Blame--Do You Know It When You See It?

The landmark Institute of Medicine Report, To Err Is Human: Building a Safer Health Care System. stated that medical error causes 44,000 to 98,000 deaths per year. There is no question that the report raised awareness of patient safety and stressed the importance of patient outcomes. Heightened awareness has produced a patient safety industry of sorts, with solutions that range from technology to outcomes measurement. Regulatory bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have recognized the need for patient safety to be embedded in the culture of healthcare organizations. In particular, the JCAHO has encouraged use of the root cause analysis process for investigating near miss and adverse events. This process emphasizes learning from system analysis over assigning individual blame, an approach used successfully in such high reliability organizations as the aviation industry and the military. Many healthcare organizations have formulated nonpunitive reporting policies to encourage error reporting and to identify systems issues. This article discusses the importance of a work complexity and human factors focus, how blame will continue to surface as patient safety efforts are implemented, and implications for outcomes management

Lessons Learned: Nurses’ Experiences with Errors in Nursing

Background Health care organizations seek to maximize the reporting of medical errors to improve patient safety. Purpose This study explored licensed nurses' decision-making with regard to reporting medical errors. Methods Grounded theory methods guided the study. Thirty nurses from adult intensive care units were interviewed, and qualitative analysis was used to develop a theoretical framework based on their narratives. Discussion The theoretical model was titled “Learning Lessons from the Error.” The concept of learning lessons was central to the theoretical model. The model included five stages: Being Off-Kilter, Living the Error, Reporting or Telling About the Error, Living the Aftermath, and Lurking in Your Mind. Conclusion This study illuminates the unique experiences of licensed nurses who have made medical errors. The findings can inform initiatives to improve error reporting and to support nurses who have made errors

Operation of an Animal Blood Bank

FOLLOWING the work of Belenki, Shamov and Yudin, many investigators have demonstrated the advantages of having preserved blood readily available for immediate use. Veterinary clinicians have long recognized the value of transfused blood in the treatment of various conditions, but because of the frequent lack of available donors and the time consumed in preparing for the operation the technique has not been widely employed. With these difficulties in mind a group of senior veterinary students at the College of Veterinary Medicine, State College of Washington, under the direction of Dr. J. E. McCoy, inaugurated an animal blood bank in 1941. This animal blood bank, the first of its kind to our knowledge, has been in operation since that time

The Power of Collaboration With Patient Safety Programs: Building Safe Passage for Patients, Nurses, and Clinical Staff

Patient safety is a relatively new field, with many opinions and few effectively proven approaches. One factor is clear: optimal patient safety outcomes cannot be achieved in isolation. Although it is well recognized that multidisciplinary collaboration in the healthcare setting is necessary to effect patient safety, collaboration with resources external to healthcare-academia and industry in particular-will not only aid but also quicken the patient safety efforts. The authors outline a healthcare system\u27s use of all available resources to build a patient safety program

“Anybody on this list that you're more worried about?” Qualitative analysis exploring the functions of questions during end of shift handoffs

Background Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood. Objective To investigate questions and the functions they serve in nursing and medicine handoffs. Research design Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs. Subjects Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center. Results Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals. Conclusions Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created

Abortive initiation and productive initiation by RNA polymerase involve DNA scrunching

Using single-molecule DNA nanomanipulation, we show that abortive initiation involves DNA "scrunching"-in which RNA polymerase (RNAP) remains stationary and unwinds and pulls downstream DNA into itself-and that scrunching requires RNA synthesis and depends on RNA length. We show further that promoter escape involves scrunching, and that scrunching occurs in most or all instances of promoter escape. Our results support the existence of an obligatory stressed intermediate, with approximately one turn of additional DNA unwinding, in escape and are consistent with the proposal that stress in this intermediate provides the driving force to break RNAP-promoter and RNAP-initiation-factor interactions in escape

Nonradioactive, ultrasensitive site-specific protein–protein photocrosslinking: interactions of α-helix 2 of TATA-binding protein with general transcription factor TFIIA and transcriptional repressor NC2

We have developed an approach that enables nonradioactive, ultrasensitive (attamole sensitivity) site-specific protein–protein photocrosslinking, and we have applied the approach to the analysis of interactions of α-helix 2 (H2) of human TATA-element binding protein (TBP) with general transcription factor TFIIA and transcriptional repressor NC2. We have found that TBP H2 can be crosslinked to TFIIA in the TFIIA–TBP–DNA complex and in higher order transcription–initiation complexes, and we have mapped the crosslink to the ‘connector’ region of the TFIIA α/β subunit (TFIIAα/β). We further have found that TBP H2 can be crosslinked to NC2 in the NC2–TBP–DNA complex, and we have mapped the crosslink to the C-terminal ‘tail’ of the NC2 α-subunit (NC2α). Interactions of TBP H2 with the TFIIAα/β connector and the NC2α C-terminal tail were not observed in crystal structures of TFIIA–TBP–DNA and NC2–TBP–DNA complexes, since relevant segments of TFIIA and NC2 were not present in truncated TFIIA and NC2 derivatives used for crystallization. We propose that interactions of TBP H2 with the TFIIAα/β connector and the NC2α C-terminal tail provide an explanation for genetic results suggesting importance of TBP H2 in TBP–TFIIA interactions and TBP–NC2 interactions, and provide an explanation—steric exclusion—for competition between TFIIA and NC2

Emerging Infectious Diseases in Mongolia

Since 1990, Mongolia’s health system has been in transition. Impressive gains have been accomplished through a national immunization program, which was instituted in 1991. Nevertheless, the country continues to confront four major chronic infections: hepatitis B and C, brucellosis, tuberculosis, and sexually transmitted diseases (STDs). As of 2001, only two cases of HIV infections had been detected in Mongolia, but concern grows that the rate will increase along with the rising rates of STDs and increase in tourism. Other infectious diseases of importance in Mongolia include echinococcus, plague, tularemia, anthrax, foot-and-mouth, and rabies

Design, construction and characterization of a set of insulated bacterial promoters

We have generated a series of variable-strength, constitutive, bacterial promoters that act predictably in different sequence contexts, span two orders of magnitude in strength and contain convenient sites for cloning and the introduction of downstream open-reading frames. Importantly, their design insulates these promoters from the stimulatory or repressive effects of many 5′- or 3′-sequence elements. We show that different promoters from our library produce constant relative levels of two different proteins in multiple genetic contexts. This set of promoters should be a useful resource for the synthetic-biology community