...Affecting Performances 6 2.3.1 Fitness and Health 5 2.3.2 Stress 7 2.3.3 Workload 10 2.3.4 Sleep 13 2.3.5 Circadian Rhythms 15 2.3.6 Fatigue & Shift Work 17 2.3.7 Alcohol, Medication and Drug Abuse 23 2.3 FACTOR AFFECTING PERFORMANCE 32 2.4 TYPES OF ERROR IN AVIATION 36 2.5 MANAGING ERROR IN AVIATION 36 CHAPTER 3 : CONTENTS 38 CHAPTER 4 : RECOMMENDATION AND CONCLUSION 42 REFRENCES 43 CHAPTER 1 : INTRODUCTION Errors are the result of actions that fail to generate the intended outcomes. In common with most other complex technical activities, human error is implicated in the majority of aviation-maintenance-related quality lapses, incidents, and accidents. General estimates of this human error contribution have increased over the years, from a low of around 20% in the 1960s to values in excess of 80% in the 1990s. Human error in aviation is somewhat of a sensitive topic due to the recent tragic events of September 11, 2001. The goal of this research is to understand human error in aviation, in order to understand how designing better computer systems can assist in making the aviation industry safer for pilots and passengers, by reducing human error. This paper does not attempt to address accidents caused by cowardly acts of terrorism. Many people do not know that on February 20, 1981 a modern Argentine jet airliner, with 58 people on board...
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...From Medscape Nurses Medication Error Prevention for Healthcare Providers Faculty and Disclosures CE Information There are between 44,000 and 98,000 individuals who die every year in hospitals due to preventable medical errors.[1] It has also been reported that this is only part of the problem, as thousands of other patients are adversely affected by medical errors or barely avoid injuries that are nonfatal.[2] These medical errors not only cost the loss of lives, but carry a financial burden that is estimated to be in a range of $17 billion to $29 billion annually. Additionally, there is physical and psychological pain and suffering related to these errors.[1] Another consequence is that medical errors diminish trust and satisfaction in the healthcare system and in healthcare professionals.[1] Ginette A. Pepper, PhD, RN, FAAN, a Professor and Helen Lowe Bamberger Colby Presidential Endowed Chair and Associate Dean for Research, University of Utah College of Nursing, Salt Lake City, spoke on medication safety for the geriatric nurse practitioner (GNP).[3] Dr. Pepper was trained as a pharmacologist with a nursing focus. She was one of the first NPs to add "geriatric" to her title as well as one of the first NPs to have prescriptive authority. Safety Principles and the Medication Use Process Dr. Pepper noted that safety issues are of the utmost importance for all healthcare providers.[3] Nursing as a profession has a long history of regarding patient safety as a primary...
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...Business Research Report Benefits of an Electronic Health Record Assessment Code: RWT1 Student Name: Student ID: Date: Mentor Name: Table of Contents Executive Summary 3 Introduction 5 Research Findings 5 Opportunity for Financial Incentives 5 Improved Quality of Patient Care 6 Increased Productivity and Efficiency 7 Recommendations 8 Conclusion 9 References 11 Executive Summary The benefits of successfully implementing an electronic health record are both vital to the future of our business as well as rewarding. The purpose of this report is to clearly demonstrate the need for implementation of an electronic health record and provide explanation of the benefits available to us with successful implementation. . The three main benefits I will be presenting research on are the financial benefits of an electronic health record, the ability to provide better quality patient care and the opportunity to increase productivity and efficiency through implementing an electronic health record. There are significant financial incentives for implementing an electronic health record and meeting Medicare and Medicaid’s requirements for meaningful use. Eligible providers can earn up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program. There are three stages involved in meeting meaningful use the first stage consists of data capture and sharing, the second involves advanced clinical...
