Miss Celie Assignment Example | Topics and Well Written Essays - 250 words

Miss Celie - Assignment Example Celie’s hardships forced her to learn others’ values and beliefs. Ms. Celie’s bank was filled with a poor self image. The banking concept did not work with Ms. Celie, especially because she was abused and taught by others around her. When Shug, Mr. Johnson’s lover, came into Ms. Celie’s life, she began to teach Ms. Celie differently. Shug respected Ms. Celie after being around her for awhile. The two became confidants and lovers. Shug taught Ms. Celie that she was worth something. This allowed Ms. Celie to blossom. She opened her own shop after leaving Mr. Johnson. Ms. Celie even contacted her sister and children after Shug showed her letters Mr. Johnson had kept from her. Ms. Celie came back after her stepfather’s death to inherit her rightful estate. None of these things would have been possible without Shug teaching her self confidence and esteem. Shug treated the pupil with respect and taught Ms. Celie in her own individual way. Paulo Frieire’s idea of respecting each individual student instead of using the banking model is admirable, but impractical. Not every one comes from a loving or nurturing home. Some like, Ms. Celie, have hard lives. Too many people, educators included, are like Mr. Johnson, Pa, and others who treated Ms. Celie cruelly. The banking concept is the best method to teach children now, but Frieires ideas cannot be applied effectively to all

Taking a side on debate Essay Example | Topics and Well Written Essays - 500 words

Taking a side on debate - Essay Example This means that Americans are still confident that the Congress is able and will perform to their expectation. Were it not for the support, then most likely the Americans would give a negative responses as opposed to the ones they gave (Lowrey, 2013). Lowrey (2013) continues to state that even in the toughest situations, the Congress attempts to maintain sobriety. This means that the Congress has never failed the citizens despite the challenges faced. In the case that the Congress is keen to put the interests of the citizens first means that the entire system is fit for the country. In fact, based on the comments on various US citizens who were positive on the performance of the Congress, there is no tangible evidence on the dysfunctionality of the Congress. Walt (2011) is of the opinion that USA has over the years been the home of liberty, and a great leader to the earth. It is for the sake of the continuity of this legacy that Walt (2011), says that America’s mission to the great continent it is today needs to be continued both by all presidents and presidential contenders. Through this, American nationalism is branded. America is destined to be the focus of the world. The universality of America’s achievements and its appeal for emulation motivates the country to believe in a unique American mission (Walt, 2011). The government and all concerned stakeholders have no option but to drive America to its destiny. American Exceptionalism can therefore be termed as the blue print of America’s functionality. America has long been characterized by freedom of its people though there have been a lot of myths surrounding the same as argued by Foner (2013). The belief in a unique mission has led to America giving its citizens freedom to enjoy the American pride, regardless of the world perception. It is this unique mission that has led to setting up a democratic system and self-rule in America, ranking America as the best state in the

El Lissitzky Essay Example | Topics and Well Written Essays - 3500 words

El Lissitzky - Essay Example He designed several exhibition display and propaganda for the Soviet Union and experimented with several techniques and styles that set him apart from other artist, in creativity, and later paved a niche for him through the 20th century (Lissitzky-Kuppers, 1980; Stedelijk Van Abbemuseum and El Lissitzy, 1990). Lazar Markovich Lissitzky, a Jew, started as an artist early in life copying and illustrating Yiddish children's books. His efforts were basically aimed a promoting the Jewish culture in Russia, in line with the several changes taking place after the country's anti-Semitic laws were repealed. Starting at the age of 15, he began teaching, a duty that he never strayed far away from, for the most part of his life (Friedberg, 1987). He taught in a variety of positions, schools, and artistic mediums, spreading and exchanging ideas at a rapid pace. The ability to imbibe people's ideas and at the time same influencing them, was his unique trait. This trait was exhibited when he met and worked with Malevich in heading the suprematist art group UNOVIS, when he developed a variant suprematist series of his own, Proun, and further still in 1921, when he took up a job as the Russian cultural ambassador in Weimar Germany, working with and influencing important figures of the Bauhaus and De Stijl movements during his stay (Stedelijk Van Abbemuseum and El Lissitzy, 1990). Also, in his later days, he significantly influenced and brought several innovations to the fields of typography, exhibition design, photomontage, and book design. He produced several internationally recognised works. This continued until his deathbed, where in 1941 he produced one of his last known works - a Soviet propaganda poster rallying the people to construct more tanks for the fight against Nazi Germany (Lissitzky-Kuppers, 1980). However, the entire career and works of El Lissitzky was inspired by his belief that art should serve the needs of the society and that the artist should be an agent of change. From this perspective, it can be argued that his innovations in the world of art were driven by his resolve to serve societal needs, or affect the lots of the people, giving his devotion to the communist movement (Lissitzky-Kuppers, 1980; Stedelijk Van Abbemuseum and El Lissitzy, 1990). This essay therefore, intends to examine the life and work of El Lissitzky with a view to analysing the impacts and effects that the ethical and ideological views prevalent during his days, especially during the Russian Revolution had on his approach to art and design. To achieve this purpose, this essay will be structured thus: the first section of this essay shall briefly describe the history of El Lissitzky and the rise of the Proletarian Culture to provide a background understanding of his early days and perhaps his motivation. The second section will describe the several popular works of this artist and attempt to critically examine the influence of the prevalent soviet ideological of the time, on such work of art. Also, by looking at how his approach to art and design metamorphosed from the early days of illustrating Yiddish books to his later days in typography, on would gain an insight into how prevalent ethics and ideological perspectives influenced his approach to, and

