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.

Biomolecular interaction analysis in functional proteomics

In der funktionellen Proteomforschung werden bekannte Interaktionen eines zellulären Netzwerkes qualitativ untersucht. Diese Veröffentlichung beschreibt verschiedene biomolekulare Interaktionsanalysen, anhand des Modellsystems PKA, die zur detaillierten Charakterisierung von Bindungen herangezogen werden können. Neben den Gleichgewichtsbindungsdaten (generiert aus AlphaScreen, FP, SPR und ITC Messungen) wurden aus ITC Messungen die thermodynamischen Parameter G, H und S ermittelt. Durch Anwendung der BRET2 (Bioluminescence resonance energy transfer) Methode konnten in lebenden Zellen Aussagen über Bindungsereignisse und deren Lokalisation getroffen werden.

Local food security and principle of organic farming (from farm to fork) in context of food culture in Indonesia: Minangkabau's case study

The basic idea behind improving local food security consists of two paths; first, accessibility (price, stock) and second, availability (quantity and biodiversity); both are perquisites to the provision of nutrients and a continuous food supply with locally available resources. The objectives of this thesis are to investigate if indigenous knowledge still plays an important role in traditional farming in the Minangkabau`s culture, thus supporting local food security. If the indigenous knowledge still plays a role in food culture in the Minangkabau`s culture which is linked to the matrilineal role and leads to a sound nutrition. Further, it should be tested if marantau influences traditional farming and food culture in Minangkabau`s, and if the local government plays a role in changing of traditional farming systems and food culture. Furthermore this thesis wants to prove if education and gender are playing a role in changing traditional farming system and food culture, and if the mass media affects traditional farming systems and food culture for the Minangkabau. The study was completed at four locations in West Sumatera; Nagari Ulakan (NU) (coastal area), Nagari Aia Batumbuak (NAB) (hilly area), Nagari Padang Laweh Malalo (NPLM) (lake area), Nagari Pandai Sikek (NPS) (hilly area). The rainfall ranged from 1400- 4800 mm annually with fertile soils. Data was collected by using PRA (Participatory Rural Appraisal) to investigate indigenous knowledge (IK) and its interactions, which is also combining with in depth-interview, life history, a survey using semi-structured-questionnaire, pictures, mapping, and expert interview. The data was collected from June - September 2009 and June 2010. The materials are; map of area, list of names, questionnaires, voices recorder, note book, and digital camera. The sampling method was snowball sampling which resulted in the qualitative and quantitative data taken. For qualitative data, ethnography and life history was used. For quantitative, a statistical survey with a semi-structured questionnaire was used. 50 respondents per each site participated voluntarily. Data was analyzed by performing MAXQDA 10, and F4 audio analysis software (created and developed by Philip-University Marburg). The data is clustered based on causality. The results show that; the role of IK on TFS (traditional farming system) shown on NPLM which has higher food crop biodiversity in comparison to the other three places even though it has relatively similar temperature and rainfall. This high food crop biodiversity is due to the awareness of local people who realized that they lived in unfavourable climate and topography; therefore they are more prepared for any changes that may occur. Carbohydrate intake is 100 % through rice even though they are growing different staple crops. Whereas most of the people said in the interviews that not eating rice is like not really eating for them. In addition to that, mothers still play an important role in kitchen activities. But when the agriculture income is low, mothers have to decide whether to change the meals or to feel insecure about their food supply. Marantau yields positive impact through the remittances it provides to invest on the farm. On the other hand, it results in fewer workers for agriculture, and therefore a negative impact on the transfer of IK. The investigation showed that the local government has a PTS (Padi Tanam Sabatang) programme which still does not guarantee that the farmers are getting sufficient revenue from their land. The low agricultural income leads to situation of potential food insecurity. It is evident that education is equal among men and women, but in some cases women tend to leave school earlier because of arranged marriages or the distances of school from their homes. Men predominantly work in agriculture and fishing, while women work in the kitchen. In NAB, even though women work on farmland they earn less then men. Weaving (NPS) and kitchen activity is recognized as women’s work, which also supports the household income. Mass media is not yielding any changes in TFS and food culture in these days. The traditional farming system has changed because of intensive agricultural extension which has introduced new methods of agriculture for the last three decades (since the 1980’s). There is no evidence that they want to change any of their food habits because of the mass media despite the lapau activity which allows them to get more food choices, instead preparing traditional meal at home. The recommendations of this thesis are: 1) The empowerment of farmers. It is regarding the self sufficient supply of manure, cooperative seed, and sustainable farm management. Farmers should know – where are they in their state of knowledge – so they can use their local wisdom and still collaborate with new sources of knowledge. Farmers should learn the prognosis of supply and demand next prior to harvest. There is a need for farm management guidelines; that can be adopted from both their local wisdom and modern knowledge. 2) Increase of non-agricultural income Increasing the non-agricultural income is strongly recommended. The remittances can be invested on non-agricultural jobs. 3) The empowerment of the mother. The mother plays an important role in farm to fork activities; the mother can be an initiator and promoter of cultivating spices in the backyard. Improvement of nutritional knowledge through information and informal public education can be done through arisan ibu-ibu and lapau activity. The challenges to apply these recommendations are: 1) The gap between institutions and organizations of local governments. There is more than one institution involved in food security policy. 2) Training and facilities for field extension agriculture (FEA) is needed because the rapid change of interaction between local government and farmer’s dependent on this agency.

