Using risk appetite and risk attitude to support appropriate risk-taking: a new taxonomy and model

The term ‘risk appetite’ is used widely and increasingly, but there is no commonly accepted definition for it. This situation is exacerbated by confusion between risk appetite and other risk-related terms, especially risk attitude. This paper offers a consistent and coherent taxonomy of these terms, showing how they relate to one another. This allows development of a rich model to explain the complementary and central roles of both risk appetite and risk attitude when individuals or organisations decide how much risk can be taken in a risky and important situation. By progressively deconstructing the full model, we conclude that the key step is to set risk thresholds. We derive a three-stage approach to setting risk thresholds that ensures that the outcomes properly reflect organisational risk culture and the individual risk propensities of key stakeholders, and also clarifies the essential role of risk attitude as a control point. This enables individuals and organisations to choose the appropriate risk attitude in order to influence the amount of risk that is taken in any given situation, so that the achievement of objectives is optimised

Risk management reconceived: reconciling economic rationality with behavioural tendencies

Risk management practices as described in many leading texts feel counterintuitive to many practitioners and are frequently ignored, despite their being evidently logical and potentially valuable. Such practices are often conceived as a remedial post-planning, audit activity. This paper proposes an approach for dealing with project uncertainty and risk, grounded in economics and taking into account behavioural biases and heuristics. The proposed approach is argued to be an enhancement to conventional risk management practices and one that can serve organisations better while also aligning to experienced practitioners’ intuitive approaches. In particular, we argue: that the focus should be on adding economic value rather than reducing risk per se; that opportunity gain/loss is a superior metric for gauging potential impacts of risky events; and that creation of real options should be emphasised as part of the repertoire of generic response actions to risk. The approach also supports the integration and handling of uncertainty and risk as part of holistic project planning and control

Skin preparation with alcohol versus alcohol followed by any antiseptic for preventing bacteraemia or contamination of blood for transfusion (Review)

Background: Blood for transfusion may become contaminated at any point between collection and transfusion and may result in bacteraemia (the presence of bacteria in the blood), severe illness or even death for the blood recipient. Donor arm skin is one potential source of blood contamination, so it is usual to cleanse the skin with an antiseptic before blood donation. One-step and two-step alcohol based antiseptic regimens are both commonly advocated but there is uncertainty as to which is most effective. Objectives: To assess the effects of cleansing the skin of blood donors with alcohol in a one-step compared with alcohol in a two-step procedure to prevent contamination of collected blood or bacteraemia in the recipient. Search methods: In December 2014, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. Selection criteria: All randomised trials (RCTs) comparing alcohol based donor skin cleansing in a one-step versus a two-step process that includes alcohol and any other antiseptic for pre-venepuncture skin cleansing were considered. Quasi randomised trials were to have been considered in the absence of RCTs. Data collection and analysis: Two review authors independently assessed studies for inclusion. Main results: No studies (RCTs or quasi RCTs) met the inclusion criteria. Authors' conclusions: We did not identify any eligible studies for inclusion in this review. It is therefore unclear whether a two-step, alcohol followed by antiseptic skin cleansing process prior to blood donation confers any reduction in the risk of blood contamination or bacteraemia in blood recipients, or conversely whether a one-step process increases risk above that associated with a two-step process

What does it take for organizations to change themselves? The influences on the internal dynamics of organizational routines undergoing planned change

Accomplishing desired benefits from investments in planned change is problematical for organizations, their leaders and the change agents charged with delivery. This is despite a well-developed literature, replete with advice on how change should be achieved. Examination of this literature shows the primary focus on change agents and their practices. This research widens the focus by observing the influence of change agents, change recipients and line managers on organizational routines undergoing planned change. It examines the interplay between stability and change in organizational routines, adopting a social practice perspective, and the routine intended to change as the unit of analysis (Feldman and Pentland, 2003, 2005). The research builds on claims that to understand the patterns of action within routines requires the internal dynamics – the claimed duality between ostensive (in principle) and performative (in practice) aspects - to be examined. A research method to operationalize the study of this claimed duality was devised following the principles of Strong Structuration (Stones, 2005). This method enabled a unique conceptualization of the study of routine dynamics, focused on planned change from the perspective of multiple, interdependent actors. Two cases of change agents following the advice in the planned change literature were explored. In one case, stability of the routine persisted when change was intended. In the other, change was relatively easy to achieve irrespective of change agent actions. The primary contribution is the demonstration of how the attitudes to change of change recipients, line managers and change agents influence the internal dynamics of routines undergoing planned change. Other contributions pertain to the method of ‘unpacking’ organizational routines and its potential for shaping future practice. This research does not offer new ‘normative’ advice but instead sensitizes planned change practitioners to the level of analysis they need to carry out to ensure that their interventions are suitably designed

