Special Investigation of the Central Iowa Fair, For the Period July 1, 2004 through September 30, 2006

Other Audit Reports - Special Investigation

Investigation of Maquoketa's Pit Bull Ban Ordinance and Enforcement, 2006

Case File 0603634 On September 13, 2006, Kelly Wilslef submitted a complaint to the Ombudsman about the Maquoketa City Council (Council). Ms. Wilslef stated a Maquoketa police officer served her an abatement notice for violating the city ordinance preventing owners from keeping pit bull terrier dogs in the city. The Council subsequently determined her dog was a pit bull mix, and ordered her to remove the dog from the city. Ms. Wilslef claimed the Council unreasonably relied on non-expert testimony supporting the city’s position her dog was a pit bull mix. She further claimed that if her dog was in fact a pit bull mix, the city ordinance did not apply to mixed-breed pit bulls; therefore, the Council acted contrary to law when it concluded she violated the city ordinance and ordered her to remove her dog from the city.

Investigation of Luther City Council Violation of Open Meetings Law, 2006

Case File 0603454 The Ombudsman received a complaint on August 29, 2006 alleging violations of the Iowa Open Meetings Law by the Luther City Council (Council) in its meeting on August 2, 2006. Based upon my review of the complaint, I identified the following allegations for investigation: • The Council violated Iowa Code section 21.5 by failing to announce the reason session on the August 2, 2006 meeting agenda. • The Council violated Iowa Code section 21.5 by holding a closed session for an impermissible reason. • The Council violated Iowa Code section 21.5(2) by discussing unrelated issues in the closed session.

Investigation Into the Timeliness of the Death Notification to the Surviving Spouse of a Motor Vehicle Accident Victim, 2005

Report: #05-02 Kirke C. Quinn, Attorney for Jo Anne Holland, first contacted the Ombudsman by letter dated January 2, 2004. Quinn also addressed his letter to the Governor’s Office, Iowa State Patrol (ISP), and Iowa Department of Public Safety (DPS). Quinn characterized his letter as a complaint against ISP regarding “the method and manner of reporting the death of Ross Holland to his surviving spouse.” According to Quinn, Mrs. Holland “went through hours of misery as a result of the patrol’s inattention to a tragic situation.” On January 7, 2004, the Ombudsman asked ISP Major Gary Hoskins, Supervisor of Field Operations, how ISP and DPS intended to respond to Mr. Quinn’s letter. Major Hoskins stated he would refer Quinn’s letter of complaint to DPS’ Professional Standards Bureau (PSB) for investigation and response. After speaking with Major Hoskins, the Ombudsman told Mr. Quinn that DPS would do an internal investigation and if he were not satisfied with the results he could contact the Ombudsman again. On March 29, 2004, Mr. Quinn contacted the Ombudsman and stated he was not satisfied with DPS’ response. Quinn stated he would send a copy of the response to the Ombudsman, along with a letter stating his outstanding issues and concerns. In his letter to the Ombudsman, dated May 5, Quinn simply stated: “Please find enclosed [a] copy of the letter received from the Department of Public Safety. We think this is an absolute outrage. We welcome your input.”

La régulation des interdépendances entre les forêts et l'eau domestique en Indonésie : études de cas sur le site de Lombok : les captages de Bak Pakem et de Ranget (Province du Nusa Tenggera Occidental, île de Lombok, Indonésie)

Ce working paper débute par une longue introduction, qui expose les spécificités du contexte institutionnel indonésien. Ensuite, la première partie traite des règles prévues sur l'île de Lombok (kabupaten de Lombok Barat, en Indonésie) pour gérer les usages des forêts et de l'eau potable ainsi que les règles qui visent à protéger le service forestier pour l'eau souterraine. Ensuite, en deuxième partie, deux études de cas montrent de quelle manière ces règles sont mises en oeuvre (ou pas) pour protéger les captages d'eau. L'écart entre les règles prévues et leur utilisation sur le terrain est expliqué, en troisième partie, à l'aide du cadre d'analyse des régimes institutionnels des ressources (RIR). Cette analyse permet de discuter en profondeur les mécanismes institutionnels en oeuvre et les enjeux en présence dans le contexte indonésien.

Report on a special investigation of programs administered by the Central Iowa Employment and Training Consortium (CIETC) and Iowa Workforce Development (IWD) for the period July 1, 2003 through December 15, 2005

Report on a special investigation of programs administered by the Central Iowa Employment and Training Consortium (CIETC) and Iowa Workforce Development (IWD) for the period July 1, 2003 through December 15, 2005

Evaluation of adherence to measures for the prevention of surgical site infections by the surgical team

AbstractOBJECTIVEEvaluate pre- and intraoperative practices adopted by medical and nursing teams for the prevention of surgical infections.METHODA prospective study carried out in the period of April to May 2013, in a surgical center of a university hospital in Belo Horizonte, Minas Gerais.RESULTS18 surgeries were followed and 214 surgical gloves were analyzed, of which 23 (10.7%) had postoperative glove perforation detected, with 52.2% being perceived by users. Hair removal was performed on 27.7% of patients in the operating room, with the use of blades in 80% of the cases. Antibiotic prophylaxis was administered to 81.8% of patients up to 60 minutes prior to surgical incision. An average of nine professionals were present during surgery and the surgery room door remained open in 94.4% of the procedures.CONCLUSIONPartial adhesion to the recommended measures was identified, reaffirming a need for greater attention to these critical steps/actions in order to prevent surgical site infection.

