Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

Assessing and monitoring impacts of genetically modified plants on agro-ecosystems: the approach of AMIGA project

The environmental impacts of genetically modified crops is still a controversial issue in Europe. The overall risk assessment framework has recently been reinforced by the European Food Safety Authority(EFSA) and its implementation requires harmonized and efficient methodologies. The EU-funded research project AMIGA − Assessing and monitoring Impacts of Genetically modified plants on Agro-ecosystems − aims to address this issue, by providing a framework that establishes protection goals and baselines for European agro-ecosystems, improves knowledge on the potential long term environmental effects of genetically modified (GM) plants, tests the efficacy of the EFSA Guidance Document for the Environmental Risk Assessment, explores new strategies for post market monitoring, and provides a systematic analysis of economic aspects of Genetically Modified crops cultivation in the EU. Research focuses on ecological studies in different EU regions, the sustainability of GM crops is estimated by analysing the functional components of the agro-ecosystems and specific experimental protocols are being developed for this scope.

Teachers’ action research in a culture of performativity

In a culture of performativity, action research offers teachers an opportunity to step back and reflect on their practice. This paper reports on a collaborative project carried out between a university and a secondary school in England, in which the university staff supported an action research project within the school. Five school teachers volunteered to engage in this project. They were given an introduction to action research and were assigned a university researcher to support them. Despite the common input and a common school culture, the teachers engaged in very different models of action research. This article reports on two teachers whose approaches were dissimilar. It examines these differences and suggests that they can be explained by considering the teachers’ different responses to a performativity culture.

The role of animal nutrition in designing optimal foods of animal origin as reviewed by the COST Action Feed for Health (FA0802)

This review provides an overview of the main scientific outputs of a network (Action) supported by the European Cooperation in Science and Technology (COST) in the field of animal science, namely the COST Action Feed for Health (FA0802). The main aims of the COST Action Feed for Health (FA0802) were: to develop an integrated and collaborative network of research groups that focuses on the roles of feed and animal nutrition in improving animal wellbeing and also the quality, safety and wholesomeness of human foods of animal origin; to examine the consumer concerns and perceptions as regards livestock production systems. The COST Action Feed for Health has addressed these scientific topics during the last four years. From a practical point of view three main scientific fields of achievement can be identified: feed and animal nutrition; food of animal origin quality and functionality and consumers’ perceptions. Finally, the present paper has the scope to provide new ideas and solutions to a range of issues associated with the modern livestock production system.

Il/legitimate risks? Occupational health and safety and the public in Britain, c. 1960-2015

The last 20 years have seen the emergence of a popular climate of antipathy towards occupational health and safety regulation within the UK, particularly within the mainstream British media. The governance of health and safety has thus in recent years become an increasingly visible and contested public and political issue. The extent of this contestation, and its impact on the State’s governance of health and safety in the workplace and beyond, is explained and historicized within this chapter. Why has public rhetoric about health and safety apparently become so important in framing the ways in which the State could legitimately act in recent years? The chapter demonstrates how since 1960 the State remained a significant player – one among many, admittedly – and that while its roles in managing health and safety had long been bounded by a number of factors, a variable that emerged with particular saliency over the last 20 years has been a mediated notion of ‘public opinion’. This focus serves to remind us of the ways in which State action has at certain moments been pushed in particular directions by factors beyond formal mechanisms of rule.

EVOLUTIONARY BIOLOGY IN BIODIVERSITY SCIENCE, CONSERVATION, AND POLICY: A CALL TO ACTION

Evolutionary biologists have long endeavored to document how many species exist on Earth, to understand the processes by which biodiversity waxes and wanes, to document and interpret spatial patterns of biodiversity, and to infer evolutionary relationships. Despite the great potential of this knowledge to improve biodiversity science, conservation, and policy, evolutionary biologists have generally devoted limited attention to these broader implications. Likewise, many workers in biodiversity science have underappreciated the fundamental relevance of evolutionary biology. The aim of this article is to summarize and illustrate some ways in which evolutionary biology is directly relevant We do so in the context of four broad areas: (1) discovering and documenting biodiversity, (2) understanding the causes of diversification, (3) evaluating evolutionary responses to human disturbances, and (4) implications for ecological communities, ecosystems, and humans We also introduce bioGENESIS, a new project within DIVERSITAS launched to explore the potential practical contributions of evolutionary biology In addition to fostering the integration of evolutionary thinking into biodiversity science, bioGENESIS provides practical recommendations to policy makers for incorporating evolutionary perspectives into biodiversity agendas and conservation. We solicit your involvement in developing innovative ways of using evolutionary biology to better comprehend and stem the loss of biodiversity.

