Identifying Risk Factors for Anchoring Bias during Emergency Department Transitions of Care

Transitions of care have been associated with breakdowns in communication and medical errors. In emergency departments (ED) these handoffs are typically known as sign outs. Sign outs provide continuity of care for ED patients whose diagnosis and care fall across shift changes. They are short interactions where pertinent information and responsibility for the patient is transferred to the physician assuming care for them. However, these exchanges may also be an opportunity for cognitive biases to be transferred or introduced, leading to erroneous decision making. Anchoring bias is known to have a significant impact on clinical decision making. Yet, little is known of the factors that increase the risk of anchoring bias during patient diagnoses that involve sign outs. This exploratory research aims to understand how the communication of patient information during sign out influences the clinician’s use the information and develop the patient’s diagnosis and thus identify the factors that contribute to anchoring bias in clinical decision making in the ED. A mixed method approach was used to identify and evaluate potential risk factors for anchoring. Initially a review of a dataset from a medical incident reporting system was conducted to identify potential contributing factors from known cases of medical error. This was followed by an interview study with emergency medicine (EM) physicians to gain their perspectives on peer influence and communication factors between outgoing and oncoming clinicians that might affect sign outs and thus potentially impact decision making. The findings were used to design an experimental evaluation study to assess the impact of potential risk factors identified on diagnostic and treatment planning of EM clinicians. The study was conducted using patient case vignettes as control cases and stimuli cases, which contained these risk factors as test conditions to assess their effect on clinical decision making. The cases were presented in a format simulating sign out communications and the volume of information presented at sign out. Volume of information was represented by the two test conditions of explicitness of the sign out information and the stage in the diagnostic process the case was in at the time of sign out. The study was conducted at two academic hospital ED sites with a total 69 participants. The results indicated that the explicitness of the sign out information had no significant influence on the diagnostic accuracy in stimuli cases or on the confidence of the clinician participants in their diagnosis for the case. However, the stage in the diagnostic process of the case at the point of sign out, did significantly influence both clinicians’ diagnostic accuracy and their confidence in the diagnosis. The earlier stage stimuli cases were associated with lower diagnostic accuracy and lower confidence in the diagnosis. The test condition of explicitness did not have a significant effect on a number of outcome measures whereas the test condition of stage of the case did not. These findings suggest that additional support may be required for during sign out for cases that are in an earlier stage in the diagnostic process at the time of sign out to as they are at higher risk for diagnostic error and for the influence of anchoring bias

Gout : what is its true aetiology?

"Gout" says Duckworth, is a constitutional or diathet is malady, manifest in; . itself in very varied aspects. In its acute forms it usually, but not invari- ably, presents the characters of localised inflammation, accompanied_ by peculiarly intense pain; the inflammation in its course, and the attendant pain, being of a specif:.- ic nature. In its chronic forms there may be no mani- fest inflammatory features, and even no pain. The hiale sex, chiefly in the third decade, is most frequently the subject of the disorder in the acute form, and the articular system not seldom bears the brunt of its inci- de.r..ce . In the earlier manifestations the infla.:. atory trouble seizes eT ecially upon the first joint of the great toe, spreading subsequently to other articulations, and a suppurative stage but very rarely occurs. The digestive system is largely involved, and in the fully developed forms of the malady, hardly any of the viscera or textures are unaffected. The nervous system is likewise specially implicated- whether primarily or not is, as yet, a vexed question.The disorder is either inherited, or newly acáuired. In most of its manifestations it is plainly associated with perturbed relations of uric acid in the economy, and the - inflammatory attacks are accompanied by deposits ofluca.te of sodium, for the most part .in articular cartilages and fibrous structures. A measure of pyrexia commonly forms part of the acuter gouty processes, but profound, though slow, nutritional changes may proceed Quietly in the chronic forms of the malady without any febrile movement".tGoutl, writes Charcot", "is -a chronic and consti- tutional affection, most often hereditary, and always connected with a peculiar dyscrasic state ; for the pres- ence of an excess of uric acid in the blood constitutes one of the principal characters of the disease. It is incontestable that most of'the morbid manifestations which give to gout its peculiar physiognomy arise from this special condition:. this is the case, for example, with regard to the diseased joints But independently of these joint, affections, and of this special state of the blood, gout may give rise to numer- ous and varied visceral affections, sometimes structural, sometimes merely functional. There is even reason to think that, in some cases, rare however, the diathesis merely produces internal troubles of this kind during the whole evolution of the disease, without ever produc- ing those external manifestations on which we are accust- omed to reckon.This is what old writers used to call irregular,as opposed to regular, gout, which corresponds to the classical type of the disease. yet, even in it we come across visceral disturbances; sometimes they appe «'r sud- denly in the midst of an attack (retrocedent gout. ), or in the interval (misplaced gout); sometimes, on the contrary, it is by a slow, progressive, almost latent, development, that those profound organic lesions are formed, which are so often met, with in gouty people. (Chronic Bright's, fatty heart.)."Gout", says Woods Hutchinson, "may be defined as a toxaemia of varying causation, usually of gastro- intestinal origin, accompanied by the formation of an excess of urates, this excess of urates being due to the breaking down of the leucocytes and fixed cells in the attempt to neutralise the poison- in Other words, being the measure of the resisting power of the body tissues.The formation and introduction of the toxins, be it well understood, are, by no means, confined to the gouty; it is only the nature of the resistance of the body to them that gives the character of gout.

