Requirements definition and testing of the new version of multi-mission generic monitoring system (GEMS) v 4.4 for operations at Eumetsat

EUMETSAT (www.eumetsat.int) e’ l’agenzia europea per operazioni su satelliti per monitorare clima, meteo e ambiente terrestre. Dal centro operativo situato a Darmstadt (Germania), si controllano satelliti meteorologici su orbite geostazionarie e polari che raccolgono dati per l’osservazione dell’atmosfera, degli oceani e della superficie terrestre per un servizio continuo di 24/7. Un sistema di monitoraggio centralizzato per programmi diversi all’interno dell’ambiente operazionale di EUMETSAT, e’ dato da GEMS (Generic Event Monitoring System). Il software garantisce il controllo di diverse piattaforme, cross-monitoring di diverse sezioni operative, ed ha le caratteristiche per potere essere esteso a future missioni. L’attuale versione della GEMS MMI (Multi Media Interface), v. 3.6, utilizza standard Java Server Pages (JSP) e fa uso pesante di codici Java; utilizza inoltre files ASCII per filtri e display dei dati. Conseguenza diretta e’ ad esempio, il fatto che le informazioni non sono automaticamente aggiornate, ma hanno bisogno di ricaricare la pagina. Ulteriori inputs per una nuova versione della GEMS MMI vengono da diversi comportamenti anomali riportati durante l’uso quotidiano del software. La tesi si concentra sulla definizione di nuovi requisiti per una nuova versione della GEMS MMI (v. 4.4) da parte della divisione ingegneristica e di manutenzione di operazioni di EUMETSAT. Per le attivita’ di supporto, i test sono stati condotti presso Solenix. Il nuovo software permettera’ una migliore applicazione web, con tempi di risposta piu’ rapidi, aggiornamento delle informazioni automatico, utilizzo totale del database di GEMS e le capacita’ di filtri, insieme ad applicazioni per telefoni cellulari per il supporto delle attivita’ di reperibilita’. La nuova versione di GEMS avra’ una nuova Graphical User Interface (GUI) che utilizza tecnologie moderne. Per un ambiente di operazioni come e’ quello di EUMETSAT, dove l’affidabilita’ delle tecnologie e la longevita’ dell’approccio scelto sono di vitale importanza, non tutti gli attuali strumenti a disposizione sono adatti e hanno bisogno di essere migliorati. Allo stesso tempo, un’ interfaccia moderna, in termini di visual design, interattivita’ e funzionalita’, e’ importante per la nuova GEMS MMI.

LEARNING FROM NEAR MISSES IN MEDICATION ERRORS: A BAYESIAN APPROACH

Medical errors originating in health care facilities are a significant source of preventable morbidity, mortality, and healthcare costs. Voluntary error report systems that collect information on the causes and contributing factors of medi- cal errors regardless of the resulting harm may be useful for developing effective harm prevention strategies. Some patient safety experts question the utility of data from errors that did not lead to harm to the patient, also called near misses. A near miss (a.k.a. close call) is an unplanned event that did not result in injury to the patient. Only a fortunate break in the chain of events prevented injury. We use data from a large voluntary reporting system of 836,174 medication errors from 1999 to 2005 to provide evidence that the causes and contributing factors of errors that result in harm are similar to the causes and contributing factors of near misses. We develop Bayesian hierarchical models for estimating the log odds of selecting a given cause (or contributing factor) of error given harm has occurred and the log odds of selecting the same cause given that harm did not occur. The posterior distribution of the correlation between these two vectors of log-odds is used as a measure of the evidence supporting the use of data from near misses and their causes and contributing factors to prevent medical errors. In addition, we identify the causes and contributing factors that have the highest or lowest log-odds ratio of harm versus no harm. These causes and contributing factors should also be a focus in the design of prevention strategies. This paper provides important evidence on the utility of data from near misses, which constitute the vast majority of errors in our data.

[Second victim : Critical incident stress management in clinical medicine]

BACKGROUND Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. METHODS A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. RESULTS In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. CONCLUSIONS The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

Critical incidence reporting systems - an option in equine anaesthesia? Results from a panel meeting.

OBJECTIVE To provide a brief introduction into Critical Incident Reporting Systems (CIRS) as used in human medicine, and to report the discussion from a recent panel meeting discussion with 23 equine anaesthetists in preparation for a new CEPEF-4 (Confidential Enquiry into Perioperative Equine Fatalities) study. STUDY DESIGN Moderated group discussions, and review of literature. METHODS The first group discussion focused on the definition of 'preventable critical incidents' and/or 'near misses' in the context of equine anaesthesia. The second group discussion focused on categorizing critical incidents according to an established framework for analysing risk and safety in clinical medicine. RESULTS While critical incidents do occur in equine anaesthesia, no critical incident reporting system including systematic collection and analysis of critical incidents is in place. CONCLUSIONS AND CLINICAL RELEVANCE Critical incident reporting systems could be used to improve safety in equine anaesthesia - in addition to other study types such as mortality studies.