Optimization-Based Robotic Manipulation for Safe Interaction with Human Operators

This thesis investigates a method for human-robot interaction (HRI) in order to uphold productivity of industrial robots like minimization of the shortest operation time, while ensuring human safety like collision avoidance. For solving such problems an online motion planning approach for robotic manipulators with HRI has been proposed. The approach is based on model predictive control (MPC) with embedded mixed integer programming. The planning strategies of the robotic manipulators mainly considered in the thesis are directly performed in the workspace for easy obstacle representation. The non-convex optimization problem is approximated by a mixed-integer program (MIP). It is further effectively reformulated such that the number of binary variables and the number of feasible integer solutions are drastically decreased. Safety-relevant regions, which are potentially occupied by the human operators, can be generated online by a proposed method based on hidden Markov models. In contrast to previous approaches, which derive predictions based on probability density functions in the form of single points, such as most likely or expected human positions, the proposed method computes safety-relevant subsets of the workspace as a region which is possibly occupied by the human at future instances of time. The method is further enhanced by combining reachability analysis to increase the prediction accuracy. These safety-relevant regions can subsequently serve as safety constraints when the motion is planned by optimization. This way one arrives at motion plans that are safe, i.e. plans that avoid collision with a probability not less than a predefined threshold. The developed methods have been successfully applied to a developed demonstrator, where an industrial robot works in the same space as a human operator. The task of the industrial robot is to drive its end-effector according to a nominal sequence of grippingmotion-releasing operations while no collision with a human arm occurs.

Teaching an Old Robot New Tricks: Learning Novel Tasks via Interaction with People and Things

As AI has begun to reach out beyond its symbolic, objectivist roots into the embodied, experientialist realm, many projects are exploring different aspects of creating machines which interact with and respond to the world as humans do. Techniques for visual processing, object recognition, emotional response, gesture production and recognition, etc., are necessary components of a complete humanoid robot. However, most projects invariably concentrate on developing a few of these individual components, neglecting the issue of how all of these pieces would eventually fit together. The focus of the work in this dissertation is on creating a framework into which such specific competencies can be embedded, in a way that they can interact with each other and build layers of new functionality. To be of any practical value, such a framework must satisfy the real-world constraints of functioning in real-time with noisy sensors and actuators. The humanoid robot Cog provides an unapologetically adequate platform from which to take on such a challenge. This work makes three contributions to embodied AI. First, it offers a general-purpose architecture for developing behavior-based systems distributed over networks of PC's. Second, it provides a motor-control system that simulates several biological features which impact the development of motor behavior. Third, it develops a framework for a system which enables a robot to learn new behaviors via interacting with itself and the outside world. A few basic functional modules are built into this framework, enough to demonstrate the robot learning some very simple behaviors taught by a human trainer. A primary motivation for this project is the notion that it is practically impossible to build an "intelligent" machine unless it is designed partly to build itself. This work is a proof-of-concept of such an approach to integrating multiple perceptual and motor systems into a complete learning agent.

