Case Studies of Near Misses in Clinical Anesthesia

Human watch-keeping is necessary to prevent incidents at sea such as groundings and collisions. For many years, electronic aids to navigation have been utilised in watch-keeping but, with electronic marine systems becoming more sophisticated, the part they play in preventing collisions and groundings should become increasingly important. However, this article uses secondary data from the Safety Digest for 2008 compiled by the Marine Accident Investigation Bureau of the United Kingdom; eight case studies are used to show that electronic marine systems, whether integrated or not, are still playing a part in poor watch-keeping resulting in collisions, near misses and groundings. Primary data from fishing skippers of British based vessels have been used to confirm the findings from the secondary data that poor watch-keeping is often the cause of not keeping a proper lookout and that the watch-keeper has a too heavy reliance on the electronic aids. Brief suggestions are made as to how the electronic aids may be adapted to overcome these problems and thus to support the watch-keeper.

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Clinical Anesthesia—Near Misses and Lessons Learned

British Journal of Anaesthesia ◽

10.1093/bja/aep148 ◽

2009 ◽

Vol 103 (1) ◽

pp. 143

Author(s):

R. Sirian ◽

J.G. Hardman

Keyword(s):

Lessons Learned ◽

Near Misses ◽

Clinical Anesthesia

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Triumphs, Disasters, and Near Misses

Risk and Reason in Clinical Diagnosis ◽

10.1093/med/9780190944001.003.0006 ◽

2019 ◽

pp. 101-138

Author(s):

Cym Anthony Ryle

Keyword(s):

Case Studies ◽

Cognitive Processes ◽

Critical Reflection ◽

Near Misses

This chapter refers to the evidence that error occurs in about 10% of diagnoses and is a potent source of harm to patients. Most error is judged to be potentially avoidable and to result from defects in the thinking of the individuals involved, defects in the systems within which they work, or more commonly from problems occurring simultaneously in both. It notes that systems factors and fallible cognition each contributes to this figure and often coexist. The chapter offers a set of clinical anecdotes that illustrate the cognitive processes described in Chapters 2 and 4, with examples of common pitfalls, including the influence of bias. The chapter includes critical reflection on these case studies, considers what lessons may be taken, and identifies opportunities for the introduction of safeguards.

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Corporate Sustainability: Challenge to Managerial Orthodoxies

Journal of Management & Organization ◽

10.1017/s1833367200004880 ◽

2003 ◽

Vol 9 (1) ◽

pp. 2-11 ◽

Cited By ~ 15

Author(s):

Dexter Dunphy

Keyword(s):

Case Studies ◽

Corporate Sustainability ◽

Central Place ◽

Marked Contrast ◽

Sustainability Management

ABSTRACTThis paper addresses the issue of corporate sustainability. It examines why achieving sustainability is becoming an increasingly vital issue for society and organisations, defines sustainability and then outlines a set of phases through which organisations can move to achieve increasing levels of sustainability. Case studies are presented of organisations at various phases indicating the benefits, for the organisation and its stakeholders, which can be made at each phase. Finally the paper argues that there is a marked contrast between the two competing philosophies of neo-conservatism (economic rationalism) and the emerging philosophy of sustainability. Management schools have been strongly influenced by economic rationalism, which underpins the traditional orthodoxies presented in such schools. Sustainability represents an urgent challenge for management schools to rethink these traditional orthodoxies and give sustainability a central place in the curriculum.

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Short-Form Application of the Screening Test of Spanish Grammar and the Northwestern Syntax Screening Test to Latino Children

Language Speech and Hearing Services in Schools ◽

10.1044/0161-1461.0904.220 ◽

1978 ◽

Vol 9 (4) ◽

pp. 220-235

Author(s):

David L. Ratusnik ◽

Carol Melnick Ratusnik ◽

Karen Sattinger

Keyword(s):

New York ◽

Case Studies ◽

Metropolitan Area ◽

Screening Test ◽

Normative Data ◽

Short Form ◽

Latino Children ◽

Data Application ◽

York Metropolitan Area ◽

Multiple Regression Technique

Short-form versions of the Screening Test of Spanish Grammar (Toronto, 1973) and the Northwestern Syntax Screening Test (Lee, 1971) were devised for use with bilingual Latino children while preserving the original normative data. Application of a multiple regression technique to data collected on 60 lower social status Latino children (four years and six months to seven years and one month) from Spanish Harlem and Yonkers, New York, yielded a small but powerful set of predictor items from the Spanish and English tests. Clinicians may make rapid and accurate predictions of STSG or NSST total screening scores from administration of substantially shortened versions of the instruments. Case studies of Latino children from Chicago and Miami serve to cross-validate the procedure outside the New York metropolitan area.

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Case Studies for Telepractice in AAC

Perspectives on Augmentative and Alternative Communication ◽

10.1044/aac23.1.42 ◽

2014 ◽

Vol 23 (1) ◽

pp. 42-54 ◽

Cited By ~ 1

Author(s):

Tanya Rose Curtis

Keyword(s):

Service Delivery ◽

Case Studies ◽

Eye Gaze ◽

Cognitive Impairments ◽

Perceived Barriers ◽

Computer Experience ◽

Access Methods ◽

Complex Communication Needs ◽

Barriers To Service ◽

Communication Needs

As the field of telepractice grows, perceived barriers to service delivery must be anticipated and addressed in order to provide appropriate service delivery to individuals who will benefit from this model. When applying telepractice to the field of AAC, additional barriers are encountered when clients with complex communication needs are unable to speak, often present with severe quadriplegia and are unable to position themselves or access the computer independently, and/or may have cognitive impairments and limited computer experience. Some access methods, such as eye gaze, can also present technological challenges in the telepractice environment. These barriers can be overcome, and telepractice is not only practical and effective, but often a preferred means of service delivery for persons with complex communication needs.

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