scholarly journals In Situ Team-Based Simulation Training to Close the Loop on Event Reporting

2021 ◽  
pp. 6-11
Author(s):  
Caoimhe Duffy ◽  
William Yi ◽  
Joshua Atkins
Keyword(s):  
Data Collection ◽  
Adverse Events ◽  
Process Improvement ◽  
Simulation Training ◽  
Mandated Reporting ◽  
Effect Change ◽  
Event Reporting ◽  
Aggregated Data ◽  
Time Required

Reporting adverse events is often stigmatized in medicine. Adverse events are underreported. Underreporting has been linked to fear, the time required to complete a report, and a belief that reporting may not result in improvement.1 The reluctance to report is multidimensional and may relate to guilt, fear of punishment of self or others, fear of embarrassment, fear of litigation, and lack of confidence to effect change. Central to this fear is the widely held belief that errors and adverse events are due to carelessness and that blame must be assigned—often to the provider “at fault” or at the sharp end of the process. However, reporting of events offers an invaluable opportunity to identify latent systems issues and review and redesign error-trapping procedures and workflows. Without measurement, it is challenging to leverage adverse events as catalysts for targeted process improvement. Mandated reporting at the state and national levels is an influential catalyst to enhance data collection of adverse events. Aggregated data across varied practice settings are powerful. Mandated reporting alleviates some of the fear associated with reporting and increases reporting volume and relevance.

Implementation of an in Situ Simulation-based Training Adapted from Morbidity and Mortality Conference Cases: Effect on the Occurrence of Aevents – Study Protocol of a Cluster Randomized Controlled Trial

2021 ◽  
Author(s):  
Nicolas Michel ◽  
Bernard Bui-xuan ◽  
Lionel Bapteste ◽  
Thomas Rimmele ◽  
Marc Lilot ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Simulation Training ◽  
Training Programme ◽  
Morbidity And Mortality ◽  
In Situ Simulation ◽  
Active Feedback ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

Abstract Background: Morbidity and Mortality Conferences provides the necessary improvement measures required for patient safety. However, it is an underused resource mainly because the conclusions to be drawn from the discussion and their implications for practice are not always well integrated by inpatient care teams. We therefore propose in this study two interventions to optimise their efficacy; a passive feedback with wide dissemination by e-mail and/or on paper of the results of the Morbidity and Mortality Conference to inpatient care teams, and an active feedback with in situ inter-professional simulation-training programme in which scenarios will be based on cases studied in Morbidity and Mortality Conference. In the present study we hypothesise that the greatest reduction the occurrence of adverse event will be in the active feedback arm.Methods: A cluster randomized controlled study will be performed at four study sites. Passive feedback and active feedback arms will be compared to standard arm in terms of occurrence of adverse events. The trigger tool methodology used to identify adverse events is a retrospective review of inpatient records using “triggers” to isolate potential adverse events. Discussion: The in situ simulation training based on cases processed in Morbidity and Mortality Conference is built according to the main topics identified for the successful implementation of healthcare simulation in patient safety programmes: technical skills, nontechnical skills, assessment, effectiveness, and system probing. The in situ simulation-training programme conducted as part of the study has the potential to improve patient safety during hospitalisation. We therefore expect the greatest reduction in the occurrence of adverse events in patients hospitalised in the active feedback arm. This expected result would have a direct impact on patient safety and would place in situ simulation at the highest level of the Kirkpatrick model. Trial registration: T he study has been registered in Clinicaltrials.gov (NCT02771613). Registered on May 12, 2016.

