Learning curves, taking instructions, and patient safety:using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors

ABSTRACT:

Different Learning Curves for Axillary Brachial Plexus Block: Ultrasound Guidance versus Nerve Stimulation

Little is known about the learning of the skills needed to perform ultrasound- or nerve stimulator-guided peripheral nerve blocks. The aim of this study was to compare the learning curves of residents trained in ultrasound guidance versus residents trained in nerve stimulation for axillary brachial plexus block. Ten residents with no previous experience with using ultrasound received ultrasound training and another ten residents with no previous experience with using nerve stimulation received nerve stimulation training. The novices' learning curves were generated by retrospective data analysis out of our electronic anaesthesia database. Individual success rates were pooled, and the institutional learning curve was calculated using a bootstrapping technique in combination with a Monte Carlo simulation procedure. The skills required to perform successful ultrasound-guided axillary brachial plexus block can be learnt faster and lead to a higher final success rate compared to nerve stimulator-guided axillary brachial plexus block.

Learning Curves of Temporary Workers in Manual Order Picking Activities

Person-to-stock order picking is highly flexible and requires minimal investment costs in comparison to automated picking solutions. For these reasons, tradi-tional picking is widespread in distribution and production logistics. Due to its typically large proportion of manual activities, picking causes the highest operative personnel costs of all intralogistics process. The required personnel capacity in picking varies short- and mid-term due to capacity requirement fluctuations. These dynamics are often balanced by employing minimal permanent staff and using seasonal help when needed. The resulting high personnel fluctuation necessitates the frequent training of new pickers, which, in combination with in-creasingly complex work contents, highlights the im-portance of learning processes in picking. In industrial settings, learning is often quantified based on diminishing processing time and cost requirements with increasing experience. The best-known industrial learning curve models include those from Wright, de Jong, Baloff and Crossman, which are typically applied to the learning effects of an entire work crew rather than of individuals. These models have been validated in largely static work environments with homogeneous work contents. Little is known of learning effects in picking systems. Here, work contents are heterogeneous and individual work strategies vary among employees. A mix of temporary and steady employees with varying degrees of experience necessitates the observation of individual learning curves. In this paper, the individual picking performance development of temporary employees is analyzed and compared to that of steady employees in the same working environment.

Learning curves of basic laparoscopic psychomotor skills in SINERGIA VR simulator

Purpose: Surgical simulators are currently essential within any laparoscopic training program because they provide a low-stakes, reproducible and reliable environment to acquire basic skills. The purpose of this study is to determine the training learning curve based on different metrics corresponding to five tasks included in SINERGIA laparoscopic virtual reality simulator. Methods: Thirty medical students without surgical experience participated in the study. Five tasks of SINERGIA were included: Coordination, Navigation, Navigation and touch, Accurate grasping and Coordinated pulling. Each participant was trained in SINERGIA. This training consisted of eight sessions (R1–R8) of the five mentioned tasks and was carried out in two consecutive days with four sessions per day. A statistical analysis was made, and the results of R1, R4 and R8 were pair-wise compared with Wilcoxon signed-rank test. Significance is considered at P value <0.005. Results: In total, 84.38% of the metrics provided by SINERGIA and included in this study show significant differences when comparing R1 and R8. Metrics are mostly improved in the first session of training (75.00% when R1 and R4 are compared vs. 37.50% when R4 and R8 are compared). In tasks Coordination and Navigation and touch, all metrics are improved. On the other hand, Navigation just improves 60% of the analyzed metrics. Most learning curves show an improvement with better results in the fulfillment of the different tasks. Conclusions: Learning curves of metrics that assess the basic psychomotor laparoscopic skills acquired in SINERGIA virtual reality simulator show a faster learning rate during the first part of the training. Nevertheless, eight repetitions of the tasks are not enough to acquire all psychomotor skills that can be trained in SINERGIA. Therefore, and based on these results together with previous works, SINERGIA could be used as training tool with a properly designed training program.

Learning curves for Gaussian processes models: fluctuations and universality

Based on a statistical mechanics approach, we develop a method for approximately computing average case learning curves and their sample fluctuations for Gaussian process regression models. We give examples for the Wiener process and show that universal relations (that are independent of the input distribution) between error measures can be derived.

A variational approach to learning curves

We combine the replica approach from statistical physics with a variational approach to analyze learning curves analytically. We apply the method to Gaussian process regression. As a main result we derive approximative relations between empirical error measures, the generalization error and the posterior variance.

