A classification for incidents and accidents in the health-care system

Problems that arise from health-care management, rather than from a disease process, are now recognized as making a substantial contribution to patient morbidity and mortality and to the cost of health care. However, most classifications of these problems do not provide sufficient detail to allow comparisons or to develop better strategies for the prevention, detection and management of these problems. A 'Generic Occurrence Classification' was developed to record their salient features, place them in context and elicit any system or human error-based contributing factors. This was done by an iterative process in which 'natural categories', identified from over 2000 incidents and 800 adverse events, were placed in a hierarchical structure created using software written in Microsoft Visual Basic; data were stored in a Microsoft Access database. This was shown to be a valid and reliable way to compare incidents and accidents from different sources and to allow sufficient detail to be retrieved to develop preventive strategies.     

The Australian Incident Monitoring Study. Oesophageal intubation: an analysis of 2000 incident reports

There were 35 oesophageal intubations in the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). These reports confirm existing impressions that misplacement of the endotracheal tube can occur in trained as well as untrained hands, and that auscultation is an unreliable test. On the other hand, the value of capnography is emphasised, with no false positives in the 16 cases in which the instrument was used. There was one false negative. Over the 4 years of the AIMS study, reports have declined in frequency. It is possible that the early detection of oesophageal intubation by capnography has altered its status to the extent that anaesthetists no longer regard it as a "critical" incident. It is highly recommended that the presence of the expected concentration of carbon dioxide in expired air be confirmed by capnography immediately after any endotracheal intubation.     

Modelling the bioelectric behaviour of halo pin-patient structures during magnetic resonance imaging

Bioelectric compatibility of electrically conductive halo fixation devices and magnetic resonance (MR) imaging has been largely based on resulting image quality. Previous studies have focused primarily on improving image quality and, although the electrical characteristics of the system during imaging may have been noted, they have not been studied in depth. Utilizing both a theoretical and experimental approximation, this study focuses on the bioelectric characteristics of the pin-patient structures typically enountered in clinical halo fixation systems. Results indicate that the halo pin-patient system can be modelled using a resistor-inductor-capacitor circuit and that simple attempts at improving compatibility through increasing interface resistance by the use of insulated pins may not be an effective approach to improving halo instrumentation compatibility with new, stronger magnetic and higher-frequency resonance imaging systems.     

Adapting combinator and SECD machines to display snapshots of functional computations

A functional computation involves substituting for function applications in an expression until that expression is reduced to normal form. The views of computations presented by the sequence- and state-oriented debugging tools of imperative systems are inappropriate for use with functional computations. New debugging tools are needed to aid the development of functional programs, especially in the context of lazy evaluation. After surveying previously reported debugging tools, we discuss a new debugging tool. Its implementation involves changing the reduction rules of the machine. The new reduction rules are applied to an interrupted computation to give a snapshot of that computation in source-level terms. We have implemented tools to produce snapshots for eager SECD and lazy combinator reduction machines. Example snapshots are shown from each. The implementation for an eager SECD machine is relatively straightforward, so we confine discussion of this to a brief sketch. A more detailed account is given of the implementation for a lazy combinator reduction machine, as this offers one solution to well-known problems with debugging functional programs in the context of lazy evaluation and combinator code.     

Olfactory associative learning in Caenorhabditis elegans is impaired in lrn-1 and lrn-2 mutants.

The C. elegans mutants, lrn-1 and lrn-2, are impaired in associative learning using conditioned taste cues. Both mutants are defective in associative learning about appetitive and aversive events, indicating that lrn-1 and lrn-2 exert effects across motivational boundaries. In a new olfactory associative learning paradigm, in which wild type worms learn to avoid a previously attractive diacetyl odor after it has been paired with an aversive acetic acid solution, lrn-1 and lrn-2 are impaired. Although defective in associative learning using a conditioned olfactory cue, nonassociative learning (habituation and dishabituation) using this same olfactory cue is unaffected. The discovery that lrn-1 and lrn-2 are defective in associative learning with both taste and olfactory cues may suggest that associative learning in different sensory modalities converges on a common genetic pathway in C. elegans that is subserved by lrn-1 and lrn-2. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relative specification and transformational re-use of functional programs

Arelative specification is a collection of laws relating the behaviour of a required new program to that of one or more existing programs. A two stage method for transforming such relative specifications into effective functional programs is described and illustrated. Theinversion stage re-arranges the specifying laws to obtain a collection ofpartial definitions for each unknown function, typically involving non-deterministic operators. The subsequentfusion stage combines each set of partial definitions into a single complete definition, thereby eliminating non-deterministic operators.Supported by Science and Engineering Research Council, Grant GR/E16571     

Mutations that prevent associative learning in C. elegans.

The nematode Caenorhabditis elegans offers a promising system for the reductionist study of learning and memory. In this article, classical conditioning in C. elegans is demonstrated with a variety of associative learning assays. These assays allowed for the isolation and behavioral characterization of 2 mutant C. elegans lines impaired in associative learning. Both lines show no short-term or long-term associative conditioning; however, they appear relatively normal in tests of nonassociative learning and sensorimotor function. In combination with the well-described genetics and neuroanatomy of C. elegans, the isolation of mutants selectively, yet completely, blocked in associative learning provides the basis for an effective characterization of the cellular and molecular aspects of associative learning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)