Formalization of an architectural model for exception handling coordination based on CA action concepts

Architectures based on Coordinated Atomic action (CA action) concepts have been used to build concurrent fault-tolerant systems. This conceptual model combines concurrent exception handling with action nesting to provide a general mechanism for both enclosing interactions among system components and coordinating forward error recovery measures. This article presents an architectural model to guide the formal specification of concurrent fault-tolerant systems. This architecture provides built-in Communicating Sequential Processes (CSPs) and predefined channels to coordinate exception handling of the user-defined components. Hence some safety properties concerning action scoping and concurrent exception handling can be proved by using the FDR (Failure Divergence Refinement) verification tool. As a result, a formal and general architecture supporting software fault tolerance is ready to be used and proved as users define components with normal and exceptional behaviors. (C) 2010 Elsevier B.V. All rights reserved.

Expert system to calculate the cofficient of friction : an approach to enhance traffic safety

Friction plays a key role in causing slipperiness as a low coefficient of friction on the road may result in slippery and hazardous conditions. Analyzing the strong relation between friction and accident risk on winter roads is a difficult task. Many weather forecasting organizations use a variety of standard and bespoke methods to predict the coefficient of friction on roads. This article proposes an approach to predict the extent of slipperiness by building and testing an expert system. It estimates the coefficient of friction on winter roads in the province of Dalarna, Sweden using the prevailing weather conditions as a basis. Weather data from the road weather information system, Sweden (RWIS) was used. The focus of the project was to use the expert system as a part of a major project in VITSA, within the domain of intelligent transport systems

A Study in the Theology of Christian Social Action

In this paper I have attempted to present a summary of my exposition of the theology of Rauschenbusch and Niebuhr, and of my own understanding of the issues of Christian Social Action. I have tried to reproduce in this short space the thought of these men, in a manner which should make it comprehensible and which should relate it to the larger questions of social action. This year’s work as a Senior Scholar has proved invaluable because of the discipline of self-directed study which the work taught, and because of myriad possibilities of future investigation which it has suggested. I hope that someday this present manuscript may be expanded into something more substantial. The personal value of such a project, in my opinion, must be measured by the contribution which the project makes to the individual’s general experience, and not merely by the written work which is produced. Therefore, although this manuscript is rather brief, it represents a great deal of value which I feel that I can measure only by my own experience.

The human side of project management - an investigation of critical chain concepts in the Argentinean Project Environment

The global marketplace is rapidly intensifying. Longer product sales lives, greater profit margins or simply survival, is dependent on management¿s ability to create and lead change. Project Management has become an important competency, combined with other business practices to adapt to the trend of changing conditions. Critical Chain is a relatively new project methodology, elaborated by Eliyahu Goldratt in order to complete projects faster, make more efficient use of resources and securing the project deliverables. The methodology is based on the assumption that traditional project techniques such as CPM and PERT, do not recognize critical human behavior. The methodology claims that many project failures are a direct result of how safety is built into the task delivery times, and then wasted by human behavior such as Student Syndrome, Parkinson Law and Multitasking. However, there has been little or no previous research regarding this topic in the Argentine marketplace. This study intended to investigate to what extent the human behavior concepts of critical chain project management are present, by performing in-depth interviews with Argentine project stakeholders. It appears that the four human behavior concepts are present in Argentina and that the majority of Argentine companies are yet to apply project management techniques.

Policiamento comunitário no amazonas: ações implementadas e a percepção dos atores envolvidos

Este trabalho tem como objetivo descrever o policiamento comunitário, correlacionando com as ações implementadas no Amazonas, e analisando a percepção dos atores envolvidos no sistema de segurança pública sobre este modelo. As experiências internacionais e nacionais demonstram que a adoção deste modelo requer mudanças estruturais, administrativas e organizacionais. A participação comunitária é uma das principais características deste modelo. O sistema de segurança pública do Amazonas ainda não adota integralmente o modelo comunitário, apesar de constar em seu projeto de revitalização procedimentos semelhantes ao modelo, como interação entre a polícia civil e militar e instalação dos Conselhos Interativos Comunitários de Segurança Pública, embora estes não estejam regulados legalmente. Um fator importante neste processo diz respeito à percepção dos atores envolvidos que necessitam ter uma visão ampla sobre a atuação policial. As entrevistas realizadas com os atores envolvidos no sistema de segurança pública demonstram que o atual modelo não atende as expectativas tanto da sociedade quanto da própria instituição. O policiamento comunitário é visto como alternativa capaz de auxiliar na melhoria do sistema.