Four Traditions of Geography Essay Example for Free

Four Traditions of Geography Essay Four Tradition of Geography The Four Traditions of Geography has many different assumptions and aspects of geography; aspects ranging from basic mapping and geometry, to the impact on nature of humans and the processes of the earth itself. Geographers can study and explain their research by selecting a certain tradition that leads to many different fields of geography. â€Å"There are four traditions whose identification provides an alternative to the competing monistic definitions that have been a geographer’s lot† (Pattison 1964). The following discussion treats the traditions in this order: (1) a spatial tradition, (2) an area studies tradition, (3) a man-land tradition and (4) an earth science tradition† (Pattison 1964). Pattison is exploring all the categories of geography and he is explaining how these different traditions can uncover the meanings of different studies of geography. â€Å"Going further one can uncover the meanings of â€Å"systematic geography,† â€Å"regional geography,† â€Å"urban geography,† â€Å"industrial geography,† etc. † (Pattison 1964). Spatial tradition is an area of concentration that relies on geometry and movement. It also is the study of mapping as seen in the ancient Greece recordings of such, and it also deals with the GIS system. GIS is any system that captures, stores, analyzes, manages, and presents data that are linked to a location. It explores the central place theory and how it is used in geography. Central place theory is the geography theory that seeks to explain the number, size and location of human settlements in an urban system. Area Studies, just like the spatial tradition it has roots from many, many years ago. The Greek philosopher, Strabo, wrote an encyclopedia about geographical knowledge. â€Å"He is Strabo, celebrated for his Geography which is a massive production addressed to the statesmen of Augustan Rome and intended to sum up and regularize knowledge not of the location of places and associated cartographic facts, as in the somewhat later case of Ptolemy, but of the nature of places, their character and their differentiation† (Pattison 1964). The area-studies tradition was tended to be excluded from early American professional geography. Today, it is beset by certain champions of the spatial tradition who would have one believe that somehow the area studies way of organizing knowledge is only a subdepartment of spatialism† (Pattison 1964). It concentrates on the descriptions of regions in order to differentiate them from other regions and areas. Being able to understand geography in these terms can reveal the deepest knowledge of the world’s environment. The Man-Land tradition describes the human impact in nature and also the impact of nature on humans, and it also defines the nature disasters our world takes on. Social Darwinism simply grabbed a theory from the biosciences and applied it to social happenings without the lengthy process of trial and error for social data which led to environmentalism. Environmentalism is a broad philosophy and social movement regarding concerns for environmental conservation and improvement of the environment. Man-Land gives us the basic perception on the environment and what is happening to it. The earth science tradition, embraces the study of the earth, the waters of the earth, and the atmosphere surrounding the earth and the association between the earth and the sun† (Pattison 1964). On two different hands of the topic, it is being used and then it is not being used. â€Å"On one hand, it is not always elected as the best tradition as it has been decreasing in use from past decades, while on the other one knows that college departments rely substantially, for justification of their role in general education, upon curricular content springing directly from this tradition† (Pattison 1964). It also acknowledges the human impact on the planet but mainly focuses on the planet itself and its physical processes. Geology, mineralogy, paleontology, glaciology, and meteorology all have rooted out of these studies. From reading â€Å"Four Traditions of Geography† and â€Å"In Search of Synthesis,† Area Studies tradition is my personal preference on this matter. Gober talks about the many different specialties that lie in between human and physical geography, and I grasped that I am more of a physical, on-hands doing person. With human geography you study societies as a whole and I am more interested in urbanization of the earth and how we can use the land we have in a fashion that is basically perfect. I am interested in the different regions because I am really fascinated in real estate and I figure I would learn a whole lot about the physical aspect of geography. I feel that I could really excel in real estate with this kind of learning. The Four Traditions of Geography has different definitions and aspects of geography. With the information given, people are given the opportunity to understand what geography is all about and be able to break geography down and select a certain practice from the very selective topic. â€Å"It is hoped that through a widened willingness to conceive of and discuss the field in terms of these traditions, geography will be better able to secure the inner unity and outer intelligibility† (Pattison 1964). William D. Pattison, The Four Traditions of Geography, (1964).

