133,761 research outputs found
Semantics for incident identification and resolution reports
In order to achieve a safe and systematic treatment of security protocols, organizations release a number of technical
briefings describing how to detect and manage security incidents. A critical issue is that this document set may suffer from
semantic deficiencies, mainly due to ambiguity or different granularity levels of description and analysis. An approach to
face this problem is the use of semantic methodologies in order to provide better Knowledge Externalization from incident
protocols management. In this article, we propose a method based on semantic techniques for both, analyzing and specifying
(meta)security requirements on protocols used for solving security incidents. This would allow specialist getting better
documentation on their intangible knowledge about them.Ministerio de EconomĂa y Competitividad TIN2013-41086-
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officer’s report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agency’s progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHS’s patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Department’s strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Department’s clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authority’s
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
Patient safety in health care professional educational curricula: examining the learning experience
This study has investigated the formal and informal ways pre-registration students from four healthcare professions learn about patient safety in order to become safe practitioners. The study aims to understand some of the issues which impact upon teaching, learning and practising patient safety in academic, organisational and practice „knowledge? contexts. In Stage 1 we used a convenience sample of 13 educational providers across England and Scotland linked with five universities running traditional and innovative courses for doctors, nurses, pharmacists and physiotherapists. We gathered examples of existing curriculum documents for detailed analysis, and interviewed course directors and similar informants. In Stage 2 we undertook 8 case studies to develop an in-depth investigation of learning and practice by students and newly qualified practitioners in universities and practice settings in relation to patient safety. Data were gathered to explore the planning and implementation of patient safety curricula; the safety culture of the places where learning and working take place; the student teacher interface; and the influence of role models and organisational culture on practice. Data from observation, focus groups and interviews were transcribed and coded independently by more than one of the research team. Analysis was iterative and ongoing throughout the study. NHS policy is being taken seriously by course leaders, and Patient Safety material is being incorporated into both formal and informal curricula. Patient safety in the curriculum is largely implicit rather than explicit. All students very much value the practice context for learning about patient safety. However, resource issues, peer pressure and client factors can influence safe practice. Variations exist in students? experience, in approach between university tutors, different placement locations – the experience each offers – and the quality of the supervision available. Relationships with the mentor or clinical educator are vital to student learning. The role model offered and the relationship established affects how confident students feel to challenge unsafe practice in others. Clinicians are conscious of the tension between their responsibilities as clinicians (keeping patients safe), and as educators (allowing students to learn under supervision). There are some apparent gaps in curricular content where relevant evidence already exists – these include the epidemiology of adverse events and error, root cause analysis and quality assessment. Reference to the organisational context is often absent from course content and exposure limited. For example, incident reporting is not being incorporated to any great extent in undergraduate curricula. Newly qualified staff were aware of the need to be seen to practice in an evidence based way, and, for some at least, the need to modify „the standard? way of doing things to do „what?s best for the patient?. A number of recommendations have been made, some generic and others specific to individual professions. Regulators? expectations of courses in relation to patient 9 safety education should be explicit and regularly reviewed. Educators in all disciplines need to be effective role models who are clear about how to help students to learn about patient safety. All courses should be able to highlight a vertical integrated thread of teaching and learning related to patient safety in their curricula. This should be clear to staff and students. Assessment for this element should also be identifiable as assessment remains important in driving learning. All students need to be enabled to constructively challenge unsafe or non-standard practice. Encounters with patients and learning about their experiences and concerns are helpful in consolidating learning. Further innovative approaches should be developed to make patient safety issues 'real' for students
Testing the Testimonial Concept and Exceptions to Confrontation: “A Little Child Shall Lead Them”
In Crawford v. Washington (2004), the Supreme Court radically transformed the analysis of the Confrontation Clause for hearsay, but left many specific questions unanswered. Two years later in Davis v. Washington (2006), it revisited the subject and answered a few of the unresolved issues, but again left much in doubt, apparently reorienting the focus of the testimonial definition from that of the party making the statement to that of the person receiving it. One of the areas where the new doctrine has greatest potential importance is in cases involving children, particularly cases involving physical and sexual abuse. The importance derives from the fact that hearsay statements to family members, doctors and nurses, forensic investigators, and family members is often critical evidence in the prosecution. Despite the radical change in doctrine, the pattern in the caselaw involving statements by children in the wake of both Crawford and Davis is one largely of continuity in results from those under the discredited analysis of Ohio v. Roberts, which was generally to receive such statements. The one exception is for statements from children to police officers and those closely analogous—where exclusion under Crawford and Davis is now relatively uniform. The most significant development in analysis in recent cases is the focus on the purpose of the questioner, which in many situations simply provides a clearer explanation for an unchanged result. Statements for medical purposes are universally received. This result is buttressed by Davis’s questioner-purpose analysis. However, the nontestimonial treatment, while generally appropriate even for statements of identity during the initial medical assessment, should not, despite a medical label, continue for subsequent examinations where the prosecutorial purpose likely predominates
Can the Heinrich ratio be used to predict harm from medication errors?
