Medical error:a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error

Introduction: There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment's response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick-and-carrot reforms of medical practice. Discussion: This paper critically reviews the literature on medical error, professional socialization and medical student education, and suggests that common themes such as uncertainty, necessary fallibility, exclusivity of professional judgement and extensive use of medical networks find their genesis, in part, in aspects of medical education and socialization into medicine. The nature and comparative failure of recent reforms of medical practice and the tension between the individualistic nature of the reforms and the collegiate nature of the medical profession are discussed. Conclusion: A more theoretically informed and longitudinal approach to decreasing medical error might be to address the genesis of medical thinking about error through reforms to the aspects of medical education and professional socialization that help to create and perpetuate the existence of avoidable error, and reinforce medical collusion concerning error. Further changes in the curriculum to emphasize team working, communication skills, evidence-based practice and strategies for managing uncertainty are therefore potentially key components in helping tomorrow's doctors to discuss, cope with and commit fewer medical errors.

Let's stick together? Explaining boundaries to territorial policy variation:the case of Germany's prisons legislation

This article offers an initial impact assessment regarding the introduction of new legislative responsibilities at the Land level in a case study of prisons policy (Strafvollzug). Combining an analysis of new legislation produced across the 16 Länder since the responsibility for prisons policy was transferred to the Land level, and insights into the mechanics of policy development obtained through a series of interviews with senior politicians and officials, this article finds that the desire among Länder to legislative independently has varied, with substantial backing for co-ordination in the development of new legislation. This has helped to confound expectations of a ‘competition of harshness’ which many expected to result from decentralisation. However, even before the 2006 reforms, there were substantial variations between the Länder when it came to implementing prisons policy, so consideration of the sub-national level in this area remains essential.

Introduction to the special issue : reframing German Federalism

In recent years, Germany’s federal system has been subject to a number of pressures for change. A constitutional debate on ‘disentangling’ the legislative roles of federal and Länder institutions which stuttered through the 1990s and into the 2000s finally led to a re-allocation of competences in 2006. These reforms shifted some areas of legislative responsibility from the federal to the Länder level and relaxed rules which had earlier justified a federal override when both levels held legislative responsibilities concurrently. At the very least, these constitutional adjustments increased the potential for policy outputs to diverge from one Land to another and give expression to territorial differences in priority and preference.

European Union - Reforms - Hungarian interests. What kind of European Union would we like?

The lecture deals with broad topics. First, it addresses some questions related to the current state of the EU integration regarding institutions and common policies. Second, it discusses the continued importance, the main results and hindering factors related to the Lisbon Programme, with a special emphasis on the educational system in Europe and Hungary. Third, the lecture deals with some possibilities in changing the EU’s rather limited external relation models to more flexible instruments.

Parametrikus nyugdíjreformok és életciklus-munkakínálat (Parametric pension reforms and life-cycle labour supply)

A társadalombiztosítási nyugdíjrendszer finanszírozása pusztán a demográfiai folyamatok következtében is jelentős terhet ró majd a költségvetésére, amin a különböző parametrikus és paradigmatikus nyugdíjreformok enyhíthetnek. A reformok azonban hosszú távon olyan viselkedési, munkakínálati reakciókat válthatnak ki, amelyek alapvetően változtatják meg a költségvetési hatásokat. Az 1999 és 2009 között Magyarországon megfigyelhető átlagos munka- és nyugdíjkorprofilok bemutatása után arra tettünk kísérletet, hogy mikroökonómiai alapon határozzuk meg néhány alapvető parametrikus nyugdíjreformnak a férfiak életciklus-munkakínálatára gyakorolt hatását. A modell paramétereit a magyar gazdaság 1999 és 2009 közötti jellemzőinek megfelelően kalibráltuk. Eredményeink szerint a helyettesítési ráta csökkentése, a nyugdíjkorhatár emelése és a svájci indexálás árindexálásra cserélése összességében számottevően növeli az egyes képzettségi csoportok munkakínálatát, s a fiatalabb korosztályok javára csoportosítja át az életciklus-munkakínálatot, míg a nyugdíj kiszámításához figyelembe vett évek számának megváltoztatása nem hoz jelentős aggregált hatást, és nem jár a munkakínálat korcsoportok közötti átcsoportosításával. ____ Financing the social-security pension system will weigh heavily on the government budget in developed countries, merely through the projected demographic processes. The burden could be eased by various parametric and paradigmatic pension reforms, but in the long run such reforms may trigger behavioural, labour-supply responses, which may alter the budgetary effects fundamentally. Having described the average work and pension profiles in Hungary between 1999 and 2009, the authors use a microeconomic approach in an attempt to assess the effect of certain parametric pension reforms on the life-cycle labour supply of males. The parameters for the model were calibrated for the characteristics of the Hungarian economy. The results show that decreasing the replacement rate, increasing the retirement age and replacing Swiss indexation of pensions by price indexation cause a considerable increase in the labour supply of all education-level groups, whereas changing the number of years considered in computing pensions does not have a significant aggregate effect. While introducing price indexation increases the labour supply of all cohorts by the same amount, the other reforms reallocate the life-cycle labour supply, mainly towards younger age-groups.

