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Near miss events

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https://www.readbyqxmd.com/read/28542628/chemical-and-structural-characterization-of-a-model-post-termination-complex-potc-for-the-ribosome-recycling-reaction-evidence-for-the-release-of-the-mrna-by-rrf-and-ef-g
#1
Nobuhiro Iwakura, Takeshi Yokoyama, Fabio Quaglia, Kaoru Mitsuoka, Kazuhiro Mio, Hideki Shigematsu, Mikako Shirouzu, Akira Kaji, Hideko Kaji
A model Post-Termination Complex (PoTC) used for the discovery of Ribosome Recycling Factor (RRF) was purified and characterized by cryo-electron microscopic analysis and biochemical methods. We established that the model PoTC has mostly one tRNA, at the P/E or P/P position, together with one mRNA. The structural studies were supported by the biochemical measurement of bound tRNA and mRNA. Using this substrate, we establish that the release of tRNA, release of mRNA and splitting of ribosomal subunits occur during the recycling reaction...
2017: PloS One
https://www.readbyqxmd.com/read/28513837/maternal-near-miss-in-low-resource-areas
#2
Robert L Goldenberg, Sarah Saleem, Sumera Ali, Janet L Moore, Adrien Lokangako, Antoinette Tshefu, Musaku Mwenechanya, Elwyn Chomba, Ana Garces, Lester Figueroa, Shivaprasad Goudar, Bhalachandra Kodkany, Archana Patel, Fabian Esamai, Paul Nsyonge, Margo S Harrison, Melissa Bauserman, Carl L Bose, Nancy F Krebs, K Michael Hambidge, Richard J Derman, Patricia L Hibberd, Edward A Liechty, Dennis D Wallace, Jose M Belizan, Menachem Miodovnik, Marion Koso-Thomas, Waldemar A Carlo, Alan H Jobe, Elizabeth M McClure
OBJECTIVE: To describe the Global Network Near-Miss Maternal Mortality System and its application in seven sites. METHODS: In a population-based study, pregnant women eligible for enrollment in the Maternal and Newborn Health Registry at seven sites (Democratic Republic of the Congo; Guatemala; Belagavi and Nagpur, India; Kenya; Pakistan; and Zambia) between January 2014 and April 2016 were screened to identify those likely to have a near-miss event. The WHO maternal near-miss criteria were modified for low-resource settings...
May 17, 2017: International Journal of Gynaecology and Obstetrics
https://www.readbyqxmd.com/read/28510604/ebola-exposure-illness-experience-and-ebola-antibody-prevalence-in-international-responders-to-the-west-african-ebola-epidemic-2014-2016-a-cross-sectional-study
#3
Catherine F Houlihan, Catherine R McGowan, Steve Dicks, Marc Baguelin, David A J Moore, David Mabey, Chrissy H Roberts, Alex Kumar, Dhan Samuel, Richard Tedder, Judith R Glynn
BACKGROUND: Healthcare and other front-line workers are at particular risk of infection with Ebola virus (EBOV). Despite the large-scale deployment of international responders, few cases of Ebola virus disease have been diagnosed in this group. Since asymptomatic or pauci-symptomatic infection has been described, it is plausible that infections have occurred in healthcare workers but have escaped being diagnosed. We aimed to assess the prevalence of asymptomatic or pauci-symptomatic infection, and of exposure events, among returned responders to the West African Ebola epidemic 2014-2016...
May 2017: PLoS Medicine
https://www.readbyqxmd.com/read/28500780/prognostic-factors-of-maternal-near-miss-events-and-maternal-deaths-in-a-tertiary-healthcare-facility-in-india
#4
Tabassum Khan, Poonam Laul, Anish Laul, Mohammed Ramzan
OBJECTIVE: To study maternal near miss (MNM) and maternal mortality to identify rectifiable risk factors. METHODS: The present cross-sectional retrospective study included pregnant women who experienced acute life-threatening pregnancy-related adverse events at Deen Dayal Upadhyay hospital, New Delhi, India, between September 1, 2009, and August 31, 2011. Patient data were analyzed to investigate factors associated with MNM events and maternal deaths. RESULTS: There were 369 patients included, and 302 MNM events and 67 maternal deaths were recorded...
