The criminalisation of medical mistakes in Canada : a review

The issue of health professionals facing criminal charges of manslaughter or criminal negligence causing death or grievous bodily harm as a result of alleged negligence in their professional practice was thrown into stark relief by the recent acquittal of four physicians accused of mismanaging Canada’s blood system in the early 1980s. Stories like these, as well as international reports detailing an increase in the numbers of physicians being charged with (and in some cases convicted of) serious criminal offences as the result of alleged negligence in their professional practice, have resulted in some anxiety about the apparent increase in the incidence of such charges and their appropriateness in the healthcare context. Whilst research has focused on the incidence, nature and appropriateness of criminal charges against health professionals, particularly physicians, for alleged negligence in their professional practice in the United Kingdom, the United States, Japan, and New Zealand, the Canadian context has yet to be examined. This article examines the Canadian context and how the criminal law is used to regulate the negligent acts or omissions of a health care professional in the course of their professional practice. It also assesses the appropriateness of such use. It is important at this point to state that the analysis in this article does not focus on those, fortunately few, cases where a health professional has intentionally killed his or her patients but rather when patients’ deaths or grievous injuries were allegedly as a result of that health professional’s negligent acts or omissions when providing health services to that patient.

New graduate occupational therapists' perceptions of near-misses and mistakes in the workplace

Purpose - The purpose of this paper is to explore the perceptions of near-misses and mistakes among new graduate occupational therapists from Australia and Aotearoa/New Zealand (NZ), and their knowledge of current incident reporting systems. Design/methodology/approach - New graduate occupational therapists in Australia and Aotearoa/NZ in their first year of practice (n=228) participated in an online electronic survey that examined five areas of work preparedness. Near-misses and mistakes was one focus area. Findings - The occurrence and disclosure of practice errors among new graduate occupational therapists are similar between Australian and Aotearoa/NZ participants. Rural location, structured supervision and registration status significantly influenced the perceptions and reporting of practice errors. Structured supervision significantly impacted on reporting procedure knowledge. Current registration status was strongly correlated with perceptions that the workplace encouraged event reporting. Research limitations/ implications - Areas for further investigation include investigating the perceptions and knowledge of practice errors within a broader profession and the need to explore definitional aspects and contextual factors of adverse events that occur in allied health settings. Selection bias may be a factor in this study. Practical implications - Findings have implications for university and workplace structures, such as clinical management, supervision, training about practice errors and reporting mechanisms in allied health. Originality/value - Findings may enable the development of better strategies for detecting, managing and preventing practice errors in the allied health professions.

Mistakes or deliberate violations? A study into the origins of rule breaking at pedestrian train crossings

Train pedestrian collisions are the most likely to result in severe injuries and fatalities when compared to other types of rail crossing accidents. However, there is currently scant research that has examined the origins of pedestrians’ rule breaking at level crossings. As a result, this study examined the origins of pedestrians’ rule breaking behaviour at crossings, with particular emphasis directed towards examining the factors associated with making errors versus deliberation violations. A total of 636 individuals volunteered to participate in the study and completed either an online or paper version of the questionnaire. Quantitative analysis of the data revealed that knowledge regarding crossing rules was high, although up to 18% of level crossing users were either unsure or did not know (in some circumstances) when it was legal to cross at a level crossing. Furthermore, 156 participants (24.52%) reported having intentionally violated the rules at level crossings and 3.46% (n = 22) of the sample had previously made a mistake at a crossing. In regards to rule violators, males (particularly minors) were more likely to report breaking rules, and the most frequent occurrence was after the train had passed rather than before it arrives. Regression analysis revealed that males who frequently use pedestrian crossings and report higher sensation seeking traits are most likely to break the rules. This research provides evidence that pedestrians are more likely to deliberately violate rules (rather than make errors) at crossings and it illuminates high risk groups. This paper will further outline the study findings in regards to the development of countermeasures as well as provide direction for future research efforts in this area.

Do health inquiries lead to health system change? What have we learnt from recent health inquiries and will the same mistakes happen again?

Since 2001 there have been numerous Commissions of Inquiry into health system failures across the world. While the Inquiries were established to examine poor patient outcomes, each has identified a range of leadership and management shortcomings that have contributed to a poor standard of patient care. While there is an acknowledgement that different heath systems have different contexts, this paper highlights a number of themes that are common across Inquiries. It will discuss a number of common system failures in Inquiries spanning from 2001 to 2013 and pose questions as to why these types of failures are likely to re-occur, as well as possible learnings for health service management and leadership to address a number of these common themes.

Towards an intelligent score following system: Handling of mistakes and jumps encountered during piano practicing

Score following has been an important area of research in AI and music since the mid 80's. Various systems were developed, but they were predominantly for providing automated accompaniment to live concert performances, dealing mostly with issues relating to pitch detection and identification of embellished melodies. They have a big potential in the area of education where student performers benefit in practice situations. Current accompaniment systems are not designed to deal with errors that may occur during practising. In this paper we present a system developed to provide accompaniment for students practising at home. First a survey of score following will be given. Then the capabilities of the system will be explained, and the results from the first experiments of the monophonic score following system will be presented.

History of several mistakes: on differences between Lev Gumilev and Eurasians

This article challenges prevalent views about Gumilev’s relation to classic Eurasianism. On the basis of previously unavailable correspondence and interviews, it is argued that Lev Gumilev had substantial degree of affinity with the original Eurasian movement understood as a scholarly tradition. This was manifested both in his personal contacts with some of its key members, and in his scholarly work on the nomad history, which remained Eurasian in its spirit. However, the most significant departure from Eurasianism, under-appreciated by most scholars, was his theory of ethnogenesis, which attempted to establish a new naturalistic paradigm for study of history.

Don't : a manual of mistakes and improprieties more or less prevalent in conduct and speech

UANL

Entry mistakes happen!

Frequently, aspiring entrants have only limited infonnation about their potential rivaIs' entry decisions. As a result, the outcome of the entry game may be that more firms enter than the market can sustain; or, at least, that unnecessary entry investments are made: entry mistakes may happen. We consider two models of non-coordinated entry. In these models, entry mistakes occur because of lags in observing rivaIs' entry decisions (grabthe- dollar entry) or because entry investments take time (war-of-attrition entry). The widebody aircraft industry in the late sixties is presented as supporting evidence for the models' assumptions. We also discuss the welfare implications of non-coordinated free entry. Both models predict that entry incentives are excessive (resp. insufficient) when duopoly profits are high (resp. low). However, if entry costs are high, entry incentives are excessive under war-of-attrition entry but insufficient under grab-the-dollar entry.