511 research outputs found
Improving patient safety by learning from near misses â insights from safety-critical industries
Background
Patients are at risk of being harmed by the very processes meant to help them. To improve patient safety, healthcare organisations attempt to identify the factors that contribute to incidents and take action to optimise conditions to minimise repeats. However, improvements in patient safety have not matched those observed in other safety-critical industries.
One difference between healthcare and other safety-critical industries may be how they learn from near misses when seeking to make safety improvements. Near misses are incidents that almost happened, but for an interruption in the sequence of events. Management of near misses includes their identification, reporting and investigation, and the learning that results. Safety theory suggests that acting on near misses will lead to actions to help prevent incidents. However, evidence also suggests that healthcare has yet to embrace the learning potential that patient safety near misses offer.
The aims of this research, in support of this thesis, were to explore how best healthcare can learn from patient safety near misses to improve patient safety, and to identify what guidance non-healthcare safety-critical industries, which have implemented effective near-miss management systems, can offer healthcare. As this research progressed the aims were updated to include consideration of whether healthcare should seek to learn from patient safety near misses.
Methods
This research took a mixed-methods approach augmented by scoping reviews of the healthcare (study 1) and non-healthcare safety-critical industry (study 3) literature. A qualitative case study (study 2) was undertaken to explore the management of patient safety near misses in the English National Health Service. Seventeen interviews were undertaken with patient safety leads across acute hospitals, ambulance trusts, mental health trusts, primary care, and national bodies. A questionnaire was also used to help access the views of frontline staff.
A grounded theory (study 4) was used to develop a set of principles, based on learning from non-healthcare safety-critical industries, around how best near misses can be managed. Thirty-five interviews were undertaken across aviation, maritime, and rail, with nuclear later added as per the theoretical sampling.
Results
The scoping reviews contributed 125 healthcare and 108 non-healthcare safety-critical industry academic articles, published internationally between 2000 and 2022, to the evidence gained from the qualitative case study and grounded theory. Safety cultures and maturity with safety management processes were found to vary in and across the different industries, and there was a reluctance for healthcare to learn about safety and near misses from other industries.
Healthcare has yet to establish effective processes to manage patient safety near misses. There is an absence of evidence that learning has led to improvements in patient safety. The definition of a patient safety near miss varies, and organisations focus their efforts on reporting and investigating incidents, with limited attention to patient safety near misses. In non-healthcare safety-critical industries, near-miss management is more established, but process maturity varies in and across industries. Near misses are often defined specifically for an industry, but there is limited evidence that learning from them has improved safety. Information about near misses are commonly aggregated and may contribute to company and industry safety management systems.
Exploration of the definition of a patient safety near miss led to the identification of the features of a near miss. The features have not been previously defined in the manner presented in this thesis. A patient safety near miss is context-specific and complex, involves interruptions, highlights system vulnerabilities, and is delineated from an incident by whether events reach a patient.
Across healthcare and non-healthcare safety-critical industries the impact of learning from near misses is often assumed or extrapolated based on the common cause hypothesis. The hypothesis is regularly cited in safety literature and is used as the basis for justifying a focus on patient safety near misses. However, the validity of the hypothesis has been questioned and has not been validated for different patient safety near miss and incident types.
Conclusions
The research findings challenge long-held beliefs that learning from patient safety near misses will lead to improvements in patient safety. These beliefs are based on traditional safety theory that is unlikely to now be valid in the complexity of modern-day systems where incidents are the result of multiple factors and can emerge without apparent warning. Further research is required to understand the relationship between learning from patient safety near misses and patient safety, and whether the common cause hypothesis is valid for different types of healthcare safety event.
