Incident-Reporting-Systeme als Möglichkeit zum organisationalem Lernen (nicht nur) aus Fehlern und kritischen Ereignissen

Die vorliegende Dissertation betrachtet institutionsinterne lokale (Critical-)Incident-Reporting-Systeme ((C)IRS) als eine Möglichkeit zum Lernen aus Fehlern und unerwünschten kritischen Ereignissen (sogenannte Incidents) im Krankenhaus. Die Notwendigkeit aus Incidents zu lernen, wird im Gesundheitswesen bereits seit den 1990er Jahren verstärkt diskutiert. Insbesondere risikoreichen Organisationen, in denen Incidents fatale Konsequenzen haben können, sollten umfassende Strategien erarbeiten, die sie vor Fehlern und unerwünschten Ereignissen schützen und diese als Lernpotenzial nutzen können. Dabei können lokale IRS als ein zentraler Bestandteil des Risikomanagements und freiwillige Dokumentationssysteme im Krankenhaus ein Teil dieser Strategie sein. Sie können eine Ausgangslage für die systematische Erfassung und Auswertung von individuellen Lerngelegenheiten und den Transfer zurück in die Organisation schaffen. Hierfür sind eine lernförderliche Gestaltung, Implementierung und Einbettung lokaler IRS eine wichtige Voraussetzung. Untersuchungen über geeignete lerntheoretisch fundierte und wirkungsvolle IRS-Modelle und empirische Daten fehlen bisher im deutschsprachigen Raum. Einen entsprechenden Beitrag leistet die vorliegende Fallstudie in einem Schweizer Universitätsspital (800 Betten, 6.100 Mitarbeitende). Zu diesem Zweck wurde zuerst ein Anforderungsprofil an lernförderliche IRS aus der Literatur abgeleitet. Dieses berücksichtigt zum einen literaturbasierte Kriterien für die Gestaltung und Nutzung aus der IRS-Literatur, zum anderen die aus der Erziehungswissenschaft und Arbeitspsychologie entlehnten Gestaltungsbedingungen und Erfolgskriterien an organisationales Lernen. Das Anforderungsprofil wurde in drei empirischen Teilstudien validiert und entsprechend adaptiert. In der ersten empirischen Teilstudie erfolgte eine Standortbestimmung der lokalen IRS. Die Erhebung erfolgte in vier Kliniken mittels Dokumentenanalyse, leitfadengestützter Interviews (N=18), sieben strukturierter Gruppendiskussionen und teilnehmender Beobachtungen über einen Zeitraum von 22 Monaten. Erfolgskritische IRS-Merkmale wurden identifiziert mit dem Ziel einer praxisgerechten lernförderlichen Systemgestaltung und Umsetzung von Incident Reporting unter Betrachtung von organisationalen Rahmenbedingungen, Lernpotenzialen und Barrieren. Die zweite Teilstudie untersuchte zwei Fallbeispiele organisationalen Lernens mittels Prozessbegleitung, welche zu einem verwechslungssicheren Design bei einem Medizinalprodukt und einer verbesserten Patientenidentifikation in Zusammenhang