The role of incident reporting in continuous quality improvement in the intensive care setting

Publisher's copy made available with the permission of the publisherU. Beckman, W.B. Runcimanhttp://www.aaic.net.au/Article.asp?D=199606

The Australian Incident Monitoring Study in intensive care: AIMS-ICU. An analysis of the first year of reporting.

Publisher's copy made available with the permission of the publisher Copyright © 1996 Australian Society of AnaesthetistsThe AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined “clinical situations”.U. Beckmann, I. Baldwin, G.K. Hart, W.B. Runcima

Study of storm weather situations in observation and ECHAM3/T42 model simulation

In this paper, we provide an estimation of the seasonal distribution of strong wind and storm weather situations in an ECHAM3/T42 climate model simulation in relation to observed conditions. Observational data of the German Eight and the southern Baltic Sea are taken to compare observations and climate model simulation. The results of the study show significant differences in the seasonal Frequency of occurrence for strong wind and storm weather situations between simulation and observations. A new objective classification routine for detecting single strong wind and storm weather situations (Bft 7 and more) in coarse resolution models is used to validate the large-scale parameters of those events in the climate simulation. The objective classification routine is able to detect strong wind and storm weather situations of two flow regimes in the German Eight in winter. The routine is applied to the ECMWF Re-Analysis (T42 resolution) and to a climate simulation of the northern Hemisphere, which was performed with the ECHAM3/T42. It is shown that the large-scale parameters of single strong wind and storm weather situations are simulated quire realistically in the ECHAM3/T42

The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care

Publisher's copy made available with the permission of the publisher © 1996 Australian Society of AnaesthetistsIntensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.U. Beckman, L.F. West, G.J. Groombridge, I. Baldwin, G.K. Hart, D.G. Clayton, R.K. Webb, W.B. Runcima

Dynamik von Staubteilchen in Saturns E-Ring

This thesis covers the dynamical evolution of dust in the outer Saturnian magnetosphere, the region of the large E ring. For the dynamical evolution a model is used, which considers the gravitation of Saturn, including the quadrupolmomentum due to Saturns oblateness, the gravi- tation of Saturns large moons embedded in the E ring, the influence of the surrounding plasma as charging of the grains and sputtering, the Lorenz force due to Saturns rotating magnetic field, and the radiation pressure caused by the sun. In this model, the charge of the grain is characterised by time depended charge currents. The material parameters are derived from the comparison with measurements of the grain potential by the dust analyser onboard the spacecraft Cassini. Further measurements done by various scientific instruments of Cassini discover a geologic active south pole on the icy moon Enceladus. This dust plumes are determined as the main source of fresh E ring particle. Dynamical simulations of dust grains launched at the position of the detected plumes determined the minimal ejection speed of the particles necessary to be- come ring particles. The ejection speed is directly related to the ring thickness near Enceladus orbit. Long time evolution of dust dynamic showed, that dust particles launched from Enceladus populate the E ring. Thereby the dynamical dynamical evolution is strongly affected by the radial dependence of the potential. A global model of the E ring could derived from the time evolution of thousands of individual particles. This model is used to predict impact rates of an in situ detector flying through the E ring

Spin Transport in Disordered Two-Dimensional Hopping Systems with Rashba Spin-Orbit Interaction

The influence of Rashba spin-orbit interaction on the spin dynamics of a topologically disordered hopping system is studied in this paper. This is a significant generalization of a previous investigation, where an ordered (polaronic) hopping system has been considered instead. It is found, that in the limit, where the Rashba length is large compared to the typical hopping length, the spin dynamics of a disordered system can still be described by the expressions derived for an ordered system, under the provision that one takes into account the frequency dependence of the diffusion constant and the mobility (which are determined by charge transport and are independent of spin). With these results we are able to make explicit the influence of disorder on spin related quantities as, e.g., the spin life-time in hopping systems.Comment: 12 pages, 6 figures, some clarifications adde

Preferences, counterfactuals and maximisation: Reasoning in game theory.

