Centennial-scale reductions in nitrogen availability in temperate forests of the United States.

Forests cover 30% of the terrestrial Earth surface and are a major component of the global carbon (C) cycle. Humans have doubled the amount of global reactive nitrogen (N), increasing deposition of N onto forests worldwide. However, other global changes-especially climate change and elevated atmospheric carbon dioxide concentrations-are increasing demand for N, the element limiting primary productivity in temperate forests, which could be reducing N availability. To determine the long-term, integrated effects of global changes on forest N cycling, we measured stable N isotopes in wood, a proxy for N supply relative to demand, on large spatial and temporal scales across the continental U.S.A. Here, we show that forest N availability has generally declined across much of the U.S. since at least 1850 C.E. with cool, wet forests demonstrating the greatest declines. Across sites, recent trajectories of N availability were independent of recent atmospheric N deposition rates, implying a minor role for modern N deposition on the trajectory of N status of North American forests. Our results demonstrate that current trends of global changes are likely to be consistent with forest oligotrophication into the foreseeable future, further constraining forest C fixation and potentially storage.

Mercury distribution across 14 U.S. Forests. Part I: spatial patterns of concentrations in biomass, litter, and soils.

Results from a systematic investigation of mercury (Hg) concentrations across 14 forest sites in the United States show highest concentrations in litter layers, strongly enriched in Hg compared to aboveground tissues and indicative of substantial postdepositional sorption of Hg. Soil Hg concentrations were lower than in litter, with highest concentrations in surface soils. Aboveground tissues showed no detectable spatial patterns, likely due to 17 different tree species present across sites. Litter and soil Hg concentrations positively correlated with carbon (C), latitude, precipitation, and clay (in soil), which together explained up to 94% of concentration variability. We observed strong latitudinal increases in Hg in soils and litter, in contrast to inverse latitudinal gradients of atmospheric deposition measures. Soil and litter Hg concentrations were closely linked to C contents, consistent with well-known associations between organic matter and Hg, and we propose that C also shapes distribution of Hg in forests at continental scales. The consistent link between C and Hg distribution may reflect a long-term legacy whereby old, C-rich soil and litter layers sequester atmospheric Hg depositions over long time periods. Based on a multiregression model, we present a distribution map of Hg concentrations in surface soils of the United States.

Adverse-event-reporting practices by US hospitals: results of a national survey.

CONTEXT: Little is known about hospitals' adverse-event-reporting systems, or how they use reported data to improve practices. This information is needed to assess effects of national patient-safety initiatives, including implementation of the Patient Safety and Quality Improvement Act of 2005 (PSQIA). This survey generated baseline information on the characteristics of hospital adverse-event-reporting systems and processes, for use in assessing progress in improvements to reporting. METHODS: The Adverse Event Reporting Survey, developed by Westat, was administered in September 2005 through January 2006, using a mixed-mode (mail/telephone) survey with a stratified random sample of 2050 non-federal US hospitals. Risk managers were the respondents. An 81% response rate was obtained, for a sample of 1652 completed surveys. RESULTS: Virtually all hospitals reported they have centralised adverse-event-reporting systems, although characteristics varied. Scores on four performance indexes suggest that only 32% of hospitals have established environments that support reporting, only 13% have broad staff involvement in reporting adverse events, and 20-21% fully distribute and consider summary reports on identified events. Because survey responses are self-reported by risk managers, these may be optimistic assessments of hospital performance. CONCLUSIONS: Survey findings document the current status of hospital adverse-event-reporting systems and point to needed improvements in reporting processes. PSQIA liability protections for hospitals reporting data to patient-safety organisations should also help stimulate improvements in hospitals' internal reporting processes. Other mechanisms that encourage hospitals to strengthen their reporting systems, for example, strong patient-safety programmes, also would be useful.

Quantifying change in distributions: a new departure index that detects, measures and describes change in distributions from population structures, size-classes and other ordered data.

Many statistics are available to compare distributions. Some are limited to nominal data while others, such as skew, Kullback-Leibler, Kolmogorov-Smirnov and the Gini coefficient, are useful for providing information about ordered distributions. While many of these tests are useful for determining properties of data in histograms, there has not been a test until now that allows for the detection of differences between distributions, describes the difference and is sensitive to the location of the departures. Such a test could be critical for comparing pre-and post-event distributions, such as a change in the distribution of biomass due to fire, for example, or for comparing data from different locations, such as soil size distributions, and even for evaluating economic disparity or examining differences in age demographics. We present a new statistic, a departure index, which allows a test distribution to be compared with any reference distribution. The resulting index contains information about the location, magnitude and direction of departure from the reference distribution to the test distribution. The departure index in turn provides a standardized response range that allows for a comparison of results from different analyses. A case study of actual fire data demonstrates the sensitivity and range of the test.

