Stress on the ward: evidence of safety tipping points in hospitals

Do hospitals experience safety tipping points as utilization increases, and if so, what are the implications for hospital operations management? We argue that safety tipping points occur when managerial escalation policies are exhausted and workload variability buffers are depleted. Front-line clinical staff is forced to ration resources and, at the same time, becomes more error prone as a result of elevated stress hormone levels. We confirm the existence of safety tipping points for in-hospital mortality using the discharge records of 82,280 patients across six high-mortality-risk conditions from 256 clinical departments of 83 German hospitals. Focusing on survival during the first seven days following admission, we estimate a mortality tipping point at an occupancy level of 92.5%. Among the 17% of patients in our sample who experienced occupancy above the tipping point during the first seven days of their hospital stay, high occupancy accounted for one in seven deaths. The existence of a safety tipping point has important implications for hospital management. First, flexible capacity expansion is more cost-effective for safety improvement than rigid capacity, because it will only be used when occupancy reaches the tipping point. In the context of our sample, flexible staffing saves more than 40% of the cost of a fully staffed capacity expansion, while achieving the same reduction in mortality. Second, reducing the variability of demand by pooling capacity in hospital clusters can greatly increase safety in a hospital system, because it reduces the likelihood that a patient will experience occupancy levels beyond the tipping point. Pooling the capacity of nearby hospitals in our sample reduces the number of deaths due to high occupancy by 34%.

超对称电磁相互作用系统的BRST量子化及其正则Ward恒等式

运用Becchi-Rouet-Stora-Tyutin路径积分量子化方法对超对称电磁相互作用系统进行了量子化.在相空间中化简了超对称电磁相互作用系统Hamiltonian量,进而使该系统的量子化被化简.构造体系的BRST生成元,得到了系统的BRST变换;给出了有效作用量,得到了Green函数生成泛函;构造了体系的规范生产元,并得到了系统的规范对称变换.最后,基于正则系统的Noether定理,给出了规范变换的Ward-Takahashi恒等式,进而讨论了正规顶角和传播子的关系,给出了正规顶角和传播子的两个关系式.

BRST quantization and canonical Ward identity of the supersymmetric electromagnetic interaction system

According to the method of path integral quantization for the canonical constrained system in Becchi-Rouet-Stora-Tyutin scheme, the supersymmetric electromagnetic interaction system was quantized. Both the Hamiltonian of the supersymmetric electromagnetic interaction system in phase space and the quantization procedure were simplified. The BRST generator was constructed, and the BRST transformations of supersymmetric fields were gotten; the effective action was calculated, and the generating functional for the Green function was achieved; also, the gauge generator was constructed, and the gauge transformation of the system was obtained. Finally, the Ward-Takahashi identities based on the canonical Noether theorem were calculated, and two relations between proper vertices and propagators were obtained.

A view of the history, literature, and religion of the Hindoos : including a minute description of their manners and customs, and translations from their principal works / by Rev. W. Ward.

http://www.archive.org/details/wardshidoos00sethuoft

The day-breaking, if not the sun-rising of the Gospell with the Indians in New-England.

University of California Libraries

Dutch influence in the urban landscape of Cork City pre-1800: Fact or myth?

The early years of the eighteenth century Irish port town, Cork saw an expansion of its city limits, an era of reconstruction both within and beyond the walls of its Medieval townscape and a reclamation of its marshlands to the east and west. New people, new ideas and the beginnings of new wealth infused the post Elizabethan character of the recently siege battered city. It also brought a desire for something different, something new, an opportunity to redefine the ambience and visual perception of the urban landscape and thereby make a statement about its intended cultural and social orientations. It brought an opportunity to re-imagine and model a new, continental style of place and surrounding environment.

The Irish House of Lords, 1780-1800: politics and ideology

This thesis covers the Irish House of Lords in the last two decades of its life. A number of important themes run through the work - the regency crisis, patronage, the management of the Lords, the relationship between the Lords and Commons. These themes, explored from different angles, are vital to an understanding of the political role of the upper house in the 1780s and 1790s. This study is confined to the Lords as a political institution and thus its judicial role as final court of appeal, which was restored to it in 1782, will not be explored here. The thesis consists of two parts. Part one examines the structure and powers of the House of Lords while part two looks at the parties and policies of the house. Chapter one discusses the British constitution as imposed upon Ireland. Chapter two suggests the reasons why constitutional changes were introduced in 1782, and looks at the contribution made by the Irish House of Lords in securing these changes. Chapter three explores the various channels of influence which the peers enjoyed. Chapter four explores the sometimes tense relationship between Lords and Commons. Chapter five examines management of the House of Lords by Dublin Castle. Part two, begins at chapter six. This chapter explores the leadership of both parties within the Lords. Chapter seven looks at how patronage was used to reward those who were loyal to the government. Chapter eight explores the influence of the Whig opposition. Chapter nine looks at the controversial attempts made by Pitt and his ministry during the 1790s to win the support of catholics and turn them from the lure of French ideas, and of the response of the peers to these attempts. Chapter ten is concerned with the relationship between the peers of the House of Lords and the lords lieutenant during the 1790s. Chapter eleven looks at the Union and the House of Lords and attempts to answer the question historians have long asked: why did the Irish parliament and the House of Lords in particular, look favourably on the proposed union of the two kingdoms and the end of their own institution? The House of Lords in the closing decades of the eighteenth century was an institution within which the wealth and power of the kingdom could be found. Its members were politically active, both inside and outside the house. It contained a majority who saw the Crown as the source of stability, but it was a living and evolving political organism and therefore it contained men who believed that the Crown should have its influence limited. This evolution is also demonstrated in its desire for political change in 1782 and 1788. Its last, and perhaps most radical decision, was to vote for its own demise in 1900.