Article

The Checklist Manifesto: How to Get Things Right

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Abstract

Today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. But avoidable failures are common, and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently. In this groundbreaking book, Atul Gawande makes a compelling argument for the checklist, which he believes to be the most promising method available in surmounting failure. Whether you're following a recipe, investing millions of dollars in a company or building a skyscraper, the checklist is an essential tool in virtually every area of our lives, and Gawande explains how breaking down complex, high pressure tasks into small steps can radically improve everything from airline safety to heart surgery survival rates. Fascinating and enlightening, The Checklist Manifesto shows how the simplest of ideas could transform how we operate in almost any field.

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... A checklist is a list of systematically ordered actions that enables users to consistently perform each action and record its completion while reducing any errors that may be caused by missing out crucial steps (Gawande, 2010). Checklists can be used to help organisations and individuals consistently measure and monitor outputs and outcomes, and hence develop a culture of continuous quality improvement. ...
... Checklists can be used to help organisations and individuals consistently measure and monitor outputs and outcomes, and hence develop a culture of continuous quality improvement. They have been shown to be effective in improving outcomes in other areas of practice, powerfully described in The Checklist Manifesto (Gawande, 2010). Aircraft safety has been transformed by the use of checklists. ...
... This was exemplified in the 'Miracle of the Hudson' landing of US Airways Flight 1549 on the River Hudson, where the pilots ran through a checklist before flying, worked through the engine failure checklists when attempting to restart the engines after colliding with a flock of geese, and then, after landing on the Hudson River, ran through the evacuation checklist. Gawande (2010) organised the creation of a checklist for use in surgery: the World Health found that when the checklist was used, rates of complications during surgery decreased from 19.9% to 11.5%, and the mean length of a hospital stay was reduced by 0.8 days. The reduction in mortality from 1.6% to 1.0% was not statistically significant. ...
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There are severe problems with the decision-making processes currently widely used, leading to ineffective use of evidence, faulty decisions, wasting of resources and the erosion of public and political support. In this book an international team of experts provide solutions. The transformation suggested includes rethinking how evidence is assessed, combined, communicated and used in decision-making; using effective methods when asking experts to make judgements (i.e. avoiding just asking an expert or a group of experts!); using a structured process for making decisions that incorporate the evidence and having effective processes for learning from actions. In each case, the specific problem with decision making is described with a range of practical solutions. Adopting this approach to decision-making requires societal change so detailed suggestions are made for transforming organisations, governments, businesses, funders and philanthropists. The practical suggestions include twelve downloadable checklists. The vision of the authors is to transform conservation so it is more effective, more cost-efficient, learns from practice and is more attractive to funders. However, the lessons of this important book go well beyond conservation to decision-makers in any field.
... High-reliability industries, including aviation and space flight, are regarded as providing the gold standard model to which healthcare organisations should aspire [6]. Many medical emergencies, although not rare events when considered across a hospital system, are not necessarily crises that individual clinicians and teams encounter on a regular basis. ...
... In the trials by St. Pierre et al.,for example, approximately half of the clinicians used the cognitive aid with the read-do approach, with the remainder adopting a do-confirm model. Following a read-do approach involves reading the checklist prompt and then acting upon it before moving on to the next one.[6,31,32]. ...
Article
Clinical emergencies can be defined as unpredictable events that necessitate immediate intervention. Safety critical industries have acknowledged the difficulties of responding to such crises. Strategies to improve human performance and mitigate its limitations include the provision and use of cognitive aids, a family of tools that includes algorithms, checklists and decision aids. This systematic review evaluates the usefulness of cognitive aids in clinical emergencies. Following a systematic search of the electronic databases, we included 13 randomised controlled trials, reported in 16 publications. Each compared cognitive aids with usual care in the context of an anaesthetic, medical, surgical or trauma emergency involving adults. Most trials used only clinicians in the development and testing of the cognitive aids, and only some trials provided familiarisation with the cognitive aids before they were deployed. The primary outcome was the completeness of care delivered to the patient. Cognitive aids were associated with a reduction in the incidence of missed care steps from 43.3% to 11% (RR (95%CI) 0.29 (0.16–0.15); p < 0.001), and the quality of evidence was rated as moderate. The use of cognitive aids was related to decreases in the incidence of errors, increases in the rate of correctly performed steps and improvement in the clinical teamwork skills scores, non‐technical skills scores, subjective conflict resolution scores and the global assessment of team performance. Cognitive aids had an inconsistent influence on the time to first intervention and time to complete care of the patient's condition. It is possible that this was a reflection of how common or rare the crisis in question was as well as the experience and expertise of the clinicians and team. Sufficient thought should be applied to the development of the content and design of cognitive aids, with consideration of the pre‐existing guideline ecosystem. Cognitive aids should be tested before their deployment with adequate clinician and team training.
... These checklists aimed to reduce clinician's cognitive load and reliance on memory [6] by documenting the steps of a specific task (e.g., a surgical procedure). Following these successes, the use of checklists has also been advocated as a tool to reduce diagnostic errors [7][8][9][10][11], a long understudied type of medical errors [12] that occur when diagnoses are wrong, missed, or delayed [13]. Diagnostic errors are a large burden on patient safety and it is estimated that a majority of people will experience a diagnostic error during their lifetime [13,14]. ...
... Content checklists can give possible diagnoses for certain symptoms [23,26,28] or ensure the clinician considers all relevant information for a diagnosis, as even those who were trained to follow the steps of a specific protocol will not always adhere to this protocol [29][30][31][32][33][34][35][36][37]. Furthermore, content checklists might have the potential to reduce clinicians' cognitive load by facilitating information integration [7,38]. ...
Article
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Objectives Checklists that aim to support clinicians’ diagnostic reasoning processes are often recommended to prevent diagnostic errors. Evidence on checklist effectiveness is mixed and seems to depend on checklist type, case difficulty, and participants’ expertise. Existing studies primarily use abnormal cases, leaving it unclear how the diagnosis of normal cases is affected by checklist use. We investigated how content-specific and debiasing checklists impacted performance for normal and abnormal cases in electrocardiogram (ECG) diagnosis. Methods In this randomized experiment, 42 first year general practice residents interpreted normal, simple abnormal, and complex abnormal ECGs without a checklist. One week later, they were randomly assigned to diagnose the ECGs again with either a debiasing or content-specific checklist. We measured residents’ diagnostic accuracy, confidence, patient management, and time taken to diagnose. Additionally, confidence-accuracy calibration was assessed. Results Accuracy, confidence, and patient management were not significantly affected by checklist use. Time to diagnose decreased with a checklist (M=147s (77)) compared to without a checklist (M=189s (80), Z =−3.10, p=0.002). Additionally, residents’ calibration improved when using a checklist (phase 1: R ² =0.14, phase 2: R ² =0.40). Conclusions In both normal and abnormal cases, checklist use improved confidence-accuracy calibration, though accuracy and confidence were not significantly affected. Time to diagnose was reduced. Future research should evaluate this effect in more experienced GPs. Checklists appear promising for reducing overconfidence without negatively impacting normal or simple ECGs. Reducing overconfidence has the potential to improve diagnostic performance in the long term.