Quality and safety by design.

Rather than continuing to try to measure the width and depths of the quality chasm, a legitimate question is how does one actually begin to close the quality chasm? One way to think about the problem is as a design challenge rather than as a quality improvement challenge. It is time to move from reactive measurement to a more proactive use of proven design methods, and to involve a number of professions outside health care so that we can design out system failure and design in quality of care. Is it possible to actually design in quality and design out failure? A three level conceptual framework design would use the six quality aims laid out in Crossing the quality chasm. The first or core level of the framework would be designing for patient centered care, with safety as the second level. The third design attributes would be efficiency, effectiveness, timeliness, and equity. Design methods and approaches are available that can be used for the design of healthcare organizations and facilities, learning systems to train and maintain competency of health professionals, clinical systems, clinical work, and information technology systems. In order to bring about major improvements in quality and safety, these design methods can and should be used to redesign healthcare delivery systems.

Improving patient safety by instructional systems design.

Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training. Instructional systems design (ISD) is a systematic method of development of education and training programs for improved learner performance. The ISD process involves five integrated steps: analysis, development, design, implementation, and evaluation (ADDIE). The application of ISD using the ADDIE approach can eliminate or prevent education and training from being a contributing factor of health associated injury or harm, and can also be effective in preventing injury or harm.

Using standardised patients in an objective structured clinical examination as a patient safety tool.

Standardised patients (SPs) are a powerful form of simulation that has now become commonplace in training and assessment in medical education throughout the world. Standardised patients are individuals, with or without actual disease, who have been trained to portray a medical case in a consistent manner. They are now the gold standard for measuring the competence of physicians and other health professionals, and the quality of their practice. A common way in which SPs are used in performance assessment has been as part of an objective structured clinical examination (OSCE). The use of an SP based OSCE can be a powerful tool in measuring continued competence in human reliability and skill performance where such skills are a critical attribute to maintaining patient safety. This article will describe how an OSCE could be used as a patient safety tool based on cases derived from actual events related to postdonation information in the blood collection process. The OSCE was developed as a competency examination for health history takers. Postdonation information events in the blood collection process account for the majority of errors reported to the US Food and Drug Administration. SP based assessment is an important patient safety tool that could be applied to a variety of patient safety settings and situations, and should be considered an important weapon in the war on medical error and patient harm.

The DNA sequence and comparative analysis of human chromosome 10.

The finished sequence of human chromosome 10 comprises a total of 131,666,441 base pairs. It represents 99.4% of the euchromatic DNA and includes one megabase of heterochromatic sequence within the pericentromeric region of the short and long arm of the chromosome. Sequence annotation revealed 1,357 genes, of which 816 are protein coding, and 430 are pseudogenes. We observed widespread occurrence of overlapping coding genes (either strand) and identified 67 antisense transcripts. Our analysis suggests that both inter- and intrachromosomal segmental duplications have impacted on the gene count on chromosome 10. Multispecies comparative analysis indicated that we can readily annotate the protein-coding genes with current resources. We estimate that over 95% of all coding exons were identified in this study. Assessment of single base changes between the human chromosome 10 and chimpanzee sequence revealed nonsense mutations in only 21 coding genes with respect to the human sequence.

Organizing patient safety research to identify risks and hazards.

Patient safety has become an international priority with major research programmes being carried out in the USA, UK, and elsewhere. The challenge is how to organize research efforts that will produce the greatest yield in making health care safer for patients. Patient safety research initiatives can be considered in three different stages: (1) identification of the risks and hazards; (2) design, implementation, and evaluation of patient safety practices; and (3) maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place. Clearly, different research methods and approaches are needed at each of the different stages of the continuum. A number of research approaches can be used at stage 1 to identify risks and hazards including the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment. No single method can be universally applied to identify risks and hazards in patient safety. Rather, multiple approaches using combinations of these methods should be used to increase identification of risks and hazards of health care associated injury or harm to patients.

A system of analyzing medical errors to improve GME curricula and programs.

