Improving Root Cause Analysis Methods to Analyze Serious Safety Events in Healthcare

Root Cause Analysis (RCA) is a process for identifying the causes underlying deviations, adverse events, serious safety events and sentinel events. All healthcare organizations conduct some level of Root Cause Analysis after an adverse event has occurred. There are varying models, tools and techniques that can be used for a Root Cause Analysis. My organization has identified that we have an opportunity to update our policies, procedures and practices in order to create a more robust process for reviewing patient safety events. Improving the Root Cause Analysis process will allow us to flush out the underlying causes of an event and develop solutions that will prevent future harm, problems or other defects. Conducting a more thorough root cause analysis will ensure we continue to offer the best care possible to our patients, families and staff

Staying Neutral: How Washington State Courts Should Approach Negligent Supervision Claims Against Religious Organizations

The torts of negligent hiring, supervision, and retention place a duty on employers to prevent their employees from using the places, things, or tasks entrusted to them to harm foreseeable victims. The negligent employment torts create an independent duty under which plaintiffs may pursue an action when suits brought under a vicarious liability or breach of fiduciary duty theory would fail. For victims of sexual misconduct by religious leaders, negligent supervision claims against religious organizations are a crucial means of remedying serious and lasting injuries. Washington state law recognizes negligent supervision, and Washington courts have applied it to religious organizations, but these claims typically implicate First Amendment religious freedom concerns. A short series of Washington appellate cases affirming grants of summary judgment to religious organization defendants on First Amendment grounds has made it more difficult for plaintiffs to assert negligent supervision claims against religious entities. This Comment argues that Washington courts have granted religious organizations an impermissibly broad level of First Amendment protection from claims of negligent supervision, and suggests a more deliberate analytical framework for evaluating the constitutionality of such claims

Opening Our Eyes : How film contributes to the culture of the UK

Opening our eyes looks at how films are consumed and the factors which affect people’s viewing choices. It also covers the relationships audiences report between film and other activities. It goes on to explore the sorts of effects which film has upon people, their sense of identity and relationship with the world. Finally it looks at the various effects which individual films have had on those surveyed and reaches a number of conclusions.Final Published versio

Moving Toward a Collective Impact Effort: The Volunteer Program Assessment

Volunteers are essential to the operation of many nonprofits, but some experience challenges in retaining their volunteer workforce. The Volunteer Program Assessment (VPA) seeks to address this issue by helping organizations to identify strengths, growth areas, and recommendations for improving volunteer experiences. To maximize the effectiveness of VPA’s mission, the organization is moving toward a collective impact (CI) approach. Although not developed as a CI effort, the program currently exemplifies many of its characteristics, which have been instrumental in expanding reach to more organizations. We examine VPA’s alignment with collective impact and outline how VPA will continue to improve efforts

Collective Impact Strategies: Introduction to the Special Issue

The societal and cultural issues facing humanity are far greater than any nonprofit, for-profit, university, or government agency to address adequately alone. Whether poverty, water shortages, socio-economic inequality, natural disasters with lasting effects, or any number of other challenges facing our communities, organizations must band together to secure the impact needed to truly create change. Increasingly, communities are turning to collective impact as an approach that brings together the collective resources of multiple institutions to address a community-identified problem or need. While a somewhat new approach, there is a growing body of evidence of supporting the effectiveness of using the collective impact approach to addressing wicked problems (Bridgeland et al., 2012; Christens & Inzeo, 2015; Kania, Hanleybrown, & Splansky Juster, 2014). As anchor institutions, Metropolitan Universities have a unique opportunity and responsibility to initiate and promote social change in a way that also advances their mission. Unlike other institutions for higher education, Metropolitan Universities are most suited for targeting social change because of the type of communities they serve and their location within large municipalities. Participating in collective impact is increasingly seen as one approach to this. This issue includes case studies and practical papers to prepare Metropolitan University administrators, faculty, and staff to initiate, facilitate, and strengthen collective impact initiatives in their communities

Quantifying the 2.5D imaging performance of digital holographic systems

Digital holographic systems are a class of two step, opto-numerical, three-dimensional imaging techniques. The role of the digital camera in limiting the resolution and field of view of the reconstructed image, and the interaction of these limits with a general optical system is poorly understood. The linear canonical transform describes any optical system consisting of lenses and/or free space in a unified manner. Expressions derived using it are parametrised in terms of the parameters of the optical system, as well as those of the digital camera: aperture size, pixel size and pixel pitch. We develop rules of thumb for selecting an optical system to minimise mean squared error for given input and digital camera parameters. In the limit, our results constitute a point spread function analysis. The results presented in this paper will allow digital holography practitioners to select an optical system to maximise the quality of their reconstructed image using a priori knowledge of the camera and object