... Aviation checklists are routinely used to assure the completion of complex tasks before takeoff and during the flight (Rantz 2009) and the Civil Air Patrol trains pilots on the IM SAFE mnemonic checklist (for illness, medication, stress, alcohol, fatigue, and eating) to determine whether a pilot is fit to fly (Hales & Pronovost, 2006). Lately, checklists have gained prominence in the popular press as policy interventions offering a rare combination of simplicity, affordability, and efficacy (see Gawande, 2009 for discussion and review). ...
... Consequently, we are very far from proposing that pilots should fly or that surgeons should operate without checklists. As noted, abundant research suggests that in the contexts in which checklists are normally used (where the environment is familiar, tasks are well rehearsed, the users are themselves experts, the listed items may otherwise be missed, and non-checklist errors are rare) the use of checklists reduces errors well below baseline (see Gawande, 2009, for a popular review). Nonetheless, the theoretical trade-off and empirical results discussed here reveal the potential vulnerability to unexpected sources of error. ...
Article
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Research suggests that checklists reduce errors in fields ranging from aviation to medicine. Checklists are effective in part because their content is not randomly selected from available information but strongly sampled from information experts believe is critical. This sampling process supports the inference that unlisted information is unlikely to be important. However, this predicts that checklists might leave learners selectively vulnerable to unlisted sources of error. In Experiment 1, we show that adults in an aviation class detect fewer unlisted sources of error given a checklist than at baseline. In Experiment 2, we show that this inductive bias does not require previous experience with checklists: given a checklist for organizing a room, children (mean: 62 months) selectively overlooked unlisted items relative to baseline, and did so even when told the list might be incomplete.
... In addition to the practices our workshop participants reported, a sample of which are provided above, material exist in both the scientific literature across various disciplines (e.g., Van Eerde, 2003;Gupta et al., 2012;Andrade, 2013;Manchester and Barbezat, 2013;Prinz et al., 2020;Wessel et al., 2020) and the popular press (e.g., Koch, 1998;Gawande, 2009;McKeown, 2014;Tracy, 2017;Covey, 2020) offering advice on how to have more of your time available to do high-priority tasks and be more productive. Being too busy is so prevalent and worrisome that an industry exists to teach "time management" for individuals, work teams and organizations. ...
... Many authors offer advice on controlling how busy one is (e.g., Koch, 1998;Gawande, 2009;McKeown, 2014;Tracy, 2017;Covey, 2020). Unfortunately, although many wildlife professionals have been exposed to such advice, they find it difficult to put the advice into practice, ironically because they are too busy to even think about the tips suggested. ...
... It could be argued these oversights are small, and that the majority of authors remember to include these criteria in some capacity as they are simple and could be argued to be 'common sense'. However, Gawande (2011) explains how forgetting the simplest actions is easy to do, even (perhaps especially) for experts in their work. ...
... A checklist approach has a variety of benefits; they are simple to follow, easy to evaluate, and improve performance of routine actions (which, arguably, writing methodology sections become for researchers). For example, Gawande (2011) discusses how checklists in intensive care units reduced ten-day line infection rates from 11 to 0%, which involved doctors being reminded by nurses to follow standardised checklist items they were aware of but infrequently forgot to do. Whilst reporting player research is not as life threatening, the same principles can be applied to improve the robustness of the field in similar ways. ...
Article
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There are many questionnaires to assess player motivation, originating from a diverse range of disciplines. Each discipline differs in their usage and reporting of questionnaires, but there has been no attempt to synthesise or standardise their application. No standard approach leads to a lack of transparency in usage reporting, which affects the ability of the field to synthesise. This has made it unclear whether player motivation research is a unified community, or a collection of individuals with a similar goal. Therefore, the current work assesses the transparency of reporting practices of player motivation questionnaires published within the last 15 years. 18 questionnaires were identified via a scoping review, then papers citing these questionnaires were analysed for their transparency of reporting practices (n=238); first via a content analysis of justifications for use, then followed by an analysis of transparency against eight criteria created for this work. Overall, reporting transparency is lacking, driven by little priority for presenting items alongside text. Many papers use questionnaires because they are theory-based or have measured specific variables in previous works, but explicit justification is rare. The work concludes with a transparency checklist based on the eight criteria used, which authors can use to standardise the field and allow for more cohesive research synthesis.
... L'absence d'informations sur certaines dimensions : Un autre point relevé dans les é tudes concerne le manque ou l'absence d'information (ou des informations inadé quates) sur des dimensions centrales qui permettent de ré pondre aux questions posé es dans l'expertise [21,25,54] (par exemple, l'absence d'investigation de la sexualité chez des auteurs d'infractions sexuelles, sans que le lecteur sache si c'est le fait de l'expert qui n'a pas investigué cette dimension, ou celui du sujet expertisé qui n'a pas souhaité ou qui n'a pas pu verbaliser autour de cette question [38]). ...
... Enfin, diffé rents auteurs proposent des listes de contrôle [21,25,54,56]. Basé es sur le travail initial de Grisso [25] et les travaux de Witt [54], ces listes permettent de passer en revue les erreurs ré currentes qui apparaissent dans les rapports. ...
Article
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Résumé Introduction L’expertise judiciaire fait fréquemment l’objet de publications ; cependant, peu de travaux francophones s’intéressent aux modalités de restitution écrite d’une évaluation expertale, c’est-à-dire à la manière dont le rapport d’expertise est présenté et rédigé par son auteur, dans l’objectif de répondre aux questions posées par les autorités judiciaires et d’aider à la prise de décision. La manière dont le rapport est rédigé peut avoir une incidence sur la perception de la situation de l’expertisé, sur la valeur accordée à ce travail complexe d’évaluation et sur les décisions judiciaires. Ainsi, cet article vise à recenser les principales critiques mentionnées dans la littérature scientifique concernant les rapports d’expertise, et les ressources pour les améliorer et les rendre conformes aux attentes professionnelles. Méthode Cet article présente une recension narrative des écrits scientifiques. Il est basé sur des publications anglophones et francophones rapportant des études et revues de littérature concernant les rapports d’expertise judiciaires dans le domaine de la psychologie et psychiatrie légales. Résultats La recension des travaux dégage quatre axes qui peuvent affecter la qualité du rapport écrit : le cadre expertal et la position de l’expert ; la terminologie et les modes d’écriture utilisés dans le rapport ; le manque de référence aux principes généraux d’une évaluation psycho-légale ; les faiblesses dans l’organisation des données présentées dans l’expertise et dans la démarche argumentative pour répondre aux questions. Conclusion Les faiblesses rapportées pourraient être améliorées par la formation des experts, les guides d’évaluation, la collégialité d’experts et les listes de contrôle.
... The idea of saving energy by a DST system was known for at least a hundred years before Franklin first suggested it in 1784 (Franklin, 1784;Hudson, 1784;Willett, 1907). The idea was so simple that Franklin initially proposed it as a joke. ...
... Although the pilot was an expert, the greater complexity of the Boeing 299 with respect to the classic aircraft induced the pilot to forget to deactivate a new steering wheel lock mechanism. A commission of experts decided to create a checklist to help both beginners and expert pilots (paradoxically, problems resolved by the checklist are actually more pertinent to mistakes made by experts than by beginners) to reduce simple but dangerous mistakes in complex processes (Gawande, 2011). ...
