The ethics and practical importance of defining, distinguishing and disclosing nursing errors : a discussion paper

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of ‘nursing error’, the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of ‘nursing error’ fits with the new ‘system approach’ to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is ‘right’ for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

The risky business of doctoral management

Universities are under no less pressure to adopt risk management strategies than other public and private organisations. The risk management of doctoral education is a particularly important issue given that a doctorate is the highest academic qualification a university offers and stakes are high in terms of assuring its quality. However, intense risk management can interfere with the intellectual and pedagogical work which are essentially part of doctoral education. This paper seeks to understand how the culture of risk meets the culture of doctoral education and with what effect. The authors draw on sociological understandings of risk in the work of Anthony Giddens (2002) and Ulrich Beck (1992), the anthropological focus on liminality in the work of Mary Douglas (1990), and the psychological theorising of human error in the work of James Reason (1990). The paper concludes that risk consciousness brings its own risks—in particular, the potential transformation of a culture based on intellect into a culture based on compliance.

Rendering optimisations for stylised sketching

We present work that specifically pertains to the rendering stage of stylised, non-photorealistic sketching. While a substantial body of work has been published on geometric optimisations, surface topologies, space-algorithms and natural media simulation, rendering-specific issues are rarely discussed in-depth even though they are often acknowledged. We investigate the most common stylised sketching approaches and identify possible rendering optimisations. In particular, we define uncertainty-functions, which are used to describe a human-error component, discuss how these pertain to geometric perturbation and textured silhouette sketching and explain how they can be cached to improve performance. Temporal coherence, which poses a problem for textured silhouette sketching, is addressed by means of an easily computed visibility-function. Lastly, we produce an effective yet surprisingly simple solution to seamless hatching, which commonly presents a large computational overhead, by using 3-D textures in a novel fashion. All our optimisations are cost-effective, easy to implement and work in conjunction with most existing algorithms.

Terminologia de incidentes com medicamentos no contexto hospitalar

Incidentes com medicamentos geram problemas aos pacientes e custos adicionais ao sistema de saúde. A variedade de termos utilizada para comunicá-los propicia divergências nos resultados de pesquisas e confundem notificadores. Objetivou-se revisar os termos utilizados para descrever estes incidentes confrontando-os com as conceituações/definições oficiais disponíveis. Pesquisaram-se as bases PubMed, MEDLINE, IPA e LILACS para selecionar estudos publicados entre janeiro de 1990 e dezembro de 2005. Selecionaram-se 33 publicações. Verificou-se que a terminologia supranacional recomendada para descrever incidentes com medicamentos é insuficiente, mas que há consenso de uso das expressões em função do gênero do incidente. O termo Reação Adversa a Medicamento é mais utilizado quando não se verifica intencionalidade. A expressão Evento Adverso a Medicamento foi mais usada quando se descreviam incidentes durante a hospitalização; e Problema Relacionado a Medicamento foi mais utilizada em estudos que avaliaram atenção/cuidados farmacêuticos (uso/falta do medicamento). Ainda assim, a linha divisória entre essas três categorias não é clara e simples. Futuros estudos das relações entre as categorias e investigações multidisciplinares sobre erro humano podem subsidiar a proposição de novas conceituações.

Forum: social network for the surveillance and prevention of workplace accidents

In 2008, academic researchers and public service officials created a university extension studies platform based on online and on-site meetings denominated "Work-Related Accidents Forum: Analysis, Prevention, and Other Relevant Aspects. Its aim was to help public agents and social partners to propagate a systemic approach that would be helpful in the surveillance and prevention of work-related accidents. This article describes and analyses such a platform. Online access is free and structured to: support dissemination of updated concepts; support on-site meetings and capacity to build educational activities; and keep a permanent space for debate among the registered participants. The desired result is the propagation of a social-technical-systemic view of work-related accidents that replaces the current traditional view that emphasizes human error and results in blaming the victims. The Forum uses an educational approach known as permanent health education, which is based on the experience and needs of workers and encourages debate among participants. The forum adopts a problematizing pedagogy that starts from the requirements and experiences of the social actors and stimulates support and discussions among them in line with an ongoing health educational approach. The current challenge is to turn the platform into a social networking website in order to broaden its links with society.

Ergonomia aplicada em posto de trabalho do operador de tratores: sistema para aquisição de coordenadas tridimensionais

Pós-graduação em Agronomia (Energia na Agricultura) - FCA

Estudo da tecnologia RFID e sua aplicação na gestão de estoques

Due to the need of more agility, dynamism and reliability in stock management, the market has turned its attention to RFID, which offers a practical solution and live up to the big corporations' expectations. The search for continuous improvement establishes a direct link with RFID, for its technology offers accurate real time information in any monitored given place. RFID is a radio frequency communication technology. A reader communicates to a tag through waves. This tag can be active, with a battery, or passive, in which its power is supplied by currents induced by the field variation it is exposed to. The RFID technology has a well defined basic principle, but there are many constructive ways of implementing it. The adaptability as well as the flexibility regard to the several kinds of stock in industry, reaching their particular needs. RFID can lower maintenance costs in stock by collecting data more accurately, lowering human error and optimizing the item handling at its reception, exit and while it is inside the company. This paper presents an example of RFID technology applied in a company's stock management. It is possible to prove that there are, in fact, great advantages in implementing this technology, as it creates the opportunity for continuous improvement in stock management, with better application of material, labour and quality tools, since the data collected through an automatized process using RFID are more reliable and dynamic