Interaction and Intelligent Behavior

We introduce basic behaviors as primitives for control and learning in situated, embodied agents interacting in complex domains. We propose methods for selecting, formally specifying, algorithmically implementing, empirically evaluating, and combining behaviors from a basic set. We also introduce a general methodology for automatically constructing higher--level behaviors by learning to select from this set. Based on a formulation of reinforcement learning using conditions, behaviors, and shaped reinforcement, out approach makes behavior selection learnable in noisy, uncertain environments with stochastic dynamics. All described ideas are validated with groups of up to 20 mobile robots performing safe--wandering, following, aggregation, dispersion, homing, flocking, foraging, and learning to forage.

Moderating effects of management control systems and innovation on performance. Simple methods for correcting the effects of measurement error for interaction effects in small samples

In the accounting literature, interaction or moderating effects are usually assessed by means of OLS regression and summated rating scales are constructed to reduce measurement error bias. Structural equation models and two-stage least squares regression could be used to completely eliminate this bias, but large samples are needed. Partial Least Squares are appropriate for small samples but do not correct measurement error bias. In this article, disattenuated regression is discussed as a small sample alternative and is illustrated on data of Bisbe and Otley (in press) that examine the interaction effect of innovation and style of use of budgets on performance. Sizeable differences emerge between OLS and disattenuated regression

The sound of words.

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Simultaneous estimation of indirect and interaction effects using structural equation models

Interaction effects are usually modeled by means of moderated regression analysis. Structural equation models with non-linear constraints make it possible to estimate interaction effects while correcting for measurement error. From the various specifications, Jöreskog and Yang's (1996, 1998), likely the most parsimonious, has been chosen and further simplified. Up to now, only direct effects have been specified, thus wasting much of the capability of the structural equation approach. This paper presents and discusses an extension of Jöreskog and Yang's specification that can handle direct, indirect and interaction effects simultaneously. The model is illustrated by a study of the effects of an interactive style of use of budgets on both company innovation and performance

Correcting Measurement Error Bias in Interaction Models with Small Samples

Several methods have been suggested to estimate non-linear models with interaction terms in the presence of measurement error. Structural equation models eliminate measurement error bias, but require large samples. Ordinary least squares regression on summated scales, regression on factor scores and partial least squares are appropriate for small samples but do not correct measurement error bias. Two stage least squares regression does correct measurement error bias but the results strongly depend on the instrumental variable choice. This article discusses the old disattenuated regression method as an alternative for correcting measurement error in small samples. The method is extended to the case of interaction terms and is illustrated on a model that examines the interaction effect of innovation and style of use of budgets on business performance. Alternative reliability estimates that can be used to disattenuate the estimates are discussed. A comparison is made with the alternative methods. Methods that do not correct for measurement error bias perform very similarly and considerably worse than disattenuated regression

Sound Recording Skills presentation by Matt Grover

Covers defining a sound in terms of amplitude, frequency, time, timbre and space. How sound behaves within a space. Digital recording settings. Winchester School of Art loan equipment. Winchester School of Art editing software overview.

MSc Sound & Vibration Library Induction, October 2010

Library induction and information skills for MSc Sound and Vibration, given in October 2010. As well as an introduction to the hartley Library and the LoC classification scheme, it covers finding material from reading lists, e-journals, making up search strategies and searching online databases using boolean operators.

INFO2009 Framework for Critical Friends Interaction

Guidance document detailing the suggested process for the critical friend team interaction

WAIS Seminar:Evaluating the Cognitive Side of Information Interaction

Abstract In this talk, I'll focus on the work we've been doing on evaluating the cognitive side of dealing with information resources and increasingly complex user interfaces. While we can build increasingly powerful user interfaces, they often come at the cost of simple design and ease of use. I'll describe two specific studies: 1) work on the ORCHID project focused on measuring mental workload during tasks using fNIRS (a blood-oxygen-based brain scanner), and 2) a evaluation metric for measuring how much people learn during tasks. Together these provide advances towards understanding the cognitive side of information interaction, in working towards building better tools for users.