Eindhoven Model Of Incident Causation Nursing Essay

Eindhoven Model Of Incident Causation Nursing Essay Patient safety is the foundation stone and one of the central concerns in quality improvement for the health care institution. Keeping our patients safe is a challenging issue because errors and mistakes can and do occur any time. Human error is inevitable, reducing error and minimizing the consequences of error is best achieved by learning from mistake, rather than blaming attitude. Over the years, nurses have assumed roles in various quality improvement and health care risk management activities. Learning from errors and near misses helps to provide opportunities to overcome system gaps, design solutions and modify management systems can reduce the chances of future errors and prevent disaster. According to U.S Agency report (2001) patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures. The Institute of Medicine (IOM) reported that between 44,000 and 98,000 patients die in hospitals setting in 1997 in the United State of America (USA) each year as a result of health care errors which includes, transfusion of incompatible blood products, medication errors, foreign objects left in bodies, equipment failures, mistaken identities of patients or body parts. These errors occurred at any phase of the health care delivery system, errors with serious consequences were observed in most vulnerable clinical settings. Department of health (2001) An Australian study reported adverse event rates of 16.6% of which 13.7% resulted in permanent disability (Wilson, 1995). The Institute of Medicine (IOM) released (2001) a report on To Err Is Human: Building a Safer Health System On the basis of two research studies: one conducted in Colorado and Utah found that 6.6 percent of adverse events led to death, as compared with another study conducted at New York, found that adverse events occurred in 13.6 percent in New York hospitals. In both of these studies over half of these adverse events resulted from medical errors and could have been prevented. When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of the study in Colorado and Utah imply that at least 44,000 Americans die each year as a result of medical errors. The results of the New York Study concluded that deaths due to medical errors exceed the number attributable to the 8th leading cause of death. Scenario During my clinical experience, I encountered a situation where I received call from hospital incharge and reporting one sentinel event, series of e-mail exchanged and on call administrator requested me to terminate assigned staff who did an error. I have utilized my leadership knowledge and skills to the best of my understanding. The scenario was an 11 years old boy (Patient A) presented to hospital with the complaint of fever, headache and vomiting. 40 years obstetrics (Patient B) was admitted through emergency department for induction of labour. Both Patients blood was arranged and both have different blood groups. At night physician order to transfused blood to Patient A. Assigned nursing staff went to the laboratory with correct transfusion request slip and blood releasing form but unfortunately Patient B blood pack was picked instead of Patient A from the blood refrigerator at laboratory. Blood checked by same nurse with on call assigned physician before transfusion but again fa iled to check for correct identification at the bed side. Transfusion started to Patient A at 0700 hours. Shift changed at 0800 hours, over taken from night staff with blood transfusion but again verification was not done as a result unrecognized transfusion reaction occurred and ultimately Patient A expired at 13:00 hrs. I have investigated the case and requested respective assigned team and stake holders for root cause analysis. The situation was very painful and challenging as an eleven years old child died due to error but it gave me lots of opportunity to identify the system gaps in order to prevent from re-occurrence in future. As a management position, I requested multidisciplinary team to do the root cause analysis. Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance. The analysis progresses from special causes, clinical processes, organizational processes and systems, identify potential improvements in these processes or systems. After did a root cause analysis the incidence was categorized as sentinel event. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called sentinel because they signal the need for immediate investigation and response. Sentinel events are identified under the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and emphasized those policies helps organization to develop preventative measures. (The Joint Commission, 2011). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has placed considerable emphasis on promoting patient safety through a variety of mechanisms, including the reporting and analysis of sentinel events that can lead to modifications and improvements in policy and practice within health care settings. We must apply the same principles learnt from our experiences. When a sentinel event occurs in a health care organization, it is necessary that appropriate individuals within the organization be aware of the event, investigate, understand the causes that underlie the event, and make changes in the organizations systems and processes to reduce the probability of such an event in the future. As a key management position it is my prime responsibility to work as a team with multidisciplinary approach, take as an opportunity to improve the system and ensure the compliances of the institution policies and procedure by nursing division. An organized approach for identification, analysis and evaluation of risks and the devising a plan to decrease the occurrence of accidents, incidents and injuries (Sullivan Decker, 2000). The Institute of Medicine has designed six aims for improving the delivery of care in the United States which includes; Safe, effective, efficient, timely provision, equitable and Patient centered approach in order to provide safe and quality health care services. (Institute of Medicine, 2001). According to Pelletier and Beaudin (2004) The Institute of Medicine defines healthcare quality as the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making. During root cause analysis I came across lots of areas which was identified for areas of improvement that, leadership needs to provide resources in order to provide quality services as evidence by provision of resources was absent in laboratory which resulted that in night shift staff went to receive blood by herself and no check and balance of patient identification was done. However, it is not clearly defined in the policy that what will be the mechanism of check and balance at laboratory end. At secondary hospital laboratory services timing is from 0800 hours to 2300 hours, but what if need arises after wards. It was taken as a granted that services will not require in night timings. In addition, it was not clearly defined in the blood transfusion policy which defines the first steps of checking blood for correct identification at laboratory level. According to Daniel (2004) Clinical Management refers to diagnosis, treatment planning and delivery and ensuring the correct identific ation of each patient and procedure. As a nursing