Schizophrenic Public Administration Reform in Hungary. Tension between anti-NPM systemic and pro-NPM organizational reforms

The aim of this paper is to shed the light on the relationship between New Public Management and Hungary’s Zoltán Magyary Public Administration Development Programme. As will be shown, the Magyary Programme has a dual structure. The systemic reforms run counter to the NPM philosophy because the main goal is the centralization of public administration, while NPM clearly advocates decentralization. At the same time, reform proposals on the organizational level conform to NPM. The inconsistencies in the Magyary Programme itself and the probable political and organizational resistance towards its proposals could delay the introduction of reforms on the organizational level.

New Public Management Reforms: Institutions matter!

New Public Management (NPM) has played a decisive role and has had a radical effect on the productivity and efficiency of the public sector in the Anglo-Saxon countries. However, the effective introduction of the NPM reforms is not an easy task. The scientific community is zealously analyzing the experiences of the developing countries. The stories, they tell, are full of failures, and ineffective reforms. The goal of the current study is to uncover the factors that might influence the successful implementation of the NPM reforms. In our analysis, by relying on the theories of new institutional economics, we developed a model with which we wish to prove that in regards to the success of the reforms the informal and the formal institutions characteristic of the given country are the decisively determining factors. When answering the question, we introduced a new indicator based on public choice theory – the politicians’ interest index – by which we could measure the success of the NPM. We tested our hypothesis by a comparative statistical analysis using the data from 31 countries. Based on our results, we find that informal institutions, the culture shared by the members of society, fundamentally determine the probability of the successful implementation of the NPM reforms, these results having a significant practical relevance.

Schizophrenic public administration reform in Hungary. Tension between anti-NPM systemic and pro-NPM organizational reforms

The aim of the paper is to highlight the main characteristics of the recent Hungarian public administration reform, as well as to reveal the inconsistent nature of some of its elements and to describe the connected risks. The starting point of the article is the Magyary Zoltán public administration development programme. The reform steps are compared to the ideal type NPM approach. The Hungarian public administration reform can be characterized by strong centralization and the revitalization of Hungarian anti-liberal traditions at macro level, and by the support of the enhancement of market rules and management at micro level.

The impacts of trade policy reforms on the Sri Lankan economy

This dissertation presents an analysis of the impacts of trade policy reforms in Sri Lanka. A Computable General Equilibrium (CGE) model is constructed with detailed description of the domestic production structure and foreign trade. The model is then used to investigate the effects of trade policy reforms on resource allocation and welfare.^ Prior to 1977, Sri Lanka maintained stringent control over its imports through rigid quantitative restrictions. A new economic policy reform package was introduced in 1977, and it shifted Sri Lanka's development strategy toward an export oriented policy regime. The shift of policy focus from a restrictive trade regime toward a more open trade regime is expected to have a significant impact on the volume of external trade, domestic production structure, allocation of resources, and social welfare.^ Simulations are carried out to assess the effects of three major policy reforms: (1) a devaluation of the Sri Lanka rupee, (2) a partial or a complete elimination of export duties, and (3) a devaluation-cum-removal of export duties.^ Simulation results indicate that the macroeconomic impact of a devaluation-cum-removal of export duties can be substantial. They also suggest that the resource-pull effects of a devaluation and a devaluation-cum-export duty removal policy are significant. However, the model shows that a devaluation combined with an export duty reduction is likely to be a superior strategy. ^

The unintended [or intended?] political consequences of electoral systems: The case of Bolivia

The present study was concerned with evaluating one basic institution in Bolivian democracy: its electoral system. The study evaluates the impact of electoral systems on the interaction between presidents and assemblies. It sought to determine whether it is possible to have electoral systems that favor multipartism but can also moderate the likelihood of executive-legislative confrontation by producing the necessary conditions for coalition building. ^ This dissertation utilized the case study method as a methodology. Using the case of Bolivia, the research project studied the variations in executive-legislative relations and political outcomes from 1985 to the present through a model of executive-legislative relations that provided a typology of presidents and assemblies based on the strategies available to them to bargain with each other for support. A complementary model that evaluated the state of their inter-institutional interaction was also employed. ^ Results indicated that executive-legislative relations are profoundly influenced by the choice of the electoral system. Similarly, the project showed that although the Bolivian mixed system for legislative elections, and executive formula favor multipartism, these electoral systems do not necessarily engender executive-legislative confrontation in Bolivia. This was mainly due to the congressional election of the president, and the formulas utilized to translate the popular vote into legislative seats. However, the study found that the electoral system has also allowed for anti-systemic forces to emerge and gain political space both within and outside of political institutions. ^ The study found that government coalitions in Bolivia that are promoted by the system of congressional election of the president and the D'Hondt system to allocate legislative seats have helped ameliorate one of the typical problems of presidential systems in Latin America: the presence of a minority government that is blocked in its capacity to govern. This study was limited to evaluating the impact of the electoral system, as the independent variable, on executive-legislative interaction. However, the project revealed a need for more theoretical and empirical work on executive-legislative bargaining models in order to understand how institutional reforms can have an impact on the incentives of presidents and legislators to form coherent coalitions. ^