Proteção de sistemas eletricos industriais: relés e suas aplicações em subestações

Electrical installations in industries involving high currents and voltages considered. On the other side is the common appearance of electrical failures, caused by human error, defects in electrical equipment or electrical installation aging itself. These failures are varied, those with the highest rate of occurrence and cause much damage to electrical installations, are overcurrent and overvoltage. Therefore there is a need to project a system that can detect and minimize possible effects caused by faults in electrical installations industries. Protection systems in electric industries emerge as an alternative to control especially voltage and current magnitudes. Engineered based on the functions of the relays, protection systems are an indispensable tool for any industrial substation. But the project of such systems becomes increasingly more complex, due to technological development. Electrical equipment not develop at the same speed that the protective devices (relays), making it indispensable knowledge of integration of technologies

O romance como veículo de preenchimento da falta humana: Reparação de Ian McEwan

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Forum: social network for the surveillance and prevention of workplace accidents

In 2008, academic researchers and public service officials created a university extension studies platform based on online and on-site meetings denominated "Work-Related Accidents Forum: Analysis, Prevention, and Other Relevant Aspects. Its aim was to help public agents and social partners to propagate a systemic approach that would be helpful in the surveillance and prevention of work-related accidents. This article describes and analyses such a platform. Online access is free and structured to: support dissemination of updated concepts; support on-site meetings and capacity to build educational activities; and keep a permanent space for debate among the registered participants. The desired result is the propagation of a social-technical-systemic view of work-related accidents that replaces the current traditional view that emphasizes human error and results in blaming the victims. The Forum uses an educational approach known as permanent health education, which is based on the experience and needs of workers and encourages debate among participants. The forum adopts a problematizing pedagogy that starts from the requirements and experiences of the social actors and stimulates support and discussions among them in line with an ongoing health educational approach. The current challenge is to turn the platform into a social networking website in order to broaden its links with society.

Applications of infrared thermography in the food industry

In the last 20-30 years, the implementation of new technologies from the research centres to the food industry process was very fast. The infrared thermography is a tool used in many fields, including agriculture and food science technology, because of it's important qualities like non-destructive method, it is fast, it is accurate, it is repeatable and economical. Almost all the industrial food processors have to use the thermal process to obtain an optimal product respecting the quality and safety standards. The control of temperature of food products during the production, transportation, storage and sales is an essential process in the food industry network. This tool can minimize the human error during the control of heat operation, and reduce the costs with personal. In this thesis the application of infrared thermography (IRT) was studies for different products that need a thermal process during the food processing. The background of thermography was presented, and also some of its applications in food industry, with the benefits and limits of applicability. The measurement of the temperature of the egg shell during the heat treatment in natural convection and with hot-air treatment was compared with the calculated temperatures obtained by a simplified finite element model made in the past. The complete process shown a good results between calculated and observed temperatures and we can say that this technique can be useful to control the heat treatments for decontamination of egg using the infrared thermography. Other important application of IRT was to determine the evolution of emissivity of potato raw during the freezing process and the control non-destructive control of this process. We can conclude that the IRT can represent a real option for the control of thermal process from the food industry, but more researches on various products are necessary.

Towards a Hybrid Method to Categorize Interruptions and Activities in Healthcare

Objective Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular and for improving healthcare quality and patient safety in general. Method The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. Results The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. Conclusions Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Towards a hybrid method to categorize interruptions and activities in healthcare.

OBJECTIVE: Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD: The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS: The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS: Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

Model-to-Code transformation from product-line architecture models to aspectJ

Software Product Line Engineering has significant advantages in family-based software development. The common and variable structure for all products of a family is defined through a Product-Line Architecture (PLA) that consists of a common set of reusable components and connectors which can be configured to build the different products. The design of PLA requires solutions for capturing such configuration (variability). The Flexible-PLA Model is a solution that supports the specification of external variability of the PLA configuration, as well as internal variability of components. However, a complete support for product-line development requires translating architecture specifications into code. This complex task needs automation to avoid human error. Since Model-Driven Development allows automatic code generation from models, this paper presents a solution to automatically generate AspectJ code from Flexible-PLA models previously configured to derive specific products. This solution is supported by a modeling framework and validated in a software factory.

Learning from incidents during bridge erection

Bridge building is a highly uncertain endeavour that entails considerable risk, as attested to by the succession of construction-related incidents and accidents recently reported in Spain and elsewhere. While efforts are being made to improve on-site safety, many issues are still outstanding, such as the establishment of reliability requirements for the ancillary systems used. The problems that must be dealt with in everyday practice, however, are more elementary and often attributable to human error. The overall organisation of the use of bridge construction equipment is in need of improvement. Close cooperation between the bridge engineers responsible for construction planning and ancillary element suppliers is imperative, for flawed interaction between building equipment and the bridge under construction may generate structural vulnerability. External quality assurance should likewise be mandatory