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.^

The number and timing of time -dependent covariate measurements for the Cox regression model

The problem of analyzing data with updated measurements in the time-dependent proportional hazards model arises frequently in practice. One available option is to reduce the number of intervals (or updated measurements) to be included in the Cox regression model. We empirically investigated the bias of the estimator of the time-dependent covariate while varying the effect of failure rate, sample size, true values of the parameters and the number of intervals. We also evaluated how often a time-dependent covariate needs to be collected and assessed the effect of sample size and failure rate on the power of testing a time-dependent effect.^ A time-dependent proportional hazards model with two binary covariates was considered. The time axis was partitioned into k intervals. The baseline hazard was assumed to be 1 so that the failure times were exponentially distributed in the ith interval. A type II censoring model was adopted to characterize the failure rate. The factors of interest were sample size (500, 1000), type II censoring with failure rates of 0.05, 0.10, and 0.20, and three values for each of the non-time-dependent and time-dependent covariates (1/4,1/2,3/4).^ The mean of the bias of the estimator of the coefficient of the time-dependent covariate decreased as sample size and number of intervals increased whereas the mean of the bias increased as failure rate and true values of the covariates increased. The mean of the bias of the estimator of the coefficient was smallest when all of the updated measurements were used in the model compared with two models that used selected measurements of the time-dependent covariate. For the model that included all the measurements, the coverage rates of the estimator of the coefficient of the time-dependent covariate was in most cases 90% or more except when the failure rate was high (0.20). The power associated with testing a time-dependent effect was highest when all of the measurements of the time-dependent covariate were used. An example from the Systolic Hypertension in the Elderly Program Cooperative Research Group is presented. ^

Effectiveness of Foliar Fungicides by Timing on Hybrid Corn

Fungicides were rarely used on hybrid corn prior to 2007, however, in the past few years, some farmers have included fungicides in their common crop production, particularly as the value of grain has increased. Fungicides are recommended for foliar disease management to protect yield potential. There also have been reports of increased yields in the absence of disease. A number of fungicides are registered for use on corn. The objectives of this project were to evaluate the yield response of hybrid corn to foliar fungicide application at various timings.

Effectiveness of Foliar Fungicides by Timing on Hybrid Corn

Fungicide use on hybrid corn has increased considerably in the past four growing seasons primarily due to reports of increased yields, even in the absence of disease and higher corn prices. A number of fungicides are registered for use on corn. The objectives of this project were to 1) assess the effect of timing of application of fungicides on standability, 2) evaluate the yield response of hybrid corn to foliar fungicide application, and 3) to discern differences, if any, between fungicide products.

Effectiveness of Foliar Fungicides by Timing on Hybrid Corn in Iowa

Fungicide use on hybrid corn has increased considerably in the past three growing seasons primarily due to reports of increased yields, even in the absence of disease and higher corn prices. A number of fungicides are registered for use on corn. The objectives of this project were to 1) evaluate the yield response of hybrid corn to foliar fungicide application, 2) compare the yield response of various products and timing of application, and 3) to assess the effect of fungicide application on stalk rot development.

Effectiveness of Foliar Fungicides by Timing on Hybrid Corn

Fungicides were rarely used on hybrid corn prior to 2007, however, in the past few years some farmers have made fungicides a regular input in their crop production, particularly as the value of grain has increased. Fungicides are recommended for foliar disease management to protect yield potential. There have also been reports of increased yields in the absence of disease. A number of fungicides are registered for use on corn. The objectives of this project were to evaluate the yield response of hybrid corn to foliar fungicide application at various timings.

Probability inundation map for a scenario combining storm surge and sea-level rise

Coastal managers require reliable spatial data on the extent and timing of potential coastal inundation, particularly in a changing climate. Most sea level rise (SLR) vulnerability assessments are undertaken using the easily implemented bathtub approach, where areas adjacent to the sea and below a given elevation are mapped using a deterministic line dividing potentially inundated from dry areas. This method only requires elevation data usually in the form of a digital elevation model (DEM). However, inherent errors in the DEM and spatial analysis of the bathtub model propagate into the inundation mapping. The aim of this study was to assess the impacts of spatially variable and spatially correlated elevation errors in high-spatial resolution DEMs for mapping coastal inundation. Elevation errors were best modelled using regression-kriging. This geostatistical model takes the spatial correlation in elevation errors into account, which has a significant impact on analyses that include spatial interactions, such as inundation modelling. The spatial variability of elevation errors was partially explained by land cover and terrain variables. Elevation errors were simulated using sequential Gaussian simulation, a Monte Carlo probabilistic approach. 1,000 error simulations were added to the original DEM and reclassified using a hydrologically correct bathtub method. The probability of inundation to a scenario combining a 1 in 100 year storm event over a 1 m SLR was calculated by counting the proportion of times from the 1,000 simulations that a location was inundated. This probabilistic approach can be used in a risk-aversive decision making process by planning for scenarios with different probabilities of occurrence. For example, results showed that when considering a 1% probability exceedance, the inundated area was approximately 11% larger than mapped using the deterministic bathtub approach. The probabilistic approach provides visually intuitive maps that convey uncertainties inherent to spatial data and analysis.