A Study Of Role Conflict In The Experience Of The Pastor-Bible Teacher In Seventh-Day Adventist Boarding Academies

Problem The pastor-Bible teacher in the Seventh-day Adventist boarding academy may be confronted with many role conflicts. His dual role as pastor and teacher multiplies the possibilities for conflict. What are some of the conflicts that may affect the pastor- Bible teacher\u27s acceptance, or loss of acceptance, by the students as a shepherd-counselor? Are the conflicts such that the pastor- Bible teacher needs to experience anxiety concerning his dual role? Methods To better understand the problem and discover possible solutions to it, the following steps were taken: 1. A study was made of the nature of role conflict as generally conceived in the literature on role theory with application to the pastor-Bible teacher. 2. A questionnaire was developed and administered to determine the attitudes of students in five selected Seventh-day , Adventist boarding academies with respect to the unique role of the pastor-Bible teacher. 3. Interviews were conducted with adults and students in these same academies to broaden and enrich the data to be studied. 4. The data gathered from the questionnaires and interviews were compiled and studied. Results There was not always fundamental agreement among the adults as to the role of the pastor-Bible teacher and how that role is affected by his function as a disciplinarian, giver of grades, and his connection with the school. The study indicated that the majority of the students perceive the pastor-Bible teacher as an effective and acceptable pastor-preacher of the Word and that his spiritual effectiveness is not lessened by involvement in discipline, the giving of grades, or Bible teaching during the week. The students did not rate the pastor-Bible teacher very high as a counselor whether a member of the discipline committee or not in the situations used for this study. Moreover, the other counselor-types, with the exception of the dormitory dean, were not rated very high either. Conclusions The conflict of the pastor-Bible teacher in his dual role may often grow out of his perception and anxiety with respect to how the students relate to him because of his involvement in discipline, the giving of grades, his preaching ministry, and his relationship to the institution. The findings in this study show that the attitude of the students toward the pastor-Bible teacher is not adversely affected by such involvement. Further study is recommended concerning the pastor-Bible teacher as a counselor with special emphasis on the effect of personality as a determiner of acceptance. Since the relationship and rapport between the pastor- Bible teacher and the majority of the students was found to be very good in all areas investigated in this study, the writer seriously questions that pastor-Bible teacher-student relationships are a major cause of drop out for the pastor-Bible teacher. Further study to determine the causes of the high drop-out rate is recommended with the suggestion that parent-teacher and board-teacher relationships be studied

The Montclarion, January 21, 1999

Student Newspaper of Montclair State Universityhttps://digitalcommons.montclair.edu/montclarion/1833/thumbnail.jp