departmental heads the need was identified to review the policies and procedure, structured quality assurance program and Total Quality Management system (TQM) is required in order to prevent from reoccurrence. TQM is a management philosophy that emphasizes a commitment to excellence throughout the organization (Sullivan Decker, 2000). Total Quality Management (TQM) is a sub-discipline of management science which deals with the issue of standardization and enhancement of organizational performance. According to Khan (personal communication November 20, 2012) research was carried out in 2006-2009 by for critical analysis of TQM implementation in Pakistani organizations located on geographical basis. This study explores the factors influencing the success and failure of the TQM program in the organizations. It particularly explores how these programs work within the context of various organizational profiles, dynamics and culture. The study found that TQM implementation is heavily dependent on various factors related to organizational context and culture. It also identified that the end results and changes expected by organizations from TQM implementation are not only dependent on its own framework but on many other cultural related intermediate impacts. These intermediate impacts are mostly related to organizational dynamics and culture and are ignored in most of the firms, resulting in early failure of TQM. Based on the findings of this research and the practical experience of implementing TQM in different organizations, the author also proposes a new framework of TQM implementation named as MSAC cycle i.e. Mobilization (trial phase), Standardization (Short term phase), Acclimatization (mid-term phase) and Culturization (long term phase). This study and the proposed TQM implementation framework is quite valuable for the organization who are presently implementing or desirous to implement TQM more effectively and successfully. The Aga Khan University Hospital started its operation in 1985. Basic quality assurance methodologies were introduced and from 1994 onwards, the continuous quality improvement (CQI) model of AKUH fostered a positive culture of change by establishing lots of core quality activities across the clinical and managerial disciplines; which includes, quality circles, basic quality control tools, education and training in quality, monitoring of quality indicators, health care professionals credentialing, Patient complaints, Patient satisfaction, morbidity and mortality reviews, nursing quality assurance program and quality grand rounds. Finally in 2006, AKUH acquired the gold seal of international accreditation in health care by the Joint Commission International Accreditation (JCIA) with the unique distinction of being the first hospital in Pakistan and among few universities based hospitals in the world to get the quality recognition. AKUH is now on the expansion and integration phase of i ts quality journey, the central driving force towards its quality vision is improvement of processes and outcomes and achieving a strong customer orientation towards both external and internal customers. This will be achieved through concentrating on the goals and strategies of the hospital and all its departments to these three major themes that is improvement in quality of care, services and cost-effectiveness. It is widely recognized that quality indicators or performance indicators can give a valuable insight into the quality of care being provided to patients. Performance indicators are best way to learn and improve, but to instill ownership in the heart of every individual is the key to having meaningful indicators. Thus making performance indicators a part of a physicians and nursing performance evaluation not only ensure that they actively participate in improving their own performance, but also ensure that, quality of care provided to the patients is always and continuously improving. In this clinical situation I also participated in developing the policies with multidisciplinary team and tool in order to control quality system and to evaluate the compliances of practice for sustainability. Fostering a culture of safety requires more than introducing new policies and procedures. Developing a culture of safety requires critical thinking, problem solving, risk identification management and human factor training. The relevant literature and websites on patient safety program has suggested many safety related performance indicators and sy stems of check and balances which can ensure patients safety during patients stay at hospital. A systematic and multidisciplinary approach is, therefore, very imperative to pick-up medical errors and devise strategies to reduce them as it defiantly plays an important part in patient safety. Literature Review The literature review will address overall concept of patient safety and its related issues and concerns, international perspective of error occurrences, safety related performance indicators and measures to create positive safety culture. Several studies are carried out on measuring and evaluating patient safety and outcomes at several health care institutions (Baker 2003; Arah, 2004; Colla, 2005; Karsh, 2006). According to Colla (2005) Achievement of a culture conducive to patient safety may be an admirable goal in its own right, but more effort should be expended on understanding the relationship between measures of safety climate and patient outcomes. The Luxembourg Declaration on Patient Safety (2005) has observed that the health sector is a high-risk area because adverse events, arising from treatment rather than disease, can lead to death, serious damage, complications and patient suffering. Although many hospitals and healthcare settings have procedures in place to ensure patient safety, the health care sector still lags behind other industries and services that have introduced systematic safety processes. Almost fifty percent of joint commission standards are directly related to safety, addressing such issues as medication usage, infection control, surgery and anesthesia, blood transfusions reactions, staff credentialing, fire safety, medical equipment, disaster management, risk identification and management, sentinel event monitoring, safety and security structures. These standards address a number of significant patient safety issues, including the implementation of patient safety programs; the response to adverse events when they occur; the prevention of accidental harm through the prospective analysis and redesigning of vulnerable patient systems and its the organizations responsibility to transparent and take ownership and accountability. Agency for Health Research and Quality (AHRQ) reports (2001) has suggested the same that to review best practices from scientific literature, Redesign care based on best practices through collaboration of multiple departments, Evaluate technology solutions, Implement performance measurements and Monitor selected measurements and present summary reports to senior leadership. Moreover, the Advisory Board Research document supports the type of error mentioned in the AHRQ 2000 reports that the most common errors per 1,000 visits are: 65 incidents per due to adverse drug events, 60 incidents due to hospital acquired infections, 51 incidents related to procedural complications and 15 incidents related