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...Why Are There So Many Deaths Caused By Medical Errors and What Solutions Can Decrease Them? Health Service Systems – HSM541 June 20 2015 Background Medical errors kill at least 44,000 people and perhaps as many as 98,000 people per year. Or do they kill over 180,000 per year? Maybe even 440,000 people killed by medical errors? Allen (2013) In 1999 the Institute of Medicine (IOM) published a report titled “To Err Is Human: Building A Safer Health System” that leveled the healthcare community. They reported that according to two studies “perhaps as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented”. IOM (1999) Then the Office of Inspector General for Health and Human Services followed up with a report in 2010 that stated “bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year”. Allen (2013) And finally in 2013, the numbers were once again raised. Per a report from the Journal of Patient Safety that approximately “440,000 PAEs (preventable/potential adverse events) that contribute to the death of patients each year from care in hospitals. This is roughly one-sixth of all deaths that occur in the United States each year”. They are now the U.S.’s third leading cause of death, behind only heart disease and cancer. All of the numbers mentioned in the first paragraph are medical errors that were “preventable”. Mistakes by the people you put your trust in killed you...
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...receive care, but past data indicates it has not always been so. The Institute of Medicine determined in the late 1990’s that 44,000 to 98,000 patients die from medical mistakes each year (Wachter, 2008). This tremendous number of deaths places medical care mishaps between the fifth and eighth leading causes of deaths in the United States (Kizer, 2001). In 2002, The Joint Commission established National Patient Safety Goals (NPSG) to help accredited organizations with patient safety in specific areas. An advisory group comprised of nurses, physicians, pharmacists, risk managers, clinical engineers, and others with appropriate experience advises The Joint Commission on how to address emerging patient safety issues. This group also periodically develops and updates the goals. The goals are grouped into broad categories and for 2011-2012, cover such categories as patient identification, health care-associated infections, improving communication, medication safety, reducing falls, and risk assessment. A discussion of selected elements underlying the current NPSG such as hand washing techniques, training, and lack of communication between healthcare personnel that can lead to medication errors, to falls, and even death, plus other related factors such as staffing shortages, problems with using outdated equipment, considerations in using the electronic medical records, and compliance with statutes provide insight into the challenges faced by today’s healthcare institutions and providers...
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...therapy is the second most common leading therapy for children with ADHD. To properly help the child behavioral therapy have to come from all facets of the child’s life. To be effective in behavioral therapy, the parents must be involve through parent training, classroom management, peer interventions, and combinations of these interventions. Parent training is very critical, because it teaches them about ADHD, in addition to, behavioral problems, and child development. This training gives the parents positive parenting strategies (Felt, Biermann, Christiner, Kochhar, & Harrison, 2014) Behavioral therapy are separated into two categories: antecedents of behavior, and consequences of behavior. The first one has to deal with the setting, environmentally structure. Things such the size of the classroom, regular classes verses special education classes. Seating arrangements and even the task that are given. To add, consequences therapy involve the school setting based on contingency management. This contingency depends on the behavior of the child (Schwiebert, Sealander, & Tollerud,...
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...healthcare. With each concept and its application, the reader is challenged to consider what is truly possible in the delivery of healthcare if standardized systems borrowed from reliable industries were implemented. Graban provides those trade secrets in an understandable and transparent fashion.” — Richard P. Shannon, MD, Frank Wister Thomas Professor of Medicine, Chairman, Department of Medicine, University of Pennsylvania School of Medicine “There is an enormous shortfall between the healthcare we are promised and what we actually get. Mark Graban explains how those in the system can make care delivery better for everyone –patients, providers, and payers.” — Steven Spear, Senior Lecturer, MIT, Senior Fellow, IHI “Mark Graban’s work has been a steady companion in the three years I have been studying and applying lean in healthcare. He...
