Search

BACKGROUND: When patients experience unexpected events, some health professionals become 'second victims'. These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery. METHODS: The purpose of this article is to report interview findings with 31 second victims. After institutional review board approval, second victim volunteers representing different professional groups were solicited for private, hour-long interviews. The semistructured interview covered demographics, participant recount of event, symptoms experienced and recommendations for improving institutional support. After interviews, transcripts were analyzed independently for themes, followed by group deliberation and reflective use with current victims. RESULTS: Participants experienced various symptoms that did not differ by sex or professional group. Our analysis identified six stages that delineate the natural history of the second victim phenomenon. These are (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. We defined the characteristics and typical questions second victims are desperate to have answered during these stages. Several reported that involvement in improvement work or patient safety advocacy helped them to once again enjoy their work. CONCLUSIONS: We now believe the post-event trajectory is largely predictable. Institutional programs could be developed to successfully screen at-risk professionals immediately after an event, and appropriate support could be deployed to expedite recovery and mitigate adverse career outcomes. [ABSTRACT FROM AUTHOR]

Rescuing the healer after trauma. [ABSTRACT FROM AUTHOR]

At-home case management is one strategy for improving quality of care for elderly patients with heart failure. Essential components of an effective heart failure case management intervention include frequent patient contact with the case manager and vigilant at-home monitoring of symptoms with responsive modifications to the treatment plan. It is just as important that the health care system (e.g., the acute care institution) is committed to assuring administrative support, financial backing, and dedicating clinical expert resources to achieve clinical quality improvements. In this article, the design, implementation, and outcomes of an at-home heart failure case management program are described, and challenges faced in implementing and sustaining the program are outlined. [ABSTRACT FROM AUTHOR]

Advanced practice nurses and staff nurse skin-care team members provided the necessary expertise and information to integrate AHCPR recommendations in a protocol for patients at risk for skin impairment. Regular practice monitoring and education regarding skin management have proven to be successful strategies. A skin-impairment mmagement protocol is provided. [ABSTRACT FROM AUTHOR]

Discusses the weaknesses of the new urban politics in dealing with the global-local relation. Characterization of the new urban politics with respect to the local economic development and the global space economy; Presence of a power relation that is rooted in relative mobilities; Scale of local dependence in the question of mobility and immobility.

Background Aims: Hu8F4 is a T-cell receptor-like antibody with high affinity for the leukemia-associated antigen PR1/HLA-A2 epitope. Adapted into a chimeric antigen receptor (CAR) format, Hu8F4-CAR is composed of the Hu8F4 single-chain variable fragment, the human IgG1 CH2CH3 extracellular spacer domain, a human CD28 costimulatory domain and the human CD3ζ signaling domain. We have demonstrated high efficacy of Hu8F4-CAR-T cells against PR1/HLA-A2-expressing cell lines and leukemic blasts from patients with acute myeloid leukemia in vitro. Previous studies have shown that modification of the Fc domains of IgG4 CH2CH3 spacer regions can eliminate activation-induced cell death and off-target killing mediated by mouse Fc gamma receptor-expressing cells., Methods: We generated Hu8F4-CAR(PQ) with mutated Fc receptor binding sites on the CH2 domain of Hu8F4-CAR to prevent unwanted interactions with Fc gamma receptor-expressing cells in vivo., Results: The primary human T cells transduced with Hu8F4-CAR(PQ) can specifically lyse HLA-A2 + PR1-expressing leukemia cell lines in vitro. Furthermore, both adult donor-derived and cord blood-derived Hu8F4-CAR(PQ)-T cells are active and can eliminate U937 leukemia cells in NSG mice., Conclusions: Herein, we demonstrate that modification of the IgG1-based spacer can eliminate Fc receptor binding-induced adverse effects and Hu8F4-CAR(PQ)-T cells can kill leukemia in vivo., Competing Interests: Declaration of competing interest The authors have no commercial, proprietary or financial interest in the products or companies described in this article., (Copyright © 2024 International Society for Cell & Gene Therapy. Published by Elsevier Inc. All rights reserved.)