An integrated general practice and pharmacy-based intervention to promote the use of appropriate preventive medications among individuals at high cardiovascular disease risk: protocol for a cluster randomized controlled trial

Background: Cardiovascular diseases (CVD) are responsible for significant morbidity, premature mortality, and economic burden. Despite established evidence that supports the use of preventive medications among patients at high CVD risk, treatment gaps remain. Building on prior evidence and a theoretical framework, a complex intervention has been designed to address these gaps among high-risk, under-treated patients in the Australian primary care setting. This intervention comprises a general practice quality improvement tool incorporating clinical decision support and audit/feedback capabilities; availability of a range of CVD polypills (fixed-dose combinations of two blood pressure lowering agents, a statin ± aspirin) for prescription when appropriate; and access to a pharmacy-based program to support long-term medication adherence and lifestyle modification. Methods: Following a systematic development process, the intervention will be evaluated in a pragmatic cluster randomized controlled trial including 70 general practices for a median period of 18 months. The 35 general practices in the intervention group will work with a nominated partner pharmacy, whereas those in the control group will provide usual care without access to the intervention tools. The primary outcome is the proportion of patients at high CVD risk who were inadequately treated at baseline who achieve target blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels at the study end. The outcomes will be analyzed using data from electronic medical records, utilizing a validated extraction tool. Detailed process and economic evaluations will also be performed. Discussion: The study intends to establish evidence about an intervention that combines technological innovation with team collaboration between patients, pharmacists, and general practitioners (GPs) for CVD prevention. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN1261600023342

Perceptions of risk: understanding cardiovascular disease

Cardiovascular disease (CVD) is still the leading cause of death and disability worldwide despite the availability of well-established and effective preventive options. Accurate perception of a patient’s risk by both the patient and the doctors is important as this is one of the components that determine health-related behavior. Doctors tend to not use cardiovascular (CV) risk calculators and underestimate the absolute CV risk of their patients. Patients show optimistic bias when considering their own risk and consistently underestimate it. Poor patient health literacy and numeracy must be considered when thinking about this problem. Patients must possess a reasonably high level of understanding of numerical processes when doctors discuss risk, a level that is not possessed by large numbers of the population. In order to overcome this barrier, doctors need to utilize various tools including the appropriate use of visual aids to accurately communicate risk with their patients. Any intervention has been shown to be better than nothing in improving health understanding. The simple process of repeatedly conveying risk information to a patient has been shown to improve accuracy of risk perception. Doctors need to take responsibility for the accurate assessment and effective communication of CV risk in their patients in order to improve patient uptake of cardioprotective lifestyle choices and preventive medications

3-D Photoionization Structure and Distances of Planetary Nebulae II. Menzel 1

We present the results of a spatio-kinematic study of the planetary nebula Menzel 1 using spectro-photometric mapping and a 3-D photoionization code. We create several 2-D emission line images from our long-slit spectra, and use these to derive the line fluxes for 15 lines, the Halpha/Hbeta extinction map, and the [SII] line ratio density map of the nebula. We use our photoionization code constrained by these data to derive the three-dimensional nebular structure and ionizing star parameters of Menzel 1 by simultaneously fitting the integrated line intensities, the density map, and the observed morphologies in several lines, as well as the velocity structure. Using theoretical evolutionary tracks of intermediate and low mass stars, we derive a mass for the central star of 0.63+-0.05 Msolar. We also derive a distance of 1050+_150 pc to Menzel 1.Comment: To be published in ApJ of 10th February 2005. 12 figure