Aircraft system-level diagnosis with emphasis on maintenance decisions

This paper proposes a diagnostic technique that can predict component degradation for a number of complex systems. It improves and clarifies the capabilities of a previously proposed diagnostic approach, by identifying the degradation severity of the examined components, and uses a 3D Principal Component Analysis approach to provide an explanation for the observed diagnostic accuracy. The diagnostic results are then used, in a systematic way, to influence maintenance decisions. Having been developed for the Auxiliary Power Unit (APU), the flexibility and power of the diagnostic methodology is shown by applying it to a completely new system, the Environmental Control System (ECS). A major conclusion of this work is that the proposed diagnostic approach is able to correctly predict the health state of two aircraft systems, and potentially many more, even in cases where different fault combinations result in similar fault patterns. Based on the engineering simulation approach verified here, a diagnostic methodology suitable from aircraft conception to retirement is proposed

How to End Our Stories: A Study of the Perspectives of Seniors on Dementia and Decision-Making

Because dementia can cause individuals to make decisions that they otherwise would not, the law needs a mechanism to determine which decisions are entitled to the respect of the legal system and which may be overridden by others. In the philosophical literature, three primary theories for how to make this determination have been offered. First, Cognitivism posits that whether a decision should be recognized is a function of the mechanical functioning of the individual\u27s brain at the time the decision is made. Second, Essentialism holds that decisions should be recognized so long as they are consistent with the cluster of values and attributes that define the individual. Third, Narrativism argues that decisions should be respected where they follow from the life story of the individual making them.In the growing tradition of experimental philosophy, this Article empirically analyzes support for these three alternative theories in a mixed-methods study involving a population of American seniors, including an online survey (n=235) and interviews (n=25). Close analysis of the results revealed a near-consensus that Narrativism is the theoretical framework through which participants understood the question of when the legal system should intervene in private decision-making. In short, participants wanted the legal capacity to make decisions taken from them only when dementia became so advanced that they would no longer be the same person they previously had been, which they understood as a question of narrative continuity

Current based condition monitoring of electromechanical systems. Model-free drive system current monitoring: faults detection and diagnosis through statistical features extraction and support vector machines classification.

A non-invasive, on-line method for detection of mechanical (rotor, bearings eccentricity) and stator winding faults in a 3-phase induction motors from observation of motor line current supply input. The main aim is to avoid the consequence of unexpected failure of critical equipment which results in extended process shutdown, costly machinery repair, and health and safety problems. This thesis looks into the possibility of utilizing machine learning techniques in the field of condition monitoring of electromechanical systems. Induction motors are chosen as an example for such application. Electrical motors play a vital role in our everyday life. Induction motors are kept in operation through monitoring its condition in a continuous manner in order to minimise their off times. The author proposes a model free sensor-less monitoring system, where the only monitored signal is the input to the induction motor. The thesis considers different methods available in literature for condition monitoring of induction motors and adopts a simple solution that is based on monitoring of the motor current. The method proposed use the feature extraction and Support Vector Machines (SVM) to set the limits for healthy and faulty data based on the statistical methods. After an extensive overview of the related literature and studies, the motor which is the virtual sensor in the drive system is analysed by considering its construction and principle of operation. The mathematical model of the motor is used for analysing the system. This is followed by laboratory testing of healthy motors and comparing their output signals with those of the same motors after being intentionally failed, concluding with the development of a full monitoring system. Finally, a monitoring system is proposed that can detect the presence of a fault in the monitored machine and diagnose the fault type and severityMinistry of Higher Education, Libya; Switchgear & Instruments Ltd

A school-based group counseling cirriculum for adolescent girls experiencing low self-esteem

Master's Project (M.Ed.) University of Alaska Fairbanks, 2017This project reviews the existing literature on adolescent development in females, and demonstrates the importance of school counselors facilitating small group counseling with students who experience low self-esteem. Although research suggests social-emotional development begins in childhood, and the American School Counselor Association requires a social-emotional component to school counseling programs, there are few resources available to secondary school counselors who see a need for an effective group counseling curriculum for females with low self-esteem. This project aims to provide secondary school counselors with such a curriculum