Background: Although hysteropexy has been used to preserve the uterus during uterine prolapse surgery for a long time, there is a scarcity of data that describe the nationwide patterns of use of this surgical procedure., Objective: This study aimed to examine the national-level use and characteristics of hysteropexy at the time of laparoscopic apical suspension surgery for uterine prolapse in the United States., Study Design: This cross-sectional study used data from the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population included 55,608 patients with a diagnosis of uterine prolapse who underwent laparoscopic apical suspension surgery from 2016 to 2019. Patients who had a hysterectomy were assigned to the hysterectomy group, and those who did not have a hysterectomy were assigned to the hysteropexy group. The main outcome was clinical characteristics associated with hysteropexy, assessed using a multivariable binary logistic regression model. A classification tree was further constructed to assess the use pattern of hysteropexy during laparoscopic apical suspension procedures. The secondary outcome was surgical morbidity, including urinary tract injury, intestinal injury, vascular injury, and hemorrhage., Results: A hysteropexy was performed in 6500 (11.7%) patients. In a multivariable analysis, characteristics associated with increased use of a hysteropexy included (1) patient factors, such as older age, Medicare coverage, private insurance, self-pay, and medical comorbidity; (2) pelvic floor dysfunction factor of complete uterine prolapse; and (3) hospital factors, including medium bed capacity center and location in the Southern United States (all P <.05). Conversely, (1) the patient factor of higher household income; (2) gynecologic factors such as uterine myoma, adenomyosis, and benign ovarian pathology; (3) pelvic floor dysfunction factor with stress urinary incontinence; and (4) hospital factors including Midwest and West United States regions and rural setting center were associated with decreased use of a hysteropexy (all P <.05). A classification tree identified a total of 14 use patterns for hysteropexies during laparoscopic apical suspension procedures. The strongest factor that dictated the use of a hysteropexy was the presence or absence of uterine myomas; the rate of hysteropexy use was decreased to 5.6% if myomas were present in comparison with 15% if there were no myomas ( P <.001). Second layer factors were adenomyosis and hospital region. Patients who did not have uterine myomas or adenomyosis and who underwent surgery in the Southern United States had the highest rate of undergoing a hysteropexy (22.6%). Across the 14 use patterns, the percentage rate difference between the highest and lowest uptake patterns was 22.0%. Patients who underwent a hysteropexy were less likely to undergo anteroposterior colporrhaphy, posterior colporrhaphy, and sling procedures (all P <.05). Hysteropexy was associated with a decreased risk for measured surgical morbidity (3.0 vs 5.4 per 1000 procedures; adjusted odds ratio, 0.57; 95% confidence interval, 0.36-0.90)., Conclusion: The results of these current, real-world practice data suggest that hysteropexies are being performed at the time of ambulatory laparoscopic apical suspension surgery for uterine prolapse. There is substantial variability in the application of hysteropexy based on patient, gynecologic, pelvic floor dysfunction, and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice may be of use., (© 2024 The Authors.)