While there are questions about the value of learning directly from patient safety near misses, the contribution of near misses to safety management systems in non-healthcare safety-critical industries looks to be beneficial for safety improvement. Safety management systems have yet to be implemented in the National Health Service and future research should look to understand how best this may be achieved and their value. In the meantime, patient safety near misses may help healthcareâs understanding of systems and their optimisation to create barriers to incidents and build resilience. This research offers an evidence-based definition of a patient safety near miss and describes principles to support identification, reporting, prioritisation, investigation, aggregation, learning, and action to help improve patient safety
Theologische ZugĂ€nge zu Technik und KĂŒnstlicher Intelligenz
The publication of this work was supported by the Open Access Publication Fund of Humboldt-UniversitĂ€t zu Berlin.Technik und KĂŒnstliche Intelligenz gehören zu den brisanten Themen der gegenwĂ€rtigen Theologie. Wie kann Theologie zu Technik und KI beitragen? Der Technikdiskurs ist aufgeladen mit religiösen Motiven, und Technologien wie Roboter fordern die Theologie, z. B. das Menschenbild, die Ethik und die religiöse Praxis, neu heraus. Der Sammelband erforscht aus theologischer Perspektive die drĂ€ngenden Themen unserer Zeit. Dazu begibt sich die Theologie in Dialog mit den Technikwissenschaften. Untersucht werden die VerĂ€nderungen des Menschenbildes durch Roboter, Religiöse Roboter, Optimierung des Körpers, medizinische Technologien, Autoregulative Waffensysteme und wie die Theologie durch die Technologisierung transformiert wird. Aus interdisziplinĂ€rer Perspektive werden neue Forschungsergebnisse aus dem internationalen Raum vorgestellt und neue Wege beschritten
50+ years of R&D Management: a retrospective synthesis and new research trajectories
In 2020, R&D Management celebrated 50 years of publication. The present study honors that milestone by conducting a retrospective examination of the research conducted in the journal over time and reflects on its rich history to look forward in the R&D management field. Using bibliometric techniques, we provide a comprehensive analysis of the journalâs most prominent topics and themes, as well as its most prolific authors, institutions, and countries.
The findings indicate that R&D Management has increased its productivity and reputation as measured by the number of published articles and citations per year and expanded its
international reach from the initial European-dominated
author base. We complement this analysis by performing an in-depth systematic literature review of the most frequently cited
papers âannually and of all time âto disentangle the themes and concepts that prominently shaped the progress of the discipline itself. The results suggest that R&D Management has
progressively widened its field of investigation from an intra-organizational perspective (1970â1992) to an inter-organizational
view (1992â2006) and then to an extra-organizational outlook (2006â2018).
Finally, based on this history and viewing the contributions from 2019 onwards, we identify an emerging set of research trajectories that we expect will pave the way for the future impact of R&D Management and the field at large
Constitutions of Value
Gathering an interdisciplinary range of cutting-edge scholars, this book addresses legal constitutions of value.
Global value production and transnational value practices that rely on exploitation and extraction have left us with toxic commons and a damaged planet. Against this situation, the book examines lawâs fundamental role in institutions of value production and valuation. Utilising pathbreaking theoretical approaches, it problematizes mainstream efforts to redeem institutions of value production by recoupling them with progressive values. Aiming beyond radical critique, the book opens up the possibility of imagining and enacting new and different value practices.
This wide-ranging and accessible book will appeal to international lawyers, socio-legal scholars, those working at the intersections of law and economy and others, in politics, economics, environmental studies and elsewhere, who are concerned with rethinking our current ideas of what has value, what does not, and whether and how value may be revalued
Metaverse. Old urban issues in new virtual cities
Recent years have seen the arise of some early attempts to build virtual cities,
utopias or affective dystopias in an embodied Internet, which in some respects appear to
be the ultimate expression of the neoliberal city paradigma (even if virtual). Although
there is an extensive disciplinary literature on the relationship between planning and
virtual or augmented reality linked mainly to the gaming industry, this often avoids design
and value issues. The observation of some of these early experiences - Decentraland,
Minecraft, Liberland Metaverse, to name a few - poses important questions and problems
that are gradually becoming inescapable for designers and urban planners, and allows
us to make some partial considerations on the risks and potentialities of these early virtual
cities
Towards a sustainable PV waste policy: Exploring the management practices of end-of-life solar photovoltaic modules in Australia
Solar photovoltaic (PV) systems are effective measures to reduce the greenhouse gas
emissions. However, the large exploitation of solar PV modules, leads to undesirable waste
accumulation, affecting the environment. Solar PV waste management research is an emerging
field that has received more attention recently, affected by the increase volume of solar PV
disposals. However, only a few studies have examined the current practices in solar
photovoltaic waste management. In Australia, because of social and economic factors (such as
the replacement of small-scale PV systems come with new rebates), residential solar systems
are decommissioned earlier than expected before reaching their end-of-life (EoL). 70% of the
market share of PV systems are predominately dominated by the residential market in Australia
as of 2020. The average practical lifetime of PV modules instead of 20-30 years is 15-20 years
in Australia. Therefore, the volume of EoL PV from the residential sector entering the waste
stream in the coming decade will be higher than previously predicted.