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...Implementation Guide for the Use of Bar Code Technology in Healthcare Sponsored by Implementation Guide for the Use of Bar Code Technology in Healthcare © 2003 HIMSS 230 E. Ohio St., Suite 500 Chicago, IL 60611 All rights reserved. No part of this publication may be reproduced, adapted, translated, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. HIBCC ® and HIN® System are trademarks of the Health Industry Business Communications Council. ISBN: 0-9725371-2-0 Table of Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi Chapter 1: The Basics What is a bar code? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 How can you benefit from bar coding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
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...9-311-061 REV: JANUARY 31, 2011 RICHARD G. HAMERMESH F. WARREN MCFARLAN MARK KEIL ANDREW KATZ MICHAEL MORGAN DAVID LABORDE Computer rized P Provide Order Entry at Emory er y ealthcar re He I think the CPOE implementation has gone exceptionally well so far. T These CPOE sy ystems are all pretty immat ture at this po oint in time. I the system we are implem In menting, the m medication reco onciliation mod dule is awful; there are some other things that are awful, but, overall, g ; , given those lim mitations, I thin the CPOE s nk system implem mentation has gone very well g l. — Dr Bill Bornste Chief Qua Officer, E r. ein, ality Emory Health hcare1 La on the drizzly afternoo of June 11, 2009, Dr. Bil Bornstein, Chief Quality Officer of E ate on , ll y Emory 2 in Atl Healthcare lanta, reflecte on the pro ed ogress of the computerize provider o ed order entry sy ystem ntation. (CPOE)3 implemen mory Healthcare’s CPOE p project, a vital cog in a $50 million elect 0 tronic medica record initi al iative, Em began in 2007. Tw years late CPOE we “live” at Emory Univ n wo er, ent versity Orthop paedics and Spine Hospi ital, Emory University Ho U ospital, and W Wesley Woods Hospital i a staged r in rollout.4 Whil Dr. le Borns stein felt good about how t implemen d the ntation had gone thus far, as he looked ahead next m month to July 13, 2009, th fast approa he aching go-live date for Em e mory University Hospital M Midtown (EU UHM) (Exhib 1), Dr. Bornstein thou bit B ught about...
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...Disorder Overview and Symptoms “Depression is related to the normal emotions of sadness and bereavement, but it does not remit when the external cause of these emotions dissipates, and it is disproportionate to their causes” (Belmaker, 2008, p. 55). Severe states of depression often have no external precipitating cause, but it is hard to truly know if there was an external cause or not when dealing with severe depression (Belmaker, 2008). It is also known to occur with other mental health conditions such as anxiety, eating disorders, substance abuse, etc. Major depressive disorder affects approximately 14.8 million American adults, which equals about 6.7 percent of the U.S. population age 18 and older in a given year. It is also the leading cause of disability in the U.S. for ages 15-44. While major depressive disorder can develop at any age, the median age at onset is 32 and is more prevalent in women than in men (Numbers Count, 2014). Diagnosis of Major Depression “The diagnosis of major depression requires a distinct change of mood, characterized by sadness or irritability and is accompanied by some psychophysiological changes” (Belmaker, 2008, p. 56). Major depression can be easy to diagnose from anyone with experience dealing with depression, but understanding the cause of the depression, internally or externally, can be a tough challenge (Carey, 2013). Symptoms of major depression can vary in impact and severity, and many people who have major depression have a...
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...Physicians are highly trained and most of them specialize in some area of medicine that uses hi-tech equipment to help them. Nurses no longer just take vital signs and tell the patient that the doctor will be with you in a few minutes even though they know it will be more like a few hours. Nurses provide a number of preventive and primary health services, take care of minor injuries and illnesses, and prescribe medication. Hospitals have same day surgery where patients arrive in the morning have surgery and are back in their own home by night-fall. Basically hospitals are one or more large buildings where sick or injured people can receive medical or surgical care and most of the time as an inpatient. Everyone takes risk every day of his or her life and the chance of a negative impact is increased by the number of unintelligent choices they make. Risk can be defined as the uncertainty of results derived from a choice or objective. Quality can have many definitions, such as the condition of an object or situation, and it can be measured by its ability to satisfy a need. In hospitals risk is associated with potential errors that can cause a patient loss or harm. The more these potential errors are reduced, the greater the quality of the...