Background: Gravid uterine prolapse refers to abnormal descent of the uterus during pregnancy. It is a rare pregnancy complication and its clinical characteristics and obstetrical outcomes are not well understood., Objective: This study aimed to assess the national-level incidence, characteristics, and maternal outcomes of pregnancies complicated by gravid uterine prolapse., Study Design: This retrospective cohort study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population was 14,647,670 deliveries from January 2016 to December 2019. The exposure assignment was the diagnosis of uterine prolapse. The coprimary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcomes of patients with gravid uterine prolapse. The inverse probability of treatment weighting cohort was created to mitigate the difference in prepregnancy confounding factors, followed by adjusting for pregnancy and delivery factors., Results: The incidence of gravid uterine prolapse was 1 in 4209 deliveries (23.8 per 100,000). In a multivariable analysis, older age (≥40 years; adjusted odds ratio, 3.21; 95% confidence interval, 2.70-3.81); age from 35 to 39 years (adjusted odds ratio, 2.66; 95% confidence interval, 2.37-2.99); Black (adjusted odds ratio, 1.48; 95% confidence interval, 1.34-1.63), Asian (adjusted odds ratio, 1.45; 95% confidence interval, 1.28-1.64), and Native American (adjusted odds ratio, 2.17; 95% confidence interval, 1.63-2.88) race/ethnicity; tobacco use (adjusted odds ratio, 1.19; 95% confidence interval, 1.03-1.37); grand multiparity (adjusted odds ratio, 1.78; 95% confidence interval, 1.24-2.55); and history of pregnancy losses (adjusted odds ratio, 2.20; 95% confidence interval, 1.48-3.26) were the patient characteristics associated with increased risk of gravid uterine prolapse. Current pregnancy characteristics associated with gravid uterine prolapse included cervical insufficiency (adjusted odds ratio, 3.25; 95% confidence interval, 1.94-5.45), preterm labor (adjusted odds ratio, 1.53; 95% confidence interval, 1.18-1.97), preterm premature rupture of membranes (adjusted odds ratio, 1.40; 95% confidence interval, 1.01-1.94), and chorioamnionitis (adjusted odds ratio, 1.64; 95% confidence interval, 1.18-2.28). Delivery characteristics associated with gravid uterine prolapse included early-preterm delivery at <34 weeks' gestation (69.1 vs 32.0 per 1000; adjusted odds ratio, 1.86; 95% confidence interval, 1.34-2.59) and precipitate labor (35.2 vs 20.1; adjusted odds ratio, 1.73; 95% confidence interval, 1.22-2.44). Moreover, risks of postpartum hemorrhage (112.1 vs 44.4 per 1000; adjusted odds ratio, 2.70; 95% confidence interval, 2.20-3.32), uterine atony (32.0 vs 15.7; adjusted odds ratio, 2.10; 95% confidence interval, 1.46-3.03), uterine inversion (9.6 vs 0.3; adjusted odds ratio, 31.97; 95% confidence interval, 16.60-61.58), shock (3.2 vs 0.7; adjusted odds ratio, 4.18; 95% confidence interval, 1.41-12.40), blood product transfusion (22.4 vs 11.1; adjusted odds ratio, 2.06; 95% confidence interval, 1.34-3.18), and hysterectomy (7.5 vs 2.3; adjusted odds ratio, 3.02; 95% confidence interval, 1.40-6.51) were increased in the gravid uterine prolapse group compared with the nonprolapse group. Conversely, patients with gravid uterine prolapse were less likely to deliver via cesarean delivery compared with those without gravid uterine prolapse (200.6 vs 322.8 per 1000; adjusted odds ratio, 0.51; 95% confidence interval, 0.44-0.61)., Conclusion: This nationwide analysis suggests that pregnancy with gravid uterine prolapse is uncommon but associated with several high-risk pregnancy characteristics and adverse delivery outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The present study employed an ex-Gaussian model of response times (RTs) to elucidate the cognitive processes related to experimentally induced state anxiety (SA) and vagally mediated heart rate variability (vmHRV), an indicator of adaptive responses in both cognitive and affective domains. Participants (n = 110) completed a dual task composed of (i) a flanker attention and (2) working memory load task, while SA was induced by threat of noise. Electrocardiography was measured during the dual task and during four baseline periods in order to calculate vmHRV. RTs on the flanker task were fit to an ex-Gaussian distribution, which estimated three RT parameters: mu (Gaussian mean), sigma (Gaussian SD), and tau (combination of exponential mean and SD). First, findings indicate that threat of noise was associated with reductions in mu and tau, suggesting that SA might improve attention and motor responding. Second, higher resting vmHRV was associated with lower tau (averaged across conditions) and stronger threat-related decreases in tau. Third, intra-individual decreases in vmHRV were accompanied by concomitant decreases in tau. These findings support roles for trait and state vagal control in guiding adaptive anxiety-related (and anxiety-unrelated) attentional responses. Findings are consistent with extant theories that emphasize functional interrelations among emotion, cognition, and vagal function., (Published by Elsevier B.V.)

