After Event Reviews

Along with incident reporting systems, hospitals should consider implementing After Event Reviews (AERs). InanAER, individuals discuss and provide feedback on critical events with the aim of detecting and learning from errors. Not ordy does this provide a forum to learn fiom errors, it also helps create a mindset that errors... 

Ellis, S., Mendel, R. and Nir, M. 2006. Learning from successful and failed experience The moderating role of kind of after-event review. Journal of Applied Psychology, 91(3), 669. 

The review of the data portion of the Indian Point 2 (IP2) and 3 (IPS) PRA (a 1982 internal document prepared by Consolidated Edison and the New York Power Authority) is confined to the plant-specific and generic component failure and service hour data sections because these were the only segments available to the reviewers. The LERs produced during a ten-year span of IP2 s operation were evaluated to determine their applicability to the PRA data needs. It was eventually decided to use only the LERs generated after IP2 became critical (from May 23, 1973 to December 31, 1979) for the component data base development, based on the availability of failure event information and more uniform operability, testing, and reporting criteria. 

At the present time it is difficult to single out any one factor that could be held ultimately responsible for cell death after cerebral ischaemia. Recent studies, however, have provided us with sufficient evidence to conclude that free radical damage is at least one component in a chain of events that leads to cell death in ischaemia/reperfiision injury. As noted earlier in this review, much of the evidence for free radicals in the brain and the sources of free radicals come from studies in animals subjected to cerebral ischaemia. Perhaps the best evidence for a role for free radicals or reactive oxygen species in cerebral ischaemia is derived from studies that demonstrate protective effects of antioxidants. Antioxidants and inhibitors of lipid peroxidation have been shown to have profound protective effects in models of cerebral ischaemia. Details of some of these studies will be mentioned later. Several reviews have been written on the role of oxygen radicals in cerebral ischaemia (Braughler and HaU, 1989 Hall and Btaughler, 1989 Kontos, 1989 Floyd, 1990 Nelson ef /., 1992 Panetta and Clemens, 1993). 

As part of maintenance, some equipment may need to be calibrated. SOPs must include calibration methods, and a report format needs to be available at the time of calibration. Calibration SOPs must include pass/fail specifications as well as corrective actions to be taken in the event of calibration failure. For quality calibration standards use National Institute of Standards and Technology (NIST) traceable standards or other intrinsic standards of known purity, quality, and stability. These standards should have certificates attesting to their performance properties. After calibration, the metrologist or other responsible person should review the calibration reports to identify any issues with the equipment that may need further attention. 

Kohl KS, Marcy SM, Blum M, et al. Fever after immunization current concepts and improved future scientific understanding. Clin Infect Dis 2004 39 389-394. MacKay IR, Rosen FS. Vaccines and vaccination. N Engl J Med 2001 345 1042-1053. Moylett EH, Hanson IC. Mechanistic actions of the risks and adverse events associated with vaccine administration. J Allergy Clin Immunol 2004 114 1010-1020. Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma a review and recommendations. J Trauma 2005 58 1082-1088. Weber DJ, Rutala WA. Immunization of immunocompromised persons. Immunol Allergy Clin North Am 2003 23 605-634. 

The second label also may be a fluorescent compound, but doesn t necessarily have to be. As long as the second label can absorb the emission of the first label and modulate its signal, binding events can be observed. Thus, the two labeled DNA probes interact with each other to produce fluorescence modulation only after both have bound target DNA and are in enough proximity to initiate energy transfer. Common labels utilized in such assay techniques include the chemiluminescent probe, N-(4-aminobutyl)-N-ethylisoluminol, and reactive fluorescent derivatives of fluorescein, rhodamine, and the cyanine dyes (Chapter 9). For a review of these techniques, see Morrison (1992). 

The authors of this excellent book provide a concise but comprehensive review of various types of weapons of mass destruction, along with sound advice and simple actions that can be taken by emergency responders and the general public to reduce risks and avoid panic in the event of a terrorist attack. By simply reading through this book, emergency responders and the public will learn what they can do to minimize danger to health and life after an attack. The most important actions are summarized at the end of the book. This summary becomes a convenient checklist. 

In trials of hospitalized patients tricyclic antidepressants have generally been more efficacious than selective serotonin reuptake inhibitors (SSRIs). Otherwise there are no overall differences between the drugs in terms of tolerability or efficacy in primary care settings. After reviewing 15 trials it was concluded that drags are effective in the treatment of dysthymia with no differences between and within class of drugs. Tricyclic antidepressants are more likely to cause adverse events and dropouts. As dysthymia is a chronic condition, there remains little information on quality of life and medium or longterm outcome. 

Tardive dyskinesia is also frequently mentioned as a reason to minimize exposure, but this condition usually develops after more chronic exposure. The relationship between TD and prior neuroleptic dosing is uncertain at this time, and the authors are not aware of any studies indicating that an acute, time-limited use of higher neuroleptic doses increases the prevalence of this disorder (338). Fortunately, the occurrence of NMS is an infrequent event (less than 1.5%), with no occurrences noted in the 676 cases reviewed by Dubin. In the discussion on adverse effects (later in this chapter), however, we note a higher incidence has been found by others during rapid dose increases. 

Jefferson T, Rudin M, Pietrantonj S. Adverse events after immunization with aluminum containing DTP vaccines systemic review of the evidence. Lancet 2004 4 84-90. 

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