Development, implementation, and evaluation of a structured reporting web tool for abdominal aortic aneurysms

BACKGROUND The majority of radiological reports are lacking a standard structure. Even within a specialized area of radiology, each report has its individual structure with regards to details and order, often containing too much of non-relevant information the referring physician is not interested in. For gathering relevant clinical key parameters in an efficient way or to support long-term therapy monitoring, structured reporting might be advantageous. OBJECTIVE Despite of new technologies in medical information systems, medical reporting is still not dynamic. To improve the quality of communication in radiology reports, a new structured reporting system was developed for abdominal aortic aneurysms (AAA), intended to enhance professional communication by providing the pertinent clinical information in a predefined standard. METHODS Actual state analysis was performed within the departments of radiology and vascular surgery by developing a Technology Acceptance Model. The SWOT (strengths, weaknesses, opportunities, and threats) analysis focused on optimization of the radiology reporting of patients with AAA. Definition of clinical parameters was achieved by interviewing experienced clinicians in radiology and vascular surgery. For evaluation, a focus group (4 radiologists) looked at the reports of 16 patients. The usability and reliability of the method was validated in a real-world test environment in the field of radiology. RESULTS A Web-based application for radiological "structured reporting" (SR) was successfully standardized for AAA. Its organization comprises three main categories: characteristics of pathology and adjacent anatomy, measurements, and additional findings. Using different graphical widgets (eg, drop-down menus) in each category facilitate predefined data entries. Measurement parameters shown in a diagram can be defined for clinical monitoring and be adducted for quick adjudications. Figures for optional use to guide and standardize the reporting are embedded. Analysis of variance shows decreased average time required with SR to obtain a radiological report compared to free-text reporting (P=.0001). Questionnaire responses confirm a high acceptance rate by the user. CONCLUSIONS The new SR system may support efficient radiological reporting for initial diagnosis and follow-up for AAA. Perceived advantages of our SR platform are ease of use, which may lead to more accurate decision support. The new system is open to communicate not only with clinical partners but also with Radiology Information and Hospital Information Systems.

Experiences with a voluntary surveillance system for early detection of equine diseases in Switzerland

Clinical observations made by practitioners and reported using web- and mobile-based technologies may benefit disease surveillance by improving the timeliness of outbreak detection. Equinella is a voluntary electronic reporting and information system established for the early detection of infectious equine diseases in Switzerland. Sentinel veterinary practitioners have been able to report cases of non-notifiable diseases and clinical symptoms to an internet-based platform since November 2013. Telephone interviews were carried out during the first year to understand the motivating and constraining factors affecting voluntary reporting and the use of mobile devices in a sentinel network. We found that non-monetary incentives attract sentinel practitioners; however, insufficient understanding of the reporting system and of its relevance, as well as concerns over the electronic dissemination of health data were identified as potential challenges to sustainable reporting. Many practitioners are not yet aware of the advantages of mobile-based surveillance and may require some time to become accustomed to novel reporting methods. Finally, our study highlights the need for continued information feedback loops within voluntary sentinel networks.

Nursing-related medication errors: A review of factors that facilitate and hinder error reporting, and recommendations for improvement

Medication errors, one of the most frequent types of medical errors, are a common cause of patient harm in hospital systems today. Nurses at the bedside are in a position to encounter many of these errors since they are there at the start of the process (ordering/prescribing) and the end of the process (administration). One of the recommendations from the IOM (Institute of Medicine) report, "To Err is Human," was for organizations to identify and learn from medical errors through event reporting systems. While many organizations have reporting systems in place, research studies report a significant amount of underreporting by nurses. A systematic review of the literature was performed to identify contributing factors related to the reporting and not reporting of medication errors by nurses at the bedside.^ Articles included in the literature review were primary or secondary studies, dated January 1, 2000 – July 2009, related to nursing medication error reporting. All 634 articles were reviewed with an algorithm developed to standardize the review process and help filter out those that did not meet the study criteria. In addition, 142 article bibliographies were reviewed to find additional studies that were not found in the original literature search.^ After reviewing the 634 articles and the additional 108 articles discovered in the bibliography review, 41 articles met the study criteria and were used in the systematic literature review results.^ Fear of punitive reactions to medication errors was a frequent barrier to error reporting. Nurses fear reactions from their leadership, peers, patients and their families, nursing boards, and the media. Anonymous reporting systems and departments/organizations with a strong safety culture in place helped to encourage the reporting of medication errors by nursing staff.^ Many of the studies included in this literature review do not allow results that can be generalized. The majority of them took place in single institutions/organizations with limited sample sizes. Stronger studies with larger sample sizes need to be performed, utilizing data collection methods that have been validated, to determine stronger correlations between safety cultures and nurse error reporting.^

Timeliness of reporting to APORS.