This thesis explores two kinds of foundational issues in game theory. The first is concerned with the interpretation of the basic structure of a game, especially the definitions of outcomes and payoffs. This discussion leads to the second issue; namely the nature of solution concepts and their relation to both explicit and implicit assumptions in game theory concerning hypothetical reasoning. Interpreting utility functions in game theory, I argue that the notion of revealed preferences is ill-suited for counterfactual reasoning and for taking account of the implicit normativity of instrumental rationality. An alternative interpretation is outlined that treats preferences as determinants of choice. Accordingly, outcomes have to be individuated so as to capture everything that matters to an agent. I consider whether this is problematic when properties of outcomes depend on choice processes themselves. Turning to a decision theoretic problem, I question Verbeek's (2001) claim that modal outcome individuation conflicts with axioms of consequentialism. Next, I critically assess Rabin's (1993) model of fairness equilibria. Hypothesising about unilateral deviation is shown to be incompatible with belief-dependent utility definitions. Counterfactuals in games are then analysed more generally. It proves to be crucial for solution concepts whether our formal framework allows us to differentiate between indicative and subjunctive conditionals. Stalnaker's (1996) prima facie counterexample to Aumann's (1995) theorem that common knowledge of rationality implies a subgame perfect equilibrium is questioned on the grounds of a plausibility criterion. Again drawing on what has been established about the structure of a game and the meaning of its elements, Gauthier's (1986) notion of constrained maximisation, an attempt to overcome the non-cooperative equilibrium of the finitely iterated prisoner's dilemma, is shown to be incompatible with orthodox game theoretical methodology. The approach of treating the unit of agency as endogenous is addressed

On some notions of good reduction for endomorphisms of the projective line

Let $\Phi$ be an endomorphism of \SR(\bar{\Q}), the projective line over the algebraic closure of \Q, of degree $\geq2$ defined over a number field $K$. Let $v$ be a non-archimedean valuation of $K$. We say that $\Phi$ has critically good reduction at $v$ if any pair of distinct ramification points of $\Phi$ do not collide under reduction modulo $v$ and the same holds for any pair of branch points. We say that $\Phi$ has simple good reduction at $v$ if the map $\Phi_v$, the reduction of $\Phi$ modulo $v$, has the same degree of $\Phi$. We prove that if $\Phi$ has critically good reduction at $v$ and the reduction map $\Phi_v$ is separable, then $\Phi$ has simple good reduction at $v$.Comment: 15 page

Reporting of unintended events in an intensive care unit: comparison between staff and observer

BACKGROUND: In order to identify relevant targets for change, it is essential to know the reliability of incident staff reporting. The aim of this study is to compare the incidence and type of unintended events (UE) reported by facilitated Intensive Care Unit (ICU) staff with those recorded concurrently by an observer. METHODS: The study is a prospective data collection performed in two 4-bed multidisciplinary ICUs of a teaching hospital. The format of the UE reporting system was voluntary, facilitated and not necessarily anonymous, and used a structured form with a predetermined list of items. UEs were reported by ICU staff over a period of 4 weeks. The reporting incidence during the first fourteen days was compared with that during the second fourteen. During morning shifts in the second fourteen days, one observer in each ICU recorded any UE seen. The staff was not aware of the observers' study. The incidence of UEs reported by staff was compared with that recorded by the observers. RESULTS: The staff reported 36 UEs in the first fourteen days and 31 in the second.. The incidence of UE detection during morning shifts was significantly higher than during afternoon or night shifts (p < 0.001). Considering only working day morning shifts, the rate of UE reporting by the staff per 100 patient days was 26.9 (CI 95% 16.9–37.0) in the first fourteen day period and 20.3 (CI 95% 10.3–30.4) in the second. The rate of UE detection by the observers was 53.1 per 100 patient days (CI 95% 40.6–65.6), significantly higher (p < 0.001) than that reported concurrently by the staff. There was excellent agreement between staff and observers about the severity of the UEs recorded (Intraclass Correlation Coefficient 0.869). The observers recorded mainly UEs involving Airway/mechanical ventilation and Patient management, and the staff Catheter/Drain/Probe and Medication errors (p = 0.025). CONCLUSION: UE incidence is strongly underreported by staff in comparison with observers. Also the types of UEs reported are different. Invaluable information about incidents in ICU can be obtained in a few days by observer monitoring