to falls. Besides analyzing the common errors in terms of patient safety, Mrayyan and Huber (2003) discussed three aspects of patient safety issues. First is the fear that is whenever any unfortunate incident happens and it is publicized; it creates fear and apprehension among team members. Second issue is errors as a system problem, which involves repetition of same type of error that requires close and immediate interventions. Third is the link between errors and inadequate resources that means inadequate number of staffs or inadequate trained staff that can jeopardize patient safety. The medical error and harm to patient safety does not only let the patient suffer but brings an impact on society at large. The Danish Society for Patient Safety (2005) discussed the effects that adverse events can have on patients; health care personnel and society at large are significant. Patients may suffer both physically and psychologically from sufferings created by the injury itself, but also by the way the incident is handled. Health care personnel on the other hand may experience shame, guilt and depression, with litigations and complaints imposing an additional burden. Society at large suffers from a lower quality of life of its members, with associated extra health care costs but also costs caused by a lower productivity of the society. After root cause analysis I also felt that it is necessary to have interaction one is to one basis to relevant health care personal who did an error in order to sensitized them and mentored through education path rather than terminating the employee, give them insight that the will be the future ambassador for patient safety because, I personally believe that quality reflect when person itself willing to do so, it should be our constant commitment towards organization that patient safety should be our top priority, which infuses the entire organization, for that it is mandatory that first we should acknowledge the error then promote blame-free environment where individuals are empowered to report errors without any fear and punishment so they can willingly address safety concerns. Daniel (2004) explains that, what can be done today to improve patient safety while we are waiting for evidence on effective interventions. First, we need leaders those at the top of organizational charts as well as leaders at all level, second, we need to focus on comprehensive systems of safety rather than attempting to address safety one problem at a time. Three elements comprise comprehensive patient safety: active case finding, methodical analysis, and system redesign. Patient safety initiatives and programs vary from institution to institution but the aim remains the same that is reducing errors and promote safety. Klazinga and Arah (2004) said it is evident that current efforts focus too narrowly on the patient with little explicit linkage to wider aspects of health system safety. Risks management entails reducing harm not just to patients but also to staff, visitors and the environment including society. Some of the patient safety alternatives and solutions proposed by Mrayyan and Hubber (2003) are emphasizing on strengthening system of error reporting and correction that is error detection and reporting system within organization to reduce medical error, patient education in all aspects of care and applying risk management skills by healthcare personnel. In addition, creating an information system and building evidence base for patient safety, analyzing the impact of various management practices like staffing, increasing of medical errors and high risk population and monitoring error rates with necessary actions can reduce medical errors and also use of information technology can work towards enhancing patient safety. Besides all this, commitment of the healthcare professional to reduce errors and promote safety in any organization enhances safety not only for patients but also for the healthcare staff and society in general. This position paper related to sentinel event also gives me insight to do a self-reflection of my job related competencies as a key management representative. I personally believe that, Knowledge can be achieve by reading literature but the art of utilizing that knowledge and skills will give confidence to fulfill job in an effective way. According to (Barker, Sullivian Emery 2006). describe three key roles organized in to three categories called interpersonal roles, informational roles and decisional roles. In interpersonal roles manager has lots of job responsibilities in order to full fill organizational goals, informational roles comprises of monitor and disseminator as that manager is the focal person and considered an as nerve center. Third category is decisional roles which consist of entrepreneur, disturbance handler, resource allocator and negotiator. The first two categories are related to day to day operation However, the third category need that how manager use his/her c ompetency in clear direction which meet the organization vision and mission. Integration of Model There are number of the clinical theories and models regarding the human error are discussed in management. Among which I have selected the Eindhoven model of incident causation. Eindhoven Model of Incident Causation: This model was originally developed to identify root causes of safety related incidents in the Netherlands and has since been tested in industrial and health care settings. The Eindhoven Model of incident causation identifies three main causes of error: human operator, organizational and technical failure. These failures, alone or in combination, are through responsible for reinitiating a chain of events that may ultimately lead to an adverse patient outcome. In performance improvement terminology, such a failure would be considered the root cause of an incident. According to this model, high risk situations will develop into incidents if inadequate system defenses are available to remediate the problem. The Eindhoven Model of Incident Causation served as the theoretical basis for developing the Eindhoven Classification Model, which has since been adapted for the health care domain (Jacob Cherry 2011). This classification model claims that errors occur either because of active failu res or latent conditions. Human Operator Error: (Active failure): Human operator errors are those made by individuals at the sharp end by health care workers. They are also referred to as active failures or active errors. Active failures fall into three major categories; skill based, rule-based or knowledge-based. Skill based error occur when an individual makes an error during the performance of a routine task that requires little conscious effort as evidence by its routine practice of nurses to bring blood from laboratory or its routine to take daily over from upcoming shift but in different intervals but nurse fails to check for correct identification with patient name and medical record number. An example of a skill based error would be a nurse forgetting to push the start button on an IV pump after priming the tubing. A rule based error occurs when an individual fails to perform a procedure or protocol correctly or chooses the wrong procedure as in this sentinel event nurse and physician fails to compliance with policies and procedure as a res ult wrong blood was transfused. An