The present investigation tested the hypotheses that there would be greater prevalence of expiratory flow limitation (EFL) in endurance-trained (ET) youth cyclists compared with a recreationally active control (CON) group., Methods: Twelve ET youth male cyclists (16.3 ± 1.0 yr (13-18 yr), 176.5 ± 6.2 cm, 64.2 ± 5.9 kg) and 12 CON subjects (17.6 ± 2.2 yr (13-18 yr), 177.9 ± 7.1 cm, 74.8 ± 11.2 kg) completed an incremental exercise test to determine peak oxygen consumption (V˙O2peak) on a cycle ergometer. Maximal flow volume loops (MFVL), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, forced expiratory flow between 25% and 75% of FVC, and peak expiratory flow were assessed before and after exercise, with inspiratory capacity maneuvers and dyspnea ratings measured in the last 20 s of each stage. EFL was quantified as the percentage of the expiratory tidal volume that overlapped with the maximal flow volume loop., Results: V˙O2peak, dyspnea ratings at peak, and ventilation were higher in the ET compared with CON group (P < 0.05). The ET group experienced greater EFL prevalence at V˙O2peak, with 11 of 12 subjects exhibiting EFL compared with 5 of 12 subjects in the CON group (P = 0.014). When matched for absolute ventilation of 20, 40, 60, 80, and 100 L·min, there were no differences in EFL severity between the ET and CON groups (P = 0.473)., Conclusions: Elite youth male cyclists have a greater prevalence of EFL at maximal exercise than do CON subjects who are similar in age, height, and lung size. Future research should determine whether EFL in youth ET male cyclists may limit their exercise performance.

By the end of the 20 th century, health care organizations worldwide were recognizing the benefits of a quick response when patients were experiencing a clinical decline and the difficulty in achieving that goal. The University of Missouri STAT Nurse program, developed in 1989, was an early innovation to deliver the "right care" at the "right time" every time. Over the years, the STAT Nurse program evolved and became the core component of a Rapid Response System. Today Rapid Response at University of Missouri Health Care is called the Targeted Interventional Group Emergency Response Team, also known as the TIGER Team after the much beloved University mascot.

Recent advances in the science of teams have provided much insight into the important attitudes (e.g., team cohesion and efficacy), cognitions (e.g., shared team cognition), and behaviors (e.g., teamwork communications) of high performing teams and how these competencies emerge as team members interact, and appropriate measurement methods for tracking development. Numerous training interventions have been found to effectively improve these competencies, and more recently have begun addressing the problem of team dynamics. Team science researchers have increasingly called for more field studies to better understand training and team development processes in the wild and to advance the theory of team development. In addition to the difficulty of gaining access to teams that operate in isolated, confined, and extreme environments (ICE), a major practical challenge for trainers of ICE teams whose schedules are already strained is the need to prioritize the most effective strategies to optimize the time available for implementation. To address these challenges, we describe an applied research experiment that developed and evaluated an integrated team training approach to improve Tactical Combat Casualty (TC3) skills in U.S. Army squads. Findings showed that employing effective team training best practices improved learning, team cognition, emergent team processes, and performance. We recommend future research should focus on understanding the types of training strategies needed to enable teams and team leaders to develop from novices to experts. Effectively modifying training to scale it to team expertise requires more research. More laboratory and field research is needed to further develop measures of team knowledge emergence for complex task domains, and include other potential emergent factors such as team leadership and resilience. Practical implications for research include developing automated tools and technologies needed to implement training and collect team data, and employ more sensitive indicators (e.g., behavioral markers) of team attitudes, cognitions and behaviors to model the dynamics of how they naturally change over time. These tools are critical to understanding the dynamics of team development and to implement interventions that more effectively support teams as they develop over time.

We present a theory to predict the structure and thermodynamics of mixtures of colloids of different diameters, building on our earlier work [A. Bansal et al., J. Chem. Phys. 145, 074904 (2016)] that considered mixtures with all particles constrained to have the same size. The patchy, solvent particles have short-range directional interactions, while the solute particles have short-range isotropic interactions. The hard-sphere mixture without any association site forms the reference fluid. An important ingredient within the multi-body association theory is the description of clustering of the reference solvent around the reference solute. Here we account for the physical, multi-body clusters of the reference solvent around the reference solute in terms of occupancy statistics in a defined observation volume. These occupancy probabilities are obtained from enhanced sampling simulations, but we also present statistical mechanical models to estimate these probabilities with limited simulation data. Relative to an approach that describes only up to three-body correlations in the reference, incorporating the complete reference information better predicts the bonding state and thermodynamics of the physical solute for a wide range of system conditions. Importantly, analysis of the residual chemical potential of the infinitely dilute solute from molecular simulation and theory shows that whereas the chemical potential is somewhat insensitive to the description of the structure of the reference fluid, the energetic and entropic contributions are not, with the results from the complete reference approach being in better agreement with particle simulations.