May 13, 2017: International Journal of Gynaecology and Obstetrics
https://www.readbyqxmd.com/read/28462894/a-survey-of-residents-experience-with-patient-safety-and-quality-improvement-concepts-in-radiation-oncology
#5
Matthew B Spraker, Matthew Nyflot, Kristi Hendrickson, Eric Ford, Gabrielle Kane, Jing Zeng
PURPOSE: The safety and quality of radiation therapy have recently garnered increased attention in radiation oncology (RO). Although patient safety guidelines expect physicians and physicists to lead clinical safety and quality improvement (QI) programs, trainees' level of exposure to patient safety concepts during training is unknown. METHODS AND MATERIALS: We surveyed active medical and physics RO residents in North America in February 2016. Survey questions involved demographics and program characteristics, exposure to patient safety topics, and residents' attitude regarding their safety education...
December 1, 2016: Practical Radiation Oncology
https://www.readbyqxmd.com/read/28453824/professional-attitudes-toward-incident-reporting-can-we-measure-and-compare-improvements-in-patient-safety-culture
#6
Pierfrancesco Tricarico, Luigi Castriotta, Claudio Battistella, Fabrizio Bellomo, Giovanni Cattani, Lucrezia Grillone, Stefania Degan, Daniela De Corti, Silvio Brusaferro
Objective: To establish categories of professionals' attitudes toward incident reporting by analyzing the trends in incident reporting while accounting for general risk indicators. Design: The incident reporting system was evaluated over 6 years. Reporting rates, stratified by year and profession, were estimated using the non-mandatory reported events/full-time equivalent (NM-IR/FTE) rate. Other indicators were collected using the hospital's official database. Staff attitudes toward self-reporting were analyzed...
April 1, 2017: International Journal for Quality in Health Care
https://www.readbyqxmd.com/read/28449900/insufficient-sleep-rather-than-the-apnea-hypopnea-index-can-be-associated-with-sleepiness-related-driving-problems-of-japanese-obstructive-sleep-apnea-syndrome-patients-residing-in-metropolitan-areas
#7
Kentaro Matsui, Taeko Sasai-Sakuma, Jun Ishigooka, Yuichi Inoue
OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) and insufficient sleep might increase the risk of drowsy driving and sleepiness-related vehicular accidents. This study retrospectively investigated the factors associated with these driving problems, particularly addressing OSAS severity and sleep amounts of affected drivers. METHODS: This study examined 161 patients (146 male and 15 female) with OSAS (apnea-hypopnea index [AHI] ≥ 5) who drove on a routine basis and who completed study questionnaires...
May 2017: Sleep Medicine
https://www.readbyqxmd.com/read/28421402/the-effect-of-losses-disguised-as-wins-and-near-misses-in-electronic-gaming-machines-a-systematic-review
#8
REVIEW
K R Barton, Y Yazdani, N Ayer, S Kalvapalle, S Brown, J Stapleton, D G Brown, K A Harrigan
Near misses and losses disguised as wins have been of interest to gambling researchers and policymakers for many years (e.g., Griffiths in J Gambl Stud 9(2):101-120, 1993). This systematic literature review describes the behavioural, psychological, and psychobiological effects of near misses and losses disguised as wins (LDWs) in an effort to evaluate their precise influence on the player and to highlight areas requiring further investigation. A systematic search for relevant studies was conducted using Scopus, PubMed, PsycINFO, ProQuest Sociology databases, and the Gambling Research Exchange Ontario Knowledge Repository...
April 18, 2017: Journal of Gambling Studies
https://www.readbyqxmd.com/read/28413825/color-change-detection-activity-in-the-primate-superior-colliculus
#9
James P Herman, Richard J Krauzlis
The primate superior colliculus (SC) is a midbrain structure that participates in the control of spatial attention. Previous studies examining the role of the SC in attention have mostly used luminance-based visual features (e.g., motion, contrast) as the stimuli and saccadic eye movements as the behavioral response, both of which are known to modulate the activity of SC neurons. To explore the limits of the SC's involvement in the control of spatial attention, we recorded SC neuronal activity during a task using color, a visual feature dimension not traditionally associated with the SC, and required monkeys to detect threshold-level changes in the saturation of a cued stimulus by releasing a joystick during maintained fixation...