Microfiber release from real soiled consumer laundry and the impact of fabric care products and washing conditions

Fiber release during domestic textile washing is a cause of marine microplastic pollution, but better understanding of the magnitude of the issue and role of fabric care products, appliances and washing cycles is needed. Soiled consumer wash loads from U.K. households were found to release a mean of 114 ± 66.8 ppm (mg microfiber per kg fabric) (n = 79) fibers during typical washing conditions and these were mainly composed of natural fibers. Microfiber release decreased with increasing wash load size and hence decreasing water to fabric ratio, with mean microfiber release from wash loads in the mass range 1.0–3.5 kg (n = 57) found to be 132.4 ± 68.6 ppm, significantly (p = 3.3 x 10−8) higher than the 66.3 ± 27.0 ppm of those in the 3.5–6.0 kg range (n = 22). In further tests with similar soiled consumer wash loads, moving to colder and quicker washing cycles (i.e. 15°C for 30 mins, as opposed to 40°C for 85 mins) significantly reduced microfiber generation by 30% (p = 0.036) and reduced whiteness loss by 42% (p = 0.000) through reduced dye transfer and soil re-deposition, compared to conventional 40°C cycles. In multicycle technical testing, detergent pods were selected for investigation and found to have no impact on microfiber release compared to washing in water alone. Fabric softeners were also found to have no direct impact on microfiber release in testing under both European and North American washing conditions. Extended testing of polyester fleece garments up to a 48-wash cycle history under European conditions found that microfiber release significantly reduced to a consistent low level of 28.7 ± 10.9 ppm from eight through 64 washes. Emerging North American High-Efficiency top-loading washing machines generated significantly lower microfiber release than traditional top-loading machines, likely due to their lower water fill volumes and hence lower water to fabric ratio, with a 69.7% reduction observed for polyester fleece (n = 32, p = 7.9 x 10−6) and 37.4% reduction for polyester T-shirt (n = 32, p = 0.0032). These results conclude that consumers can directly reduce the levels of microfibers generated per wash during domestic textile washing by using colder and quicker wash cycles, washing complete (but not overfilled) loads, and (in North America) converting to High-Efficiency washing machines. Moving to colder and quicker cycles will also indirectly reduce microfiber release by extending the lifetime of clothing, leading to fewer new garments being purchased and hence lower incidence of the high microfiber release occurring during the first few washes of a new item

Socioeconomic Disparities in Academic Achievement: A Multi-Modal Investigation of Neural Mechanisms in Children and Adolescents

Growing evidence suggests that childhood socioeconomic status (SES) influences neural development, which may contribute to the well-documented SES-related disparities in academic achievement. However, the particular aspects of SES that impact neural structure and function are not well understood. Here, we investigate associations of childhood SES and a potential mechanism—degree of cognitive stimulation in the home environment—with cortical structure, white matter microstructure, and neural function during a working memory (WM) task across development. Analyses included 53 youths (age 6–19 years). Higher SES as reflected in the income-to-needs ratio was associated with higher parent-reported achievement, WM performance, and cognitive stimulation in the home environment. Although SES was not significantly associated with cortical thickness, children raised in more cognitively stimulating environments had thicker cortex in the frontoparietal network and cognitive stimulation mediated the assocation between SES and cortical thickness in the frontoparietal network. Higher family SES was associated with white matter microstructure and neural activation in the frontoparietal network during a WM task, including greater fractional anisotropy (FA) in the right and left superior longitudinal fasciculi (SLF), and greater BOLD activation in multiple regions of the prefrontal cortex during WM encoding and maintenance. Greater FA and activation in these regions was associated higher parent-reported achievement. Together, cognitive stimulation, WM performance, FA in the SLF, and prefrontal activation during WM encoding and maintenance significantly mediated the association between SES and parent-reported achievement. These findings highlight potential neural, cognitive, and environmental mechanisms linking SES with academic achievement and suggest that enhancing cognitive stimulation in the home environment might be one effective strategy for reducing SES-related disparities in academic outcomes

First order statistical properties of simulated speckle fields

Publikation entstand im Rahmen der Veranstaltung: Photonics Ireland 2011, 7th – 9th September 2011, Malahide, Dublin