mit Blutentnahmen führten. Für das organisationale Lernen im Spital wurden dabei Chancen, Barrieren und Gestaltungsansätze abgeleitet, wie erwünschte Veränderungen und Lernen unter Nutzung von IRS initiiert werden können und dabei ein besseres Gesundheitsresultat erreicht werden kann. Die dritte Teilstudie überprüfte, inwiefern die Nutzung und Implementierung lokaler IRS mittels einer Mitarbeitervollbefragung zur Sicherheitskultur gefördert werden kann. Hierfür wurde eine positive Interaktion, zwischen einer starken Sicherheitskultur und der Bereitschaft ein IRS zu implementieren und Incidents zu berichten, angenommen. Zum Einsatz kam eine deutschsprachige Version des Hospital Survey on Patient Safety Culture (Patientensicherheitsklimainventar) mit einem Rücklauf von 46.8% (2.897 gültige Fragebogen). In 23 von 37 Kliniken führte laut einer Nachbefragung die Sicherheitskulturbefragung zum Implementierungsentscheid. Dies konnte durch Monitoring der IRS-Nutzung bestätigt werden. Erstmals liegen mit diesen Studien empirische Daten für eine wirkungsvolle und lernförderliche Gestaltung und Umsetzung von lokalen IRS am Beispiel einer Schweizer Gesundheitsorganisation vor. Die Ergebnisse der Arbeit zeigen Chancen und Barrieren für IRS als Berichts- und Lernsysteme im Krankenhaus auf. Als Resultat unsachgemäss gestalteter und implementierter IRS konnte dabei vor allem Lernverhinderung infolge IRS aufgezeigt werden. Blinder Aktionismus und eine fehlende Priorisierung von Patientensicherheit, unzureichende Kompetenzen, Qualifikationen und Ressourcen führten dabei zur Schaffung neuer Fehlerquellen mit einer Verstärkung des Lernens erster Ordnung. Eine lernförderliche Gestaltung und Unterhaltung der lokalen IRS, eingebettet in eine klinikumsweite Qualitäts- und Patientensicherheitsstrategie, erwiesen sich hingegen als wirkungsvoll im Sinne eines organisationalen Lernens und eines kontinuierlichen Verbesserungsprozesses. Patientensicherheitskulturbefragungen erwiesen sich zudem bei entsprechender Einbettung als effektives Instrument, um die Implementierung von IRS zu fördern. Zwölf Thesen zeigen in verdichteter Form auf, welche Gestaltungsprinzipien für IRS als Instrument des organisationalen Lernens im Rahmen des klinischen Risikomanagements und zur Förderung einer starken Patientensicherheitskultur zu berücksichtigen sind. Die Erkenntnisse aus den empirischen Studien münden in ein dialogorientiertes Rahmenmodell organisationalen Lernens unter Nutzung lokaler IRS. Die Arbeit zeigt damit zum einen Möglichkeiten für ein Lernen auf den verschiedenen Ebenen der Organisation auf und weist auf die Notwendigkeit einer (Re-)Strukturierung der aktuellen IRS-Diskussion hin.