Learning curves: analysing pace and challenge in four successful puzzle games

The pace at which challenges are introduced in a game has long been identified as a key determinant of both the enjoyment and difficulty experienced by game players, and their ability to learn from game play. In order to understand how to best pace challenges in games, there is great value in analysing games already demonstrated as highly engaging. Play-through videos of four puzzle games (Portal, Portal 2 Co-operative mode, Braid and Lemmings), were observed and analysed using metrics derived from a behavioural psychology understanding of how people solve problems. Findings suggest that; 1) the main skills learned in each game are introduced separately, 2) through simple puzzles that require only basic performance of that skill, 3) the player has the opportunity to practice and integrate that skill with previously learned skills, and 4) puzzles increase in complexity until the next new skill is introduced. These data provide practical guidance for designers, support contemporary thinking on the design of learning structures in games, and suggest future directions for empirical research.

Upper and lower bounds on the learning curve for Gaussian processes

In this paper we introduce and illustrate non-trivial upper and lower bounds on the learning curves for one-dimensional Gaussian Processes. The analysis is carried out emphasising the effects induced on the bounds by the smoothness of the random process described by the Modified Bessel and the Squared Exponential covariance functions. We present an explanation of the early, linearly-decreasing behavior of the learning curves and the bounds as well as a study of the asymptotic behavior of the curves. The effects of the noise level and the lengthscale on the tightness of the bounds are also discussed.

Bayesian online algorithms for learning in discrete Hidden Markov Models

We propose and analyze two different Bayesian online algorithms for learning in discrete Hidden Markov Models and compare their performance with the already known Baldi-Chauvin Algorithm. Using the Kullback-Leibler divergence as a measure of generalization we draw learning curves in simplified situations for these algorithms and compare their performances.

Online learning in discrete hidden Markov models

We present and analyze three different online algorithms for learning in discrete Hidden Markov Models (HMMs) and compare their performance with the Baldi-Chauvin Algorithm. Using the Kullback-Leibler divergence as a measure of the generalization error we draw learning curves in simplified situations and compare the results. The performance for learning drifting concepts of one of the presented algorithms is analyzed and compared with the Baldi-Chauvin algorithm in the same situations. A brief discussion about learning and symmetry breaking based on our results is also presented. © 2006 American Institute of Physics.

Fluoroscopic-Guided Radial Endobronchial Ultrasound Without Guide Sheath For Peripheral Pulmonary Lesions: A Safe And Efficient Combination.

BACKGROUND: Several guidelines recommend computed tomography scans for populations with high-risk for lung cancer. The number of individuals evaluated for peripheral pulmonary lesions (PPL) will probably increase, and with it non-surgical biopsies. Associating a guidance method with a target confirmation technique has been shown to achieve the highest diagnostic yield, but the utility of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance without a guide sheath has not been reported. METHODS: We conducted a retrospective analysis of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy procedures for the investigation of PPL performed by experienced bronchoscopists with no specific previous training in this particular technique. Operator learning curves and radiological predictors were assessed for all consecutive patients examined during the first year of application of the technique. RESULTS: Fifty-one PPL were investigated. Diagnostic yield and visualization yield were 72.5 and 82.3% respectively. The diagnostic yield was 64.0% for PPL ≤20mm, and 80.8% for PPL>20mm. No false-positive results were recorded. The learning curve of all diagnostic tools showed a DY of 72.7% for the first sub-group of patients, 81.8% for the second, 72.7% for the third, and 81.8% for the last. CONCLUSION: Bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance is safe and simple to perform, even without specific prior training, and diagnostic yield is high for PPL>and ≤20mm. Based on these findings, this method could be introduced as a first-line procedure for the investigation of PPL, particularly in centers with limited resources.

Investigación sobre empresas que perduran en América

Investigación sobre las empresas mas antiguas de America, tomando en la cuenta elementos comunes y diferenciados de su gestión.