Chemical and Sr isotopic compositions and timing of carbonate mineral precipitation, ODP Leg 115

The strontium isotope ratios of authigenic carbonates from Indian Ocean sea-floor basalts have been used to determine the timing of carbonate mineral precipitation and fluid flow. The samples include calcites from 57.2 Ma crust from Ocean Drilling Project (ODP) Site 715, and calcites, aragonites, and siderites from 63.7 Ma crust from ODP Site 707. At Site 715, calcite precipitation may have begun at any time after the basalts cooled, and it continued until approximately 31 Ma, or 26 m.y. after basalt eruption. At Site 707, aragonite and siderite did not begin to precipitate until about 36 Ma, almost 30 m.y. after basalt eruption, and continued to precipitate until at least 30 and 28 Ma, respectively. Calcite precipitation began at approximately 32 Ma and continued until 22 Ma. These ages suggest that vein mineral deposition and low-temperature fluid circulation in the ocean crust may continue for much longer periods of time than previously observed.

Simulated agricultural subsistence, timing of transition, and percentage of immigrant farmers

Farming and herding were introduced to Europe from the Near East and Anatolia; there are, however, considerable arguments about the mechanisms of this transition. Were it the people who moved and either outplaced, or admixed with, the indigenous hunter-gatherer groups? Or was it material and information that moved---the Neolithic Package---consisting of domesticated plants and animals and the knowledge of their use? The latter process is commonly referred to as cultural diffusion and the former as demic diffusion. Despite continuous and partly combined efforts by archaeologists, anthropologists, linguists, palaeontologists and geneticists, a final resolution of the debate has not yet been reached. In the present contribution we interpret results from the Global Land Use and technological Evolution Simulator (GLUES). GLUES is a mathematical model for regional sociocultural development, embedded in the geoenvironmental context, during the Holocene. We demonstrate that the model is able to realistically hindcast the expansion speed and the inhomogeneous space-time evolution of the transition to agropastoralism in western Eurasia. In contrast to models that do not resolve endogenous sociocultural dynamics, our model describes and explains how and why the Neolithic advanced in stages. We uncouple the mechanisms of migration and information exchange and also of migration and the spread of agropastoralism. We find that: (1) An indigenous form of agropastoralism could well have arisen in certain Mediterranean landscapes, but not in Northern and Central Europe, where it depended on imported technology and material. (2) Both demic diffusion by migration and cultural diffusion by trade may explain the western European transition equally well. (3) Migrating farmers apparently contribute less than local adopters to the establishment of agropastoralism. Our study thus underlines the importance of adoption of introduced technologies and economies by resident foragers.

Paleomagnetic reconstructions of sediments at ODP Sites 135-840 and 135-841

The geometry of the Tonga Arc implies that it has rotated approximately 17° clockwise away from the Lau Ridge as the Lau Basin formed in between. Questions have arisen about the timing of the opening, whether the arc behaved rigidly, and whether the opening occurred instead from motion of the Lau Ridge, the remanent arc. We undertook to address these questions by taking paleomagnetic samples from sediment cores drilled on the Tonga Arc at Sites 840 and 841, orienting the samples in azimuth, and comparing the paleodeclinations to expected directions. Advanced hydraulic piston corer (APC) cores from Holes 840C and 841A were oriented during drilling with a tool based on a magnetic compass and attached to the core barrel. Samples from Hole 841B were drilled with a rotary core barrel (RCB) and therefore are azimuthally unoriented. They were oriented by identifying faults and dipping beds in the core and aligning them with the same features in the Formation MicroScanner (FMS) wireline logs, which were themselves oriented with a three-axis magnetometer in the FMS tool. The best results came from the APC cores, which yielded a mean pole at -69.0°S, 112.2°E for an age of 4 Ma. This pole implies a declination anomaly of 20.8° ± 12.6° (95% confidence limit), which appears to have occurred by tectonic rotation of the Tonga Arc. This value is almost exactly that expected from the geometry of the arc and implies that it did indeed rotate clockwise as a rigid body. The large uncertainty in azimuth results from core orientation errors, which have an average standard deviation of 18.6°. The youngest cores used to calculate the APC pole contain sediments deposited during Subchron 2A (2.48-3.40 Ma), and their declinations are indistinguishable from the others. This observation suggests that most of the rotation occurred after their deposition; this conclusion must be treated with caution, however, because of the large azimuthal orientation errors. Poles from late and early Miocene sediments of Hole 841B are more difficult to interpret. Samples from this hole are mostly normal in polarity, fail a reversal test, and yield poles that suggest that the normal-polarity directions may be a recent overprint. Late Miocene reversed-polarity samples may be unaffected by this overprint; if so, they imply a declination anomaly of 51.1° ± 11.5°. This observation may indicate that, for older sediments, Tonga forearc rotations are larger than expected.