March 2017: ENeuro
https://www.readbyqxmd.com/read/28406275/high-self-reported-non-adherence-to-antiretroviral-therapy-amongst-adolescents-living-with-hiv-in-malawi-barriers-and-associated-factors
#10
Maria H Kim, Alick C Mazenga, Xiaoying Yu, Saeed Ahmed, Mary E Paul, Peter N Kazembe, Elaine J Abrams
INTRODUCTION: Globally adolescents and young adults account for more than 40% of new HIV infections, and HIV-related deaths amongst adolescents increased by 50% from 2005 to 2012. Adherence to antiretroviral therapy (ART) is critical to control viral replication and preserve health; however, there is a paucity of research on adherence amongst the growing population of adolescents living with HIV/AIDS (ALHIV) in Southern Africa. We examined levels of self-reported ART adherence, barriers to adherence, and factors associated with non-adherence amongst ALHIV in Malawi...
March 30, 2017: Journal of the International AIDS Society
https://www.readbyqxmd.com/read/28404198/molecular-fluorescence-guided-surgery-of-peritoneal-carcinomatosis-of-colorectal-origin-a-single-centre-feasibility-study
#11
Niels J Harlaar, Marjory Koller, Steven J de Jongh, Barbara L van Leeuwen, Patrick H Hemmer, Schelto Kruijff, Robert J van Ginkel, Lukas B Been, Johannes S de Jong, Gursah Kats-Ugurlu, Matthijs D Linssen, Annelies Jorritsma-Smit, Marleen van Oosten, Wouter B Nagengast, Vasilis Ntziachristos, Gooitzen M van Dam
BACKGROUND: Optimum cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is essential for the curative treatment of peritoneal carcinomatosis of colorectal origin. At present, surgeons depend on visual inspection and palpation for tumour detection. Improved detection of tumour tissue using molecular fluorescence-guided surgery could not only help attain a complete cytoreduction of metastatic lesions, but might also prevent overtreatment by avoiding resection of benign lesions...
December 2016: Lancet. Gastroenterology & Hepatology
https://www.readbyqxmd.com/read/28400712/inverted-u-shaped-curvilinear-relationship-between-challenge-and-one-s-intrinsic-motivation-evidence-from-event-related-potentials
#12
Qingguo Ma, Guanxiong Pei, Liang Meng
The balance between task demand and one's competence is critical for the maintenance of intrinsic motivation. According to Flow theory and Self-determination theory, optimal challenge gives rise to the maximum intrinsic motivation, and an inverted U-shaped curvilinear relationship between perceived challenge and one's intrinsic motivation is suggested. In order to provide direct experimental evidences for predictions of these theories, in this study, we employed the two-player StopWatch game that we previously designed, which made references to the game format of a badminton tournament...
2017: Frontiers in Neuroscience
https://www.readbyqxmd.com/read/28364581/self-reported-confidence-in-patient-safety-knowledge-among-australian-undergraduate-nursing-students-a-multi-site-cross-sectional-survey-study
#13
Kim Usher, Cindy Woods, Glenda Parmenter, Marie Hutchinson, Judy Mannix, Tamara Power, Wendy Chaboyer, Sharon Latimer, Jane Mills, Lesley Siegloff, Debra Jackson
BACKGROUND: Patient safety is critical to the provision of quality health care and thus is an essential component of nurse education. OBJECTIVE: To describe first, second and third year Australian undergraduate nursing students' confidence in patient safety knowledge acquired in the classroom and clinical settings across the three years of the undergraduate nursing program. DESIGN: A cross-sectional online survey conducted in 2015. SETTING: Seven Australian universities with campuses across three states (Queensland, New South Wales, South Australia)...
March 25, 2017: International Journal of Nursing Studies
https://www.readbyqxmd.com/read/28362186/a-proposal-for-a-new-classification-of-complications-in-craniosynostosis-surgery
#14
Dmitri Shastin, Sharron Peacock, Velu Guruswamy, Melpo Kapetanstrataki, David T Bonthron, Maggie Bellew, Vernon Long, Lachlan Carter, Ian Smith, John Goodden, John Russell, Mark Liddington, Paul Chumas
OBJECTIVE Complications have been used extensively to facilitate evaluation of craniosynostosis practice. However, description of complications tends to be nonstandardized, making comparison difficult. The authors propose a new pragmatic classification of complications that relies on prospective data collection, is geared to capture significant morbidity as well as any "near misses" in a systematic fashion, and can be used as a quality improvement tool. METHODS Data on complications for all patients undergoing surgery for nonsyndromic craniosynostosis between 2010 and 2015 were collected from a prospective craniofacial audit database maintained at the authors' institution...