Indigenous Knowledge (IK) of Water Resources Management in West Sumatra, Indonesia

This study was aim to describe the indigenous knowledge of farmers at Nagari Padang laweh Malalo (NPLM) and their adaptability to climate change. Not only the water scarcity is feared, but climate change is also affecting their food security. Local food security can be achieved if biodiversity in their surrounding area is suitable to the local needs. The study was conducted by using Participatory Rural Appraisal (PRA) such as observation and discussion. The combination of in depth interview, life history, semi structure questionnaire, pictures, mapping and expert interviews was implemented. Data was analyzed by using MAXQDA 10 and F4 audio analysis software. The result shows awareness of the people and scarcity of water conditions has allowed the people of NPLM to face this challenge with wisdom. Aia adat (water resources controlled and regulate by custom) is one of their strategies to distribute the water. The general rule is that irrigation will flow from 6 pm – 6 am regularly to all farm land under supervision of kapalo banda. When rains occur, water resources can be used during the day without special supervision. They were used traditional knowledge to manage water resources for their land and daily usage. This study may be helpful for researcher and other farmers in different region to learn encounter water scarcity.

An integrated assessment of resource use strategies in the Borana pastoral system of southern Ethiopia

In the pastoral production systems, mobility remains the main technique used to meet livestock’s fodder requirements. Currently, with growing challenges on the pastoral production systems, there is urgent need for an in-depth understanding of how pastoralists continue to manage their grazing resources and how they determine their mobility strategies. This study examined the Borana pastoralists’ regulation of access to grazing resources, mobility practices and cattle reproductive performances in three pastoral zones of Borana region of southern Ethiopia. The central objective of the study was to contribute to the understanding of pastoral land use strategies at a scale relevant to their management. The study applied a multi-scalar methodological approach that allowed zooming in from communal to individual herd level. Through participatory mapping that applied Google Earth image print out as visual aid, the study revealed that the Borana pastoralists conceptualized their grazing areas as distinctive grazing units with names, borders, and specific characteristics. This knowledge enables the herders to communicate the condition of grazing resources among themselves in a precise way which is important in management of livestock mobility. Analysis of grazing area use from the participatory maps showed that the Borana pastoralists apportion their grazing areas into categories that are accessed at different times of the year (temporal use areas). This re-organization is an attempt by the community to cope with the prevailing constraints which results in fodder shortages especially during the dry periods. The re-organization represents a shift in resource use system, as the previous mobility practice across the ecologically varied zones of the rangelands became severely restricted. Grazing itineraries of 91 cattle herds for over 16 months obtained using the seasonal calendar interviews indicated that in the areas with the severest mobility constraints, the herders spent most of their time in the year round use areas that are within close proximity to the settlements. A significant change in mobility strategy was the disallowing of foora practice by the communities in Dirre and Malbe zones in order to reduce competition. With the reduction in mobility practices, there is a general decline in cattle reproductive parameters with the areas experiencing the severest constraints showing the least favourable reproductive performances. The study concludes that the multi-scalar methodology was well suited to zoom into pastoral grazing management practices from communal to individual herd levels. Also the loss of mobility in the Borana pastoral system affects fulfilment of livestock feed requirements thus resulting in reduced reproductive performances and herd growth potentials. While reversal of the conditions of the situations in the Borana rangelands is practically unfeasible, the findings from this research underscore the need to protect the remaining pastoral lands since the pastoral production system remains the most important livelihood option for the majority of the Borana people. In this regards the study emphasises the need to adopt and domesticate regional and international policy frameworks such as that proposed by the African Union in 2010.

Over Expression of the CMP-sialic Acid Transporter in Chinese Hamster Ovary Cells Leads to Increased Sialylation

Most glyco-engineering approaches used to improve quality of recombinant glycoproteins involve the manipulation of glycosyltransferase and/or glycosidase expression. We investigated whether the over expression of nucleotide sugar transporters, particularly the CMP-sialic acid transporter (CMP-SAT), would be a means to improve the sialylation process in CHO cells. We hypothesized that increasing the expression of the CMP-SAT in the cells would increase the transport of the CMP-sialic acid in the Golgi lumen, hence increasing the intra-lumenal CMP-sialic acid pool, and resulting in a possible increase in sialylation extent of proteins being produced. We report the construction of a CMP-SAT expression vector which was used for transfection into CHO-IFNγ, a CHO cell line producing human IFNγ. This resulted in approximately 2 to 5 times increase in total CMP-SAT expression in some of the positive clones as compared to untransfected CHO-IFNγ, as determined using real-time PCR analysis. This in turn concurred with a 9.6% to 16.3% percent increase in site sialylation. This engineering approach has thus been identified as a novel means of improving sialylation in recombinant glycoprotein therapeutics. This strategy can be utilized feasibly on its own, or in combination with existing sialylation improvement strategies. It is believed that such multi-prong approaches are required to effectively manipulate the complex sialylation process, so as to bring us closer to the goal of producing recombinant glycoproteins of high and consistent sialylation from mammalian cells.

Adaptive intelligent agent approach to guide the web navigation on the PLAN-G distance learning platform

Hypermedia systems based on the Web for open distance education are becoming increasingly popular as tools for user-driven access learning information. Adaptive hypermedia is a new direction in research within the area of user-adaptive systems, to increase its functionality by making it personalized [Eklu 961. This paper sketches a general agents architecture to include navigational adaptability and user-friendly processes which would guide and accompany the student during hislher learning on the PLAN-G hypermedia system (New Generation Telematics Platform to Support Open and Distance Learning), with the aid of computer networks and specifically WWW technology [Marz 98-1] [Marz 98-2]. The PLAN-G actual prototype is successfully used with some informatics courses (the current version has no agents yet). The propased multi-agent system, contains two different types of adaptive autonomous software agents: Personal Digital Agents {Interface), to interacl directly with the student when necessary; and Information Agents (Intermediaries), to filtrate and discover information to learn and to adapt navigation space to a specific student