Article
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Why is it that both complex and simple solutions that have proved to be effective have low rates of adoption? The literature on innovation (i.e., a specific category of solutions) management has provided some clues, identifying barriers of several types: organizational, technological, economic, human behavior and the nature of the innovation. We suggest that one reason is the misalignment between the degrees of complexity i.e., the degree of knowledge embedded, of the problem and its solution. A solution perceived to be too simple for a complex problem falls into the category of what might be called “Columbus' egg”. At the basis of this effect there is the tendency to minimize expected frustration as the difference between the effort made in looking for a solution and the obtained reward. When the solution is too complex for a simple problem, this is the case of the “Engineer's effect”. This effect has its cognitive underpinnings in the tendency to minimize decision-making costs. We discuss and illustrate these phenomena and propose some guidelines for technology developers and product innovation managers, as well as for forecasting solutions adoption.
... Checklists provide transparency, organization, and reduction in the risk of human error [1]. They have been successfully implemented in many different processes specifically for these reasons. ...
... The authors would like to thank the participants for undertaking this survey that can improve the education of future cohorts. 1 ...
Article
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Background Students face hardships in determining what are the main points that need more studying in every subject. Checklists are one of the ways that can help students identify the most important pieces of information. Accordingly, in this study, we aimed at examining the impact of using educational checklists on the learning process of postgraduate students at Nagasaki University, Japan. Methods Thirty-one Master's students, who finished a “how to write a research protocol” course were recruited by sending them an invitation email that had an attached link to a previously developed and tested questionnaire on the SurveyMonkey® platform. After signing the electronic informed consent, twenty-two participants (response rate = 71%) finished the survey. The data was analyzed using Microsoft Excel and expressed in the form of frequencies and percentages. Results More than half of the students declared that they know the checklist will be used in the course that we investigated. Only two students used checklists as a means of studying (9%). Twelve students (55%) confirmed that no other courses or lessons in the School of Tropical Medicine and Global Health (TMGH) use checklists. No students found the usage of checklists not easy or not practical to apply. Many students thought the length of the checklist was suitable and not too short (64%), although three students (14%) found it lengthy. Moreover, most students described the checklist as beyond good (86%) and they would recommend using a checklist for teaching other college students (73%). Conclusion Using checklists in education can facilitate the learning process, help in memorization, and deepen the concepts being studied. Further studies are required to examine the impact of checklists in teaching undergraduate students and students from other non-healthcare disciplines.
... 6 Concise checklist-type tools to provide the right question at the right time have provided proven, feasible methods for guiding effective implementation of operational healthcare initiatives, even in complex settings such as operating rooms. 7,8 The current report describes the rationale, development, evaluation, revision, and adoption of a concise research-to-implementation planning instrument within a delivery science and applied research program embedded within a large learning healthcare system. Its creation integrated core concepts of existing frameworks and utilized a systematic process of end-user stakeholder engagement. ...
Article
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Learning health systems require rapid‐cycle research and nimble implementation processes to maximize innovation across disparate specialties and operations. Existing detailed research‐to‐implementation frameworks require extensive time commitments and can be overwhelming for physician‐researchers with clinical and operational responsibilities, inhibiting their widespread adoption. The creation of a short, pragmatic checklist to inform implementation processes may substantially improve uptake and implementation efficiency across a variety of health systems. We conducted a systematic review of existing implementation frameworks to identify core concepts. Utilizing comprehensive stakeholder engagement with 25 operational leaders, embedded physician‐researchers, and delivery scientists, concepts were iteratively integrated to create and implement a final concise instrument. A systematic review identified 894 publications describing implementation frameworks, which included 15 systematic reviews. Among these, domains were extracted from three commonly utilized instruments: the Quality Implementation Framework (QIF), the Consolidated Framework for Implementation Research (CFIR), and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) framework. Iterative testing and stakeholder engagement revision of a four‐page draft implementation document with five domains resulted in a concise, one‐page implementation planning instrument to be used at project outset and periodically throughout project implementation planning. The instrument addresses end‐user feasibility concerns while retaining the main goals of more complex tools. This instrument was then systematically integrated into projects within the Kaiser Permanente Northern California Delivery Science and Applied Research program to address stakeholder engagement, efficiency, project planning, and operational implementation of study results. A streamlined one‐page implementation planning instrument, incorporating core concepts of existing frameworks, provides a pragmatic, robust framework for evidence‐based healthcare innovation cycles that is being broadly implemented within a learning health system. These streamlined processes could inform other settings needing a best practice rapid‐cycle research‐to‐implementation tool for large numbers of diverse projects.
... After we received the milestone list from each core, we checked in annually to determine whether the stated milestones were met. We did this using a simple checklist format to ascertain whether a milestone was met (Gawande, 2009). ...
Article
Despite being a common evaluation metric, milestones are poorly defined, and guidance for their use is underdeveloped in the evaluation literature. This practice note attempts to address this oversight by providing evaluation-specific guidance for tracking and reporting milestones. Using a case study, we share our initial approach to tracking and reporting milestones, as well as how critical reflection guided by the evaluation standards provided us with key insights that allowed us to make improvements to our initial process. We hope this practice note acts as a springboard for elevating the critical dialogue surrounding milestones in the evaluation literature.
... Proporcionar alternativas de segurança do paciente através de check-list pode auxiliar os profissionais a uma qualidade da assistência e também à difusão da cultura de segurança do paciente com comportamento suicida, leva a melhores resultados e uma prática mais confiável de lembrete para a equipe atender esse paciente nas etapas críticas para evitar as falhas de processo (Gawande, 2009). ...
Article
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Objetivos: Identificar ferramentas de gestão do risco na segurança do paciente com comportamentos suicidas, utilizadas nas emergências hospitalares. Metodologia: Revisão integrativa da literatura, no período de 2017 a 2021, a fim de responder à questão norteadora da pesquisa: Quais são as ferramentas de gestão utilizadas no gerenciamento do risco e da segurança do paciente em comportamentos suicidas no âmbito hospitalar? Utilizou-se a estratégia de busca PICO e a seleção dos estudos foi realizada por dois revisores de forma independente, no qual utilizaram como fontes de buscas as bases do Scopus, Web of Science e Pubmed. Resultados: Identificaram-se 863 artigos, dos quais 8 foram selecionados. Observou-se nos estudos que as ferramentas gerenciais foram: Protocolos de atendimento; Análise do Modo de Falha e Efeitos na Assistência Médica (HFMEA); Lista de Verificação (Check-list) e o Safety Huddle (reunião de segurança). Conclusões: As ferramentas de gestão do risco na segurança do paciente com comportamentos suicidas utilizadas em emergências hospitalares mostram resultados positivos com relação à prevenção ao suicídio nestes ambientes e que contribuem para uma assistência de qualidade e segura, porém carecem de mais evidências científicas.