example of a fuel-based error is a phlebotomist failing to check the patients identification before obtaining a blood specimen. A knowledge based error refers to the conscious but incorrect application of existing knowledge to a new situation. An example of a knowledge-based error would be when first patient develop fever or sign of reaction she took as an granted and stop blood for time being neither nurse or physician utilized their knowledge and integrated theory in to practice or critically analyze that what would be the possible reasons for fever. Human errors have typically been the focus of traditional incident report monitoring because they are more obvious that latent conditions. Although some of the factors leading to human error are amenable such as knowledge deficit, staffing shortages, work over load etc. Technical or organizational error (Latent Condition/ Latent error): Technical and organizational errors are referred to as latent condition or latent errors. Latent conditions result from sanctions or decisions made by administrators or others in leadership positions that affect technical issues, organizational policy or the allocation of resources. These errors are called latent because of the delayed and unintended consequences that may affect patient safety at a later point. Technical error occurs when there are problems with equipment, forms, labels, etc. (e.g. a computer does not print out patient identification labels in a timely manner). Organizational error can be related to various, often complex issues involving management priorities and organizational culture. An Example of a latent error would be an organizational decision not to use a computerized provider order entry system which results in a high number of medication errors related to illegible handwriting. Other Error (Unclassified): A third category in the Einhoven Classification Model accounts for errors that cannot be classified as active or latent. In health care, such errors are generally due to patient-related factors that contribute to error, for instance, if patient gave the history of allergy and this can lead to potential medication error. An error whose cause cannot be placed in any category (i.e. latent, active, or patient-related) is termed unclassifiable. In order to continuous quality improvement and promote patient safety culture it is necessary to promote culture of reporting of errors is the first step along with a constructive process towards understanding that what factors within a system enable an error to take place. This systems approach is gaining ground and many hospital administrators are becoming well versed in its theory and practice. To promote a culture of safety the leadership of an organization promulgates an atmosphere in which the reporting of errors is welcomed, so that others may benefit from knowledge of the situation and can develop strategies based on the data. A major element of this framework is a non-punitive stance towards the individual who reports or who has involved in an incident. In a just culture an organization lets its employee know that they will not be disciplined for making mistakes and that the leaders value the importance of learning from mishaps and seek to improve the system that allowed the m to occur. Recommendation Based on sentinel event which I address in my position paper and in light of literature, I would like to recommend few suggestions/ recommendations to strengthen our quality system. First in order to promote in healthcare organization, major emphasis required in order to create non-punitive environment where health care workers can report events, errors and near misses without fear of reprisal or disciplinary action. Next, the risk management forum should be structured at organizational level where relevant multidisciplinary key stake holders should identified in order to take ownership and facilitate clinicians and organizational managers at all levels, the in order to create such an atmosphere which promotes patient safety culture in an organizations. Needs to develop and implement a reporting system that encourages and enhances reporting by all department and staff. Educate all clinicians, staff, and management personnel on the nature and importance of the event reporting process, including disclosure and discovery issue. Needs to do timely and accurate documentation of sentinel events help organizations improve their safety and quality of care and learn from other organizations unexpected outcomes, which allow other health care organizations to be aware of the possibility of certain sentinel events, thus giving staff the time and knowledge to develop strategies to avoid these events before they actually occur. Utilization of event report data to trend and analyzes organizational risks and distributes this information to appropriate staff of the organization so that risk-prevention measures can be developed and implemented. Last but not least provide clinicians and staff ongoing feedback on their risk-reduction efforts, results of event reporting should be discussed at the departmental level, and input on corrective actions/process improvements should be solicited. Conclusion: In conclusion, I must say that errors can occur at any point in the health care delivery system. Acknowledging that errors, learning from those errors, and working to prevent future errors represents a major change in the culture of health care, a paradigm shift from blame and punishment to analysis of the root causes of errors and strategies to improve systems and processes by implementing patient safety measures which provide an objective, validated measure for identifying Potential Safety Issues. Management should make an effort to break down barriers by adopting non-punitive cultures based on industry best practices. This will sheds new light on traditional methods for removing reporting barriers, develop employee commitment to recognize and report errors or incident occurrences. When the staff proactively participates in reporting, the reporting process becomes a vehicle for making practices improvements in the delivery of patient health care and management receives information that otherwise would not be available. As one manager said, if nobody reports it, you dont know. When some occurrences are not reported, management receives limited information on which to base their decision. It goes without saying that better data mean better decisions. According to Daniel (2004) the goal should be not only to increase the number and quality of reports but also to increase their usefulness as rich sources of information for the generation of strategies tactics aimed toward medical-error reduction (p. 27). According to Minesota Alliance for Patient Safety (2005) safety culture is not blame-free approach; it is an approach that balances the need to promote open reporting and the need to hold practitioners accountable for their behavioral choices. Hospitals should identify potential safety issues, having proactive approach, measure baseline performance, and set priorities for process improvement efforts. Using this methodology, hospitals can implement patient safety program with minimal investment on their part. Informational reports can be generated and disseminated to proactively identify safety issues and drive improvements for the better health care outcomes.