The report of the Institute of Medicine (IOM) To Err is Human recommended that both mandatory and voluntary event-reporting systems be established to identify and learn from errors. Because of the tight coupling of graduate medical education (GME) programs and the delivery of care, any event-reporting system used in a teaching hospital should be able to document the types of errors that are being made by graduate medical trainees (GTs). The authors performed an analysis of the root causes of events involving GTs that were recorded in hospital-based near-miss reporting systems. The root causes were classified using the Eindhoven Classification Model, medical version. Case histories of three separate events, one from an accident and emergency department in the United Kingdom, and two from a large teaching hospital in the United States, are used to illustrate the method. In all three cases, lack of knowledge on the part of the trainee contributed to the incident. Inadequate educational preparation had the potential for causing significant harm to the patient. Organizational causes were also present in each case, which illustrates the need to examine not only educational issues but also procedural and management issues related to GME. In each case, the analysis revealed in striking clarity deficiencies of educational content and problems of program structure. The authors conclude that doing a root-cause analysis in conjunction with a near-miss event-reporting system in a teaching hospital can be a valuable source of documented information to guide needed educational and system changes to GME programs.

Measuring and predicting academic generalists' work satisfaction: implications for retaining faculty.

PURPOSE: To develop a measure that could be used to identify interventions to improve the work satisfaction of academic generalists. METHODS: To field-test the measure, the authors surveyed the generalist faculty at the University of Texas Southwestern Medical Center at Dallas. Ninety-four (80%) of the faculty responded. The measure's reliability was established using Cronbach's alpha, and its validity was established with the Pearson correlation coefficient using a previously validated global work-satisfaction measure. Using ten work-satisfaction dimensions and selected faculty characteristics, the authors performed univariate and stepwise multiple regression analyses to predict the generalist faculty's global work satisfaction and intentions of leaving their positions. RESULTS: Work-satisfaction dimension predictors were autonomy in the workplace, professional status, teaching activities, clinical resources and activities, professional relationships, institutional governance, compensation, and professional advancement. Faculty characteristic predictors were gender, age, race or ethnicity, and living with children. CONCLUSION: The measure includes eight valid and reliable work-satisfaction dimensions that predict global work satisfaction or intentions to leave. Others may want to use this measure, along with the four faculty-characteristic predictors, as a management tool for improving academic generalists' work satisfaction and, ultimately, their performances and retention.

Using antecedents of medical care to develop valid quality of care measures.

OBJECTIVE: To present a new model for using the antecedents of medical care in outcomes assessment to develop valid quality of care measures. METHODS: The pertinent literature describing the history of outcomes assessment and the influence of patient and environmental risk factors on health status were reviewed. RESULTS: Past outcomes assessment studies have not consistently demonstrated a correlation between the processes and the outcomes of care. The use of the model described in this article indicates that the lack of correlation between process and outcome is probably because past outcomes assessment studies lacked the inclusion of medical care antecedents (primarily patient and environmental risk factors) that had a significant influence on the outcomes measured. Included is a description of a study that tests the utility of incorporating the antecedents of medical care into outcomes assessment to develop valid quality of care measures. CONCLUSION: The model presented in this article advances quality of care measure development by using: (i) qualitative research to characterize the pertinent antecedents of medical care; and (ii) as many of the pertinent antecedents of medical care as possible to develop risk adjustment models for measuring outcomes that are more likely to identify the true linkages between the processes and outcomes of care. Knowing the linkages between the processes and outcomes of care would provide the information needed to develop valid quality of care measures, so that quality can be measured accurately and the groundwork for its improvement can be laid.

Identification and classification of the causes of events in transfusion medicine.

BACKGROUND: Transfusion medicine lacks a standard method for the systematic collection and analysis of event reports. Review of event reports from the Food and Drug Administration (FDA) showed a relative paucity of information on event causation. Thus, a causal analysis method was developed as part of a prototype Medical Event Reporting System for Transfusion Medicine (MERS-TM). STUDY DESIGN AND METHODS: MERS-TM functions within existing quality assurance systems and utilizes descriptive coding and causal classification schemes. The descriptive classification system, based upon current FDA coding, was modified to meet participant needs. The Eindhoven Classification Model (Medical Version) was adopted for causal classification and analysis. Inter-rater reliability for the MERS-TM and among participating organizations was performed with the development group in the United States and with a safety science research group in the Netherlands. The MERS-TM was then tested with events reported by participants. RESULTS: Data from 503 event reports from two blood centers and two transfusion services are discussed. The data showed multiple causes for events and more latent causes than previously recognized. The distribution of causes was remarkably similar to that in an industrial setting outside of medicine that uses the same classification approach. There was a high degree of inter-rater reliability when the same events were analyzed by quality assurance personnel in different participating organizations. These personnel found the method practical and useful for providing new insights into conditions producing undesired events. CONCLUSION: A generally applicable and reliable method for identifying and quantifying problems that exist throughout transfusion medicine will be a valuable addition to event reporting activity. By using a common taxonomy, participants can compare their experience with that of others. If proven as readily implementable and useful as shown in initial studies, MERS-TM is a potential standard for transfusion medicine.

