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

Metamorphism and metasomatism around the Shap and Eskdale granites

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Prevention of poultry disease

"An adequate disease prevention program is essential to the profitable production of commercial poultry. While a disease outbreak that wipes out an entire flock of birds is obviously costly, chronic disease can also reduce production efficiency and increase production costs. Although a disease prevention program may not show immediate returns for the investment, it will be profitable in the long run."--First page.J.D. Firman (Department of Animal Science, College of Agriculture)New 7/87/4

Tinjauan Yuridis Mengenai Tindak Pidana Penangkapan Ikan Dengan Bahan Kimia Di Wilayah Zee Indonesia (UU No. 31 Tahun 2004 Jo UU No. 45 Tahun 2009)

Tujuan dilakukannya penelitian ini adalah untuk mengetahui bagaimana bentuk tindak pidana penangkapan ikan di wilayah ZEE Indonesia dan bagaimana upaya penegakan hukum terhadap tindak pidana penangkapan ikan dengan bahan kimia menurut Undang-Undang No. 45 Tahun 2009 Perubahan dari Undang-Undang No. 31 Tahun 2004 di wilayah ZEE Indonesia. Dengan menggunakan metode penelitian yuridis normative, maka dapat disimpulkan: 1. Berdasarkan Undang-undang No. 31 Tahun 2004 jo UU No. 45 Tahun 2009, bentuk tindak pidana perikanan di wilayah ZEE Indonesia dapat digolongkan sebagai: -Tindak pidana yang menyangkut penggunaan bahan yang dapat membahayakan kelestarian sumber daya ikan dan lingkungannya, Tindak pidana sengaja menggunakan alat penangkap ikan yang mengganggu dan merusak sumber daya ikan di kapal perikanan. -Tindak pidana yang berkaitan dengan pencemaran / kerusakan sumber daya ikan / lingkungannya. -Tindak pidana yang berkaitan dengan melakukan USAha perikanan tanpa SIUP. -Tindak pidana melakukan penangkapan ikan tanpa memiliki SIPI. -Tindak pidana melakukan pengangkutan ikan tanpa memiliki SIKPI. -Tindak pidana memalsukan SIUP, SIPI, dan SIKPI. -Tindak pidana yang berkaitan dengan pengoperasian kapal perikanan asing. -Tindak pidana tanpa memiliki surat persetujuan berlayar, Tindak pidana melakukan penelitian tanpa izin pemerintah. -Tindak pidana melakukan USAha pengelolaan perikanan yang tidak memenuhi ketentuan yang ditetapkan UU Perikanan. 2. Kegiatan tindak pidana penangkapan ikan telah memberikan banyak kerugian bagi Negara sehingga pemerintah Indonesia melalui Kementerian Kelautan dan Perikanan melakukan upaya penegakan hukum yang di dasari oleh Undang-Undang Nomor 31 Tahun 2004 tentang perikanan jo, Undang-Undang Nomor 45 Tahun 2009 telah memberikan landasan hukum yang kuat, sehingga melalui kerja sama antara TNI AL, Polisi Air, BAKAMLA, TNI AU, dan PPNS dapat mengurangi tindak pidana perikanan di wilayah perairan Indonesia

Is child weight status correctly reported to parents? Cross-sectional analysis of National Child Measurement Programme data using ethnic-specific BMI adjustments.