A mixture of solvent particles with short-range, directional interactions and solute particles with short-range, isotropic interactions that can bond multiple times is of fundamental interest in understanding liquids and colloidal mixtures. Because of multi-body correlations, predicting the structure and thermodynamics of such systems remains a challenge. Earlier Marshall and Chapman [J. Chem. Phys. 139, 104904 (2013)] developed a theory wherein association effects due to interactions multiply the partition function for clustering of particles in a reference hard-sphere system. The multi-body effects are incorporated in the clustering process, which in their work was obtained in the absence of the bulk medium. The bulk solvent effects were then modeled approximately within a second order perturbation approach. However, their approach is inadequate at high densities and for large association strengths. Based on the idea that the clustering of solvent in a defined coordination volume around the solute is related to occupancy statistics in that defined coordination volume, we develop an approach to incorporate the complete information about hard-sphere clustering in a bulk solvent at the density of interest. The occupancy probabilities are obtained from enhanced sampling simulations but we also develop a concise parametric form to model these probabilities using the quasichemical theory of solutions. We show that incorporating the complete reference information results in an approach that can predict the bonding state and thermodynamics of the colloidal solute for a wide range of system conditions.

Purpose: Quality improvement (QI) has been part of medical education for over a decade. Assessment of QI learning remains challenging. The Quality Improvement Knowledge Application Tool (QIKAT), developed a decade ago, is widely used despite its subjective nature and inconsistent reliability. From 2009 to 2012, the authors developed and assessed the validation of a revised QIKAT, the "QIKAT-R.", Method: Phase 1: Using an iterative, consensus-building process, a national group of QI educators developed a scoring rubric with defined language and elements. Phase 2: Five scorers pilot tested the QIKAT-R to assess validity and inter- and intrarater reliability using responses to four scenarios, each with three different levels of response quality: "excellent," "fair," and "poor." Phase 3: Eighteen scorers from three countries used the QIKAT-R to assess the same sets of student responses., Results: Phase 1: The QI educators developed a nine-point scale that uses dichotomous answers (yes/no) for each of three QIKAT-R subsections: Aim, Measure, and Change. Phase 2: The QIKAT-R showed strong discrimination between "poor" and "excellent" responses, and the intra- and interrater reliability were strong. Phase 3: The discriminative validity of the instrument remained strong between excellent and poor responses. The intraclass correlation was 0.66 for the total nine-point scale., Conclusions: The QIKAT-R is a user-friendly instrument that maintains the content and construct validity of the original QIKAT but provides greatly improved interrater reliability. The clarity within the key subsections aligns the assessment closely with QI knowledge application for students and residents.

Intermolecular potential models for water and alkanes describe pure component properties fairly well, but fail to reproduce properties of water-alkane mixtures. Understanding interactions between water and non-polar molecules like alkanes is important not only for the hydrocarbon industry but has implications to biological processes as well. Although non-polar solutes in water have been widely studied, much less work has focused on water in non-polar solvents. In this study we calculate the solubility of water in different alkanes (methane to dodecane) at ambient conditions where the water content in alkanes is very low so that the non-polar water-alkane interactions determine solubility. Only the alkane-rich phase is simulated since the fugacity of water in the water rich phase is calculated from an accurate equation of state. Using the SPC/E model for water and TraPPE model for alkanes along with Lorentz-Berthelot mixing rules for the cross parameters produces a water solubility that is an order of magnitude lower than the experimental value. It is found that an effective water Lennard-Jones energy ε(W)/k = 220 K is required to match the experimental water solubility in TraPPE alkanes. This number is much higher than used in most simulation water models (SPC/E-ε(W)/k = 78.2 K). It is surprising that the interaction energy obtained here is also higher than the water-alkane interaction energy predicted by studies on solubility of alkanes in water. The reason for this high water-alkane interaction energy is not completely understood. Some factors that might contribute to the large interaction energy, such as polarizability of alkanes, octupole moment of methane, and clustering of water at low concentrations in alkanes, are examined. It is found that, though important, these factors do not completely explain the anomalously strong attraction between alkanes and water observed experimentally.