This study aims to assess the environmental impacts of waste from rooftop solar photovoltaic
panels in Australia to inform sustainable policies. To achieve the aim of the research, the
following objectives are investigated: 1) exploring the current practices of managing end-oflife
rooftop solar photovoltaic panels in Australia; 2) developing an optimised system approach
in dealing with solar photovoltaic waste in Australia; and 3) assessing the environmental
impacts of end-of-life rooftop solar photovoltaic panels in Australia within the developed
assessment framework.
To achieve the research objectives, several methods are adopted to analyse the primary and
secondary data for this research. A modified Fuzzy Delphi Method (FDM) is adopted in
gathering data through interviews and questionnaires from experts in the field. The results show
that, crystalline silicon panels were the most common panels on the Australian market and the
ones that are being installed frequently. On policies, although the Australian government has
banned PV waste from going to landfill since 2014, there were no regulations or action plans
to manage PV waste. The absence of policies and regulations results in unregulated movement
and tracking of solar PV waste in and out of Australia as well as within and across the states.
The extent of the PV recovery and recycling warrants further investigation. Moreover,
infrastructure and logistics has been a significant problem because of the geographical spread
of the country and how it affects transportation and the supply chain. Findings led to the establishment of a conceptual framework for the current treatment of solar PV waste in
Australia.
Furthermore, a Weibull distribution model is employed to forecast the PV waste in the next
three decades in South Australia. The study further estimates the pollutant emission associated
with the collection and transportation of the waste for recycling and recovery. Results indicate
that, there will be 109,007 tons of PV waste generated in urban and suburban context in South
Australia by 2050. Among the three routing scenarios generated, the third scenario with
optimised transfer stations and an additional recycling facility showed more than 34%
reduction in pollutant emission.
This study evaluates the environmental impacts of three policy options for mono and multi
crystalline silicon (c-Si) solar panel waste modules. The impact of transport distance from
transfer stations to the recycling centre is also assessed. The life cycle assessment revealed that,
-1E+06 kgCO2eq and -2E+06 kgCO2eq are associated with the mandatory product stewardship
scenarios under global warming potential for mono and multi c-Si solar modules respectively.
However, the non-existence of a product stewardship will produce a global warming impact of
1E+05 kgCO2eq for both modules. The global warming effects revealed that, collecting and
recycling most of the multi c-Si panels were not effective (-365 kg CO2-eq, -698.4 kg CO2-eq,
-1032 kg CO2-eq) compared to keeping them away from the landfills and fully recycling (-
2E+06 kg CO2-eq) them. It was also highlighted that, the highest environmental impact
regarding the transport distances was the scenario of one recycling centre serving over 107
transfer stations with a global warming potential of 1E+06 kgCO2eq.