At head of title: Adverse Pregnancy Outcomes Reporting System.

Web services based state of the environment reporting

The Environmental Sciences Division within Queensland Environmental Protection Agency works to monitor, assess and model the condition of the environment. The Division has as a legislative responsibility to produce a whole-of-government report every four years dealing environmental conditions and trends in a ”State of the Environment report” (SoE)[1][2][3]. State of Environment Web Service Reporting System is a supplementary web service based SoE reporting tool, which aims to deliver accurate, timely and accessible information on the condition of the environment through web services via Internet [4][5]. This prototype provides a scientific assessment of environmental conditions for a set of environmental indicators. It contains text descriptions and tables, charts and maps with spatiotemporal dimensions to show the impact of certain environmental indicators on our environment. This prototype is a template based indicator system, to which the administrator may add new sql queries for new indicator services without changing the architecture and codes of this template. The benefits are brought through a service-oriented architecture which provides an online query service with seamless integration. In addition, since it uses web service architecture, each individual component within the application can be implemented by using different programming languages and in different operating systems. Although the services showed in this demo are built upon two datasets of regional ecosystem and protection area of Queensland, it will be possible to report on the condition of water, air, land, coastal zones, energy resources, biodiversity, human settlements and natural culture heritage on the fly as well. Figure 1 shows the architecture of the prototype. In the next section, I will discuss the research tasks in the prototype.

Standardising bull breeding soundness evaluations and reporting in Australia

There is substantial variation in bull breeding soundness evaluation procedures and reports in Australia; the situation is compounded by difficulties in interpretation and the validity of many reports. In an effort to overcome this, the scientific literature was reviewed [Fordyce G. In: Fordyce G, editor. Bull fertility: selection and management in Australia. Eight Mile Plains, Australia: Australian Cattle Vets; 2002] and the needs of stakeholders were considered in preparing a manual, Evaluating and Reporting Bull Fertility [Entwistle KW, Fordyce G. Evaluating and reporting bull fertility. Eight Mile Plains, Australia: Australian Cattle Vets; 2003.] that outlined standards for assessing and reporting bull breeding soundness. A new recording and reporting system, called Bull Reporter, is based on standards from this manual and groups bull fertility traits into five summary categories: Scrotum, Physical, Crush-side Semen, Sperm Morphology, and Serving. The client will generally select which categories they wish to have included in the evaluation to suit their specific purposes. While there is adequate room for comments, the veterinarian is not required to make an overall judgment of whether the bull has normal capacity to sire calves under natural mating management, but ensures the standards for each selected category are met. Professional, standardised, easy-to-read reports are produced either electronically [Entwistle KW, Fordyce G. Evaluating and reporting bull fertility. Eight Mile Plains, Australia: Australian Cattle Vets; 2003.] or manually. A bull owner or their agent signs the certificate to affirm that bulls have not undergone procedures to rectify faults which may have otherwise caused them to fail the standards. An accreditation system for assessing sperm morphology was established because of its demonstrated relationship with pregnancy rates and because of the difficulties in achieving consistent and accurate assessments among laboratories. It is considered that Bull Reporter is applicable to beef and dairy bulls across all levels of management, genotypes and environments throughout Australia, with substantial potential for application elsewhere in the world. Crown Copyright (c) 2006 Published by Elsevier Inc. All rights reserved.

Reflections on the development and implementation of an early warning system for ecstasy and related drug markets in Australia

Regular and systematic monitoring of drug markets provides the basis for evidence-based policy. In Australia, trends in ecstasy and related drug (ERD) markets have been monitored in selected jurisdictions since 2000 and nationally since 2003, by the Party Drugs Initiative (PDI). The PDI maximises the validity of conclusions by triangulating information from (a) interviews with regular ecstasy users (REU), (b) interviews with key experts and (c) indicator data. There is currently no other system in Australia for monitoring these markets systematically; however, the value of the PDI has been constrained by the quality of available data. Difficulties in recruiting and interviewing appropriate consumers (REU) and key experts have been experienced, but largely overcome. Limitations of available indicator data from both health and law enforcement continue to present challenges and there remains considerable scope for enhancing existing routine data collection systems, to facilitate monitoring of ERD markets. With an expanding market for ecstasy and related drugs in Australia, and in the context of indicator data that continue to be limited in scope and detail, there is a strong argument for the continued collection of annual, comparable data from a sentinel group of REU, such as those recruited for the PDI.