Example General Feedback on Routes to Success Portfolios

This document provides example feedback which has been generated following the marking of a class set of portfolios. It is used as a part of the Routes to Success Module, specifically on the section titled Sustaining Success. Students can read the feedback prior to completing the portfolio to alert them to the possible shortfalls which may occur when they undertake this type of task. The feedback is introduced in the context that the task of completing the portfolio is a developmental one, and that students can expect to learn and improve their performance for this type of task as they develop and refine their skills.

How Minecraft Affects How Young People Learn About Computer Science

Abstract: As one of the newest art forms available to young people, gaming has become an increasing influence on young people’s education, even if not used in a classroom environment. This talk aims to explore examples of how video games have changed how young people understand and learn about certain subjects, with particular focus on how the indie title Minecraft allows them to learn about the world of Computer Science and how groups are looking to forward the cause of education though games.

I Don`t Want to Present the ECAES! Quality of Education in Health Careers

This paper makes a reflection about a panorama of higher education quality, and referring to that it reviews and discusses what should be ongoing, what was made in history and what is today in curse, that is the basic strategies used by the government to improve higher education. An emphasis is made on higher education quality tests (ECAES, in Spanish) for health careers, in order to solve some doubts in students and teachers about those tests. My excuses to the reader for often using first person and some references of personal interviews or unprinted conferences.

Conceptuals Mentefactos as a Didactic-Pedagogical Strategy of the Basic Concepts in the Sampling Theory Applyed to the Health Research

In populational sampling it is vitally important to clarify and discern: first, the design or sampling method used to solve the research problem; second, the sampling size, taking into account different components (precision, reliability, variance); third, random selection and fourth, the precision estimate (sampling errors), so as to determine if it is possible to infer the obtained estimates from the target population. The existing difficulty to use concepts from the sampling theory is to understand them with absolute clarity and, to achieve it, the help from didactic-pedagogical strategies arranged as conceptual “mentefactos” (simple hierarchic diagrams organized from propositions) may prove useful. This paper presents the conceptual definition, through conceptual “mentefactos”, of the most important populational probabilistic sampling concepts, in order to obtain representative samples from populations in health research.

Desarrollo de un estado de la cuestión acerca de las interacciones entre el control de gestión y el aprendizaje organizacional.

Las organizaciones en la actualidad deben encontrar diferentes maneras de sobrevivir en un tiempo de rápida transformación. Uno de los mecanismos usados por las empresas para adaptarse a los cambios organizacionales son los sistemas de control de gestión, que a su vez permiten a las organizaciones hacer un seguimiento a sus procesos, para que la adaptabilidad sea efectiva. Otra variable importante para la adaptación es el aprendizaje organizacional siendo el proceso mediante el cual las organizaciones se adaptan a los cambios del entorno, tanto interno como externo de la compañía. Dado lo anterior, este proyecto se basa en la extracción de documentación soporte valido, que permita explorar las interacciones entre estos dos campos, los sistemas de control de gestión y el aprendizaje organizacional, además, analizar el impacto de estas interacciones en la perdurabilidad organizacional. ​

Cultura e innovación en empresas con relaciones de cooperación inter organizacional