The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine.

OBJECTIVE: To design, develop, and implement a prototype medical event-reporting system for use in transfusion medicine to improve transfusion safety by studying incidents and errors. METHODS: The IDEALS concept of design was used to identify specifications for the event-reporting system, and a Delphi and subsequent nominal group technique meetings were used to reach consensus on the development of the system. An interdisciplinary panel of experts from aviation safety, nuclear power, cognitive psychology, artificial intelligence, and education and representatives of major transfusion medicine organizations participated in the development process. Setting.- Three blood centers and three hospital transfusion services implemented the reporting system. RESULTS: A working prototype event-reporting system was recommended and implemented. The system has seven components: detection, selection, description, classification, computation, interpretation, and local evaluation. Its unique features include no-fault reporting initiated by the individual discovering the event, who submits a report that is investigated by local quality assurance personnel and forwarded to a nonregulatory central system for computation and interpretation. CONCLUSIONS: An event-reporting system incorporated into present quality assurance and risk management efforts can help organizations address system structural and procedural weakness where the potential for errors can adversely affect health care outcomes. Input from the end users of the system as well as from external experts should enable this reporting system to serve as a useful model for others who may develop event-reporting systems in other medical domains.

Verifying the curriculum of a family medicine clerkship.

The learning experience during a medical school clinical rotation is largely shaped by students' patient encounters. This paper reports on how a log system for recording these encounters can be used for course planning and evaluation. Over the past 5 years, 960 third-year students completed log forms based on their clinical encounters during a required 4-week family medicine clerkship at UT Southwestern. These forms were then optically scanned and the information entered into a computerized database. Log form data revealed that the most common medical problems encountered by students in their ambulatory settings were similar to those reported in the general family practice literature. There was a great deal of consistency in the types of encounters from year to year. The data also showed some differences among clerkship sites in terms of patient demographics and the most frequently reported diagnoses. Information generated from student log forms has been used by the clerkship faculty to determine required readings, prioritize didactic topics and other teaching, adjust curriculum content, prepare support materials and develop examinations. Given the utility of the information obtained and the ease of use of optical mark encounter sheets, we recommend this system for other clerkships.

Inflammatory large bowel disease in immunodeficient rats naturally and experimentally infected with Helicobacter bilis.

Proliferative and ulcerative typhlitis, colitis, and proctitis were found incidentally in a breeding colony of male athymic nude (Cr:NIH-rnu) rats. Within the crypts of the large intestine, modified Steiner's silver stain revealed spiral organisms that were identified by culture, polymerase chain reaction, and sequencing to be Helicobacter bilis. The large bowel disease was reproduced in H. bilis-free male athymic nude rats that were injected intraperitoneally with a culture of H. bilis from the affected colony. The organism was isolated from the feces and cecum of the experimentally infected rats. H. bilis should be considered a potential pathogen in immunocompromised rats. The infection in immunocompromised rats may serve as an animal model for inflammatory large bowel disease.

Job satisfaction reported by AS, BS degree radiographers.

This study evaluated the job satisfaction of graduates of a large radiography program in the Southeast, comparing the overall job satisfaction of those who had earned an associate degree with those who had earned both an associate and a baccalaureate degree. In general, both groups of radiographers exhibited a similarly high level of job satisfaction, showing no statistically significant differences. The results suggest that the baccalaureate degree, although important in providing specific skills and additional education for radiographers, may not directly affect radiographers' job satisfaction.

Developing strategic plans for academic general internal medicine.

There is an increasing need to train more primary care physicians. Therefore, it would be advantageous for academic general internal medicine (GIM) to develop strategies to meet these demands. Our GIM division developed a strategic planning process with the participant groups being the division faculty, a pertinent literature review (the surrogate expert), and selected medical administrators. The IDEALS systems design provided the conceptual framework for the strategic planning process. This process used the Delphi technique to develop the theoretically ideal work system based on the division's vision for its future role, and the Nominal Group Process Technique to create the recommended work system, using the Delphi results. The strategic planning process was economical and division faculty agreed that it was useful.

Natural and experimental bovine immunodeficiency virus infection in cattle.

Since 1989, the LSU dairy herd, with its high seroprevalence of BIV, was recognized to have a high incidence of common diseases that reduced the economic viability of the dairy. The herd had a high percentage of cows with encephalitis associated with depression and stupor, alteration of the immune system associated with secondary bacterial infections, and chronic inflammatory lesions of the feet and legs. The occurrence of disease problems was associated with the stresses of parturition and early lactation and/or with unusual environmental stress cofactors.