The ubiquitous use of surfactants in commercial and industrial applications has led to many experimental, theoretical, and simulation based studies. These efforts seek to provide a molecular level understanding of the effects on structuring behavior and the corresponding impacts on observable properties (e.g., interfacial tension). With such physical detail, targeted system design can be improved over typical techniques of observational trends and phenomenological correlations by taking advantage of predictive system response. This research provides a systematic study of part of the broad parameter space effects on equilibrium microstructure and interfacial properties of amphiphiles at a liquid-liquid interface using the interfacial statistical associating fluid theory density functional theory as a molecular model for the system from the bulk to the interface. Insights into the molecular level physics and thermodynamics governing the system behavior are discussed as they relate to both predictions qualitatively consistent with experimental observations and extensions beyond currently available studies., (© 2011 American Institute of Physics)

A unique rapid response system was designed to provide social, psychological, emotional, and professional support for health care providers who are "second victims"--traumatized as a result of their involvement in an unanticipated adverse event, medical error, or patient-related injury.

Objectives: In an effort to improve patient safety attitudes and skills among third-year medical students, two patient safety training sessions were added to their curriculum, complementing a previously implemented second-year curriculum on quality improvement, patient safety and teamwork., Methods: Safety attitudes and skills were assessed before and after students completed the medicine clerkship training and were compared with historical controls. Students identified and reported on observed safety events, with their reports matched to event type and harm score with contemporaneous safety reports from University of Missouri's Patient Safety Network (PSN). Comparisons were assessed by five internal safety experts using criteria for report submission "worthiness", blame tone, target of blame and presence/strength of proposed solutions., Results: Students completing the third-year safety booster conferences expressed statistically higher comfort levels with identifying the cause of an error than did the student control group (p<0.05). Medical students proposed safety interventions that were more robust than those suggested by event reporters regarding similar events within our health system (p<0.0001). The worthiness and blame tone of medical student reports were not statistically different than event reports in PSN., Conclusions: Completion of two 1-h patient safety booster conferences in the third year of medical school led to increased student comfort in safety event analysis. Students documented stronger resolution robustness scores, suggesting similar training should be offered to PSN reporters. Medical students represent an underutilised resource for identifying and proposing solutions for patient safety issues.

In response to the Institute of Medicine challenge to improve patient safety and quality of care, an office directing patient safety/quality of care at an academic medical center and faculty from health professions schools collaborated on design, delivery, and evaluation of an interprofessional student curriculum on patient safety, quality, and teamwork. Annually for 6 years, second-year medical students, senior baccalaureate nursing students, second-year masters in health administration students, and junior baccalaureate respiratory therapy students participated. A pre-/postsurvey assessing students' attitudes about quality, safety, and teamwork was developed and modified to reflect course revisions. Survey items were grouped into 1 of the 6 subscales: human fallibility, disclosure, teamwork/communication, error reporting, systems of care, and curricular time spent with other professionals. At pretest, there were significant professional group differences in all the 6 subscales. At completion, differences in 4 subscales were resolved with the exception of human fallibility (P < .001) and curricular time spent together (P < .001). Interprofessional exercises within our curriculum mediated most differences among student groups. As more interprofessional curricular experiences are designed, examining baseline group differences is essential to optimize learning outcomes.

Background and Methods: Medical students, nursing students, and other health care professionals in training were integrated with health care workers on interprofessional quality improvement (QI) teams at our academic health center. Teams received training in QI, accompanied by expert QI mentoring, with dual goals of increasing expertise in improvement while improving care., Results: Eighty-six learners and health system workers participated in 12 improvement teams in 2 years. Upon completion of the training, participants expressed that the program enhanced QI and teamwork skills and increased understanding of other health care professions. At the end of the program, fourth-year medical students showed greater ability to apply QI skills, as measured by the QI Knowledge Assessment Tool than did control students who did not participate in the program (P < .0001 in 2006-2007 and P < .0005 in 2007-2008). Many teams were successful in improving care processes., Conclusion: The design of "learning QI by doing," accompanied by just-in-time training and ongoing expert mentoring in QI, was identified by faculty as the most important factor contributing to success. This model successfully improved application of QI skills by learners while improving care within our academic health center. Testing of the model at other academic health centers and in other training environments is warranted.

