrete elements without stirrups subjected to fatigue loads. In addition, the analysis is extended in order to study the transverse behaviour of cantilever slabs of concrete bridges that traditionally are designed without shear reinforcement. These elements usually are designed on the basis of static strength and it is unusual that codes consider fatigue strength of concrete in shear. Accordingly, it is important to take into account the fatigue behaviour of structural members subjected to cyclic loads although these loads are lower than those which produce the static failure. Existing experimental works show important differences between the static and cyclic failure modes of reinforced concrete beams without stirrups. These works concluded that beams without transverse reinforcement, designed to have a ductile failure mode in flexure, can submit a brittle shear failure mode when they are subjected to repeated loads. Shear fatigue failure of reinforced concrete beams without stirrups is a rather complex process from the mechanical viewpoint. Since it leads to a brittle failure mode it should be better understood. Experimental evidence indicates that a diagonal crack first develops from the inclination of flexural cracks in the shear span. Thereafter, the diagonal crack propagates into the compression zone. Failure normally takes place by the destruction of the compression zone when its depth is too small to resist the applied force. The propagation of the diagonal crack can also be instantaneous, leading to sudden diagonal cracking fatigue failure rather than shear-compression failure. Fatigue process is studied in this Thesis on a mechanical basis. On the one hand, a predictive model is derived to obtain the number of cycles up to diagonal cracking, as a function of the stress state at the tip of a critical flexural crack. On the other hand, the residual fatigue strength after diagonal cracking is analyzed taking into account the fatigue damage accumulated by the compression zone and the variables affecting the propagation of the diagonal crack. In order to assess the residual fatigue strength after diagonal cracking of such elements, a theoretical model is proposed based on concepts from fracture mechanics adapted to concrete. This model can be successfully applied for straight or haunched reinforced concrete beams without stirrups following different procedures. In order to achieve a more advanced knowledge in this subject, an experimental campaign has been carried out with the aim of study the shear behaviour of reinforced concrete haunched beams without stirrups subjected to static and fatigue loads. A total of ten static and fatigue tests have been performed with distinct load levels and shear span-to-depth ratios, presenting different failures modes. These elements were designed to reproduce in a simplified form the cantilever slab of concrete bridges at real scale. Experimental results showed that the type of failure depends on several parameters as for example the maximum load level, the stress oscillation level on the longitudinal reinforcement, the shear span-to-depth ratio or the quality of the concrete used among others. For a similar value of the shear span-to-depth ratio, tests evidenced that shear fatigue failure is related to high maximum load levels, while steel fatigue failure is easier to occur in elements subjected to high stress oscillation level on the reinforcement bars. Besides, these tests have been analyzed through the proposed model in order to clarify the structural behaviour of such elements subjected to fatigue loads.