... 8 Systematic checklists have been shown to reduce complications and errors in various fields such as aeronautics, engineering, manufacturing and the construction industries. 9 In healthcare, systematic checklists are widespread across several specialties, predominantly in the surgical field. [10][11][12][13][14][15][16] In the ICU setting, daily rounding safety checklists have been associated with increased adherence to guidelines, higher compliance with prophylactic measures, reduced rates of ...
Article
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Background and objectives Structured and systematised checklists have been shown to prevent complications and improve patient care. We evaluated the implementation of systematic safety checklists in our neurocritical care unit (NCCU) and assessed its effect on patient outcomes. Design/methods This quality improvement project followed a Plan–Do–Study–Act (PDSA) methodology. A checklist for medication reconciliation, thromboembolic prophylaxis, glycaemic control, daily spontaneous awakening, breathing trial, diet, catheter/lines duration monitoring and antibiotics de-escalation was implemented during daily patient rounds. Main outcomes included the rate of new infections, mortality and NCCU-length of stay (LOS). Intervened patients were compared with historical controls after propensity score and Euclidean distance matching to balance baseline covariates. Results After several PDSA iterations, we applied checklists to 411 patients; the overall average age was 61.34 (17.39). The main reason for admission included tumour resection (31.39%), ischaemic stroke (26.76%) and intracerebral haemorrhage (10.95%); the mean Sequential Organ Failure Assessment (SOFA) score was 2.58 (2.68). At the end of the study, the checklist compliance rate throughout the full NCCU stays reached 97.11%. After controlling for SOFA score, age, sex and primary admitting diagnosis, the implementation of systematic checklists significantly correlated with a reduced LOS (ß=−0.15, 95% CI −0.24 to −0.06), reduced rate of any new infections (OR 0.59, 95% CI 0.40 to 0.87) and reduced urinary tract infections (UTIs) (OR 0.23, 95% CI 0.09 to 0.55). Propensity score and Euclidean distance matching yielded 382 and 338 pairs with excellent covariate balance. After matching, outcomes remained significant. Discussion The implementation of safety checklists in the NCCU proved feasible, easy to incorporate into the NCCU workflow, and a helpful tool to improve adherence to practice guidelines and quality of care measurements. Furthermore, our intervention resulted in a reduced NCCU-LOS, rate of new infections and rate of UTIs compared with propensity score and Euclidean distance matched historical controls.
... When this fails and using the proper surgical techniques, most patients can be treated successfully and return to their previous level of play. It is important that a surgeon develop a preoperative "check list" [89] to make sure that all imaging studies are up to date and available and that all the proper equipment is also available in the operating room suite. Besides having the proper anchors for a SLAP repair, the surgeon must be ready and able to address other shoulder pathology including rotator cuff tears, which can also be present at the time of surgery. ...
Chapter
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Superior labral anterior to posterior (SLAP) tears in overhead athletes can be a career-ending injury because of the high failure rates with surgical intervention. There are many factors for this including the failure to establish the correct diagnosis, inadequate nonoperative management, the repair of normal variants of the superior labrum by inexperienced surgeons, and improper poor surgical technique. SLAP lesions rarely occur in isolation and can be associated with other shoulder disorders. The mechanism of injury can be an acute episode of trauma or a history of repetitive overhead use as in baseball pitchers or volleyball players. The physical exam findings can be confusing as these injuries often occur with other shoulder pathology. There is no single physical exam finding that is pathognomonic for SLAP tears. Nonoperative treatment should always be undertaken for a minimum of 3 months before surgery is recommended. If this fails to return the overhead athlete to competitive participation, a diagnostic arthroscopy with SLAP repair can yield excellent results if the proper technique is employed. The technique that we describe can be technically demanding but can be reproduced and give excellent results with a predictable return to play for overhead athletes.
... Hence, unwarranted geographical variations of health services pose the core question "what is right care?" which is an ethically relevant issue. While professionally developed standards, guidelines, and checklists can be helpful for deciding on "right care" in specific contexts [106] there is empirical evidence that much more work needs to be done in order to reduce geographical variations. In particular, defining good care more explicitly is a crucial task which requires ethical reflection. ...
Article
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Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.
... In his book The Checklist Manifesto, Atul Gawande explains how many processes, and particularly those in the health care sector, have become so complex in modern society that it is impossible to consistently remember to do them all (129). The results are frequent unintended errors and poor outcomes. ...
Article
Achieving target inpatient glycemic management outcomes has been shown to influence important clinical outcomes such as hospital length of stay and readmission rates. However, arguably the most profound, lasting impact of inpatient diabetes management is achieved at the time of discharge—namely reconciling and prescribing the right medications and making referrals for follow-up. Discharge planning offers a unique opportunity to break through therapeutic inertia, offer diabetes self-management education, and institute an individualized treatment plan that prepares the patient for discharge and promotes self-care and engagement. However, the path to a successful discharge plan can be fraught with potential pitfalls for clinicians, including lack of knowledge and experience with newer diabetes medications, costs, concerns over insurance coverage, and lack of time and resources. This article presents an algorithm to assist clinicians in selecting discharge regimens that maximize benefits and reduce barriers to self-care for patients and a framework for creating an interdisciplinary hospital diabetes discharge program.
... One of the most frequently used forms of describing non-traditional, unstructured business processes in practice are checklists and increasinglyprioritized checklists (Gawande, 2009;Wolff et al., 2004). Without restricting the decision-making power of the process executor, they allow for the following in an intuitive and clear way: ...
Article
Purpose The aim of the article is to propose BPMN extensions that facilitate the modeling of Clinical Pathways in a way that enables for various groups of users, the transfer of a much wider range of information in the form of process models without compromising their readability and usefulness. Design/methodology/approach The paper uses the design science research methodology (DSRM) and covers phases of a design-oriented research project extending BPMN notation for clinical pathway modeling. Findings The article proposes extensions of BPMN in 5 areas, enabling standardization of the description of business processes of different natures and complexity and in turn meeting the needs and requirements of modeling clinical pathways and, more broadly speaking, knowledge-intensive business processes (kiBPs) in general. As shown by the evaluation carried out among medical personnel, the proposed extensions allow for the readable transfer of a considerably larger body of information relevant to the planned, conducted and assessed therapy (kiBPs) than the current BPMN 2.0 standard. Originality/value The BPMN extensions proposed in the article fill the gaps in this notation and do not require users to know many notations, which in practice is unrealistic. Defined extensions to the BPMN specification makes it possible to standardise the description of processes of different natures and levels of complexity. In this way, both simplified models (and views of models) dedicated to users unfamiliar with BPMN and models (or views) using advanced possibilities provided by BPMN can be based on one standard, even if they use only a small part of its possibilities.
... Checklists are commonly used in other industries which are susceptible to human error and cognitive biases, namely in aviation (Gawande, 2009). Though many components of checklists in high-risk industries are obvious and familiar, the routine use of them ensures a reproducible approach across all users and could prevent easily avoided disasters (Ely et al., 2011). ...