Aislamiento de venas pulmonares en el Centro Internacional de Arritmias ‘Andrea Natale’ - Fundación Cardio infantil

Introducción: El Aislamiento de Venas Pulmonares (AVP) es un procedimiento de alto costo al cual son sometidos pacientes con riesgo cardiovascular elevado. Requiere un alto grado de especialización en el personal médico y paramédico que lo ejecuta, con curvas de aprendizaje que sobrepasan los dos años de formación académica y entrenamiento específico. Metodología: Se realizó un estudio de cohorte retrospectivo, donde se incluyeron 88 sujetos sometidos al procedimiento en el lapso comprendido entre el 1º de enero y el 31 de diciembre de 2013, con el objetivo de evaluar su proceso de atención en el Centro Internacional de Arritmias ‘Andrea Natale’ de la FCI – Instituto de Cardiología. Se realizó análisis de regresión lineal y logística múltiple. Resultados: Se encontró que en el 97,73%% de los pacientes el diagnóstico principal era algún tipo de Fibrilación Auricular (FA); a su vez, la comorbilidad más frecuente fue HTA en el 30,68% y ningún paciente presentaba enfermedad coronaria, no hubo diferencias significativas por sexo. La complicación peri operatoria tuvo una incidencia del 3,41%, el 22,73% requirió ingreso a UCI con un promedio de días estancia 0,25+0,51. El 98,86% de la población estudiada recibió educación pos procedimiento acerca de sus cuidados y signos de alarma. Los factores encontrados en el estudio que afectan la duración del procedimiento y la estancia hospitalaria son las interconsultas pre procedimiento, el manejo médico de la cardiomiopatía de base y el uso de anti agregantes plaquetarios pre procedimiento; los cuales, son puntos por mejorar previo al ingreso o programación del paciente para ser llevado a AVP. Discusión: Como recomendaciones específicas se destacan: La necesidad de incluir en el protocolo de preparación para ablación de venas pulmonares la realización de interconsultas a las especialidades requeridas, antes de su ingreso para la realización del procedimiento. Es importante que el paciente que lo amerite haga parte de un programa de falla cardiaca previamente al procedimiento

Find the difference! : eye tracking study on information seeking behavior using an online game

With the advent of digital era web applications have become inevitable part of our lives. We are using the web to manage even the financially or ethically sensitive issues. For this reason exploration of information seeking behavior is an exciting area of research. Current study provides insight on information seeking behavior using a classic ‘Find the Difference’ game. 50 university students between the age of 19 and 26 participated in the study. Eye movement data were recorded with a Tobii T120 device. Participants carried out 4 continuous tasks. Each task included two pictures side by side with 7 hidden differences. After finishing the tasks, participants were asked to repeat the game with the same picture set. This data collection methodology allows the evaluation of learning curves. Additionally, participants were asked about their hand preference. For the purpose of analysis the following metrics were applied: task times (including saccades), fixation count and fixation duration (without saccades). The right- and left-hand side on each picture was selected as AOI (Area of Interest) to detect side preference in connection with hand preference. Results suggest a significant difference between male and female participants regarding aggregated task times (male 58.37s respectively female 68.37s), deviation in the number of fixations and fixation duration (apparently female have less but longer fixations) and also in the distribution of fixations between AOIs. Using eyetracking data current paper highlights the similarities and differences in information acquisition strategies respectively reveals gender and education (Arts vs. Sciences) dependent characteristics of interaction.

Accuracy considerations in navigated cup placement for total hip arthroplasty

Computer assisted orthopaedic surgery (CAOS) technology has recently been introduced to overcome problems resulting from acetabular component malpositioning in total hip arthroplasty. Available navigation modules can conceptually be categorized as computer tomography (CT) based, fluoroscopy based, or image-free. The current study presents a comprehensive accuracy analysis on the computer assisted placement accuracy of acetabular cups. It combines analyses using mathematical approaches, in vitro testing environments, and an in vivo clinical trial. A hybrid navigation approach combining image-free with fluoroscopic technology was chosen as the best compromise to CT-based systems. It introduces pointer-based digitization for easily assessable points and bi-planar fluoroscopy for deep-seated landmarks. From the in vitro data maximum deviations were found to be 3.6 degrees for inclination and 3.8 degrees for anteversion relative to a pre-defined test position. The maximum difference between intraoperatively calculated cup inclination and anteversion with the postoperatively measured position was 4 degrees and 5 degrees, respectively. These data coincide with worst cases scenario predictions applying a statistical simulation model. The proper use of navigation technology can reduce variability of cup placement well within the surgical safe zone. Surgeons have to concentrate on a variety of error sources during the procedure, which may explain the reported strong learning curves for CAOS technologies.