Reiki Therapy Essay -- Research Japanese Papers

Reiki Therapy The History of Reiki According to the Reiki Holistic Healing at Christal Center web page, the word â€Å"Reiki† is defined as the Japanese word for â€Å"universal energy†. Reiki therapy is a â€Å"laying on of hands† by a therapist who has studied Reiki, and therefore has enabled him/herself to provide a channel of healing energy for their clients. Although Dr. Makao Usui, a Christian monk, is credited with rediscovering Reiki therapy in Japan during the 1800’s, believers say this therapy dates all the way back to when Jesus healed others through his touch thousands of years ago (http://www.cwizard.com/christal/reiki.htm). Wade Ryan (a Reiki Master) claims in his web page on facts about Reiki that this is not a religion, but that the spiritual energy received by clients often leads to an expansion of one’s own personal faith (http://www.freeyellow.com/members/Reiki/page1.html). â€Å"The Three Reikis† (http://www.freeyellow.com/members/Reiki/page2.html) explains that about five years ago distinctions for three forms of Reiki were recognized. The three forms are Usui Reiki, Vajra Reiki, and Karuna Reiki. Usui Reiki is the traditional form of Reiki rediscovered by Dr. Usui. Usui Reiki is noted for being a very gentle therapy, and therefore appropriate for adults and children seeking to maintain their good health, for providing energy to those who are lacking it due to illness or treatment, and also for the elderly. During Usui Reiki, the Practitioner’s Hand Positions are centered mainly on the head or torso. Although most Practitioners are satisfied with Usui Reiki Ability, those who are interested in a wider range of Healing Energy (i.e. caregivers of the extremely ill) would be more interested in Vajra R... ... very few studies out on this topic, and those that are out seem to disagree with each other; some are in favor of the benefits of Reiki, and some claim that these benefits only exist because of psychological reasons or don’t exist at all. Although Reiki is an ancient practice, it is just beginning to become popular in modern medicine. We can expect more and more research to be published in the near future as more studies are conducted and completed. Bibliography Green, CA (1998). Reflection of a therapeutic touch experience: case study 2. Complementary Therapies in Nursing & Midwifery, 4(1), 17-21. Samarel, N. (1997). Therapeutic touch, dialogue, and women's experiences in breast cancer surgery. Holistic Nursing Practice, 12(1), 62-70. Thornton, Lucia Marie (1993). Effects of energetic healing on female nursing students. MAI, 31/01, 284.