Potentialities of two solventless extraction approaches—Stir bar sorptive extraction and headspace solid-phase microextraction for determination of higher alcohol acetates, isoamyl esters and ethyl esters in wines

A stir bar sorptive extraction with liquid desorption followed by large volume injection coupled to gas chromatography–quadrupole mass spectrometry (SBSE-LD/LVI-GC–qMS) was evaluated for the simultaneous determination of higher alcohol acetates (HAA), isoamyl esters (IsoE) and ethyl esters (EE) of fatty acids. The method performance was assessed and compared with other solventless technique, the solid-phase microextraction (SPME) in headspace mode (HS). For both techniques, influential experimental parameters were optimised to provide sensitive and robust methods. The SBSE-LD/LVI methodology was previously optimised in terms of extraction time, influence of ethanol in the matrix, liquid desorption (LD) conditions and instrumental settings. Higher extraction efficiency was obtained using 60 min of extraction time, 10% ethanol content, n-pentane as desorption solvent, 15 min for the back-extraction period, 10 mL min−1 for the solvent vent flow rate and 10 °C for the inlet temperature. For HS-SPME, the fibre coated with 50/30 μm divinylbenzene/carboxen/polydimethylsiloxane (DVB/CAR/PDMS) afforded highest extraction efficiency, providing the best sensitivity for the target volatiles, particularly when the samples were extracted at 25 °C for 60 min under continuous stirring in the presence of sodium chloride (10% (w/v)). Both methodologies showed good linearity over the concentration range tested, with correlation coefficients higher than 0.984 for HS-SPME and 0.982 for SBES-LD approach, for all analytes. A good reproducibility was attained and low detection limits were achieved using both SBSE-LD (0.03–28.96 μg L−1) and HS-SPME (0.02–20.29 μg L−1) methodologies. The quantification limits for SBSE-LD approach ranging from 0.11 to 96.56 μg L−and from 0.06 to 67.63 μg L−1 for HS-SPME. Using the HS-SPME approach an average recovery of about 70% was obtained whilst by using SBSE-LD obtained average recovery were close to 80%. The analytical and procedural advantages and disadvantages of these two methods have been compared. Both analytical methods were used to determine the HAA, IsoE and EE fatty acids content in “Terras Madeirenses” table wines. A total of 16 esters were identified and quantified from the wine extracts by HS-SPME whereas by SBSE-LD technique were found 25 esters which include 2 higher alcohol acetates, 4 isoamyl esters and 19 ethyl esters of fatty acids. Generally SBSE-LD provided higher sensitivity with decreased analysis time.

A oficina como método de desenvolvimento de projeto do produto aplicado à atividade jangadeira de Ponta Negra Natal-RN

The jangadas (brazilian fishing rafts) are rudimentary artisanal vessels intrinsic to the Northeast of Brazil. The fishery with jangadas is highly representative in the State of Rio Grande do Norte, and source of income for many families in addition to being a strong cultural icon. Is still alive despite the difficulties, bringing the history and customs of the fishermen and their people. However, is in process of extinction due to factors such as the low profitability of the activity, tourism and urbanization. From the understanding of activity involving their context and circumstances, based on identified problems regarding the conditions of use of jangadas as the unpredictability, the risk of accidents, poor working conditions, hygiene and housing, this dissertation aims to: analyzing the design of the jangada on the beach of Ponta Negra and its relationship with the activity in relation to health, safety, productivity and environment, and from such assessments, together with the results achieved during the workshops of the project, proposing a cart to move the raft, adapted to the local fisherman activity studied. To perform analysis of jangadeira activity, we used a methodology based on ergonomic work analysis - AET (WISNER, 1987; GUÈRIN, 2001; VIDAL, 2008, SALDANHA, 2004 and Carvalho, 2005). For data collection were used observational and interaction methods as a conversational action, verbalizations, photographs and video. It is emphasized that the search for solutions appropriate to the jangadeira activity was possible through the collaboration of several people, not just an informational level and understanding during the work activity, but effectively contributing to the making decisions