Special investigation of the Washington Community School District for the period June 1, 2003 through October 31, 2006

Special investigation of the Washington Community School District for the period June 1, 2003 through October 31, 2006

Audit report on a special investigation of the Bear Creek Narcotics Task Force for the period July 1, 2003 through November 30, 2006

Audit report on a special investigation of the Bear Creek Narcotics Task Force for the period July 1, 2003 through November 30, 2006

Readmission from orthopedic surgical site infections: an integrative review

Abstract OBJECTIVE Characterizing readmissions from orthopedic surgical site infections. METHOD An integrative review of literature in the LILACS, IBECS, MEDLINE, Cochrane, SciELO and PUBMED databases, using the descriptors Patient readmission, Wound infection, Cross infection, Orthopedic procedures, Orthopedics. RESULTS 78 studies were identified and 10 publications were selected. Surgical site infections are the most common cause of unplanned orthopedic readmissions, representing long periods of hospitalization, new surgical procedures and high costs, and greater possibility of subsequent hospitalizations. Most significant predictors have indicated average length of hospitalization, need for intensive care, emergency status at admission, risk of death, age > 65 years, males and higher body mass index. CONCLUSION Readmission rates have increasingly become measures of quality and concerns about costs. New studies could involve issues related to indirect costs, specifically social and psychological costs.

Report on a special investigation of the Dallas County Jail for the period July 31, 2000 through February 5, 2007

Report on a special investigation of the Dallas County Jail for the period July 31, 2000 through February 5, 2007

Special investigation of the Crawford County Conservation Department for the period January 25, 2002 through December 7, 2006

Special investigation of the Crawford County Conservation Department for the period January 25, 2002 through December 7, 2006

Special investigation of the City of McCausland for the period January 1, 1999 through January 31, 2007

Special investigation of the City of McCausland for the period January 1, 1999 through January 31, 2007

Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon.

Objective: To determine the role of the surgeon in the occurrence of surgical site infection (SSI) following colon surgery, with respect to his or her adherence to guidelines and his or her experience.Design, Setting, and Patients: Prospective cohort study of 2393 patients who underwent colon surgery performed by 31 surgeons in 9 secondary and tertiary care public Swiss hospitals, recruited from a surveillance program for SSI between March 1, 1998, and December 31, 2008, and followed up for 1 month after their operation.Main Outcome Measures: Risk factors for SSI were identified in univariate and multivariate analyses that included the patients' and procedures' characteristics, the hospitals, and the surgeons as candidate covariates. Correlations were sought between surgeons' individual adjusted risks, their self-reported adherence to guidelines, and the delay since their board certification.Results: A total of 428 SSIs (17.9%) were identified, with hospital rates varying from 4.0% to 25.2% and individual surgeon rates varying from 3.7% to 36.1%. Features of the patients and procedures associated with SSI in univariate analyses were male sex, age, American Society of Anesthesiologists score, contamination class, operation duration, and emergency procedure. Correctly timed antibiotic prophylaxis and laparoscopic approach were protective. Multivariate analyses adjusting for these features and for the hospitals found 4 surgeons with higher risk of SSI (odds ratio [OR] = 2.37, 95% confidence interval [CI], 1.51-3.70; OR = 2.19, 95% CI, 1.41-3.39; OR = 2.15, 95% CI, 1.02-4.53; and OR = 1.97, 95% CI, 1.18-3.30) and 2 surgeons with lower risk of SSI (OR = 0.43, 95% CI, 0.19-0.94; and OR = 0.19, 95% CI, 0.04-0.81). No correlation was found between surgeons' individual adjusted risks and their adherence to guidelines or their experience.Conclusion: For reasons beyond adherence to guidelines or experience, the surgeon may constitute an independent risk factor for SSI after colon surgery.

The investigation of deaths in custody: a qualitative analysis of problems and prospects.

The right to be treated humanely when detained is universally recognized. Deficiencies in detention conditions and violence, however, subvert this right. When this occurs, proper medico-legal investigations are critical irrespective of the nature of death. Unfortunately, the very context of custody raises serious concerns over the effectiveness and fairness of medico-legal examinations. The aim of this manuscript is to identify and discuss the practical and ethical difficulties encountered in the medico-legal investigation following deaths in custody. Data for this manuscript come from a larger project on Death in Custody that examined the causes of deaths in custody and the conditions under which these deaths should be investigated and prevented. A total of 33 stakeholders from forensic medicine, law, prison administration or national human rights administration were interviewed. Data obtained were analyzed qualitatively. Forensic experts are an essential part of the criminal justice process as they offer evidence for subsequent indictment and eventual punishment of perpetrators. Their independence when investigating a death in custody was deemed critical and lack thereof, problematic. When experts were not independent, concerns arose in relation to conflicts of interest, biased perspectives, and low-quality forensic reports. The solutions to ensure independent forensic investigations of deaths in custody must be structural and simple: setting binding standards of practice rather than detailed procedures and relying on preexisting national practices as opposed to encouraging new practices that are unattainable for countries with limited resources.