Adverse events following adenovirus type 4 and type 7 vaccine, live, oral in the Vaccine Adverse Event Reporting System (VAERS), United States, October 2011–July 2018

Vaccine ◽  
2019 ◽  
Vol 37 (44) ◽  
pp. 6760-6767 ◽  
Author(s):  
Michael M. McNeil ◽  
Iwona Paradowska-Stankiewicz ◽  
Elaine R. Miller ◽  
Paige L. Marquez ◽  
Srihari Seshadri ◽  
...  
Keyword(s):  
United States ◽  
Adverse Event ◽  
Adverse Events ◽  
Reporting System ◽  
Adverse Event Reporting System ◽  
Adenovirus Type ◽  
Adverse Event Reporting ◽  
Event Reporting

Repeatability, Reproducibility, and Calibration of the MyotonPro® on Tissue Mimicking Phantoms

2013 ◽  
Author(s):  
John Dougherty ◽  
Emily Schaefer ◽  
Kalyani Nair ◽  
Joseph Kelly ◽  
Alfonse Masi
Keyword(s):  
Data Collection ◽  
Dynamic Stiffness ◽  
Correlation Study ◽  
Living Tissue ◽  
Polymeric Gel ◽  
Stiffness Properties ◽  
Tissue Phantoms ◽  
Repeatability And Reproducibility ◽  
Living Tissues

The MyotonPro® (Myoton AS, Tallinn, Estonia) is commonly used to quantify stiffness properties of living tissues in situ. Current studies quantify the dynamic stiffness properties of living tissues, but do not validate or compare these measurements to a standardized method. Additionally, living tissue, being dynamic in nature, presents much variability in data collection. To address these issues this study focuses on the repeatability and reproducibility of the MyotonPro® on polymeric gel-based tissue phantoms. In addition, a correlation study is also performed to translate dynamic stiffness to a more standardized property, Young’s modulus. Such studies help to confirm the reliability of the measurements obtained in situ.

In situ enzymatic removal of orthophosphate by the nucleoside phosphorylase catalyzed phosphorolysis of nicotinamide riboside

1982 ◽  
Vol 60 (9) ◽  
pp. 917-921 ◽  
Author(s):  
John W. Shriver ◽  
Brian D. Sykes
Keyword(s):  
Nuclear Magnetic Resonance ◽  
Magnetic Resonance ◽  
Nucleoside Phosphorylase ◽  
Nicotinamide Riboside ◽  
Time Required ◽  
Removal System ◽  
Nuclear Magnetic

An enzymatic orthophosphate removal system is described which can be effectively used to continuously remove orthophosphate from biochemical samples. The phosphorolysis of nicotinamide riboside is catalyzed by calf spleen nucleoside phosphorylase to give ribose-1-PO4 and nicotinamide along with a proton. At pH 8 the production of ribose-1-PO4 from orthophosphate is essentially quantitative. This reaction can be monitored optically or by 31P nuclear magnetic resonance (NMR). Equations are given for determining the time required to remove a given amount of phosphate from a typical NMR sample with a known amount of nucleoside phosphorylase. The effects of a competing orthophosphate-producing reaction are considered.

Using digital data collection tools to improve overall cost-efficiency and provide timely analysis for decision making during invasive species eradication campaigns

2014 ◽  
Vol 41 (6) ◽  
pp. 499 ◽  
Author(s):  
David J. Will ◽  
Karl J. Campbell ◽  
Nick D. Holmes
Keyword(s):  
Decision Making ◽  
Data Collection ◽  
Cost Efficiency ◽  
Relational Databases ◽  
Cost Effective ◽  
Digital Data ◽  
Capital Costs ◽  
Project Costs ◽  
Time Required ◽  
Data Collection Effort

Context Worldwide, invasive vertebrate eradication campaigns are increasing in scale and complexity, requiring improved decision making tools to achieve and validate success. For managers of these campaigns, gaining access to timely summaries of field data can increase cost-efficiency and the likelihood of success, particularly for successive control-event style eradications. Conventional data collection techniques can be time intensive and burdensome to process. Recent advances in digital tools can reduce the time required to collect and process field information. Through timely analysis, efficiently collected data can inform decision making for managers both tactically, such as where to prioritise search effort, and strategically, such as when to transition from the eradication phase to confirmation monitoring. Aims We highlighted the advantages of using digital data collection tools, particularly the potential for reduced project costs through a decrease in effort and the ability to increase eradication efficiency by enabling explicit data-informed decision making. Methods We designed and utilised digital data collection tools, relational databases and a suite of analyses during two different eradication campaigns to inform management decisions: a feral cat eradication utilising trapping, and a rodent eradication using bait stations. Key results By using digital data collection during a 2-year long cat eradication, we experienced an 89% reduction in data collection effort and an estimated USD42 845 reduction in total costs compared with conventional paper methods. During a 2-month rodent bait station eradication, we experienced an 84% reduction in data collection effort and an estimated USD4525 increase in total costs. Conclusions Despite high initial capital costs, digital data collection systems provide increasing economics as the duration and scale of the campaign increases. Initial investments can be recouped by reusing equipment and software on subsequent projects, making digital data collection more cost-effective for programs contemplating multiple eradications. Implications With proper pre-planning, digital data collection systems can be integrated with quantitative models that generate timely forecasts of the effort required to remove all target animals and estimate the probability that eradication has been achieved to a desired level of confidence, thus improving decision making power and further reducing total project costs.