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Background The prevalence of cognitive bias and its contribution to diagnostic errors has been documented in recent research. Debiasing interventions or educational initiatives are key in reducing the effects and prevalence of cognitive biases, contributing to the prevention of diagnostic errors. The objectives of this review were to 1) characterize common debiasing strategies implemented to reduce diagnosis-related cognitive biases, 2) report the cognitive biases targeted, and 3) determine the effectiveness of these interventions on diagnostic accuracy. Methods Searches were conducted on April 25, 2022, in MEDLINE, Embase, Healthstar, and PsycInfo. Studies were included if they presented a debiasing intervention which aimed to improve diagnostic accuracy. The Rayyan review software was used for screening. Quality assessments were conducted using the JBI Critical Appraisal Tools. Extraction, quality assessment, and analysis were recorded in Excel. Results Searches resulted in 2232 studies. 17 studies were included in the final analysis. Three major debiasing interventions were identified: tool use, education of biases, and education of debiasing strategies. All intervention types reported mixed results. Common biases targeted include confirmation, availability, and search satisfying bias. Conclusion While all three major debiasing interventions identified demonstrate some effectiveness in improving diagnostic accuracy, included studies reported mixed results when implemented. Furthermore, no studies examined decision-making in a clinical setting, and no studies reported long-term follow-up. Future research should look to identify why some interventions demonstrate low effectiveness, the conditions which enable high effectiveness, and effectiveness in environments beyond vignettes and among attending physicians. PROSPERO registration number CRD42022331128
... Dr. Atul Gawande, Professor of Surgery at Harvard Medical School, argues that using checklists can help surgeons to cope with increasing complexity. Use of a rigorous checklist in this rapidly changing environment will consolidate surgeons' aims to enhance both patient safety and clinical professionalism [24]. Strategy for wrong-site, wrong-patient, wrong-procedure events ...
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Patient safety is fundamental to high-quality patient care. Hospitalization has its inherent complications. Medical errors can further comprise patient safety. Hospitals provides an opportunity for practicing preventive medicine. Two important areas are (i) making treatment and hospitalization free from side-effects (ii) obviating medical errors. In hospitals these can have serious consequences. Patient safety compromise can occur at the individual or system level. A methodical model for this should include (i) Intervention design (ii) Intervention implementation (iii) Intervention institutionalization. Managerial perspective important for leadership and team work. Leadership can energize excellence in the coordination and mobilization of the large number of inter-dependent processes and resources needed for achievement of patient safety. Three-dimensional strategy for Leadership is suggested (i) Initiatives appealing (ii) Integrating all (iii) Incremental advancements. The ‘Five Es’ for Teamwork, and the ‘Five Cs’ for Organizational Change are elaborated. Artificial Intelligence has the potential to improve healthcare safety. AI enables analysis of data from multiple sources simultaneously using advanced algorithms. This identifies predictors and outcomes. Ensemble learning algorithms, used by advanced practitioners of machine learning, are useful with high final accuracy. Hence in matters of health these should be utilized. All this will make prevention targeted, better, and timely.
... " Audit and feedback (A&F) is a practice that motivates behavior change by generating an awareness of current practices and has been observed to perform best when compliance is low in healthcare settings [19]. Dr. Moher brings up the long and positive history of A&F [19,20]. He is troubled by the fact that neither institutions nor funding agencies collect data to answer questions about open access and reporting practices. ...
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Background The torrent of research during the coronavirus (COVID-19) pandemic has exposed the persistent challenges with reporting trials, open science practices, and scholarship in academia. These real-world examples provide unique learning opportunities for research methodologists and clinical epidemiologists-in-training. Dr. David Moher, a recognized expert on the science of research reporting and one of the founders of the Consolidated Standards of Reporting Trials (CONSORT) statement, was a guest speaker for the 2021 Hooker Distinguished Visiting Professor Lecture series at McMaster University and shared his insights about these issues. Main text This paper covers a discussion on the influence of reporting guidelines on trials and issues with the use of CONSORT as a measure of quality. Dr. Moher also addresses how the overwhelming body of COVID-19 research reflects the “publish or perish” paradigm in academia and why improvement in the reporting of trials requires policy initiatives from research institutions and funding agencies. We also discuss the rise of publication bias and other questionable reporting practices. To combat this, Dr. Moher believes open science and training initiatives led by institutions can foster research integrity, including the trustworthiness of researchers, institutions, and journals, as well as counter threats posed by predatory journals. He highlights how metrics like journal impact factor and quantity of publications also harm research integrity. Dr. Moher also discussed the importance of meta-science, the study of how research is carried out, which can help to evaluate audit and feedback systems and their effect on open science practices. Conclusion Dr. Moher advocates for policy to further improve the reporting of trials and health research. The COVID-19 pandemic has exposed how a lack of open science practices and flawed systems incentivizing researchers to publish can harm research integrity. There is a need for a culture shift in assessing careers and “productivity” in academia, and this requires collaborative top-down and bottom-up approaches.
... Visit records using specific history and physical examination templates. Examples are available for hypertension, asthma, diabetes, COPD, heart disease, breast problems, breathing problems, gynecological problems, diarrhea, abdominal pain, acute fever/chills, headache/pain, BMI<18, BMI>25, stroke, tobacco smoking, betel-nut chewing, palliative care, general unspecified problem, trauma emergency management (49). Alerts and links for clinical finding or problem and diagnosis decision-support Intra-record facilitated test ordering Laboratory testing and image reports Extra-systemic health records As discussed above, the key to successful EMR implementation is having paraprofessionals record the preponderance of EMR information, along with intense and ongoing training [19,40,41]. ...
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While there is a dearth of value-based primary care services in low- and middle-income countries, primary care has been demonstrated to be associated with enhanced access to health services and better health outcomes. The demonstrated barriers to high-quality primary care are under-resourcing, inadequate payment models, lack of community linkages, limited scope and comprehensiveness, limited integration with other components of the health system, and unexciting/unattractive conditions for physicians. Based on global data, we propose a transformative community-oriented primary care program model with a network of ambulatory, virtual, and comprehensive community services. Community-oriented primary care is medical practice that undertakes responsibility for the health of a defined population. Key components of this medical service program are 1. Community health workers (CHWs) responsible for specific populations, with expanded portfolios to provide communicable and noncommunicable disease home health care, health education, and disease registry maintenance; 2. A 24/7 virtual care service to back up and supplement CHW activities; 3. A primary care ambulatory service facility with major paraprofessional-specialist conduct of routine processes and record-keeping utilizing algorithmic guidelines; 4. Multiple point-of-care diagnostic capacities and immediate tele-consults for both ambulatory facility and CHW services; 5. A customized interoperable electronic medical record system, focused on patient care functionalities such as charting and decision-support; 6. Wireless broadband connections for all program workers; and 7. Sustainable economics with revenue from locally determined subscription systems, sliding scale fees for services from ambulatory care facilities, limited CHW service fees, core per capita government support, research projects, and philanthropy.
... One lesson learned is that elaborate assessment tools were not plausible for The Plaster House and perhaps are overly complex in U.S. settings as well. Studies have shown that simple, utilitarian tools such as checklists can improve quality of care and save lives (Gawande, 2011). Other research in Tanzania has focused on developing simple tools to monitor client outcomes post-operation. ...