March 31, 2017: Journal of Neurosurgery. Pediatrics
https://www.readbyqxmd.com/read/28351257/understanding-and-responding-to-severe-and-enduring-patient-distress-resulting-from-episodes-of-healthcare
#15
Linda Kenward
This article focuses on the severe, long-term and debilitating distress that may be experienced by patients as a result of their interactions with healthcare professionals and services. It is essential for healthcare professionals to be able to respond effectively to severe patient distress resulting from episodes of healthcare. Severe and enduring patient distress can occur in response to neglect - even when unintentional, misdiagnosis, surgical errors and/or deficits in the quality of care. Severe and enduring distress experienced by patients may go unacknowledged; the long-term consequences may not be recognised, or resolution may be presumed following formal apologies or receipt of compensation...
March 29, 2017: Nursing Standard
https://www.readbyqxmd.com/read/28344140/high-value-cost-conscious-care-iterative-systems-based-interventions-to-reduce-unnecessary-lab-testing
#16
Brett W Sadowski, Alison B Lane, Shannon M Wood, Sara L Robinson, Chin Hee Kim
BACKGROUND: Inappropriate testing contributes to soaring health care costs within the United States and teaching hospitals are vulnerable to providing care largely for academic development. Via its 'Choosing Wisely' campaign, the American Board of Internal Medicine recommends avoiding repetitive testing for stable inpatients. We designed systems-based interventions to reduce laboratory orders for patients admitted to the wards at an academic facility. METHODS: We identified the computer-based order entry system as an appropriate target for sustainable intervention...
March 23, 2017: American Journal of Medicine
https://www.readbyqxmd.com/read/28334586/processes-for-identifying-and-reviewing-adverse-events-and-near-misses-at-an-academic-medical-center
#17
William Martinez, Lisa Soleymani Lehmann, Yue-Yung Hu, Sonali Parekh Desai, Jo Shapiro
BACKGROUND: Conferences, processes, and/or meetings in which adverse events and near misses are reviewed within clinical programs at a single academic medical center were identified. METHODS: Leaders of conferences, processes, or meetings-"process leaders"-in which adverse events and near misses were reviewed were surveyed. RESULTS: On the basis of responses from all 45 process leaders, processes were classified into (1) Morbidity and Mortality Conferences (MMCs), (2) Quality Assurance (QA) Meetings, and (3) Educational Conferences...
January 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/28299848/specimen-identification-errors-in-breast-biopsies-age-matters-report-of-two-near-miss-events-and-review-of-the-literature
#18
Gary Tozbikian, Mary L Gemignani, Edi Brogi
The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories...
March 16, 2017: Breast Journal
https://www.readbyqxmd.com/read/28289254/mechanistic-movement-models-to-understand-epidemic-spread
#19
REVIEW
Abdou Moutalab Fofana, Amy Hurford
An overlooked aspect of disease ecology is considering how and why animals come into contact with one and other resulting in disease transmission. Mathematical models of disease spread frequently assume mass-action transmission, justified by stating that susceptible and infectious hosts mix readily, and foregoing any detailed description of host movement. Numerous recent studies have recorded, analysed and modelled animal movement. These movement models describe how animals move with respect to resources, conspecifics and previous movement directions and have been used to understand the conditions for the occurrence and the spread of infectious diseases when hosts perform a type of movement...
May 5, 2017: Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences
https://www.readbyqxmd.com/read/28248748/informing-the-design-of-a-new-pragmatic-registry-to-stimulate-near-miss-reporting-in-ambulatory-care
#20
Elizabeth R Pfoh, Lilly Engineer, Hardeep Singh, Laura Lee Hall, Ethan D Fried, Zackary Berger, Albert W Wu
OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents...
February 28, 2017: Journal of Patient Safety
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