Fate and transport of faecal contamination microbial indicators, pathogenic protozoa and Campylobacter in the artificially recharged fractured aquifer of Salento, Italy

2008 ◽  
Vol 57 (6) ◽  
pp. 849-856 ◽  
Author(s):  
R. La Mantia ◽  
C. Masciopinto ◽  
C. Levantesi ◽  
V. Tandoi
Keyword(s):  
Pathogenic Bacteria ◽  
Fate And Transport ◽  
Fractured Aquifer ◽  
Specific Detection ◽  
Microbial Indicators ◽  
Faecal Contamination ◽  
Time Required ◽  
Indicators Of Faecal Contamination ◽  
Campylobacter Spp

The study investigates the fate and transport of microorganisms introduced by artificial groundwater recharge at the Nardò fractured aquifer in Salento, Italy. Microbial indicators of faecal contamination, parasitic protozoa (Giardia and Cryptosporidium) and pathogenic bacteria (Campylobacter spp.), were monitored into injected water and groundwater to test the efficiency of the “natural disinfection” into the fractured aquifer. A remarkable decrease of microbial indicators and pathogens was observed suggesting that pathogens removal or inactivation may be possible during water flow in fractured aquifer. The recently described PNA probe CJE195 (Lehtola et al. 2005) was utilised for the rapid and specific detection of Campylobacter spp. by fluorescence in situ hybridization (FISH) after enrichment. FISH results were consistent with those of traditional cultural method (ISO 17995) applied in parallel: time required for Campylobacter identification was reduced of 4 days.

In-Situ, Time Resolved, Kinetics of Reactions in Co-Ge thin Films

1991 ◽  
Vol 237 ◽  
Author(s):  
R. M. Walser ◽  
Byung-Hak Lee ◽  
Alaka Valanju ◽  
Winston Win ◽  
M. F. Becker
Keyword(s):  
Depth Profiling ◽  
Laser Interferometry ◽  
Semiconductor Interface ◽  
Time Resolved ◽  
Interface Reactions ◽  
Valuable Adjunct ◽  
Diffusion Controlled ◽  
Sputter Deposited ◽  
Time Required

ABSTRACTWe report the first kinetic study of metal-semiconductor interface reactions using in-situ, time resolved, laser interferometry. Diffusion couples with Co/Ge thicknesses of 1500 Å/1500 Å were sputter deposited on silicon wafers, and vacuum-annealed at temperatures between 300°C-400°C. Under these conditions polycrystalline CoGe was expected to form [1]. Real time laser (HeNe 6328 Å) interferograms for each anneal were recorded in-situ. These data were supplemented by information from AES and X-ray.For temperatures below 400°C the diffusion controlled formation of CoGe was observed. The composition was confirmed by Auger depth profiling that showed uniform Co and Ge concentrations when the reaction went to completion. The well defined interferences fringes were formed by the dissolution of amorphous Ge. The activation energy = 1.6 eV for the formation of CoGe were determined with precision from the temperature dependence of the time required to anneal the fixed λ/4 distance between adjacent minima and maxima of the interferogram. We discuss the evidence for formation of an intermediate Co-rich compound following the initial diffusion of Co into Ge. The results of these experiments indicate that optical interferometry will be a valuable adjunct to other techniques used to study metal-semiconductor interface reactions.