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...Advanced Information Management and the Application of Technology C156/WTT Task 1 Teresa Miller Student id: 000273119 Proposal Our one hundred bed hospital is in need of updating from paper charting to computerized health records. In doing this, we will meet our goal of compliance with meaningful use legislation. We assembled a team of members to assist with this task and together we have narrowed the search to two health care systems. Those two systems are EPIC and Meditech and we will now discuss the advantages and disadvantages of each, with a final recommendation for our new healthcare system. Identification and Roles of Team Members/Expertise The first person on this team is the acute care nurse manager. The acute care nurse manager is a bachelor prepared nurse and is beneficial to this team because of her close relationship with staff nurses. She will have input from floor nurses and be able to contribute important information about charting from the nursing standpoint. The nurse manager will be able to assist with questions that staff nurses may have during implementation and training. This member is able to discuss what the nursing staff needs for adequate charting. She will be able to look at each computerized system and contribute a nurses point of view. The second team member will be the chief medical officer. The physician has the input from other doctors and will be able to answer questions for other...
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...http://www.nap.edu/catalog/9728.html We ship printed books within 1 business day; personal PDFs are available immediately. To Err Is Human: Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine ISBN: 0-309-51563-7, 312 pages, 6 x 9, (2000) This PDF is available from the National Academies Press at: http://www.nap.edu/catalog/9728.html Visit the National Academies Press online, the authoritative source for all books from the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council: • Download hundreds of free books in PDF • Read thousands of books online for free • Explore our innovative research tools – try the “Research Dashboard” now! • Sign up to be notified when new books are published • Purchase printed books and selected PDF files Thank you for downloading this PDF. If you have comments, questions or just want more information about the books published by the National Academies Press, you may contact our customer service department tollfree at 888-624-8373, visit us online, or send an email to feedback@nap.edu. This book plus thousands more are available at http://www.nap.edu. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF File are copyrighted by the National Academy of Sciences. Distribution, posting, or copying...
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...competency.1 Nurses and other health care professionals are under increased scrutiny to provide safe, effective care. Likewise, nursing education programs are faced with increased pressure to produce graduates who are capable of providing safe patient care. Toward that end, nursing education programs develop curricula, hire qualified faculty, and select learning experiences for students in an effort to train and graduate competent, effective nurses. The instructional strategies utilized in both didactic and clinical components of nursing education courses are highly influential in determining critical thinking and clinical decisionmaking ability as well as in developing the psychomotor skill performance of new graduates. Of course, it is unrealistic to think that graduates of nursing education programs have received all the training they need when they depart the doors of academia. Orientation programs for new graduates and continuing education for nurses are essential tools to help practitioners improve their knowledge, skills, and expertise so that quality patient care is provided and outcomes are optimized while errors are minimized. Ongoing evaluation of nursing competence is necessary to promote patient safety. In the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health Care System, simulation training is recommended as one strategy that can be used to prevent errors in the clinical setting.1 The report states that “… health care organizations...
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...Organizational Systems and Quality Leadership Task 2 Jill Riccobono Western Governors University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root cause analysis (RCA) looks at an event and considers what happened, why it happened what will be done to prevent it from happening again and how will we know that the changes made will improve the safety of the system. It takes into consideration causative factors, errors and hazards that led to a sentinel event. In this case it was a patient’s death. RCA should not look to place blame on people, but rather processes that need to be improved. The first step in a RCA is to identify what happened. In the scenario, presented in this task, the patient was over sedated and subsequently died. Step two is to identify why this happened. There were preventable causative factors, or errors, that led to this sentinel event. The hospital’s conscious sedation policy requires that the patient remains on continuous BP, ECG, and pulse oximeter throughout the procedure and there was no mention that this was performed at all throughout the procedure. It was not until after the procedure that Mr. B was placed on continuous BP and pulse oximeter, and at that time, the patient was left in the room, with only a family member while Nurse J attended to another patient. When the alarm is heard that the patient has low O2 sats, the LPN, enters the room and resets the alarm and repeats the B/P reading. His oxygen level...
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