Decision-Making Model Essay

The human decision-making process has been described by the development of several frameworks. The alternative for the maximize utility of the decision is selected by a fully informed, as well as, knowledgeable decision maker in the Rational Model. A satisfactory decision alternative is sought by the decision maker due to the causes of time, information, and space constraints according to the Bounder Rationality Model. It is hypothesized by the Organizational Model that available procedures are used by the decision maker for the solution of problems of decisions in a continuously updated organizational memory. Conflicting values and interests are confronted by the decision makers in the Muddling through Model, and an incremental improvement in the outcome is achieved by the selection of alternative with minimal organizational changes. An intermeshing of problems, solutions, and decision maker interest are represented by decisions that are forced by social and political factors in an anarchistic environment according to the Garbage Can Model. The criteria are met best by the identification of alternative with the use of relationship that is made between the criteria, events, and alternative by the decision maker in the Classical Decision Theory Model. During the selection process, conflicting constraints can be confronted by the decision maker, as intangible or tangible criteria would have to be dealt in uncertain events. The situation is assessed, a single alternative is generated and evaluated, and alternative for a satisfactory solution of the problem is selected by the decision makers according to the Naturalistic Decision-Making Model. Outcomes of the decision-making process are focused by some of the proposed models like Classical and Rational Decision Theory formulations. A limited set of decision activities is highlighted by other models like Bounded Rationality Models and Naturalistic Decision-Making Models. A comprehensive and integrated view of decision-making has been offered by none of the proposals. In addition, not all the situations of the decision-making can be applied with any formulations of these proposals. For instance, operational and tactical decisions can be applied with the Organizational Model. However, strategic decisions cannot be applied with this model due to incomplete understanding of the problem, as well as, limited availability of the knowledge of the problem. In this regard, the most popular model of the human decision-making process has been the three-phase paradigm of design, intelligence, and choice by the Simon. Virtually, all other proposed frameworks have been implied by this most general paradigm. However, an implementation phase of the Simon’s formulation has been concluded with the expansion of such scrutiny. Reality is observed by the decision maker during the intelligence phase. A fundamental understanding regarding the existing problems, as well as, new opportunities is gained by the maker. In addition, the general quantitative and qualitative information is acquired by the decision maker for the addressing of different opportunities, as well as, the problems. In the design phase, a specific and precise model is developed by the decision-maker, by which, the discovered problems and opportunities are examined systematically. Decision alternatives, uncontrollable events, criteria, and numerical, as well as, symbolic relationships will be consist in this model. The ensuing choice phase constitutes of the generation of recommended actions from the evaluation of the specified alternatives by the usage of explicit models logically. The analyses and recommendations are pondered by the decision maker during the subsequent implementation phase. In this regard, the consequences are weighed, and sufficient confidence is gained in the decision-making process. In addition, an implementation plan is developed, financial, human, and material resources are secured, the plan is put into the action. After the implementation of the final choice, the new reality should be observed by the decision maker. In addition, intelligence, design, choice, and implementation should be regarded and followed by the decision maker. Moreover, the need for revisions at preceding phases might be suggested by the phase’s analyses. For instance, adjustments of the previous design might be necessitated by the analyses during the choice. Conceptually, individual or group decision-making is applied with the decision-making process in the same manner. In practice, the communication-intensive aspects of cooperative problem solving must be accommodated by the group decision-making. In addition, voting, ranking, rating, and other consensus-developing methodologies should be supported by the usage of structured techniques. Group and organizational collaboration support should be provided by the development of this consensus. Decision-making model can be operated by the use of a variety of measures. Outcomes are dealt by some measures, and process outcomes are involved by the others. Positive decision outcomes can include: Increases in returns, costs reduction, and increment in the flow of information are some of the examples of the gains in the performance of the organization. When the understanding of a person regarding a current problem, as well as, its solution is developed, the decision-maker’s maturity develops. In addition, the improvement of the general problem-solving skills also results in the maturation of the decision-maker. Objectively, recording can be done regarding the number of opportunities, problems, as well as, alternatives. Experts, as well as, person’s evaluations can assess such efforts and subjective assessments. In expert’s evaluations, practice would be observed by the experienced decision makers and the examinee’s efforts will be rated. In this regard, a structured rating form will be used for its support. The examinees are used by the directed self-examinations, and a facilitator is used for the purpose of guidance. In some decision-making situations, the improvement of the organizational performance becomes impossible due to the competition, internal restrictions, external constraints, and several other factors. Under these circumstances, the main decision outcome will be the learning, training, and various other beneficial side effects during the maturation of the decision maker. Process Enhancements in the ability of a person or group are involved in the process improvements for the implementation of the phases and steps in the decision-making process. Experts, as well as, person’s evaluations can assess such efforts and with the help of subjective assessments. In expert’s evaluations, practice would be observed by the experienced decision makers and the proficiency of the examinee during each phase and step of the decision-making process will be rated. In this regard, a structured rating form will be used for its support. The examinees are used by the directed self-examinations, and a facilitator is used for the purpose of guidance. The use of accounting tools is involved in the process tracing, in which, the decision aid is embedded for the recording, as well as, reporting of the actions of the examinee during the decision-making process. In addition, the process enhancements may be manifested through: The time that is needed during the structuring of the problem by the user is reduced in a hike in personal efficiency. In addition, in a given time period, the number of alternatives is increased during the evaluation of the user, which is also an example of the hike in personal efficiency. The time of the decision-making is reduced, and the amount of pertinent information is increased from the decision-making is an improvement in the personal productivity. Objectively, recording can be done regarding the time and number of evaluated alternatives. Expert, as well as, direct self-evaluations by the activity of an individual or group can assess the amount of pertinent information, wisdom, and knowledge, that is, subjective assessments. In any particular management situation, more importance might be given to the support for some phases, as compared with the support for others. The process should be improved for at least the relevant phases by a given aid in the decision-making process. The decision outcome and process measures have been summarized in the Table 1. In addition, the measurements have been obtained by the available approaches, which have also been summarized in the table. As such, a series of guidelines has been offered by the table for the operation of the decision-making process. For instance, the implementation phase of the decision-making process consists of confidence and commitment of the decision maker. The performance of the decision maker during these steps is measured by the process tracing, expert ratings, and directed self-evaluations, as indicated by the Table 1.