Improved quality of reporting safety data of medication in paediatric randomised controlled trials

2021 ◽  
pp. archdischild-2020-321197
Author(s):  
Taco Jan Prins ◽  
Corine Rollema ◽  
Eric van Roon ◽  
Tjalling de Vries
Keyword(s):  
Adverse Events ◽  
Randomised Controlled Trials ◽  
Safety Data ◽  
Drug Event ◽  
Controlled Trials ◽  
Quality Of Reporting ◽  
Event Reporting ◽  
The Past ◽  
Randomised Controlled

ObjectiveEvaluating the reporting of safety data of medication in paediatric randomised controlled trials (RCTs) in 2017–2018 compared with our earlier study.DesignLiterature search with a systemic appraisal of adverse drug event reporting.Main outcome measuresQuality of reporting of safety data using Consolidated Standards of Reporting Trials (CONSORT) and Ioannidis scores in paediatric drug RCTs. The CONSORT score consists of nine recommendations of the CONSORT Group issued to improve the quality of reporting adverse events. The Ioannidis score is based on these advices. We considered a CONSORT score of at least 6 and an Ioannidis score of at least 3 as sufficient.ResultsWe reviewed 100 RCTs published in 2017 and 2018. Ninety-four (94%) articles mentioned adverse events compared with 78% in the earlier study. Fifty-seven per cent used a standardised method for reporting adverse events compared with 34% in our earlier study. In 26 of the articles, the expected adverse events were defined, and 27 articles had a preset standardised scale for adverse events. Of these, 62 articles (62%) had a CONSORT score of 6 or higher compared with 18% in 2010. In the present study, 67% had an Ioannidis score of 3 or higher, whereas in the earlier study this was 29%. Both differences are statistically significant (p<0.05).ConclusionsReporting safety data in paediatric RCTs has improved over the past 10 years. However, there is still room for improvement and for further improvement. Authors and editors should give more attention to methods for collecting, reporting and presenting safety data of RCTs in studies and manuscripts.

EFFECTS OF GROWING SEASON SOIL TEMPERATURE, MOISTURE, AND NH4-N ON SOIL NITROGEN

1974 ◽  
Vol 54 (4) ◽  
pp. 403-412 ◽  
Author(s):  
C. A. CAMPBELL ◽  
D. W. STEWART ◽  
W. NICHOLAICHUK ◽  
V. O. BIEDERBECK
Keyword(s):  
Quantitative Relationship ◽  
Growing Season ◽  
Stepwise Multiple Regression ◽  
Soil N ◽  
N Transformations ◽  
Temperature Changes ◽  
Diurnal Patterns ◽  
Multiple Regression Technique ◽  
Time Required

Wood Mountain loam was wetted with water or (NH4)2SO4 solution to provide a factorial combination among three moisture and three NH4-N levels. Samples in polyethylene bags were incubated at 2.5-cm depths in fallow, and in an incubator that simulated the diurnal patterns of temperature fluctuation recorded in the field. During the growing season, treatments were sampled regularly for moisture, NO3− and exchangeable NH4-N. Similar determinations were made on in situ samples taken in fallow Wood Mountain loam. The incubator simulated the effects of growing season temperatures on soil N transformations satisfactorily. Pronounced increases or decreases in temperature led to flushes in N mineralization. However, in the 1972 growing season, temperature was suboptimal and temperature changes were generally small. Consequently, when a stepwise multiple regression technique was used to analyze the data, neither ammonification nor nitrification showed a quantitative relationship to temperature. Comparison of the nitrification occurring in laboratory-incubated soils with that occurring in situ led to the conclusion that 70 to 90% of the NO3-N produced in surface soil resulted from wetting and drying. Estimates of potentially ammonifiable soil N(No) and its rate of mineralization (k) were derived from cumulative ammonification by assuming that the laws of first-order kinetics were applicable. In the 10, 15, and 20% moisture treatments the average No was 27, 41, and 82 ppm, respectively. Under the conditions of this study, the time required to mineralize half of No was about 7 wk.

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