... For instance, future research could use a modified Dephi technique to develop a checklist (Miller et al., 2020;Ogden et al., 2016) that outlines relevant and appropriate care for patients presenting to the ED for SIB. Checklists improve patient outcomes and provide clinicians with tools that result in reliable practice (Gawande, 2010). Over the years, checklists have been developed to identify and mitigate risks in caring for patients with mental health or suicidal behaviors, such as the Mental Health Environment of Care Checklist (Mills et al., 2010); the Safety Planning checklist (Stanley-Brown Safety Plan, 2021) to help reduce subsequent crises; and the recent Care of the Suicide and Self-Injury Patient Checklist (SSIPCL) covering safety and environmental aspects of care in nonbehavioral inpatient units (Frost et al., 2020). ...
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To understand ED providers’ perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to “What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?” were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.
... Visit records using specific history and physical examination templates. Examples are available for hypertension, asthma, diabetes, COPD, heart disease, breast problems, breathing problems, gynecological problems, diarrhea, abdominal pain, acute fever/chills, headache/pain, BMI<18, BMI>25, stroke, tobacco smoking, betel-nut chewing, palliative care, general unspecified problem, trauma emergency management (49). Alerts and links for clinical finding or problem and diagnosis decision-support Intra-record facilitated test ordering Laboratory testing and image reports Extra-systemic health records As discussed above, the key to successful EMR implementation is having paraprofessionals record the preponderance of EMR information, along with intense and ongoing training [19,40,41]. ...
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Regulatory compliance is vital for promoting the public values served by regulation. Yet many businesses remain out of compliance with at least some of the regulations that apply to them – not only presenting possible dangers to the public but also exposing themselves to potentially significant liability risk. Compliance management systems (CMSs) may help reduce the likelihood of noncompliance. In recent years, managers have begun using CMSs in an effort to address compliance issues in a variety of domains: environment, workplace health and safety, finance, health care, and aviation, among others. CMSs establish systematic, checklist-like processes by which managers seek to improve their organizations’ compliance with government regulation. They can help managers identify compliance obligations, assign responsibility for meeting them, track progress, and take corrective action as needed. In effect, CMSs constitute and structure firms’ own internal inspection and enforcement responsibilities. At least in theory, CMSs reduce noncompliance by increasing information available to employees and managers, facilitating internal incentives to correct instances of noncompliance once identified, and helping to foster a culture of compliance. Recognizing these potential benefits, some government policymakers and regulators have even started to require certain firms to adopt CMSs. But do CMSs actually achieve their theoretical benefits? We review the available empirical research related to CMSs in an effort to discern how they work, paying particular attention to whether CMSs help firms fulfill both the letter as well as the spirit of the law. We also consider lessons that can be drawn from research on the effectiveness of still broader systems for risk management and corporate codes of ethics, as these systems either include regulatory compliance as one component or present comparable challenges in terms of internal monitoring and the shaping of organizational behavior. Overall, we find evidence that firms with certain types of CMSs in place experience fewer compliance violations and show improvements in risk management. But these effects also appear to be rather modest. Compliance in large organizations generally requires more than just a CMS; it also demands appropriate managerial attitudes, organizational cultures, and information technologies that extend beyond the systematic, checklist processes that are characteristic of CMSs. We address implications of what we find for policy and future research, especially about the conditions under which CMSs appear to work best, the types or features of CMSs that appear to work better than others, and the possible value of regulatory mandates that firms implement CMSs.
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Introduction to Routines-Based Model and Its Implementation in Taiwan The Routines-Based Model (RBM) is an empirical family-centered early childhood intervention (ECI) practice and also an innovative tele-intervention in ECI services during the pandemic. With the support of the RBM founder Dr. McWilliam, Taiwan started the RBM implementation in 2014 and had some outcomes, but the application of implementation science is still insufficient. This article introduces the concepts of the RBM and its components, with particular emphasis on the content and steps of the Routines-Based Interview plus (RBI+), describing the history and challenges of promoting RBM in Taiwan, as well as the strategies and principles for adopting the RBM under the COVID-19 outbreak. The principle of the RBM is that in ECI services the primary caregiver provides children with learning opportunities and experiences through daily life arrangement and environmental modification in natural settings with the support of service providers. The RBM components consist of the RBI+, service team model, collaborative consultation, and outcome evaluation. The RBI+ practices are strategies for needs assessment and individualized program planning including an ecological map of family, the routines-based interview, participation-based child goals and family goals, and a goal-routines matrix. The service delivery models of the RBM are the primary service provider model and the comprehensive service provider model. One early interventionist provides collaborative consultation to the primary caregiver of each child with developmental delay/disability to enhance the child’s engagement, independence and social relationships in daily life. We recommend that implementation of the RBM in Taiwan could be carried out at three levels: the policy/system, the service unit and the individual.
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As an introduction to a special, thematic issue, the author reviews four possible analytic approach to information history centered view of lists. The microhistory explanation (1), a tipology-driven, time-sensitive contextualization (through melting the given type of list with similar ones, extending the scope to other information managing objects, actors and institutions of a given age (2), the macrohistory framing, when we try to insert the list into different sets of trendlines and trajectories (3), and a group of content-oriented, functional, structural points of views, reviving the epistemological nature of list-making, regarding to different societies, cultures and situations (4). After speculating on the validity and possible significance of a substantive and dedicated ‘science of lists’, the author summarizes the aspects, which can be devoted to specially information history-related dissections.
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In Kap. 8 wird die Durchführung des Experiments genauer beschrieben. Zunächst wird noch einmal erklärt, welche zusätzlichen Voraussetzungen erfüllt sein müssen, um mit dem Experiment zu starten. Anschließend wird das Experiment Dokument als zentraler Bestandteil der Durchführung eingeführt und die wichtigsten Bestandteile dieses Elements beschrieben. Im letzten Abschnitt wird erläutert, wie die Durchführung der Experimente im Rahmen eines Sprints organisiert werden kann und welche Besonderheiten es dabei zu beachten gilt.
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Large ships, both military and commercial, are dependent on many complex and interdependent systems, necessitating notoriously intensive maintenance regimens. For instance, low event rates, ambiguous problem presentation, temporal stressors, and high working memory demands are common challenges for shipboard maintenance and repair personnel. Operational support systems are often employed in this context to supplement or fill training gaps at the point-of-need. Such support, however, has traditionally been heavily dependent on insight and input from subject matter experts, which places a steep premium on personal experience. Recent advances in augmented reality (AR), especially head-worn displays (HWDs), present a promising avenue for improving the efficacy of operational support by leveraging multimodal interactions and displays. Multimodal solutions provide an opportunity to present support information, in a more veridical form, and, if carefully designed, without increasing demand on operators. Real-world spatialization of such information sources via AR is one technique that can be used to increase the level of operational support while simultaneously reducing short-term memory demands imposed by traditional operational support tools, the latter of which require mental transformation from the medium of the support tool (e.g., a technical manual) to the operator’s environment. The broad range of capabilities of AR HWDs also affords tailoring operational support tools to the unique sensory needs of each use case and, in conjunction with adaptive training techniques and advances in AI, to the needs of each operator. Herein, we provide an overview of how multimodal AR can be implemented within operational support tools; best practices for the design and development of multimodal interactions and displays within AR are discussed.KeywordsOperational supportJob performance aidMaintenance training
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The acceptance of the bio-psychosocial model of disease and health in oral health sciences and oral healthcare has prompted the need for increased psychological knowledge and understanding among oral health professionals. Consequently, this chapter highlights selected themes of basic psychology, most notably themes from cognitive psychology, and intends to provide an insight into how these topics impact the health-related behaviours of both patients and oral health professionals. Suggestions are provided as to how oral health professionals could increase their metacognitive functioning in order to benefit their clinical performance and general well-being.KeywordsPsychologyHealth PsychologyCognitionMetacognitionEmotionsPsychological StressDentistryOral Health
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A sentinel event is any unexpected event that results in death or serious physical or psychological injury to a patient unrelated to a patient's illness. Establishing and determining cause-and-effect relationships is key to preventing future sentinel/near-miss events. However, it can be challenging to establish a cause-and-effect relationship when a process involves multiple steps or people. Root cause analysis (RCA) is a technique that can pinpoint the causes of sentinel events for medical procedures involving numerous steps and people. This article provides a rationale for RCA and the basic steps in a nonmedical RCA investigation. The article then describes a more detailed, nine-step RCA approach for investigating sentinel events and illustrates the technique with a nuclear medicine example.