In conclusion, this study contributes to the management of the supply market of solar PV
technologies, using Australia as a case study. The recommendations derived from the
study include: creating collection centres for EoL PV modules in South Australia, developing
a logistic network to for the collection of EoL PV modules, creating and enhancing the
PV recycling market for recovered materials, issuing a regulatory landfill ban for EoL
solar PV module in South Australia, developing a mandatory product stewardship for PV
waste in Australia, promoting and providing financial incentives to current and future
infrastructure for PV recycling, minimising the exportation of PV waste overseas and
interstate, encouraging industry led research on new innovations to improve the recovery
of different PV technology families, developing sustainable measures to cut emissions for recycling through research and development in South Australia, and building the
capacity and promoting awareness on the benefits of PV recycling in South Australia.Thesis (Ph.D.) -- University of Adelaide, School of Architecture and Civil Engineering, 202
Authentic alignment : toward an Interpretative Phenomenological Analysis (IPA) informed model of the learning environment in health professions education
It is well established that the goals of education can only be achieved through the constructive alignment of instruction, learning and assessment. There is a gap in research interpreting the lived experiences of stakeholders within the UK learning environment toward understanding the real impact â authenticity â of curricular alignment. This investigation uses a critical realist framework to explore the emergent quality of authenticity as a function of alignment.This project deals broadly with alignment of anatomy pedagogy within UK undergraduate medical education. The thread of alignment is woven through four aims: 1) to understand the alignment of anatomy within the medical curriculum via the relationships of its stakeholders; 2) to explore the apparent complexity of the learning environment (LE); 3) to generate a critical evaluation of the methodology, Interpretative Phenomenological Analysis as an approach appropriate for realist research in the complex fields of medical and health professions education; 4) to propose a functional, authentic model of the learning environment.Findings indicate that the complexity and uncertainty inherent in the LE can be reflected in spatiotemporal models. Findings meet the thesis aims, suggesting: 1) the alignment of anatomy within the medical curriculum is complex and forms a multiplicity of perspectives; 2) this complexity is ripe for phenomenological exploration; 3) IPA is particularly suitable for realist research exploring complexity in HPE; 4) Authentic Alignment theory offers a spatiotemporal model of the complex HPE learning environment:the T-icosa
The grammar of immersion: a social semiotic study of nonfiction cinematic virtual reality
Cinematic virtual reality (CVR) is an audio-visual form viewed in a virtual reality headset. Its
novelty lies in the way it immerses its audience in highly realistic 360° visual representations.
Being camera-based, CVR facilitates many of the practices of conventional filmmaking but
fundamentally alters them through its lack of a rectangular frame. As such, CVR has garnered
scholarly attention as a âframelessâ storytelling medium yet to develop its own language. The form
has gained traction with producers of nonfiction who recognize CVRâs capacity to transport
audiences to remote social worlds, leading to claims that equate CVRâs immersion with a social
and emotional response to its filmed subjects. A strand of CVR scholarship has emerged,
grounding nonfiction CVR theoretically and critiquing such deterministic claims. Broadly
speaking, these parallel strands of inquiry point to a common concern with CVRâs semiotics; as
the meaning potential of the 360° format, and the social aspects of its use in documenting reality.
Currently however, there appears to be a lack of systematic analyses that foreground CVRâs
semiotics.
This study addresses this gap by using social semiotic methods to complement these threads of
inquiry, subsuming them into a holistic account of CVRâs semantics. Utilizing systemic functional
methods, multimodal discourse analyses were performed on nonfiction CVR texts addressing
core research objectives. The first objective is the systematic description of CVR as a semiotic
technology, and the configuring of discourse through its novel 360° modality. The CVR spectator
is described for their role in the real-time construction of low-level meanings. Higher-level
concepts further characterize CVR texts as technologically enabled, virtual sites of social
discourse. The second research objective concerns clarifying the implications of CVR for
nonfiction practitioners. Nonfiction discourse is conceptualized as the negotiation of semiotic
autonomy, independence, and control, between viewing spectator, filmed subject, and CVR author
respectively. The third objective concerns the development of an analytical approach tailored
specifically for CVR. Extant systems from image, text, film, and action analyses are reflexively
applied, appraised, and adapted for use in the study of CVR and new frames are presented to cater
for the 360° modality.
The findings show CVR to be an inherently logical, contextualizing form, where the spectator has
a degree of sense-making autonomy in the construction of representational and social meanings.
This semantic autonomy is found to camouflage the deeper textual constructions in what appear
as âreality experiencesâ. The repercussions for the CVR producer are the indeterminacy of
meanings which are âat riskâ in particular ways when conventional framing methods cannot be
utilized, and when the spectator is given reflexive agency to make meaningful connections across
the 360° image. Systemic functional analytical methods prove flexible enough to be applied to the
texts, and open enough for the study to present additional systems and frames for a more fulsome
approach to the analysis of CVR
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