Un gran número de empresas están inmersas actualmente en espacios de mercado conocidos y saturados de competidores. La innovación constituye una de las principales alternativas de las empresas para encontrar su posicionamiento estratégico y adaptarse a los cambios del entorno (Kim & Mauborgne, 2005). Igualmente, Demirci (2013) asegura que la cultura es un factor clave en la innovación, dado que está fuertemente asociada con los valores, actitudes, comportamientos y prácticas organizacionales. Esta investigación abarca el estudio de la cultura organizacional y la innovación en el marco de estrategias de cooperación inter-organizacional donde se plantea que el grado de cooperación que existe entre las empresas tiene un efecto sobre los valores culturales y la incorporación de innovaciones en cada organización. Para esto se llevó a cabo una investigación cuantitativa con un alcance de tipo descriptivo y de carácter no experimental y trans seccional, cuya unidad de análisis fueron 20 empresas de la red ParqueSoft Manizales. Para la medición de las variables de innovación se aplicó un instrumento basado en el Manual de Oslo de la OECD y Eurostat (2005) el cual contempla la innovación de producto, proceso, mercadotecnia y organización. A nivel de los valores culturales, la medición se realizó a través de un cuestionario inspirado en el modelo de Hofstede (1980). Los resultados obtenidos permiten demostrar que existe un grado de relación entre la cooperación y los valores culturales ‘distancia al poder’ y ‘tolerancia a la incertidumbre´, sin poder determinar la relación con la generación de innovación de producto, proceso, mercadotecnia y organización, así como con las otras dimensiones del modelo de valores de Hofstede.

Harinera Pardo S.A.: experiencias de crisis y recuperación en empresas colombianas

Este estudio de caso consiste en analizar el funcionamiento al interior de la empresa Harinera Pardo S.A, las inversiones realizadas y las decisiones tomadas. También en ver el comportamiento del sector agroindustrial molinero, específicamente de trigo, ya que la empresa se desenvuelve en este mercado. Y por último, entender los factores que llevaron a la empresa objeto de estudio a verse afectada por una crisis empresarial. Con base en el concepto de “crisis” que cita Martin (2008), las causas que la generan en la empresa pueden ser internas, como problemas comerciales, de producción, de calidad, inadecuada infraestructura de costos, problemas de dirección, inversiones y demás o externas, como cambios en el mercado, el fenómeno de la globalización, influencia de los competidores, entre otros. Decidimos citar este autor ya que su visión sobre el concepto de crisis encierra varios factores que hacen parte del desarrollo del estudio de caso. De este estudio se espera aprender con una empresa del sector real, que caer en una crisis no necesariamente significa llegar a su fin, sino que con una adecuada reestructuración, esta puede enfrentar y superar el mal momento que esté atravesando. Para ello tendremos en cuenta la influencia del mercado internacional en la época de los 90´s y la coyuntura que se presentaba alrededor del sector molinero, al igual que el comportamiento al interior de la empresa durante este mismo periodo de tiempo, que fue previo a la recaída de la empresa. A demás, expondremos las opiniones y estrategias utilizadas por Rafael Pardo, presidente de Harinera Pardo, con las que gracias a su puesta en marcha durante los años de crisis, finalmente logró recuperarse en el año 2009. El trabajo es desarrollado por estudiantes de pregrado de Administración de Empresas y Administración de Negocios Internacionales de la Universidad del Rosario, y la investigación a realizar trata temas administrativos de crisis y recuperación.

Prediction of postprandial blood glucose under intra-patient variability and uncertainty and its use in the design of insulin dosing strategies for type 1 diabetic patients

In this thesis I propose a novel method to estimate the dose and injection-to-meal time for low-risk intensive insulin therapy. This dosage-aid system uses an optimization algorithm to determine the insulin dose and injection-to-meal time that minimizes the risk of postprandial hyper- and hypoglycaemia in type 1 diabetic patients. To this end, the algorithm applies a methodology that quantifies the risk of experiencing different grades of hypo- or hyperglycaemia in the postprandial state induced by insulin therapy according to an individual patient’s parameters. This methodology is based on modal interval analysis (MIA). Applying MIA, the postprandial glucose level is predicted with consideration of intra-patient variability and other sources of uncertainty. A worst-case approach is then used to calculate the risk index. In this way, a safer prediction of possible hyper- and hypoglycaemic episodes induced by the insulin therapy tested can be calculated in terms of these uncertainties.

