6,876 research outputs found
Developing a System Resilience Approach to the Improvement of Patient Safety in NHS Hospitals
Developing a system resilience approach using Rasmussen's (1997) safe working envelope to develop theory about patient safety failure in NHS hospitals. Case study research design with multiple data collection methods.The objective of this thesis is to explore how a systems approach can be used to provide an insight into patient safety in NHS hospitals in England. Healthcare delivers considerable benefits yet there remains a relatively high rate of harm and death for patients through adverse events occurring during the process of treatment. The extant patient safety literature acknowledges the influence of organisational or system factors on patient safety. However, the literature is weak in explaining how system factors affect patient safety. To provide an insight into the interactions within healthcare systems, this research explores the characteristics of NHS hospitals, regarded as complex socio-technical systems, using concepts from resilience, systems, accident and social theory.
A theoretical Safe Working Envelope (SWE) model (Rasmussen, 1997) is developed and contextualised for use in the NHS. The case study field work was carried out in two NHS hospitals during consecutive winter months at times of high demand for inpatient services. A third case study uses secondary data about patient safety failures in the Mid Staffordshire NHS Foundation Trust.
The original SWE model has three failure boundaries. The model is developed by introducing an additional boundary to take account of Government targets. Social theory and system dynamics are used to include the dialectic feedback of social actors and the dynamics of workload. The model depicts the competing pressures, constraints and the workload associated with the need to meet the financial, target, staff workload and patient safety requirements. Three interacting construct sets are explored. These are the constraints within which the system operates, the pressures from the context, and the system dynamics of demand, capacity and decision making. Insights into system behaviours of the hospitals are derived from examining the construct set interactions. The proposition is made that there are five system behaviour archetypes which create the conditions that influence patient safety. The archetypes are derived from the system dynamics and in particular the relationship between reinforcing and balancing feedback loops. The five archetypes are safe practice, drift, tip, collapse and transition towards failure. As hospitals become overcrowded the complexity increases and the reinforcing feedback loops dominate the system and potentially increase the risk to patients. An element of risk arises from staff normalising to the drift in standards of care.NHS South West Strategic Health Authorit
Technique utilisation and efficiency in competitive Brazilian Jiu-Jitsu matches at white and blue belts
Despite its increasing popularity, little is known about Brazilian Jiu- Jitsu and what makes a successful fighter. This work aims to start answering questions about the most used and successful techniques to allow development of coaching methods towards enhancing performance at lower belt levels. One-hundred and forty tournament fights were analysed. The most common takedown was guardpull with 94% success. Significantly more single leg takedowns were attempted for blue belts (BBs), compared to white belts (WBs) (p = 0.013). However, there was no significant difference in success (p = 0.150). WBs used three main guardpasses with 93% covering knee slice, knee pin and bullfighter. A greater variety of passes were witnessed at BB with 71% coming from these three passes. The four most commonly attempted guard sweeps were scissor sweep, back take, Xguard sweep and SitUp sweep all experiencing varying levels of success: 55% for the scissor sweep, 60% back take, 63% Xguard sweep and 38% for the sit up sweep. Of all the submissions attempted 34% were for arm bar, 21% triangle, 12% cross collar choke but there were almost an inverse relationship between use and success with the least used having higher success rates, demonstrating that variety in submissions could lead to greater chances of success
Student Usage of Q&A Forums: Signs of Discomfort?
Q&A forums are widely used in large classes to provide scalable support. In
addition to offering students a space to ask questions, these forums aim to
create a community and promote engagement. Prior literature suggests that the
way students participate in Q&A forums varies and that most students do not
actively post questions or engage in discussions. Students may display
different participation behaviours depending on their comfort levels in the
class. This paper investigates students' use of a Q&A forum in a CS1 course. We
also analyze student opinions about the forum to explain the observed
behaviour, focusing on students' lack of visible participation (lurking,
anonymity, private posting). We analyzed forum data collected in a CS1 course
across two consecutive years and invited students to complete a survey about
perspectives on their forum usage. Despite a small cohort of highly engaged
students, we confirmed that most students do not actively read or post on the
forum. We discuss students' reasons for the low level of engagement and
barriers to participating visibly. Common reasons include fearing a lack of
knowledge and repercussions from being visible to the student community.Comment: To be published at ITiCSE 202
Atlas of Butterflies and Diurnal Moths in the Monsoon Tropics of Northern Australia
"Northern Australia is one of few tropical places left on Earth in which biodiversity—and the ecological processes underpinning that biodiversity—is still relatively intact. However, scientific knowledge of that biodiversity is still in its infancy and the region remains a frontier for biological discovery. The butterfly and diurnal moth assemblages of the area, and their intimate associations with vascular plants (and sometimes ants), exemplify these points.
However, the opportunity to fill knowledge gaps is quickly closing: proposals for substantial development and exploitation of Australia’s north will inevitably repeat the ecological devastation that has occurred in temperate southern Australia—loss of species, loss of ecological communities, fragmentation of populations, disruption of healthy ecosystem function and so on—all of which will diminish the value of the natural heritage of the region before it is fully understood and appreciated. Written by several experts in the field, the main purpose of this atlas is to compile a comprehensive inventory of the butterflies and diurnal moths of northern Australia to form the scientific baseline against which the extent and direction of change can be assessed in the future. Such information will also assist in identifying the region’s biological assets, to inform policy and management agencies and to set priorities for biodiversity conservation.
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