The purpose of this study was to establish whether, for medication errors, there exists a fixed Heinrich ratio between the number of incidents which did not result in harm, the number that caused minor harm, and the number that caused serious harm. If this were the case then it would be very useful in estimating any changes in harm following an intervention. Serious harm resulting from medication errors is relatively rare, so it can take a great deal of time and resource to detect a significant change. If the Heinrich ratio exists for medication errors, then it would be possible, and far easier, to measure the much more frequent number of incidents that did not result in harm and the extent to which they changed following an intervention; any reduction in harm could be extrapolated from this
Introducing realist ontology for the representation of adverse events
The goal of the REMINE project is to build a high performance prediction, detection and monitoring platform for managing Risks against Patient Safety (RAPS). Part of the work involves developing in ontology enabling computer-assisted RAPS decision support on the basis of the disease history of a patient as documented in a hospital information system. A requirement of the ontology is to contain a representation for what is commonly referred to by the term 'adverse event', one challenge being that distinct authoritative sources define this term in different and context-dependent ways. The presence of some common ground in all definitions is, however, obvious. Using the analytical principles underlying Basic Formal Ontology and Referent Tracking, both developed in the tradition of philosophical realism, we propose a formal representation of this common ground which combines a reference ontology consisting exclusively of representations of universals and an application ontology which consists representations of defined classes. We argue that what in most cases is referred to by means of the term 'adverse event' - when used generically - is a defined class rather than a universal. In favour of the conception of adverse events as forming a defined class are the arguments that (1) there is no definition for 'adverse event' that carves out a collection of particulars which constitutes the extension of a universal, and (2) the majority of definitions require adverse events to be (variably) the result of some observation, assessment or (absence of) expectation, thereby giving these entities a nominal or epistemological flavour
Addendum to Informatics for Health 2017: Advancing both science and practice
This article presents presentation and poster abstracts that were mistakenly omitted from the original publication
Finding the signal in the noise: Could social media be utilized for early hospital notification of multiple casualty events?
IntroductionDelayed notification and lack of early information hinder timely hospital based activations in large scale multiple casualty events. We hypothesized that Twitter real-time data would produce a unique and reproducible signal within minutes of multiple casualty events and we investigated the timing of the signal compared with other hospital disaster notification mechanisms.MethodsUsing disaster specific search terms, all relevant tweets from the event to 7 days post-event were analyzed for 5 recent US based multiple casualty events (Boston Bombing [BB], SF Plane Crash [SF], Napa Earthquake [NE], Sandy Hook [SH], and Marysville Shooting [MV]). Quantitative and qualitative analysis of tweet utilization were compared across events.ResultsOver 3.8 million tweets were analyzed (SH 1.8 m, BB 1.1m, SF 430k, MV 250k, NE 205k). Peak tweets per min ranged from 209-3326. The mean followers per tweeter ranged from 3382-9992 across events. Retweets were tweeted a mean of 82-564 times per event. Tweets occurred very rapidly for all events (<2 mins) and represented 1% of the total event specific tweets in a median of 13 minutes of the first 911 calls. A 200 tweets/min threshold was reached fastest with NE (2 min), BB (7 min), and SF (18 mins). If this threshold was utilized as a signaling mechanism to place local hospitals on standby for possible large scale events, in all case studies, this signal would have preceded patient arrival. Importantly, this threshold for signaling would also have preceded traditional disaster notification mechanisms in SF, NE, and simultaneous with BB and MV.ConclusionsSocial media data has demonstrated that this mechanism is a powerful, predictable, and potentially important resource for optimizing disaster response. Further investigated is warranted to assess the utility of prospective signally thresholds for hospital based activation
How the Justice System Responds to Juvenile Victims: A Comprehensive Model.
The justice system handles thousands of cases involving juvenile victims each year. These victims are served by a complex set of agencies and institutions, including police, prosecutors, courts, and child protection agencies. Despite the many cases involving juvenile victims and the structure in place for responding to them, the juvenile victim justice system model presented in this Bulletin is a new concept. Although the juvenile victim justice system has a distinct structure and sequence, its operation is not very well understood. Unlike the more familiar juvenile offender justice system, the juvenile victim justice system has not been conceptualized as a whole or implemented by a common set of statutes. This Bulletin identifies the major elements of the juvenile victim justice system by delineating how cases move through the system. It reviews each step in the case flow process for the child protection and criminal justice systems and describes the interaction of the agencies an individuals involved. Recognizing how the juvenile victim justice system works can inform policy decisions and improve outcomes for juvenile victims. Acknowledging the existence of the system has important implications for system integration, information sharing, and data collection—all of which play a key role in ensuring the safety and well-being of juvenile victims
- …