460 research outputs found
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
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
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