BACKGROUND: BMI underestimates and overestimates body fat in children from South Asian and Black ethnic groups, respectively. METHODS: We used cross-sectional NCMP data (2015-17) for 38 270 children in three inner-London local authorities: City & Hackney, Newham and Tower Hamlets (41% South Asian, 18.8% Black): 20 439 4-5 year-olds (48.9% girls) and 17 831 10-11 year-olds (49.1% girls). We estimated the proportion of parents who would have received different information about their child's weight status, and the area-level prevalence of obesity-defined as ≥98th centile-had ethnic-specific BMI adjustments been employed in the English National Child Measurement Programme (NCMP). RESULTS: Had ethnic-specific adjustment been employed, 19.7% (3112/15 830) of parents of children from South Asian backgrounds would have been informed that their child was in a heavier weight category, and 19.1% (1381/7217) of parents of children from Black backgrounds would have been informed that their child was in a lighter weight category. Ethnic-specific adjustment increased obesity prevalence from 7.9% (95% CI: 7.6, 8.3) to 9.1% (8.7, 9.5) amongst 4-5 year-olds and from 17.5% (16.9, 18.1) to 18.8% (18.2, 19.4) amongst 10-11 year-olds. CONCLUSIONS: Ethnic-specific adjustment in the NCMP would ensure equitable categorization of weight status, provide correct information to parents and support local service provision for families

TINJAUAN YURIDIS MENGENAI TINDAK PIDANA PENANGKAPAN IKAN DENGAN BAHAN KIMIA DI WILAYAH ZEE INDONESIA (UU NO. 31 TAHUN 2004 jo UU NO. 45 TAHUN 2009)

Tujuan dilakukannya penelitian ini adalah untuk mengetahui bagaimana bentuk tindak pidana penangkapan ikan di wilayah ZEE Indonesia dan bagaimana upaya penegakan hukum terhadap tindak  pidana penangkapan ikan dengan bahan kimia menurut Undang-Undang No. 45 Tahun 2009 perubahan dari Undang-Undang No. 31 Tahun 2004 di wilayah ZEE Indonesia.  Dengan menggunakan metode penelitian yuridis normative, maka dapat disimpulkan: 1. Berdasarkan Undang-undang No. 31 Tahun 2004 jo UU No. 45 Tahun 2009, bentuk tindak pidana perikanan di wilayah ZEE Indonesia dapat digolongkan sebagai: -Tindak pidana yang menyangkut penggunaan bahan yang dapat membahayakan kelestarian sumber daya ikan dan lingkungannya,  Tindak pidana sengaja menggunakan alat penangkap ikan yang mengganggu dan merusak sumber daya ikan di kapal perikanan. -Tindak pidana yang berkaitan dengan pencemaran / kerusakan sumber daya ikan / lingkungannya. -Tindak pidana yang berkaitan dengan melakukan usaha perikanan tanpa SIUP. -Tindak pidana melakukan penangkapan ikan tanpa memiliki SIPI. -Tindak pidana melakukan pengangkutan ikan tanpa memiliki SIKPI. -Tindak pidana memalsukan SIUP, SIPI, dan SIKPI. -Tindak pidana yang berkaitan dengan pengoperasian kapal perikanan asing. -Tindak pidana tanpa memiliki surat persetujuan berlayar, Tindak pidana melakukan penelitian tanpa izin pemerintah. -Tindak pidana melakukan usaha pengelolaan perikanan yang tidak memenuhi ketentuan yang ditetapkan UU Perikanan. 2. Kegiatan tindak pidana penangkapan ikan telah memberikan banyak kerugian bagi Negara sehingga pemerintah Indonesia melalui Kementerian Kelautan dan Perikanan melakukan upaya penegakan hukum yang di dasari oleh Undang-Undang Nomor 31 Tahun 2004 tentang perikanan jo, Undang-Undang Nomor 45 Tahun 2009 telah memberikan landasan hukum yang kuat, sehingga melalui kerja sama antara TNI AL, Polisi Air, BAKAMLA, TNI AU, dan PPNS dapat mengurangi tindak pidana perikanan di wilayah perairan Indonesia. Kata kunci: Penangkapan ikan, bahan kimia

KARAKTERISTIK ALIRAN FLUIDA PADA WASTEWATER PIT DENGAN BERBAGAI TIPE SIRIP RODA AIR

KARAKTERISTIK ALIRAN FLUIDA PADA WASTEWATER PIT DENGAN BERBAGAI TIPE SIRIP RODA AI