Inclusão ou ilusão? Intervenção com uma criança com autismo, no âmbito da componente de apoio à família

RESUMO: Cada vez mais, os desafios que se impõem a toda a comunidade educativa, estão relacionados com a inclusão e o ensino de crianças com Necessidades Educativas Especiais, nas escolas de ensino regular. Este trabalho, é o relatório de uma intervenção, feita junto de uma criança com autismo, com sete anos de idade, matriculada no 2º ano de escolaridade, de uma escola básica da cidade de Lisboa, e a intervenção realizou-se no âmbito da Componente de Apoio à Família. Esta intervenção testou a pertinência das estratégias lúdico-pedagógicas, na evolução, tanto no processo de aprendizagem da leitura e da escrita, como da sua inclusão. A metodologia utilizada, assentou nos pressupostos teórico-práticos da investigação-acção. Este trabalho parece-nos espelhar a realidade vivida por muitas crianças com Necessidades Educativas Especiais, que muitas vezes não encontram um cenário escolar inclusivo, capaz de oferecer a todas o direito de aprenderem juntas. ABSTRACT: The challenges that impose into the entire educational community are increasingly related to the inclusion and education of children with Special Educational Needs in regular schools. This work is a report of an intervention with a seven year old child with autism. This child is enrolled in the 2nd grade of an elementary school in the city of Lisbon, and the intervention occurred in the context of the Family Support Component. This intervention has tested the relevance of the playful – pedagogical strategies in evolution, both in the learning process of reading and writing of the child in the study, as in her inclusion. The used methodology was based on the theorethical-pratical assumptions for a research-action project. This work seems to reflect the reality experienced by many children with Special Educational Needs, who often do not find an inclusive school setting, able to offer to them all, the right to learn together.

A educação inclusiva e a hiperactividade no jardim de infância

RESUMO: Propomos com este trabalho conhecer e aprofundar conhecimentos, através duma investigação-acção, relativamente à problemática em estudo - Perturbação de Hiperactividade com Défice de Atenção (PHDA). Também procurámos mostrar, através da intervenção, que o educador pode auxiliar no desenvolvimento e aprendizagem de uma criança com um diagnóstico de PHDA. Realizámos uma pesquisa bibliográfica sobre esta Perturbação, com uma breve perspectiva histórica, sobre o que é a PHDA, o diagnóstico, os subtipos e problemas associados e a intervenção em crianças com esta problemática. Pesquisámos, também, estratégias educativas de como actuar a nível pedagógico com esta criança e com o grupo onde se encontra incluída. Demos uma grande centralidade ao trabalho empírico, através da pesquisa documental, observações, entrevistas e sociometria. De seguida, elaborámos um projecto de investigação-acção, para o grupo onde a criança está incluída, utilizando estratégias de educação inclusiva, de modo a colmatar problemas comportamentais e de aprendizagem, derivados de défices de atenção e de concentração do grupo, através do grupo. Todo este processo deu resultados positivos, a nível dos comportamentos sociais e das aprendizagens académicas do grupo e do aluno desencadeador do Trabalho Projecto. Obrigou a uma acção, reflexão, acção que desencadeou uma procura e experimentação sistemática para dar resposta aos problemas surgidos, o que ajudou ao meu desenvolvimento pessoal e profissional e a uma vontade de investir mais e melhor no desencadeamento de práticas de educação cada vez mais inclusivas. ABSTRACT: With this paper, we want to learn, using the investigation-action, about the team we are working with, that is Perturbation of Hyperactivity and Deficit of Attention (PHDA). We also want to show that it is possible to help the children with the PHDA in their learning process using the right intervention. We searched for different opinions on this team, its history, how to diagnostic it and the different problems that this children can have. We also search for different strategies to teach the students with this problem as well as the others of the group. We gave special attention to the empirical work. For this reason we used the documental research, the observation, interviews and sociometry. After this we prepared the action research project for the group of children that work with the PHDA child. To do so, we used different inclusion strategies so that we could help him improving his behavior and learning process using the help of other students. On the end we had positive results in the behavior and also in the learning process with the group and the student who we based this work on. We used action/reflection/action that helped us to find out about the PHDA and the different strategies to try to solve this problem. All of this helped me as a teacher and as a person. It gave me the will to keep looking for better and different inclusive strategies.