Cost-effective node monitoring for online hot event detection in sina weibo microblogging

We propose a cost-effective hot event detection system over Sina Weibo platform, currently the dominant microblogging service provider in China. The problem of finding a proper subset of microbloggers under resource constraints is formulated as a mixed-integer problem for which heuristic algorithms are developed to compute approximate solution. Preliminary results show that by tracking about 500 out of 1.6 million candidate microbloggers and processing 15,000 microposts daily, 62% of the hot events can be detected five hours on average earlier than they are published by Weibo.

Optimal Reporting Systems With Investor Information Acquisition

This paper analyzes a manager's optimal ex-ante reporting system using a Bayesian persuasion approach (Kamenica and Gentzkow (2011)) in a setting where investors affect cash flows through their decision to finance the firm's investment opportunities, possibly assisted by the costly acquisition of additional information (inspection). I examine how the informativeness and the bias of the optimal system are determined by investors' inspection cost, the degree of incentive alignment between the manager and the investor, and the prior belief that the project is profitable. I find that a mis-aligned manager's system is informative

only when the market prior is pessimistic and is always positively biased; this bias decreases as investors' inspection cost decreases. In contrast, a well-aligned manager's system is fully revealing when investors' inspection cost is high, and is counter-cyclical to the market belief when the inspection cost is low: It is positively (negatively) biased when the market belief is pessimistic (optimistic). Furthermore, I explore the extent to which the results generalize to a case with managerial manipulation and discuss the implications for investment efficiency. Overall, the analysis describes the complex interactions among determinants of firm disclosures and governance, and offers explanations for the mixed empirical results in this area.

EuroClonality/BIOMED-2 guidelines for interpretation and reporting of Ig/TCR clonality testing in suspected lymphoproliferations.

PCR-based immunoglobulin (Ig)/T-cell receptor (TCR) clonality testing in suspected lymphoproliferations has largely been standardized and has consequently become technically feasible in a routine diagnostic setting. Standardization of the pre-analytical and post-analytical phases is now essential to prevent misinterpretation and incorrect conclusions derived from clonality data. As clonality testing is not a quantitative assay, but rather concerns recognition of molecular patterns, guidelines for reliable interpretation and reporting are mandatory. Here, the EuroClonality (BIOMED-2) consortium summarizes important pre- and post-analytical aspects of clonality testing, provides guidelines for interpretation of clonality testing results, and presents a uniform way to report the results of the Ig/TCR assays. Starting from an immunobiological concept, two levels to report Ig/TCR profiles are discerned: the technical description of individual (multiplex) PCR reactions and the overall molecular conclusion for B and T cells. Collectively, the EuroClonality (BIOMED-2) guidelines and consensus reporting system should help to improve the general performance level of clonality assessment and interpretation, which will directly impact on routine clinical management (standardized best-practice) in patients with suspected lymphoproliferations.

[repeated Fine-needle Aspiration Cytology For The Diagnosis And Follow-up Of Thyroid Nodules].

The recently-proposed Bethesda reporting system has offered clinical recommendations for each category of reported thyroid cytology, including repeated fine-needle aspiration (FNA) for non-diagnostic and atypia/follicular lesions of undetermined significance, but there are no sound indications for repeated examination after an initial benign exam. To investigate the clinical validity of repeated FNA in the management of patients with thyroid nodules. The present study evaluated 412 consecutive patients who had repeated aspiration biopsies of thyroid nodules after an initial non-diagnostic, atypia/follicular lesion of undetermined significance, or benign cytology. The majority of patients were female (93.5%) ranging from 13 to 83 years. Non-diagnostic cytology was the most common indication for a repeated examination in 237 patients (57.5%), followed by benign (36.8%), and A/FLUS (5.6%) cytology. A repeated examination altered the initial diagnosis in 70.5% and 78.3% of the non-diagnostic and A/FLUS patients, respectively, whereas only 28.9% of patients with a benign cytology presented with a different diagnosis on a sequential FNA. Repeat FNA is a valuable procedure in cases with initial non-diagnostic or A/FLUS cytology, but its routine use for patients with an initial benign examination appears to not increase the expected likelihood of a malignant finding.