Problem: Although Morbidity and Mortality conferences (MMC) were originally designed to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes., Design: Pre- and post-intervention assessments of participant attitudes toward patient safety and conference redesign were performed utilizing an attitudinal survey. Participants provided a unique identifier for paired-means procedure. A list of contributing factors, recommended solutions, and targeted system improvements was maintained with ongoing progress recorded., Setting: Department of Internal Medicine training program at University of Missouri-Columbia, an academic health care center affiliated with the University of Missouri Hospitals and Clinics and the Harry S. Truman Veteran's Administration Hospital., Participants: Residents and fellows from the Department of Internal Medicine residency program., Educational Objectives: (1) Distinguish between culture of blame/shame and patient safety culture, (2) Identify gaps in quality contributing to adverse outcomes, (3) Identify strategies to close gaps, (4) Participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan., Strategies for Change: An interdisciplinary team modified the internal medicine MMC to emphasize a better understanding of patient safety principles and system-based practice interventions. For each adverse event analyzed, root causes were identified, followed by discussion of system interventions that might prevent future such events., Key Measures for Improvement: (1) Attitudes of residents and fellows regarding patient safety, as measured on a 20 item, five-point ordinal scale (strongly disagree to strongly agree) survey, (2) System improvements generated from the Patient Safety M&M Conferences (PSMMC), and (3) Attendance at PSMMC., Effects of Change: Clinical outcomes: Conference participants offered 121 system improvement recommendations; 39 suggested system interventions were pursued based upon the likelihood of achieving high impact changes. These targeted changes were assigned to department/facility representatives with 23 (59%) improvements implemented, 11 (28%) partially implemented or in progress, and five (13%) abandoned due to impracticality or redundancy. Educational outcomes: Surveys were completed by 58 residents and fellows before and after modification of conference format. Six of the 20 survey items showed significant change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction, but did not reach statistical significance. Average MMC attendance increased from 41+/-8 to 50+/-10 (p<0.03) participants., Lessons Learnt: The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

Problem: Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes., Design: Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded., Setting: Department of Internal Medicine training programme at University of Missouri-Columbia., Participants: Residents and fellows from the above residency programme., Educational Objectives: (1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan., Strategies for Change: An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system-based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events., Key Measures for Improvement: (1) Attitudes of residents and fellows regarding patient safety, as measured on a 20-item, five-point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC., Effects of Change: Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41+/-8 to 50+/-10 participants (p<0.03)., Lessons Learnt: The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

Purpose: To study the effects of a patient safety and medical fallibility curriculum on second-year medical students at the University of Missouri-Columbia School of Medicine in 2003-2004., Method: Students completed a knowledge, skills, and attitudes questionnaire before the curriculum, after the final learning experience, and one year later. A 95% confidence interval (CI) for paired differences assessed change over time. At one year, students also responded to items about their use of the curriculum, error reporting, and disclosure experiences., Results: Fifty three of 92 students (55%) completed the questionnaire at all three assessment points. Students' eight items and the calculated knowledge score improved after the curriculum but only seven of these improvements were sustained one year. Responses to seven items did not change and five changed in an undesired direction after the curriculum and/or after one year. Seventy two students completed the self-reported behavior questions at one year. More than half reported using what they learned in the curriculum. Although 76% of students reported observing an error, 71% of these disclosed an error to their peers, 56% to a resident, and 46% to faculty. Only 7% reported an error using our electronic error reporting system., Conclusions: The curriculum led to changes in second-year medical students' knowledge, skills, and attitudes, but not all of the changes were sustained at one year, were in the desired direction, or were supported by their self-reported behaviors. The extent to which other informal or hidden curriculum experiences reversed the gains and affected the changes at one year is unknown.

Asthma is the most frequent reason for preventable hospital admissions among children regardless of race or socioeconomic status. Since hospitalizations are preventable, a reasonable assumption is that parents are not optimally managing their child's asthma. Using Orem's self-care deficit nursing theory, 14 conditions were uncovered in the pediatric asthma literature that influence development of competency by parents. Twelve of the 14 antecedent conditions are influenced by factors partly or completely controlled by the healthcare system. Healthcare system gaps associated with asthma symptom control have come to light through the articulation of the pediatric asthma literature and Orem's theory.