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Successful drug discovery is like finding oases of safety and efficacy in chemical and biological deserts. Screens in disease models, and other decision tools used in drug research and development (R&D), point towards oases when they score therapeutic candidates in a way that correlates with clinical utility in humans. Otherwise, they probably lead in the wrong direction. This line of thought can be quantified by using decision theory, in which ‘predictive validity’ is the correlation coefficient between the output of a decision tool and clinical utility across therapeutic candidates. Analyses based on this approach reveal that the detectability of good candidates is extremely sensitive to predictive validity, because the deserts are big and oases small. Both history and decision theory suggest that predictive validity is under-managed in drug R&D, not least because it is so hard to measure before projects succeed or fail later in the process. This article explains the influence of predictive validity on R&D productivity and discusses methods to evaluate and improve it, with the aim of supporting the application of more effective decision tools and catalysing investment in their creation. The ‘predictive validity’ of decision tools such as disease models that are used in drug research and development (R&D) — the degree to which the output from a tool correlates with clinical utility in people — has a major influence on R&D productivity. This article explains this influence and discusses methods to evaluate and improve the predictive validity of decision tools, with the aim of supporting the application of more effective tools and catalysing investment in their creation.
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There are many questionnaires to assess player motivation, originating from a diverse range of disciplines. Each discipline differs in their usage and reporting of questionnaires, but there has been no attempt to synthesise or standardise their application. No standard approach leads to a lack of transparency in usage reporting, which affects the ability of the field to synthesise. This has made it unclear whether player motivation research is a unified community, or a collection of individuals with a similar goal. Therefore, the current work assesses the transparency of reporting practices of player motivation questionnaires published within the last 15 years. 18 questionnaires were identified via a scoping review, then papers citing these questionnaires were analysed for their transparency of reporting practices (n=238); first via a content analysis of justifications for use, then followed by an analysis of transparency against eight criteria created for this work. Overall, reporting transparency is lacking, driven by little priority for presenting items alongside text. Many papers use questionnaires because they are theory-based or have measured specific variables in previous works, but explicit justification is rare. The work concludes with a transparency checklist based on the eight criteria used, which authors can use to standardise the field and allow for more cohesive research synthesis.
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Data science is the foundation of our modern world. It underlies applications used by billions of people every day, providing new tools, forms of entertainment, economic growth, and potential solutions to difficult, complex problems. These opportunities come with significant societal consequences, raising fundamental questions about issues such as data quality, fairness, privacy, and causation. In this book, four leading experts convey the excitement and promise of data science and examine the major challenges in gaining its benefits and mitigating its harms. They offer frameworks for critically evaluating the ingredients and the ethical considerations needed to apply data science productively, illustrated by extensive application examples. The authors' far-ranging exploration of these complex issues will stimulate data science practitioners and students, as well as humanists, social scientists, scientists, and policy makers, to study and debate how data science can be used more effectively and more ethically to better our world.
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The world is abuzz with experts who can help us in domains where we understand too little to help ourselves. But sometimes experts in one domain carry their privileged status into domains outside their specialization, where they give advice or otherwise presume to speak authoritatively. Ballantyne (in: Knowing our limits. Oxford University Press, New York, 2019) calls these boundary crossings “epistemic trespassing” and argues that they often violate epistemic norms. In the few cases where traveling in other domains is permissible, Ballantyne suggests there should be regulative checks (“easements”) for the experts who are crossing domain boundaries. I argue that boundary crossing is warranted more often than Ballantyne allows. And while Ballantyne argues that boundary crossing is prima facie epistemically problematic, I contend that many cases of boundary crossing are not properly instances of “trespassing,” and, therefore, raise no prima facie epistemic concerns. I further argue that identifying cases of what I call “epistemic neighborliness” bolsters Ballantyne’s project, making it easier for novices and other experts to identify epistemic trespassing along with its epistemic problems.
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Have you ever had multiple goals and aspirations at once? Psychologically, planning a written list and working through the plan is likely to lead to more productivity than simply dreaming about achievements. Professionals in many disciplines use written checklists to ensure productivity and safety in the workplace. For example, Dr. Atul Gawande’s checklists for the healthcare industry have improved healthcare outcomes for many patients by reducing errors and getting things done more efficiently. We can all use similar checklists as touchstones or reminders to increase our efficiency and engagement in pursuing our own goals and thus to improve our own personal outcomes through greater sensemaking and mindfulness. In this article, we undertake a literature review identifying and synthesizing key concepts from various areas of organizational and leadership theories to provide a broadly valuable basis for constructing a professional and personal development checklist. Professional communication is about representing yourself in the best sense of your character, image, and abilities through sensemaking, collaboration, storytelling, listening, and effective conflict management practices. Having a professional checklist works best when it is aligned with your true inner character as well as outward personality and social identity. Professional communication is about being sincere, principled, deliberate, meaningful, and authentic in all circumstances. The key is to balance your life’s important values-based priorities and be yourself, instead of acting as someone you are not. In other words, focus on the deontological view of ethical decision-making, as opposed to always leaning toward the teleological or consequentialism perspective. People often attribute their own moral or amoral decisions and behaviors to situational factors. The reality is that the human mind is a complex biological machine that is programmed and reprogrammed from the time of one’s conception until the day we die. The complexity of genetic and environmental factors, socialization under different circumstances, and lived experience across culture and opportunity mean people have varied capacities to make choices and attributions. As professionals, we all play the cards we are dealt and the more effectively and strategically we use these “cards,” the better will be the future outcomes. Human behavior is often influenced and driven by factors that we might not fully understand, but we must make the best use of what we do comprehend at any given time before the opportunity is gone. Science has proven that the use of an appropriate checklist for personal development can lead to productivity, professional career success, better work-life balance, and personal happiness.