State legislative term limits and the law of unintended consequences: An examination of member behavior, power structures, and legislative organization in Florida

The implementation of term limits on state legislators has provided a wealth of data for study. Florida, the second largest state in the Union with term limits, has not been comprehensively studied. This research examines the effects of term limits on electoral competition, member composition, legislator career paths, legislative leadership, and intra- and inter-governmental influences on Florida's legislature. This study looks at the Florida legislature from 1992 when term limits were enacted through 2004, three electoral cycles in which term limits have been in effect. This study uses both quantitative and qualitative data where appropriate. Electoral data is used to assess electoral and demographic effects, as well as member career trajectories. Interview data with current and former legislators, lobbyists, and executive branch officials is used to analyze both changes in legislative organization and intra- and inter-governmental influences on the legislative process. Term limits has only created greater competition when a legislative seat opens and has actually created a greater advantage for incumbents. Women and minorities have only made minimal gains in winning seats post-term limits. Newly elected legislators are not political novices with a vast majority having previous elective experience. Leadership is more centralized under term limits and the Senate has gained an advantage over the more inexperienced House. Lastly, the influence of staff, lobbyists, and most importantly, the governor has greatly increased under term limits. This research finds that term limits have not produced the consequences that proponents had envisioned.^

Raúl Castro's Government: Recent Economic Reforms and Some Political Considerations.

Four years after calling for structural and conceptual changes, Raúl Castro finally unveiled a roadmap of substantive economic reforms. Over the next 18 months, at least a million workers will be laid off from the bloated state sector. Alternative forms of earning a living – self-employment, cooperatives, leasing of land or physical space, among others – are being authorized as old constraints on these alternatives are rescinded. From the perspective of ordinary Cubans, these reforms – called an actualizaciόn, or an update of the economic model – were long overdue. Yet, in hindsight, the slow-paced process can be explained, not in terms of the need for time to “identify” Cuba’s economic problems which have been known for decades, but by Raúl Castro’s emphasis on la institucionalidad, the need to channel decision making through institutions. His brother left a chaotic state apparatus which first needed mending before an elite consensus on the reform package could be forged. Cuba is entering a situation without precedent: this package is likely to run its own course without the Comandante (Fidel Castro) stopping it. By 2015, Cuban society will probably look different than today, featuring unprecedented inequality and living standards that are on the rise.

Mapping Transnational Crime in El Salvador: New Trends and Lessons from Colombia

Since El Salvador’s civil war formally ended in 1992 the small Central American nation has undergone profound social changes and significant reforms. However, few changes have been as important or as devastating as the nation’s emergence as a central hub in the transnational criminal “pipeline” or series of recombinant, overlapping chains of routes and actors that illicit organizations use to traffic in drugs, money weapons, human being, endangered animals and other products. The erasing of the once-clear ideological lines that drove the civil war and the ability of erstwhile enemies to join forces in criminal enterprises in the post-war period is an enduring and dangerous characteristic of El Salvador’s transnational criminal evolution. Trained, elite cadres from both sides, with few legitimate job opportunities, found their skills were marketable in the growing criminal structures. The groups moved from kidnapping and extortion to providing protection services to transnational criminal organizations to becoming integral parts of the organizations themselves. The demand for specialized military and transportation services in El Salvador have exploded as the Mexican DTOs consolidate their hold on the cocaine market and their relationships with the transportista networks, which is still in flux. The value of their services has risen dramatically also because of the fact that multiple Mexican DTOs, at war with each other in Mexico and seeking to physically control the geographic space of the lucrative pipeline routes in from Guatemala to Panama, are eager to increase their military capabilities and intelligence gathering capacities. The emergence of multiple non-state armed groups, often with significant ties to the formal political structure (state) through webs of judicial, legislative and administrative corruption, has some striking parallels to Colombia in the 1980s, where multiple types of violence ultimately challenged the sovereignty of state and left a lasting legacy of embedded corruption within the nation’s political structure. Organized crime in El Salvador is now transnational in nature and more integrated into stronger, more versatile global networks such as the Mexican DTOs. It is a hybrid of both local crime – with gangs vying for control off specific geographic space so they can extract payment for the safe passage of illicit products – and transnational groups that need to use that space to successfully move their products. These symbiotic relationships are both complex and generally transient in nature but growing more consolidated and dangerous.