Although current literature supports the use of evidence-based clinical practice guidelines (CPGs) by physicians, there is limited research concerning operational issues that may be inhibiting effective CPG implementation. The objective of our research was to increase understanding of clinical practice patterns by identifying physician preferences for CPG accessibility, format, content and learning strategies. Semistructured interviews were conducted with resident and faculty physicians in an academic medical center after they were presented with a CPG during treatment of a patient with acute pancreatitis. The results of our study revealed that physicians prefer CPGs in the form of evidence-based algorithms with treatment-specific information that is placed on the front of the patient chart during treatment. In addition, they felt that discussion of the guideline with colleagues, reminder notes/stickers on front of the patient chart, and verbal reminders from a nurse were the most effective means of encouraging utilization.

With clear and accurate peritoneal dialysis departmental policies, procedures, and patient care standards, the creation of an orientation module with objective and measurable patient care and staff performance outcomes is easily produced. This article describes revision of policies, procedures, and patient care standards, and an approach for building linkages with the employee orientation program. No formal classroom time is required, and the level of orientee experience is accommodated. All peritoneal dialysis staff members are capable of equal preceptor participation.

Peritoneal dialysis is one of the treatments for end stage renal disease that requires considerable expertise. When neonates or children develop end stage renal disease, both the patient and family members must be provided with substantial education and training. The organization of education and training is paramount, especially as length of stay is limited with managed care. The development of an organized interdisciplinary approach for this instruction and pediatric patient teaching protocol for management of home peritoneal dialysis therapy is discussed in this article. The protocol provides learning content, methodologies and patient/family outcomes and is accompanied by a documentation tool that serves as communication for directing team member reinforcement of content until outcomes are met. Since completion of the protocol, eight pediatric patients have been placed on this teaching plan with extremely positive outcomes.

Creative planning and well-executed graphics produced an upbeat approach to preparing staff for a JCAHO accreditation visit. Five humorous and highly visible strategies were used in a coordinated eight-week "campaign." Not only did the institution "pass the test" but there was a consensus among staff nurses that they had felt comfortable, confident and in control during interviews with the JCAHO surveyor.

Multiple-choice questions classified as requiring problem-solving skills have been interpreted as measuring problem-solving skills within students, with the implicit hypothesis that questions needing an increasingly complex intellectual process should present increasing difficulty to the student. This hypothesis was tested in a 150-question paper taken by 721 students in seven Australian medical schools. No correlation was observed between difficulty and assigned process. Consequently, the question-answering process was explored with a group of final-year students. Anecdotal recall by students gave heavy weight to knowledge rather than problem solving in answering these questions. Assignment of the 150 questions to the classification by three teachers and six students showed their congruence to be a little above random probability.

The conduct of College examinations has seemed a mystery to many candidates. Both candidates and supervisors of training have echoed this concern with the R.A.C.S. new Part 1 examination. This paper describes the work of the Board of Examiners of the Royal Australasian College of Surgeons and the procedures by which the new Part 1 examination is constructed, administered, analysed and refined. It sets out how the examination has been developed into an educational instrument to provide feedback to candidates, to teachers and to examiners, so that each can improve his performance. In addition, the Board has acquired data from each candidate on his learning opportunities, and from each candidate's mentor on various performance characteristics of the candidate.

Regional perfusion has been carried out in the limbs of a group of patients with recurrent melanoma, and has achieved disappearance of visible disease in the affected limb in 10 patients out of 28 (36%), prevention of local recurrence in five, and no effect on the disease in nine. This control of recurrent melanoma cost no mortality, but did carry a definite but acceptable morbidity.

Per capita expenditure on health is low in developing countries. Distribution of health care resources reflects the tension among perceived health priorities. Medical perceptions of "best care" generate expectations of technologically advanced, hospital-based, urban care within a staged referral system. World Health Organization presses a decentralized model for accessible, acceptable illness care linked with education for prevention, infrastructure development and peripheral responsibility.

The setting out of management problems in the sequence of question--evidence--action follows practice realities in many situations more closely than the inductive sytle of evidence--diagnosis--action. Explicit setting out of the decision-making process provides a framework for clearer role-identification for different practice specialities, with the opportunity for closer cooperation and joint investigation. Sequential investigation and decision-making separate categories of patients. This streaming can maximize efficiency of investigation and minimize wasteful over-investigation. Teaching a sequential approach to diagnosis and management provides the student with a practical method for solving problems in the real world. If every investigation sought must be justified in terms of the specific question it is to answer, the student will be trained to avoid unnecessary investigation, and the young graduate will find it more difficult to "procrastinate by investigation" because of inability to face up to decision-making.