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Relevance the issues of patient care and quality management have acquired particular relevance in modern healthcare. Improvement in the clinical performance of medical technologies has led to a significant reduction in deaths and complications associated with the disease and side effects of interventions. As a result, the share of additional harm related to the process of providing medical services has become more noticeable. Accurate data regarding the type, frequency and severity of active threats and incidents they cause are needed to reduce the likelihood and severity of additional harm. In this respect, emergency medical care is the subject of special attention and is characterized by the greatest difficulty in terms of obtaining valid and relevant information about deviations associated with health worker performance, equipment operation and patient behavior. The aim of the study was to explore the main epidemiological characteristics of medical errors and incidents associated with the provision of emergency medical care. Material and methods We present a literature review followed by an analytical study of the epidemiology of incidents and active threats (including medical errors) that precede those incidents in various areas of emergency medical care. By an incident, the authors understood an event with a patient that was more related to the process of providing medical care than to the course of the disease or comorbid conditions which led or could lead to causing additional harm. Active threats included events that subsequently became the direct cause of the incident (medical errors and malpractice, mistakes and deviations in patient behavior, emergency situations in the physical environment). By the “mortality from adverse events”, the authors understood the proportion of deaths from adverse events among all hospitalized patients. By the concept of “lethality associated with adverse events”, the authors denoted the proportion of deaths from adverse events among all the patients affected by adverse events. The search for information was carried out for the period of 1995–2021 using the following medical databases: medline; cochrane collaboration; embase; scopus; isi web of science. For analysis, we used prospective and retrospective observational studies of high methodological quality, meta-analyses and systematic reviews. For the statistical evaluation of frequency characteristics, indicators of incidence, prevalence, and incidence density were used. The calculation of generalized frequency indicators for large samples was carried out with a 95% confidence interval. Results The epidemiology of medical errors and incidents depends on the area in which emergency care is provided. For prehospital emergency medical care, there are 12.45 medical errors and 4.50 incidents with consequences for every 100 visits. In emergency departments, one in fourteen patients suffers additional harm which in 10.14% of cases has severe consequences, and in 3.18% of cases leads to unexpected death. In intensive care units, incidents related to the provision of medical care are recorded in every third patient in the amount of 1.55 per 1 patient. Of these, 58.67% of incidents are accompanied by harm, but the fatality associated with the incidents is only 0.77%. The prevalence of patients affected by incidents during the provision of anesthesia for children is almost 2 times higher than for adults (4.79% vs. 2.03%). At the same time, mortality due to anesthesia-related incidents in children is 11 times lower than in adults (0.27% versus 3.09%). The author draws attention to a number of factors contributing to the development of incidents during the provision of emergency medical care. These include environmental complexity, suboptimal configuration of the workspace, technological interface complexity, the effects of acute stress on performers, and organizational vulnerabilities. A special role was assigned to environmental complexity which was studied in detail both in terms of the complexity of the tasks being solved, and in connection with obstacles to solving problems. It was shown that the intensity of the influence of various components of environmental complexity is not the same in different departments providing emergency care. Particular attention was paid to the fact that organizational vulnerabilities reduce the effectiveness of protective mechanisms during the interaction of the human factor with a complex environment. Conclusion The study showed that the provision of emergency medical care is associated with moderately high risks of incidents, including severe and critical consequences for patients. The main factor contributing to the development of incidents is environmental complexity which becomes much harder to counter under the influence of organizational vulnerabilities. Identification and registration of errors and incidents in units providing medical care is difficult due to the short time of contact with patients, the high speed of situation update, and the constant impact of chronic and acute stressors on staff. In this connection, the optimization and improvement of the efficiency of the system for recording errors and incidents in departments providing emergency medical care remains an area for improvement.
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Many orthopedic surgical procedures are performed on a non-urgent basis, with many patients having multiple medical co-morbidities which increase their risks for complications. Preoperative medical optimization should be performed for all patients, focusing on both modifiable and non-modifiable medical risk factors. As this optimization may involve input from multiple medical providers, preoperative checklists may be implemented to help the orthopedic surgeon organize these factors and ensure patient readiness for surgery.KeywordsPatient safetyPreoperative optimizationPreoperative checklists
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Background Preventable diagnostic errors are a large burden on healthcare. Cognitive reasoning tools, that is, tools that aim to improve clinical reasoning, are commonly suggested interventions. However, quantitative estimates of tool effectiveness have been aggregated over both workplace-oriented and educational-oriented tools, leaving the impact of workplace-oriented cognitive reasoning tools alone unclear. This systematic review and meta-analysis aims to estimate the effect of cognitive reasoning tools on improving diagnostic performance among medical professionals and students, and to identify factors associated with larger improvements. Methods Controlled experimental studies that assessed whether cognitive reasoning tools improved the diagnostic accuracy of individual medical students or professionals in a workplace setting were included. Embase.com, Medline ALL via Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar were searched from inception to 15 October 2021, supplemented with handsearching. Meta-analysis was performed using a random-effects model. Results The literature search resulted in 4546 articles of which 29 studies with data from 2732 participants were included for meta-analysis. The pooled estimate showed considerable heterogeneity (I ² =70%). This was reduced to I ² =38% by removing three studies that offered training with the tool before the intervention effect was measured. After removing these studies, the pooled estimate indicated that cognitive reasoning tools led to a small improvement in diagnostic accuracy (Hedges’ g =0.20, 95% CI 0.10 to 0.29, p<0.001). There were no significant subgroup differences. Conclusion Cognitive reasoning tools resulted in small but clinically important improvements in diagnostic accuracy in medical students and professionals, although no factors could be distinguished that resulted in larger improvements. Cognitive reasoning tools could be routinely implemented to improve diagnosis in practice, but going forward, more large-scale studies and evaluations of these tools in practice are needed to determine how these tools can be effectively implemented. PROSPERO registration number CRD42020186994.
Article
In theory, implementing an Enterprise Architecture (EA) should enable organizations to increase the accuracy of information security risk assessments. In reality, however, organizations struggle to fully implement EA frameworks because the requirements for implementing an EA and the benefits of commercial frameworks are unclear, and the overhead of maintaining EA artifacts is unacceptable, especially for smaller organizations. In this paper, we describe a novel approach called CAESAR8 (Continuous Agile Enterprise Security Architecture Review in 8 domains) that supports dynamic and holistic reviews of information security risks in IT projects. CAESAR8’s nonlinear design supports continuous reassessment of information security risks, based on a checklist that assesses the maturity of security considerations in eight domains that often cause information security failures. CAESAR8 assessments can be completed by multiple stakeholders independently, thus ensuring consideration of their tacit knowledge while preventing groupthink. Our evaluation with experienced industry professionals showed that CAESAR8 successfully addresses real-world problems in information security risk management, with significant benefits particularly for smaller organizations.
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Successful application of transplant surgery for definitive management of end-stage organ disease occurred, while our understanding of immunology was still rudimentary. Immunosuppression was developed by surgeons, about the middle of the last century, battling with biological forces that nobody understood and often in the face of opposition from those who thought they did. The primary function of the immune system—to defend the body from invasion by foreign organisms—was being ‘suppressed’, and that could only have deleterious effects! The undeniable success of transplantation however led to a considerable evolution of our knowledge of how the immune system works, especially of our understanding of mechanisms that terminate an immune attack and regulate balance within the immune system. Today, the term ‘immunomodulation’ might be better than the older ‘immunosuppression’ to describe what makes a transplant work.
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