Unusual and Exigent: My First Year at the Fed

Speech by former banker and then-Richmond Fed governor about discount-window stigm

Blood Transfusion Errors within a Health System: A Review of Root Cause Analyses

IntroductionBlood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process. MethodsThis study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes. ResultsThe most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent. ConclusionThese RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility

Minutes of the Board of Governors of the Federal Reserve System 6-5-2009

Present at this meeting were the following members of the Federal Reserve System: Ms. Johnson, Mr. Frierson, Ms. Smith, Mr. Skidmore, Mr. Alvarez, Ms. Liang, Mr. Cole, Ms. Stefansson, Mr. Clark, and Mr. Foley

Minutes of the Board of Governors of the Federal Reserve System 6-17-2009

Present at this meeting were the following members of the Federal Reserve System: Ms. Johnson, Mr. Frierson, Ms. Ross, Mr. Hiratsuka, Ms. Smith, Mr. Blanchard, Mr. Skidmore, Mr. Gross, Mr. Alvarez, Ms. O\u27Day, Ms. Liang, Mr. Clark, and Mr. Foley. In addition, those present to represent the Federal Reserve Bank of New York include: Mr. Dudley, Mr. Rutledge, Mr. Angulo, and Mr. Whynott

Minutes of the Board of Governors of the Federal Reserve System 11-23-2008

The following members of the Federal Reserve System were present at the time of this meeting : Ms. Johnson, Mr. Frierson, Ms. Shanks, Ms. Beattie, Ms. Smith, Mr. Blanchard, Mr. Skidmore, Mr. Gross, Mr. Pribble, Mr. Alvarez, Mr. Ashton, Mr. Fallon, Mr. Van Der Weide, Mr. Stockton, Mr. Parkinson, Ms. Liang, Mr. Madigan, Mr. Clouse, Mr. Danker, Mr. English, Mr. Carpenter, Ms. Bailey, Ms. Barger, Ms. Stefanson, Mr. Treacy, Mr. Marquardt, and Mr. Malphrus. Representing the Federal Reserve Bank of New York, Mr. Dudley was also present

Minutes of the Board of Governors of the Federal Reserve System 5-10-2008

Additionally, present at this meeting were the following members of the Federal Reserve System: Ms. Johnson, Ms. Shanks, Ms. Beattie, Ms. Smith, Mr. Blanchard, Mr. Skidmore, Mr. Gross, Mr. Alvarez, Mr. Ashton, Ms. O\u27Day, Mr. Fallon, Ms. Robison, Mr. Van Der Weide, Mr. Parkinson, Mr. Wilcox, Mr. Madigan, Mr. Clouse, Ms. Danker, Mr. English, Mr. Nelson, Mr. Sheets, Mr. Cole, Ms. Bailey, Ms. Barger, Mr. Greenlee. Ms. DeFerrari, Ms. Roseman, Mr. Marquardt, Mr. Evans, and Mr. Malphrus

Minutes of the Board of Governnors of the Federal Reserve System

Present at this meeting were the following members of the Federal Reserve Systems Board of Governors: Ms. Johnson, Mr. Frierson, Ms. Shanks, Ms. Beattie, Mr. Hiratsuka, Ms. Smith, Mr. Blanchard, Mr. Skirdmore, Mr. Gross, Mr. Pribble, Mr. Alvarez, Ms. O\u27Day, Ms. Martin, Ms. Misback, Mr. Fallon, Ms. Robison, Mr. Van Der Weide, Mr. Parkinson, Mr. Kwast, Ms. Liang, Ms. Prager, Mr. Covitz, Mr. Madigan, Mr. Clouse, Ms. Danker, Mr. English, Ms. Edwards, Mr. Nelson, Mr. Carpenter, Mr. Perli, Mr. Karmin, Mr. Cole, Ms. Bailey, Ms. Bargerm Mr. Greenlee, Ms. DeFerrari, Ms, Roseman, Mr. Hammond, Mr. Marquardt, Mr. Evans, and Mr. Malphru

Parasitophorous vacuole poration precedes its rupture and rapid host erythrocyte cytoskeleton collapse in Plasmodium falciparum egress.

In the asexual blood stages of malarial infection, merozoites invade erythrocytes and replicate within a parasitophorous vacuole to form daughter cells that eventually exit (egress) by sequential rupture of the vacuole and erythrocyte membranes. The current model is that PKG, a malarial cGMP-dependent protein kinase, triggers egress, activating malarial proteases and other effectors. Using selective inhibitors of either PKG or cysteine proteases to separately inhibit the sequential steps in membrane perforation, combined with video microscopy, electron tomography, electron energy loss spectroscopy, and soft X-ray tomography of mature intracellular Plasmodium falciparum parasites, we resolve intermediate steps in egress. We show that the parasitophorous vacuole membrane (PVM) is permeabilized 10-30 min before its PKG-triggered breakdown into multilayered vesicles. Just before PVM breakdown, the host red cell undergoes an abrupt, dramatic shape change due to the sudden breakdown of the erythrocyte cytoskeleton, before permeabilization and eventual rupture of the erythrocyte membrane to release the parasites. In contrast to the previous view of PKG-triggered initiation of egress and a gradual dismantling of the host erythrocyte cytoskeleton over the course of schizont development, our findings identify an initial step in egress and show that host cell cytoskeleton breakdown is restricted to a narrow time window within the final stages of egress

Associative memory in chronic schizophrenia: a computational model

We developed a computer model to simulate associative memory recall of patients with chronic schizophrenia. Model inputs consisted of words derived from normative data that differed in terms of connectivity and network size, with the former quantitatively represented by parametric weights and the latter by the specific number of word associates that formed a particular network. Previous behavioral studies of normal subjects indicated better recall for words of high connectivity-small network (HCSN), followed by low connectivity-small network (LCSN), high connectivity-large network (HCLN), and low connectivity-large network (LCLN). This pattern of recall differed from that observed in behavioral studies of schizophrenic patients, which showed better recall for high connectivity words, regardless of network size. Holding constant network size while manipulating connection weights effectively simulated this schizophrenic pattern of recall. That is, manipulation of parametric weights coupled with a slight increase in noise significantly and reliably elicited the response pattern of abnormal connectivity demonstrated in the prior behavioral study of patients with chronic schizophrenia. An increase in noise was a necessary, but insufficient step in modeling the response pattern of abnormal connectivity. These findings provide support for the use of computational models to investigate dynamics of associative word recall in patients with chronic schizophrenia